Iatrogenic peripheral nerve injury: a guide to management for the orthopaedic limb surgeon

Abstract

Nerves may be inadvertently injured during trauma surgery due to distorted anatomy, traction applied to a limb, soft tissue retraction, by power tools, instrumentation and from compartment syndrome. Elective orthopaedic surgery has additional risks of joint dislocation for arthroplasty surgery, limb lengthening, thermal injury from cement and direct injury from peripheral nerve blocks. The true incidence is unknown, and many cases are diagnosed as neurapraxia with the expectation of a full and timely recovery without the need for intervention. The incorrect assignation of a neurapraxia diagnosis may delay treatment for a higher grade of injury and in addition fails to recognize that a diagnosis of neurapraxia should be made with caution and a commitment to regular clinical review. Untreated, a neurapraxia can deteriorate and result in axonopathy. The failure to promptly diagnose such a nerve injury and instigate treatment may result in further deterioration and expose the clinician to medicolegal challenge. The focus of this review is to raise awareness of iatrogenic peripheral nerve injuries in orthopaedic limb surgery, the importance of regular clinical examination, the role of investigations, timing and nature of interventions and also to provide a guide to when onward referral to a specialist peripheral nerve injury unit is recommended. Cite this article: EFORT Open Rev 2021;6:607-617. DOI: 10.1302/2058-5241.6.200123

Neurologic outcomes with peripheral nerve blockade in distal upper extremity nerve trauma: a retrospective study

“…Neurotoxicity of local anaesthetics injected adjacent to nerve injury may confer a greater risk than PNB performed quite proximal to nerve injuries. It is also possible that surgeon technique or experience may play a role in recovery 5. In our single-centre study, surgeons who regularly perform hand/wrist trauma most frequently requested PNB, and these patients displayed better recovery rates.…”

Causes of Dorsal Cutaneous Branch of the Ulnar Nerve Neuropathy Among Patients Undergoing Electrodiagnostic Studies: A Series of 14 Patients

“…Not only is US an important test prior to orthopedic surgeries to document the origin and course of the DCBUN, but it is also essential postoperatively if an iatrogenic injury to the DCBUN occurs [8]. In addition to EDX and US studies in the assessment of a DCBUN injury, a regional anesthetic block of the DCBUN may also be useful to confirm the diagnosis [29]. Furthermore, an MRI of the distal forearm may be helpful to confirm or rule out lesions that may be compressing or entrapping the nerve [30].…”

Incidence, demographics and rehabilitation after digital nerve injury: A population-based study of 1004 adult patients in Sweden

“…There is currently a lack of national guidelines in Sweden for the postoperative care of patients with digital nerve injuries. For many other diagnoses, national guidelines have been developed [39,40] that may minimise differences in health care use. National guidelines may also reduce health inequalities influenced by education and socio-economic differences [41].…”