Management of Iatrogenic Nerve Injuries

Review Article Management of Iatrogenic Nerve Injuries

Abstract Nicholas Pulos, MD Iatrogenic peripheral nerve injuries from orthopaedic surgery can Emily H. Shin, MD occur via many scenarios, including direct injury to the nerve during surgery, indirect injury via retraction or compartment syndrome, and Robert J. Spinner, MD injury from nonsurgical treatments such as injections and splinting. Alexander Y. Shin, MD Successful management of iatrogenic nerve injuries requires an accurate diagnosis and timely, appropriate treatment. All orthopaedic surgeons must understand the preclinical study of nerve injury and the evaluation and treatment options for iatrogenic nerve injuries. Although a sharply transected nerve can be repaired immediately in the operating room under direct visualization, many injuries are not appreciated until the postoperative period. Advances in diagnostic studies and nerve repair techniques, nerve grafting, and nerve transfers have improved our ability to identify and treat such injuries.

From the Division of Hand Surgery, rthopaedic surgery is the most forfascicularrepairandnervetransfer Department of Orthopaedic Surgery, Ocommon cause of iatrogenic surgeries. Mayo Clinic, Rochester, MN peripheral nerve injury requiring Table 2 lists common mechanisms (Dr. Pulos, Dr. Spinner, and Dr. A. Y. treatment.1 A retrospective study of of iatrogenic nerve injury. Intra- Shin), the Department of Orthopaedic Surgery, Madigan Army Medical 722 traumatic nerve lesions across operatively, direct trauma to periph- Center, Joint Base Lewis-McChord, multiple disciplines found that 17.4% eral nerves may involve complete or WA (Dr. E. H. Shin), and the were iatrogenic in nature.1 In the partial transection during dissection. Department of Neurosurgery, Mayo upper extremity, the median nerve is Surgeons must appreciate anatomic Clinic, Rochester, MN (Dr. Spinner). most commonly injured, followed by variations in the course of peripheral Dr. Pulos or an immediate family the spinal accessory, superficial nerves to minimize the risk of iatro- ’ member is a member of a speakers radial, common peroneal, and ulnar genic nerve injuries during dissection.2 bureau or has made paid 2 presentations on behalf of Trimed. nerves. Common iatrogenic nerve Implants add an additional risk factor Dr. Spinner or an immediate family injury scenarios are listed in Table 1. because nerves may be impinged by member serves as a paid consultant plates, penetrated or twisted with drill to Mayo Medical Ventures. Dr. A. Y. bits, screws, or K-wires, particularly Shin or an immediate family member “ has received IP royalties from Mayo Mechanisms of Injury when percutaneous or minimally Medical Ventures and Trimed. Neither invasive” techniques are used.4 Nerves Dr. E. H. Shin nor any immediate A peripheral nerve is composed of can be indirectly injured and stretched family member has received anything of value from or has stock or stock single-cell axons surrounded by during retraction or with the insertion options held in a commercial company myelin sheaths grouped into fascicles and removal of orthopaedic implants. or institution related directly or with the interstitial endoneurium. Thermal injury (secondary to exo- indirectly to the subject of this article. Fascicles are surrounded by a thin thermic reaction of cement or cautery J Am Acad Orthop Surg 2019;27: perineurial layer, providing tensile devices) can result in irreversible e838-e848 strength. The epineurium is the con- damage to nearby neural structures. In DOI: 10.5435/JAAOS-D-18-00510 nective tissue layer, which encircles and some cases, determining the exact eti- runs between the fascicles3 (Figure 1). ology of the nerve deficit may be Copyright 2019 by the American Academy of Orthopaedic Surgeons. The internal topography of peripheral confounded by the mechanism of the nerves is relatively consistent, allowing injury, such as in a supracondylar

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Table 1 Common Iatrogenic Nerve Injuries Procedure Nerve Affected

Upper extremity procedures Cervical lymph node dissection Spinal accessory nerve Sternotomy Ulnar nerve Medial cord Clavicle fracture ORIF Supraclavicular nerve Submuscular biceps tenodesis Musculocutaneous nerve Proximal humerus fracture ORIF Axillary nerve Humeral shaft fracture ORIF Radial nerve Supracondylar humerus fracture CRPP Median, radial, or ulnar nerve Distal humerus fracture ORIF Ulnar nerve Distal biceps tendon repair Lateral antebrachial cutaneous nerve Radial shaft fracture ORIF Posterior interosseous nerve 1st extensor compartment release Radial sensory nerve Distal radius fracture ORIF Palmar cutaneous branch of the median nerve Carpal tunnel release Median nerve Recurrent motor branch of the median nerve Lower extremity procedures Total hip arthroplasty Sciatic nerve (posterior approach) Femoral nerve (anterior approach) Total knee arthroplasty Peroneal nerve Infrapatellar branch of the saphenous nerve Hamstring tendon harvest Saphenous nerve Tibial shaft fracture ORIF with LISS Deep peroneal nerve Distal tibia fracture ORIF Tibial nerve Distal fibula fracture ORIF Superficial peroneal nerve Calcaneus fracture ORIF Sural nerve Plantaris tendon harvest Sural nerve Bunionectomy Medial dorsal cutaneous nerve

CRPP = closed reduction percutaneous pinning, LISS = less invasive stabilization system, ORIF = open reduction internal fixation

humerus fracture. Other orthopaedic terminal branches of the brachial or Common Upper Extremity interventions, such as injections, lumbosacral plexus may be involved. splinting, and bracing treatments, may External nerve compression or trac- Lesions also cause a nerve deficit to develop. tion due to patient malpositioning is Lastly, a peripheral nerve may be re- often considered the mechanism of Brachial Plexus Nerve sected when it is mistaken for a lymph injury. In contradistinction, Warner Injuries node, vessel, or tendon.5 Therefore, all reported that patients who sustained Rates of iatrogenic nerve injury after patients with postoperative neurologic perioperative ulnar nerve palsy were shoulder surgery range from 0.2% to deficits should be approached with a more likely to have had contralateral 8.0%.8 The entire brachial plexus high index of suspicion to prevent ulnar nerve dysfunction, suggesting and several peripheral nerves have diagnosis and treatment delays. that patient factors may be important. the potential to be injured. Structures Perioperative nerve injury is one of Nevertheless, prolonged duration in at risk include the musculocuta- the most common etiologies for one position increases the risk of neous, median, and ulnar nerves anesthesia-associated medicolegal neuropathy and is a common factor in during subpectoral biceps tenodesis, claims.6 Ulnar and sciatic nerves are both upper and lower extremity nerve the axillary nerve during arthro- most commonly affected, but other palsies after surgery.7 scopic Bankart repair, and the entire

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Figure 1 and trapezius muscles and is most commonly injured in cervical lymph node dissection or radical neck dissection. Patients present with shoulder weakness, pain, and dysfunction. Although injury to the spinal accessory nerve may not be the result of an orthopaedic procedure, orthopaedic surgeons are likely to be the first to correctly identify the diagnosis and must be aware of this common injury and its sequela.10

Radial Nerve Injuries Radial nerve dysfunction is a well- documented sequela of surgically treated diaphyseal humerus fractures, and iatrogenic injury is reported in approximately 7% of fracture fixation cases. Claessen 11 Diagram showing the anatomy of a peripheral nerve. (Reproduced with et al found that the surgical permission from the Mayo Foundation for Medical Education and Research, approach was the most important Rochester, MN. All rights reserved.) factor relating to iatrogenic nerve injury with the highest incidence in brachial plexus during open surgery postoperative neurologic symptoms the lateral exposure. Notably, there for instability.8 Although it is possi- lasting more than 6 months was only was 18.5% incidence of iatrogenic ble that injury may be the result of 0.9 per 1,000 blocks.9 radial nerve palsy after nonunion regional anesthesia, a prospective The spinal accessory nerve (CN XI) repair, where débridement of frac- registry found that the incidence of innervates the sternocleidomastoid ture callus may add an additional

Table 2 Common Causes of Iatrogenic Nerve Injuries Mechanism of Injury Example(s)

Orthopaedic surgical procedure Procedure Nerve injured Direct Nerve cut ACL reconstruction Infrapatellar branch of the saphenous nerve Nerve injured by implant Supracondylar humerus CRPP Ulnar, median, or radial nerve Indirect Nerve stretched or contused by Anterior hip surgery Lateral femoral cutaneous nerve dissection Nerve stretched or contused during Prone positioning Ulnar nerve patient positioning Compartment syndrome Tibial shaft fracture Peroneal nerve Orthopaedic surgical procedure with Gunshot wound to the humeral Radial nerve unknown nerve status preoperatively shaft Nonsurgical orthopaedic intervention Injection De Quervain release Radial sensory nerve Splint application Ankle fractures Common peroneal nerve Regional anesthesia associated Total shoulder arthroplasty Axillary nerve Surgery by another specialty Cervical lymph node biopsy Spinal accessory nerve (CN XI) e840 Journal of the American Academy of Orthopaedic Surgeons

12 risk factor. In a retrospective study Table 3 of 707 humeral shaft fractures treated Seddon3 Classification of Peripheral Nerve Injuries surgically, Wang et al13 concluded that there was no advantage to early Nerve Injury Pathophysiology Management Prognosis exploration after iatrogenic nerve Neurapraxia Local myelin Serial examinations. Usually recovers injury in the absence of obviously damage, intact spontaneously and misplaced instrumentation or frac- axons completely in a short ture displacement. period Axonotmesis Axonal loss, Serial examinations. May recover epineurium Therapy to maintain spontaneously but Median Nerve Injuries intact joint range of over a longer time. Corticosteroid injections are com- motion. May require surgery. mon in the nonsurgical management Neurotmesis Complete division Early nerve repair or No recovery without of carpal tunnel syndrome. Injury to of the nerve reconstruction. treatment leading to the median nerve is uncommon.14-16 persistent severe However, intraneural injection of a deficits local anesthetic or corticosteroid can lead to permanent impairment because nearly all injectable anesthetic agents incisions with blunt dissection to bone, tion. Injection injuries to the sciatic are neurotoxic.15 and soft-tissue protectors including nervehavealsobeenreportedandare In a review of major nerve injuries large-gauge needles may be used to more commonly seen in children and associated with carpal tunnel release, limit the risk of iatrogenic injury. elderly patients with less soft-tissue Azari et al16 reported that the most coverage. significant factor resulting in a re- ’ ferral was the operative surgeon s Common lower Extremity Common Peroneal Nerve lack of specialized training in hand Lesions Injuries surgery. The true incidence of nerve injury associated with carpal tunnel Sciatic Nerve Injuries The superficial position of the com- could not be ascertained. mon peroneal nerve, lateral to the The incidence of sciatic nerve injury fibular head, makes it susceptible to after total hip arthroplasty ranges Sensory Nerve Injuries compression injury during casting from 0.6% to 3%. Patients under- and intraoperatively due to posi- Damage to sensory nerves can lead to going surgery for hip dysplasia or tioning. The nerve may be injured 18 dysesthesias and the formation of revision are most at risk. Clinical surgically during exposure and retrac- painful neuromas. Injuries to sensory assessment alone may underestimate tion in open cases and arthroscopically 19 nerve branches are frequently de- the true incidence of these lesions. during lateral meniscal repair. scribed but are likely under-reported. After total hip arthroplasty, iatrogenic “Minimally invasive” techniques In a large series, only 25% of docu- injury may be a result of patient put the common peroneal nerve at mented radial nerve injuries involved positioning, retractor placement, pen- risk, and injury has been reported 17 the superficial sensory branch. The etrating implant, traction associated with stab incisions for varicose vein radial sensory nerve can be damaged with leg lengthening, thermal injury procedures22 and percutaneous fix- with De Quervain release and other (ie, electrocautery or methyl methac- ation of distal tibia fractures. The radial-sided hand and wrist proce- rylate cement), or compression sec- deep peroneal nerve is most at risk dures. The lateral antebrachial cuta- ondary to hematoma. Because of its with the less invasive stabilization neous nerve is similarly at risk with anatomic location, the common per- system (LISS plating system).23 radial-sided wrist procedures distally oneal division is more commonly and distal biceps repair proximally. injured than the tibial division.20 In The palmar cutaneous branch of the treating more than 350 sciatic nerve Sensory Nerve Injuries median nerve can be injured during lesions surgically, Kim et al21 recom- In the lower extremity, damage to exposure to the volar distal radius. mended surgical exploration in patients sensory nerve branches can range Percutaneous fixation of hand frac- without clinical or electrodiagnostic from numbness and paresthesias to tures has many advantages but can put evidence of improvement by 4 to the development of a painful neuroma several neurovascular structures at 5 months after injury. Rarely was the and neuropathic pain on a weight- risk.4 Knowledge of anatomy, small nerve transected on surgical explora- bearing surface. The infrapatellar

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Figure 2 ciotomy. Constrictive dressings may put pressure on the peroneal nerve as it crosses the fibular neck, and knee braces may stretch the nerve beyond its physiologic tolerance. These should be loosened and the nerve function re- assessed. Patients with sciatic nerve palsies after hip procedures should be positioned to relieve tension on the nerve (ie, hip extension and knee flex- ion). Poor positioning of the elbow, wrist, and ankle may similarly place nerves on stretch and tension and are potentially reversible causes of nerve palsy in the acute postoperative period. For a patient whose nerve deficit is first recognized after the acute postoperative period, a history Flowchart showing management of iatrogenic nerve injuries. should be performed documenting the patient’s symptoms, pain, and branch of the saphenous nerve is fre- under anesthesia for the index pro- any changes over time. A thorough quently damaged with any para- cedure, the injury should be assessed physical examination should be patellar incision over the knee and immediately treated. For small performed with a comparison to the including patellar tendon harvest for sensory nerve branches, the nerve contralateral side and to the docu- ACL reconstruction, total knee ar- ends may be left untreated or buried mented preoperative examination. throplasty, proximal tibia open to minimize the risk of developing a Every attempt should be made to reduction internal fixation (ORIF), symptomatic neuroma. For motor obtain an accounting of the surgical and placement of an intramedullary nerves and large sensory nerves, the procedure. Additional confirmation nail for tibial shaft fracture. In addi- decision to directly repair or graft with electrodiagnostic and imaging tion, the saphenous nerve proper may acutely (if direct repair is not possi- studies may be warranted. Our be injured during hamstring tendon ble) is relatively uncontroversial.3 approach to the nonsurgical and graft harvesting. In a meta-analysis, Ideally, this should be done imme- surgical management of iatrogenic Pekala et al24 found a rate of injury diately by a surgeon familiar with the nerve injuries is based on a large of 51.4% with vertical incisions and management of peripheral nerve in- volume of referrals and an under- advocated for the use of the shortest juries, one who is comfortable ob- standing of the preclinical study of possible oblique incision during taining autologous nerve grafts and nerve injury (Figure 2). harvesting over the pes anserinus. experienced with the use of an operating microscope to facilitate fascicular repair. An intraoperative History and Physical Management of Iatrogenic consult by such a surgeon is war- Examination Nerve Injuries ranted in this scenario if possible. A history of unremitting severe neu- When intraoperative consultation is ropathic pain immediately after sur- The Seddon25 classification of periph- not available, the nerve ends may be gery or after the anesthetic block has eral nerve injuries helps to define the tagged and the wound closed with worn off is an ominous sign that affected structures and to guide treat- immediate postoperative consulta- needs to be taken seriously. This sce- ment (Table 3). The challenge in de- tion with a nerve surgeon for early nario typically occurs with entrapped termining which treatment strategy to re-exploration and repair. or strangulated nerves. Hyperalgesia useliesindeterminingwhichtypeof When a patient is identified in the and allodynia are concerning symp- nerve injury is present because all acute postoperative setting with a toms for nerve transection and/or nerve lesions may present similarly in nerve deficit, urgent evaluation is stump neuroma formation. the immediate postoperative period. necessary. Pain with passive stretch is In contrast, a history of being nor- In the setting of a known iatrogenic concerning for compartment syndrome mal postoperatively, then a few days nerve transection with the patient still and may necessitate immediate fas- later having an episode of sharp e842 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Nicholas Pulos, MD, et al debilitating pain, followed by paral- tions or after nerve surgery. Re- tion potentials) as soon as 10 days ysis, is more consistent with a brachial generating axons will produce a Tinel after injury.29 Earlier examinations, plexus neuritis (ie, Parsonage-Turner sign that advances distally along the before the completion of Wallerian syndrome). Thus, a critical history is course of the nerve. A repaired nerve degeneration, will be misleading imperative regarding the characteriza- that continues to demonstrate a because they will falsely indicate that tion of pain, weakness, function, tim- strong Tinel sign at the site of repair the muscles are normal. ing, and chronology. rather than progressing distally is When monitoring for recovery Physical examination includes concerning for neuroma formation. of nerve function, serial electro- observing muscle bulk and atrophy, diagnostic examinations performed measuring active and passive range of Imaging Studies every few months by the same prac- motion, testing of sensory nerve dis- titioner in conjunction with repeat Postoperative orthogonal radiographs tributions and muscle strength, and physical examination are ideal. should be scrutinized for any aberrant noting the presence or absence of a Reduced recruitment of motor unit implant or fracture gapping, which Tinel sign. When assessing sensation, potentials (MUPs) can be seen after suggestacauseofthepostoperative static and moving two-point dis- weakness on physical exam. Low nerve deficit. Advanced imaging is crimination, light touch, pinprick, amplitude, short-duration MUPs are often complicated by the use of metallic and vibratory sense should all be indicative of early reinnervation due implants, which create artifact at what examined. In patients who are unable to regrowth. In contrast, re- is invariably the site most in need of to cooperate with an examination, a innervation via collateral sprouting scrutiny. skin wrinkle test may be valuable. from undamaged, neighboring axons Ultrasonography provides at least Disruption of sympathetic tone re- is demonstrated by high-amplitude, two benefits over MRI. In the setting sults in the absence of skin wrinkling short-duration MUPs. It is critical to of metallic implants, interference may with the fingertips placed in warm understand that electrodiagnostic obscure imaging of the nerve even water. Similarly, anhidrosis in a cuta- studies correlate with muscle grade with metal subtraction sequences. neous nerve distribution indicates loss and objective sensory testing and do Furthermore, ultrasonography is of autonomic function. not correlate with functional out- particularly well suited for visualiz- Muscle strength testing in the come scores.30 ing nerves longitudinally. Ultrasound affected and contralateral extremities has been shown to identify both the is graded according to a modified topography of the nerve and patho- British Medical Research Council Surgical Treatment logic changes in muscle as a result of scale. Even if a muscle is not thought Appropriate timing of surgical inter- denervation.26 It is noninvasive and to be involved or related to the injured vention is one of the most important relatively low cost. Early ultrasonog- nerve, documentation of strength is factors in the prognosis of these in- raphy may be helpful in identifying a important because it allows for future juries. Primary nerve repair may be transected nerve requiring surgical surgical planning for tendon or nerve feasible at the time of injury, and intervention or a nerve in continuity transfers. Serial examinations over a acute transection of any major nerve allowing continued observation. Ul- period by the same evaluator allows identified in the operating room trasonographic evaluation can also for consistency in grading and deter- should be repaired in that setting. If a demonstrate later findings such as mining whether any improvement has direct repair can be performed with- the presence of a neuroma.27,28 occurred. Our convention is that to be out excessive tension, it is done under grade 3, the patient must have active an operating microscope to facilitate range of motion against gravity equal Electrodiagnostic Studies fascicular repair. The repair tech- to the passive range of motion. Even if All patients with continued neuro- nique is surgeon dependent with no the patient has some strength against logic deficits should undergo an ini- one method clearly outperforming resistance, the muscle group may not tial electrodiagnostic examination any other. Typically, the fascicles are be graded at a 4 unless active and (ie, nerve conduction velocity and aligned with several epineural 8-0 or passive motion are equal. electromyography [EMG] studies) 3 9-0 nylon sutures. Augmentation of A strongly positive Tinel sign after to 4 weeks after surgery. Nerve con- the repair has been described with suspected nerve injury indicates axo- duction velocity studies include the fibrin glue and with a variety of bio- nal disruption. The location and amplitude of compound muscle absorbable nerve wraps/conduits.31 radiating features should be well action potentials and sensory nerve When a direct neural repair cannot documented so that they may be action potentials (NAPs). EMG may be performed because of segmental loss, compared on subsequent examina- show denervation changes (fibrilla- blunt or stretch injury, interposition

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Figure 3

Photographs showing nerve grafting with cabled sural nerve autograft. A, Median nerve defect after harvest for tendon transfer. B, Resection of the proximal nerve stump to healthy fascicles. C, Proximal reconstruction using the cabled sural nerve graft to approximate the caliber of the median nerve. cable grafting should be performed. tion. In a multicenter study of upper grafting with autologous nerve or Autologous cable grafting remains extremity lesions treated with allo- nerve transfers are performed ide- the benchmark for large mixed and graft reconstruction, Cho et al33 re- ally by 6 months from injury. Nerves motor nerve lesions (Figure 3). The ported meaningful recovery in 89% regenerate at approximately 1 mm sural nerve can be easily harvested of digital nerve repairs and 75% per day (or inch per month), and a and provides nearly 30 to 35 cm of of median nerve repairs. When motor end plate remains viable for graft per leg, leaving only an area of reconstructing a noncritical function approximately 1 year. Delay in rees- numbness on the lateral side of the or the potential for recovery is lim- tablishing continuity of a motor nerve foot. Other potential sites of auto- ited, the ease of use and limited may doom the chance of success if graft include the superficial peroneal, donor site morbidity may favor the the time for the nerve to regenerate saphenous, and medial antebrachial use of allografts.34 For critical motor to the target muscles is greater than cutaneous nerves. Cable grafting to or mixed senory motor nerves, cabled the survival time of the motor end match the diameter of the nerve to be autograft reconstruction remains the plate.37 Although sensory innervation is repaired increases the number of ax- benchmark.35 important, sensory nerve function may ons while maximizing the viability of a Made up of a variety of absorbable return as late as three years after nonvascularized graft. Vascularized and nonabsorbable materials, nerve repair, thus timing for sensory recon- grafts have been described in the conduits maintain a physical barrier struction can be delayed if necessary. management of brachial plexus in- containing a milieu that serves as a When surgical exploration and juries but are less often used. Sensory substrate for regenerating axons. The reconstruction is chosen, all injured nervegraftshavebeenplacedretro- best indication for nerve tubes is in neural structures are identified. Pre- grade so that regenerating nerve fibers the reconstruction of digital sensory vious surgery may make distinguish- are not lost to branching points. nerves. Their use in treating large ing these nerves difficult. Using the However, this dogma has not been mixed or motor nerve lesions is not axiom of working from “known to shown to improve functional currently supported by the literature.36 unknown,” a wider surgical expo- outcomes.32 Delayed management of iatrogenic sure is usually necessary, confirming Decellularized nerve allografts nerve injuries considers the patient’s the identity of normal proximal and have been advocated by some au- age, comorbidities, neurologic deficit, distal nerve, followed by dissection thors because of donor site morbidity time from injury, and intraoperative to the zone of injury. and the limited options for autolo- findings. If there is potential for If a nerve has been completely gous nerve grafts and concerns re- spontaneous recovery (and possibility transected, it will likely have formed a garding size mismatch. Motor for complete transection is low), the neuroma. The neuroma is serially regeneration has been inferior to surgeon must balance observation excised (ie, breadloafed) until healthy autogenous grafts. However, sensory for spontaneous recovery with time- fascicles are identified. The same nerve function of small nerve defects dependent irreversible end plate principles of tension-free surgical has been successful after reconstruc- degeneration. Interposition nerve repair apply. When direct opposition e844 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Nicholas Pulos, MD, et al is not possible, interposition grafting Table 4 discussed earlier should be used. Common Scenarios and Application of Treatment Principles If the nerve is not transected, it may have formed a neuroma in continuity. Scenario Treatment Algorithm Neuromonitoring can be informative Complete radial nerve palsy after Exploration of the radial nerve, with at this later stage. NAPs can be per- humeral shaft fracture plating, no probable cable grafting if the formed as early as 6 weeks from clinical recovery at 3 months, and neurotmesis is confirmed. injury and can provide information electrodiagnositic studies suggest PT to ECRB transfer is useful as a neurotmesis temporary dynamic wrist extensor about conduction across the site of splint during 6 months until injury, dictating whether to perform anticipated motor recovery neurolysis. When NAPs are present, Ulnar nerve palsy is found after medial Most of these injuries resolve the probability of reinnervation of pin for a pediatric supracondylar spontaneously over several months. the target muscle has been reported to humerus fracture. Pin revision and nerve exploration are be 88%. In these cases, careful neu- intuitive, but some suggest that the medial pin does not have to be 38 rolysis of scar is performed. When removed39 the injury is more severe in one part Lateral femoral cutaneous nerve is cut Intraoperatively bury the distal end of of the nerve than another, internal during pelvic osteotomy. the proximal nerve in muscle. neurolysis may be indicated. If NAPs PIN deficit in the recovery room after Check for compartment syndrome, are absent, there is a block to conduc- radial plating from the anterior releasing tight bandages. Monitor for tion. Excision of the damaged nerve as approach recovery and follow-up at 3 weeks and consider ultrasonography if no described earlier and interposition cable recovery at that time. nerve grafting with autograft nerve or Dense sciatic palsy in the recovery Extend hip and flex knee and monitor for nerve transfers are recommended. room after THR with lengthening recovery. Nerve transfers have been devel- Peroneal palsy in the recovery room Release tight or compressive dressings oped to provide restoration of a more after medial closing wedge osteotomy around the knee and monitor for nuanced motion that direct innerva- of the proximal tibia recovery. tion provides. A nerve transfer is the Thumb opposition weakness after Early ultrasonography if no recovery. transfer of a less important and ex- carpal tunnel release Consider nerve repair/grafting if identified early. Opposition tendon pendable motor nerve to a more transfer if identified late. important and denervated motor Axillary palsy after arthroscopic Monitor for recovery and consider nerve. Nerve transfers diminish the Bankart repair ultrasonography if no recovery at time to reinnervation by coapting the 3 months. Consider nerve repair/ viable nerve close to the motor end grafting or nerve transfer if identified early. plate and eliminate the need for Phantom limb pain after a transtibial Consider pain management and PM&R autologous nerve graft. They do, amputation consultation for multimodal regimen however, require one donor for each including mirror therapy. function and do not address sensory recovery. Sensory nerve transfers PIN = posterior interosseous nerve have been described as well to pro- mote sensory nerve recovery. Al- though popularized in the upper end-to-side nerve transfers is beyond mon clinical scenarios and subsequent extremity, nerve transfers in the set- the scope of this review, but suffice it application of these treatment princi- ting of foot drop have also been to say that early referral to a pe- ples are outlined in Table 4. demonstrated to be successful in ripheral nerve surgeon permits many select patients.40 more surgical options than may be End-to-side transfers have been available once the motor end plates Outcomes of Surgery reported to potentially preserve the become nonviable. motor end plates. They are most If the time to motor nerve recon- As in any peripheral nerve lesion, commonly used with ulnar nerve le- struction exceeds 12 months, tradi- outcomes are dependent on the sions, where an anterior interosseous tional tendon transfer options, location and type of lesion, patient nerve is transferred end to side distal selected joint arthrodesis, or tenodesis factors, and time to intervention. to a mixed ulnar nerve repair.41 A full should be considered to improve Lesions in continuity treated with discussion of both end-to-end and function. Specific examples of com- neurolysis have a better prognosis

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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Iatrogenic Nerve Injuries than discontinuous lesions. Within Medicolegal Aspects means putting the needs of the patient discontinuous lesions, shorter seg- Medical malpractice litigation is first. When appropriate, immediate ment reconstructions are associated common, and most orthopaedic sur- referrals to a peripheral nerve surgeon should be made. If the patient pursues with better outcomes. geons are predicted to have a medical litigation, it is important to seek legal Although iatrogenic nerve injuries malpractice claim during their ca- counsel. During the entire process, are usually isolated lesions, results reers.44 A recent analysis of 464 thorough documentation, prompt rec- can still be devastating. A retrospec- malpractice claims in California for ognition and diagnosis, referral to tive study of 126 surgically treated orthopaedic surgery demonstrates specialists, and being a patient advo- iatrogenic nerve injuries demonstrated that the highest impact allegations cate can support the surgeon’sdefense. some improvement in approximately were failure to protect structures in 70% of patients. However, at a mean the surgical field. Nerve injury was follow-up of 18 months, only 24% the most common allegation, with Second Victim Phenomenon achieved a “very good” outcome, 41 cases resulting in more than $5.8 A recent brave reflection of an ulnar defined as the patient experiencing million in payment to plaintiffs.6 nerve transection in an orthopaedic considerably less pain and/or consid- Surgeons must appreciate that no surgeon highlights, among other erable improvement in motor or sen- matter how skilled or intelligent they topics of operating room safety, the sory nerve function. Notably, nearly think themselves to be, they are second victim effects that have pre- two thirds of the injuries were treated human, and the possibility of iatro- viously gone under-reported.46 The greater than 6 months from injury, genic nerve injury exists in every case. second victim phenomenon occurs whichmayhaveledtopoorerresults.1 Surgeons should communicate with when health care providers involved Early identification and manage- patients that despite all the ways in an adverse event feel trauma- 47 ment of iatrogenic nerve injuries is nerve injuries are avoided, the risk tized themselves. It is important to crucial to maximize outcomes. Exper- of iatrogenic injury is real and does appreciate the societal and personal ’ imental evidence shows that immediate occur. This phenomenon is especially factors associated with the surgeon s response to iatrogenic injury, where it direct nerve repair can halt motor important in the consent process and is possible that shame and guilt unin- neuron loss, maximizing the potential critical to forming a good therapeutic tentionally impede the process of for return of function.42 The results relationship with patients based in honesty. Good therapeutic relation- prompt referral. A compassionate of a recent 2017 study with 122 pa- ships are helpful in preventing and handling of not only the patient but tients show a statistically significant limiting litigation. One analysis also the surgeon facilitates appropriate difference in satisfactory recovery shows that having an adverse out- surgical intervention in a timely rates for patients receiving interven- come not well explained in the sur- manner, maximizing outcomes. tion before 6 months compared with gical consent process was a risk factor after 6 months, which are consistent for malpractice suits.45 Finally, the 43 Summary with the previous literature. documentation process should be Therefore, patients should have the thorough, from preoperative exami- appropriate referrals to a surgeon Orthopaedic and hand procedures nations (perhaps the injury was not are the most common cause of iatro- who specializes in nerve repair and truly iatrogenic), to intraoperative reconstruction as soon as feasible. genic nerve injury, with rates ap- notations that nerves were protected, proaching 20% in revision upper Rarely does a review of the previous to the identification and description extremity surgery. The Seddon clas- surgical report provide any informa- of the injury (was the nerve cut, sification of nerve injury is useful in tion regarding the iatrogenic nerve crushed by a plate, or caused by identifying the prognosis and man- injuries.2 The most efficient method retraction) to help maximize patient agement of iatrogenic nerve injuries of referral comes directly from the outcomes. outlined in Table 3. When iatro- operating surgeon. Even then, there If a nerve is damaged intra- genic nerve injuries are discovered is often a delay in presentation. In operatively, notify the patient as soon during a surgery, an intraoperative one large series at a single center spe- as feasible. Inevitably, the patient and consult is warranted and appropri- cializing in traumatic nerve repair, his or her family will have questions ately addressed. Nerve injuries sus- most patients presented after 6 months, about the injury. Maintaining the pected in the acute postoperative and most of the referrals were not from physician-patient relationship is criti- period should be evaluated for any the operating surgeon who caused the cal, and communication must be open reversible causes and addressed. injury.1 and honest. Being a patient advocate Early clinical follow-up is warranted e846 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Nicholas Pulos, MD, et al to ensure improvement and appro- 7. Warner MA: Perioperative neuropathies. surgically treated sciatic nerve lesions. J priate therapy. When iatrogenic Mayo Clin Proc 1998;73:567-574. Neurosurg 2004;101:8-17. nerve injuries are identified late or 8. Carofino BC, Brogan DM, Kircher MF, 22. Giannas J, Bayat A, Watson SJ: Common et al: Iatrogenic nerve injuries during peroneal nerve injury during varicose vein have no recovery, additional studies, shoulder surgery. J Bone Joint Surg Am operation. Eur J Vasc Endovasc Surg 2006; such as ultrasonography and/or 2013;95:1667-1674. 31:443-445.

EMG, are helpful in correctly diag- 9. Sites BD, Taenzer AH, Herrick MD, et al: 23. Pichler W, Grechenig W, Tesch NP, nosing the injury. Treatment options Incidence of local anesthetic systemic Weinberg AM, Heidari N, Clement H: The include exploration and neurolysis, toxicity and postoperative neurologic risk of iatrogenic injury to the deep symptoms associated with 12,668 peroneal nerve in minimally invasive nerve repair, nerve grafting, or nerve ultrasound-guided nerve blocks: An osteosynthesis of the tibia with the less transfers. In cases with no potential analysis from a prospective clinical registry. invasive stabilisation system: A cadaver Reg Anesth Pain Med 2012;37:478-482. study. J Bone Joint Surg Br 2009;91: for recovery, tendon transfers may 385-387. be warranted. Early recognition in 10. Camp SJ, Birch R: Injuries to the spinal accessory nerve: A lesson to surgeons. J 24. Pekala PA, Tomaszewski KA, Henry BM, the operating room and a high index Bone Joint Surg Br 2011;93:62-67. et al: Risk of iatrogenic injury to the of suspicion in the postoperative 11. Claessen FM, Peters RM, Verbeek DO, infrapatellar branch of the saphenous nerve period can positively affect out- Helfet DL, Ring D: Factors associated with during hamstring tendon harvesting: A meta-analysis. Muscle Nerve 2017;56: comes. The injury can be devastating radial nerve palsy after operative treatment of diaphyseal humeral shaft fractures. J 930-937. to the patient and the surgeon and 2015;24:e307-e311. Shoulder Elbow Surg 25. Seddon HJ: A classification of nerve has the potential for significant 12. Kakazu R, Dailey SK, Schroeder AJ, injuries. Br Med J 1942;2:237-239. medicolegal consequences, but nei- Wyrick JD, Archdeacon MT: Iatrogenic 26. Bodner G, Harpf C, Gardetto A, et al: radial nerve palsy after humeral shaft ther should get in the way of prompt Ultrasonography of the accessory nerve: nonunion repair: More common than you Normal and pathologic findings in cadavers referral to a surgeon familiar with think. J Orthop Trauma 2016;30:256-261. the management of iatrogenic nerve and patients with iatrogenic accessory nerve 13. Wang JP, Shen WJ, Chen WM, Huang CK, palsy. J Ultrasound Med 2002;21: injuries. Shen YS, Chen TH: Iatrogenic radial nerve 1159-1163. palsy after operative management of humeral shaft fractures. J Trauma 2009;66: 27. Cesmebasi A, Smith J, Spinner RJ: Role of 800-803. sonography in surgical decision making for References iatrogenic spinal accessory nerve injuries: A 14. Jones C, Widdowson D, Davidson DM: paradigm shift. J Ultrasound Med 2015;34: References printed in bold type are Iatrogenic injury to the motor branch of the 2305-2312. median nerve during percutaneous needle those published within the past 5 fasciotomy. J Hand Surg Eur Vol 2018;43: 28. Ashwell ZR, Froelich JM, Strickland CD: years. 331-332. Unique utility of sonography for detection of an iatrogenic radial nerve injury. J 15. Fremling MA, Mackinnon SE: Injection 1. Kretschmer T, Antoniadis G, Braun V, Rath Ultrasound Med 2016;35:1101-1103. injury to the median nerve. Ann Plast Surg SA, Richter HP: Evaluation of iatrogenic 1996;37:561-567. 29. Lee DH, Claussen GC, Oh S: Clinical nerve lesions in 722 surgically treated cases of conduction and needle electromyography peripheral nerve trauma. J Neurosurg 16. Azari KK, Spiess AM, Buterbaugh GA, studies. J Am Acad Orthop Surg 2004;12: 2001;94:905-912. Imbriglia JE: Major nerve injuries 276-287. associated with carpal tunnel release. Plast 2. Antoniadis G, Kretschmer T, Pedro MT, Reconstr Surg 2007;119:1977-1978. 30. Sahin F, Atalay NS, Akkaya N, Ercidogan Konig RW, Heinen CP, Richter HP: O, Basakci B, Kuran B: The correlation of Iatrogenic nerve injuries: Prevalence, 17. Kretschmer T, Heinen CW, Antoniadis G, neurophysiological findings with clinical diagnosis and treatment. Dtsch Arztebl Int Richter HP, Konig RW: Iatrogenic nerve and functional status in patients following 2014;111:273-279. injuries. Neurosurg Clin N Am 2009;20: traumatic nerve injury. J Hand Surg Eur 73-90, vii. 3. Lee SK, Wolfe SW: Peripheral nerve injury 2014;39:199-206. and repair. J Am Acad Orthop Surg 2000;8: 18. Schmalzried TP, Amstutz HC, Dorey FJ: 31. Aberg M, Ljungberg C, Edin E, et al: 243-252. Nerve palsy associated with total hip Clinical evaluation of a resorbable wrap- replacement: Risk factors and prognosis. J 4. Akinleye SD, Garofolo-Gonzalez G, around implant as an alternative to nerve Bone Joint Surg Am 1991;73:1074-1080. Culbertson MD, Choueka J: Iatrogenic repair: A prospective, assessor-blinded, injuries in percutaneous pinning techniques 19. Weale AE, Newman P, Ferguson IT, randomised clinical study of sensory, motor for fifth metacarpal neck fractures. Hand Bannister GC: Nerve injury after posterior and functional recovery after peripheral (N Y) 2019;14:386-392. and direct lateral approaches for hip nerve repair. J Plast Reconstr Aesthet Surg replacement: A clinical and 2009;62:1503-1509. 5. Weber RV, Mackinnon SE: Median nerve electrophysiological study. J Bone Joint 32. Roberts SE, Thibaudeau S, Burrell JC, mistaken for palmaris longus tendon: Surg Br 1996;78:899-902. Restoration of function with sensory nerve Zager EL, Cullen DK, Levin LS: To reverse transfers. Hand (N Y) 2007;2:1-4. 20. Park JH, Hozack B, Kim P, et al: Common or not to reverse? A systematic review of peroneal nerve palsy following total hip autograft polarity on functional outcomes 6. 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nerve allograft. J Hand Surg 2012;37: 39. Khademolhosseini M, Abd Rashid AH, 43. Rasulic L, Savic A, Vitosevic F, et al: 2340-2349. Ibrahim S: Nerve injuries in supracondylar Iatrogenic peripheral nerve injuries-surgical fractures of the humerus in children: is treatment and outcome: 10 years’ 34. Henry M: Management of iatrogenic ulnar nerve exploration indicated? J Pediatr experience. World Neurosurg 2017;103: nerve transection. J Hand Microsurg 2015; Orthop B 2013;22:123-126. 841-851.e6. 7:173-176. 40. Giuffre JL, Bishop AT, Spinner RJ, Levy 44. Jena AB, Seabury S, Lakdawalla D, Chandra 35. Rbia N, Shin AY: The role of nerve graft BA, Shin AY: Partial tibial nerve transfer to A: Malpractice risk according to physician substitutes in motor and mixed the tibialis anterior motor branch to treat specialty. NEnglJMed2011;365:629-636. motor/sensory peripheral nerve injuries. J peroneal nerve injury after knee trauma. Hand Surg 2017;42:367-377. Clin Orthop Relat Res 2012;470:779-790. 45. Ahamed S, Haas G: Analysis of lawsuits 36. de Ruiter GC, Spinner RJ, Yaszemski MJ, against general surgeons in Connecticut 41. Barbour J, Yee A, Kahn LC, Mackinnon SE: Windebank AJ, Malessy MJ: Nerve tubes during the years 1985 to 1990. Conn Med Supercharged end-to-side anterior for peripheral nerve repair. Neurosurg 1992;56:139-141. interosseous to ulnar motor nerve transfer Clin N Am 2009;20:91-105, vii. for intrinsic musculature reinnervation. J 46. Taylor DC, Matson AP, Gibson SD, et al: 37. Shin AY, Spinner RJ, Steinmann SP, Bishop Hand Surg 2012;37:2150-2159. Ulnar nerve transection in an orthopaedic AT: Adult traumatic brachial plexus injuries. surgeon sustained during surgery: A case JAmAcadOrthopSurg2005;13:382-396. 42. Ma J, Novikov LN, Kellerth JO, Wiberg M: report and commentary. J Bone Joint Surg Early nerve repair after injury to the Am 2018;100:e2. 38. Kim DH, Han K, Tiel RL, Murovic JA, postganglionic plexus: An experimental Kline DG: Surgical outcomes of 654 ulnar study of sensory and motor neuronal 47. Wu AW: Medical error: The second victim. nerve lesions. J Neurosurg 2003;98: survival in adult rats. Scand J Plast The doctor who makes the mistake needs 993-1004. Reconstr Surg Hand Surg 2003;37:1-9. help too. Br Med J 2000;320:726-727.

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