Median Nerve Injuries Associated With Distal Radius Fractures

Abstract

Median nerve dysfunction associated with distal radius fractures may present acutely, subacutely, or late, and may also be thought of as being from either primary or secondary causes. Primary nerve injuries are rare and secondary factors are more commonly responsible for median nerve dysfunction following distal radius fractures. Secondary factors may include bleeding, fracture displacement, and swelling, as well as the position of the wrist in the cast, splint, or external fixator. Careful inspection and examination of the patient at the time of injury is critical to identify median nerve dysfunction. In cases of identified dysfunction related to secondary factors, prompt intervention [reduction, carpal tunnel release (CTR)] is likely to yield an excellent outcome while the outcome of primary injury (in the absence of other extrinsic factors) is more related to the degree of the initial insult. Serial examination of sensibility, pain, and thenar muscle function is paramount. Measurement of carpal tunnel pressure may be helpful but does not negate physical examination findings. Controversy remains over whether prophylactic CTR is necessary after volar plating of distal radius fractures. There is incomplete data regarding this issue, but thus far, it would appear that routine prophylactic carpal tunnel is not necessary. Patients with a preinjury carpal tunnel syndrome, symptoms of median nerve dysfunction or those that have higher energy injuries that may be difficult to monitor postoperatively, are perhaps better candidates for concomitant carpal tunnel release.

Volar Plate Osteosynthesis of Distal Radius Fractures With Concurrent Prophylactic Carpal Tunnel Release Using a Hybrid Flexor Carpi Radialis Approach

“…24 Unrecognized postoperative median nerve compression can develop in patients with polytrauma or head injuries or in those who are intubated; these patients might lack the capacity to report sensory deficits after surgery. 3 In addition, with the increasing use of regional anesthesia for outpatient upper extremity surgery, patients might not be able to reliably report sensory or motor disturbances unrelated to the anesthetic for up to 24 hours after surgery, depending on the anesthetic agent used. Prophylactic release of the carpal tunnel can prevent delay in diagnosis and alleviate concerns of postoperative compressive median neuropathy after distal radius fracture fixation in these patients.…”

“…[7][8][9] Some surgeons also advocate adjunctive prophylactic CTR for fractures with substantial comminution or displacement 3,6,9 -14 or in patients who cannot reliably report sensory deficits after surgery, such as patients with polytrauma or head injuries or those who are intubated. 3 Although delayed CTS has been reported in as many as 20% of patients with distal radius fractures, 15 the role of prophylactic CTR in patients without signs or symptoms of median nerve dysfunction at the time of fracture fixation remains controversial. 3,16 -19 To effectively decompress the median nerve at the time of fracture fixation, the transverse carpal ligament (TCL) is typically divided through either a separate proximal palm incision or extension of a volar Henry approach across the wrist flexion crease.…”

“…[1][2][3] When open reduction and internal fixation of these fractures is planned, specific patient factors, examination findings, and/or fracture characteristics can influence a surgeon to perform concurrent CTR.…”

Complex distal radius fracture (CDRF) with median nerve injury management using one-stage distraction bridge plate fixation (DBPF) without nerve exploration allows nerve function recovery: a case report

“…Finding the factors associated with nerve dysfunction and appropriate detection of abnormalities on physical examination, coupled with directed intervention, are the key points in achieving optimal outcomes. 7 Numerous surgical techniques treat these fractures, including percutaneous pinning, external fixation, and plate fixation. The goals of surgical treatment are anatomic reduction of the distal radius, placement of a stable construct to enable fracture healing, and restoration of normal wrist kinematics.…”