Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed

Strategies in Trauma and Limb Reconstruction, Oct 2012

We present a case of painful radial nerve palsy following application of a humeral lengthening frame. At re-operation, the radial nerve was found to be compressed against a distal pin. This was re-sited providing immediate pain relief and a gradual resolution of the radial nerve palsy. Pain in association with a nerve palsy should alert the clinician to the possibility of nerve compression that may benefit from urgent decompression.

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Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed

Strat Traum Limb Recon Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed Jane Halliday 0 1 Tim Hems 0 1 Hamish Simpson 0 1 0 T. Hems Department of Trauma and Orthopaedics, Glasgow Royal Infirmary , 84 Glasgow St, Glasgow G4 0SF , UK 1 J. Halliday (&) H. Simpson Department of Trauma and Orthopaedics, Edinburgh Royal Infirmary , 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA , UK We present a case of painful radial nerve palsy following application of a humeral lengthening frame. At re-operation, the radial nerve was found to be compressed against a distal pin. This was re-sited providing immediate pain relief and a gradual resolution of the radial nerve palsy. Pain in association with a nerve palsy should alert the clinician to the possibility of nerve compression that may benefit from urgent decompression. Neurostenalgia; Limb lengthening; Decompression; Radial nerve Introduction Neuropathic pain, arising from a lesion of the nervous system, is defined as persistent intractable pain disproportional between the extent of the lesion and the severity of the pain. It is associated with sensory and/or motor disturbance [ 1 ]. Neurostenalgia is a neuropathic pain that results from continuing irritation of an anatomically intact nerve by a noxious agent [ 1 ]. It may be chronic or acute and is not associated with excess sudomotor or vasomotor activity. Common causes include compression, distortion, ischaemia or tethering of the nerve. Removal of the causative agent typically results in immediate relief of pain and A 10-year-old girl underwent application of a humeral lengthening frame of her right humerus to correct severe humeral shortening gradually. The shortening was secondary to osteomyelitis of the right proximal humerus aged 10 weeks. This had left her with a 10-cm discrepancy between the lengths of the right and left humeri, resulting in significant functional difficulties. The lengthening frame was applied with the elbow extended without any intraoperative complications. In recovery, her right hand was warm and well perfused with full sensation and movement of the wrist and small hand joints. On the first post-operative day, however, she complained of severe burning pain in her right arm and hand requiring significant opiates for relief and a pain team review. Examination revealed evidence of a partial right radial nerve palsy; weakness of right wrist extension, an inability to extend the fingers and diminished sensation on the dorsum of the first webspace. She displayed evidence of hyperalgesia with an exaggerated response to pin-prick on the dorsum of the first webspace. There was no mechanical allodynia. All other hand and wrist movements and sensation were intact. An ultrasound scan of the right arm was performed. This revealed no haematoma or collection. The radial nerve was not visualised. On the second post-operative day, her symptoms decreased slightly. However, on the third post-operative day, her symptoms did not settle further and the patient was taken back to theatre for exploration of the radial nerve due to ongoing severe pain. The radial nerve was found to be in continuity without any bruising or contusion. Distally, it was found to pass tightly against the most distal external fixator pin such that, with the elbow flexed the nerve became tightly pressed against the pin. The distal pin was removed and re-sited slightly proximal. Post-operatively, there was complete resolution of the right arm pain and hyperalgesia. Sensation to the first webspace recovered on the second post-operative day with motor function returning more gradually. There was full recovery of radial nerve motor function at 4 months postoperatively. Discussion In 1943, Seddon [ 2 ] introduced a classification of nerve injuries based on three main types of nerve fibre injury and whether there was continuity of the nerve: neurotmesis, axonotmesis and neurapraxia [ 2 ]. Neurotmesis is the most severe injury. It is a lesion in which the axon and its encapsulating connective tissue lose their continuity, resulting in Wallarian degeneration. Axonotmesis is also a degenerative lesion in which the relative continuity of an axon and its myelin sheath is lost, with preservation of its connective tissue framework. Neurapraxia is a nondegenerative lesion in which there is a local conduction block, typically of large myelinated fibres. Anatomical continuity is preserved with selective demyelination. Neurology may deteriorate as a result of progressive damage to the nerve. Neurapraxia commonly results from compression and/or ischaemia of peripheral nerves. Recovery occurs by Schwann cell repair, which occurs over weeks to months [ 1 ]. Neurapraxia can occur with or without pain. Normal sensory function is the product of an actively maintained equilibrium between neurons and their environment [ 3 ]. Any disruption of this equilibrium that results from changes in sensitiv (...truncated)


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Jane Halliday, Tim Hems, Hamish Simpson. Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed, Strategies in Trauma and Limb Reconstruction, 2012, pp. 177-179, Volume 7, Issue 3, DOI: 10.1007/s11751-012-0143-6