ABSTRACT
Herein we present the case of a 78-year-old fe- male who suffered a radial nerve injury follow- ing her third left shoulder arthroplasty. At first follow-up two and a half weeks following shoul- der surgery, she presented with left arm weak- ness and profound, persistent hand weakness.
This was diagnosed as complete radial nerve palsy. After three months, the patient still had no return of function. At that point, she became a candidate for tendon transfer surgery to remedi- ate her complete radial nerve palsy. At six months post-arthroplasty, it was noted on exam that she unexpectedly regained weak wrist ex- tension two weeks before her scheduled three tendon transfer surgery. The decision was made to proceed with a modified two tendon transfer procedure. Surgery is the most reliable treat- ment to restore function, but it must be tailored for each patient’s specific needs. A current as- sessment of the patient’s reconstructive needs must be performed to prevent overtreatment.
We suggest referral for surgical evaluation, with emphasis on up-to-date clinical exam and func- tionality, as the typical course of action for pa- tients with non-resolution of radial nerve palsy.
Neurologic injury after shoulder arthroplasty is a relatively uncommon occurrence, complicat- ing only 4% of cases in one study.1 Of those cases, 88% went on to report a point of maxi- mum improvement. This subset of patients who experience iatrogenic radial nerve palsy and who do not experience recovery of function with conservative treatment are candidates for wrist, thumb, and finger extension reconstruction.
Surgical evaluation should include physical ex- amination with electrodiagnostic studies (nerve conduction study and needle electromyogra- phy). Considering the extent to which activities of daily life are compromised as a result of im- paired grip, tendon transfer surgery is a reason- able course of treatment despite the technical challenges of such a procedure. Before under- taking a complete surgical remediation of radial nerve innervated extension, functional deficits should be monitored and characterized up to the point of surgery with the goal of surgically inter- vening up to, but not beyond, what the case re- quires.
Unexpected Partial Return of Wrist Extension
1Johns Hopkins University School of Medicine, Baltimore, MD
2Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD Nicholas Calotta, BA1; E. Gene Deune, MD, MBA2
Corresponding Author:Nicholas Calotta, BA, Johns Hopkins University School of Medicine,733 North Broadway, Baltimore, MD 21205.
Email:[email protected]
The authors claim no conflicts of interest or disclosures.
AMSRJ 2015; 1(2):152—156
http://dx.doi.org/10.15422/amsrj.2015.03.007
INTRODUCTION
B R IE F R E P O R
A 78-year-old female was referred for evalua- tion of a radial nerve palsy that failed to resolve five months after shoulder surgery. The patient presented with inability to extend the left fin- gers, thumb, and wrist; there was no weakness with elbow extension. Sensory response was present in the first dorsal webspace. Her medical history included bilateral carpal tunnel syn- drome, treated surgically, a cervical spinal fu- sion and three separate shoulder arthrodesis pro- cedures (left humeral arthroplasty and left par- tial removal of prosthesis in 2006, left revision arthroplasty in 2012). Physical exam showed left radial nerve deficits with inability to supinate the hand or extend the fingers, thumb, and wrist (Video 1).
Further examination revealed normal median nerve innervation with a powerful palmaris longus, flexor carpi radialis, flexor carpi ulnaris, and palpable contraction of the pronator teres.
The patient’s right upper extremity was normal.
A post-arthroplasty electromyography and nerve conduction study was done three months after shoulder surgery, which was two months before initial presentation. It demonstrated pro- found denervational changes in radial nerve in- nervated muscles. Extensor indicis proprius and extensor digitorum communis showed 4+ fibril- lations and 4+ positive sharp waves along with no recruitment activity. The median nerve inner- vated muscles, the abductor pollicis brevis and pronator teres, were normal. Triceps and del- toids were also normal. A tendon transfer opera- tion was recommended to move palmaris longus (PL) to extensor pollicus longus (EPL), flexor carpi radialis (FCR) to extensor digitorum com- munis (EDC), and pronator teres (PT) to exten- sor carpi radialis brevis (ECRB). Electrical studies were repeated one week after presenta- tion and were consistent with earlier results.
Surgery was scheduled for five weeks later.
Three weeks after initial presentation and two weeks prior to surgery, the patient was re-exam- ined and observed to have a spontaneous return of ability to extend the wrist with some radial deviation.
In light of this very unusual development, the surgeon decided to forego the PT to ECRB trans- fer, proceeding instead with a two tendon, modi- fied Tsuge technique. Splinting was done with a palmar thumb spica splint with the wrist extend- ed to thirty degrees and the metacarpopha- langeal, proximal interphalangeal, and distal in- terphalangeal joints in zero degrees with the thumb held in maximal extension and palmar abduction. Post-operative rehabilitation was re- quired for three months. At six months follow- ing tendon transfer, the patient had regained ex- cellent functionality in the radial nerve distribu- tion with active wrist extension maintained against gravity (4/5) and active finger extension assisted by a tenodesis effect of her tendon trans- fers (Video 2).
CASE PRESENTATION
Video 1. Spontaneous return of wrist extension. Available at:http://
www.amsrj.org/public/journals/1/articlevideos/180-665-1-SP.wmv
BRIEF REPORTS
Our case of radial nerve injury and recovery is quite unusual. The anatomical course of the nerve makes it susceptible to lesions. Originat- ing from the posterior cord of the brachial plexus, it travels snugly along the humerus in the spiral groove before continuing distally. The likelihood of nerve injury is elevated in this re- gion due to high nerve tension and the spiraling course of the nerve.2Lesions can include rup- ture, neurapraxia, axonotmesis, and neu- rotmesis. Most radial nerve damage suffered in- traoperatively turns out to be neurapraxic.3By definition, these patients experience complete recovery in three months. In cases of more se- vere, unresolved nerve palsy, other modes of in- jury are present with or without concomitant neurapraxia. Spontaneous recovery is very un- usual; our case demonstrates an exceptional in- stance of late recovery. More severe injuries, like the one presented here, have very low proba- bility of recovery and require surgery as the ulti- mate treatment. Direct repair of the nerve is un- common; one group’s experience showed only 44 surgical radial nerve repairs in 22 years at a large tertiary care center.4Because most radial nerve lesions are not directly repaired via nerve surgery, tendon transfer is the most common treatment. For these patients, further consulta- tion by a hand surgeon is necessary.
The most important aspect of caring for patients with these injuries is to conduct a thorough phys- ical examination.5Establishing a new baseline clinical functionality, after the onset of nerve palsy but before treatment, will be essential in monitoring recovery progression. It is the re- sponsibility of the physician to ensure accurate, current physical exam information. This be- comes even more crucial in cases of invasive treatment when the threat of overtreatment be- comes more likely. Once the clinician has fully
explored the lesion, a variety of treatment op- tions are available.
The medical literature sparsely covers surgical overtreatment. Many of these publications focus on abdominal surgery.10Popular media outlets, such as healthcare and news websites, cover this topic narrowly, predominantly discussing breast and prostate surgeries.11,12 Overtreatment via surgery leads to increased spending and could lead to increased morbidities associated with po- tentially unnecessary procedures. Some authors have even suggested that overuse of medical treatment can lead to overuse of surgical treat- ment in a given patient, which may compound the deleterious effects of surgical overtreat- ment.15
For cases similar to the one presented here, con- servative treatment could begin with rehabilita- tion and splinting.6Patients can expect mild im- provement. A literature search performed in November 2014 reveals no cases of symptom resolution using splinting and therapy alone.
Pharmacological treatment can be used to treat neuropathic pain from a lesion but cannot repair functional loss. Surgical treatment is indicated as the best treatment option for restoration of function. One surgical approach is to repair the radial nerve with a nerve graft. One study sug- gested that 72% of patients treated by nerve grafting experienced some return of function.7 Despite this, nerve repair requires exact local- ization of a nerve lesion, which is often impracti- cal, as in this case. Tendon transfer surgery should also be considered. This is a reliable op- eration for functional improvement. Results are generally excellent and, in contrast to non-oper- ative treatment, multiple studies have shown successful outcomes.8,9
Surgery must be carefully discussed with the pa- tient. In cases of iatrogenic radial nerve palsy, the patient may not be entirely enthusiastic about the prospects of another surgery. More- DISCUSSION
B R IE F R E P O R T S
over, while results are generally good, some variation does exist and this can depend on the skill of the surgeon and the tendon transfer tech- nique employed. Possible complications in- clude tendon adhesions, transfer rupture, tendon weakness, and infection.14 Recovery also re- quires determination on the part of the patient, with an expected recovery time of about six months. Tendon re-education is essential to re- gaining maximal extensor functionality; some people will accomplish this through cortical ‘tri- al and error’, in which the motor cortex slowly reassigns neurons, while others may require oc- cupational therapy.9,13 Further, it is absolutely essential that the surgeon continually reassess the patient’s hand extensor functionality. As we presented above, a patient can spontaneously re- cover certain functional aspects. It is the respon- sibility of the surgeon to recognize progressive recovery, appropriately tailor the surgical tech- nique, and prevent overtreatment.
In the case presented here, we display how dili- gent attention to physical exam can prevent overtreatment in surgery; this helped avoid the pitfalls mentioned earlier. By continually re- assessing the patient, especially in the weeks leading to surgery, critical observations were made that fundamentally altered the patient’s surgical needs. On the other hand, physicians must remain open-minded in regard to altering treatment plans based on new exam findings.
Willingness to accept changes in the immediate pre-operative time period is as important to the prevention of overtreatment as continually up- dating the clinical assessment. In our case, slight recovery was observed and the finding was treated as significant. Flexibility on the part of the surgeon is required for translating real-time clinical progress into real-time surgical plans.
This translation occurs best when up-to-date clinical observation acts synergistically with flexible pre-operative planning. In this context, the risk of surgical overtreatment can be effec- tively and efficiently mitigated.
Surgeons can easily adopt this virtually costless practice to work towards preventing overtreat- ment of their patients. We have not attempted to quantify the magnitude of this positive effect, the extent to which surgical patients are overtreated (intra- or peri-operatively) or the specific benefits of this approach for generalized tendon transfer procedures. Future research in these directions will be necessary to comple- ment this case report and to fully comprehend the often-overlooked concern of overtreatment with surgery.
1. Surgeons must be diligent about continu- ously reassessing patients and tailoring a surgical treatment plan based on new find- ings.
2. Overtreatment can be avoided with con- scientious clinical examination.
The authors would like to thank Dr. Sophia Strike for her valuable assistance and Mark Is- coe for his editorial insights.
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LEARNING POINTS
ACKNOWLEDGEMENTS
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B R IE F R E P O R T S
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