Case Study - Upper Limb Peripheral Nerve Injury in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Tarina van der Stockt, Wendy Walker, Kim Jackson and Olajumoke Ogunleye      

Title[edit | edit source]

Multi-fragmentary, Open, Mid-shaft Humeral Fracture managed with External Fixator with Suspected Radial Nerve Injury potentially sustained at time of initial injury or intra-operatively [1]

Thanks to Humanity and Inclusion for Case Study taken from Early Rehabilitation in Conflicts and Disasters.

Abstract[edit | edit source]

Mahmoud is a 26-year-old male who sustained a penetrating wound to the back of his right arm when he was hit by a piece of metal roofing during storm-force winds in a cyclone 10 days ago, resulting in a multi-fragmentary, open, mid-shaft humeral fracture that required external fixation and now presents with a suspected neurotmesis radial nerve injury sustained either at the time of initial injury or intra-operatively.

Key Words [edit | edit source]

Open Fracture, Peripheral Nerve Injury, Radial Nerve, Neurotmesis

Patient Characteristics[edit | edit source]

Background[edit | edit source]

Ten days ago, twenty-six-year-old Mahmoud sustained a penetrating wound to the back of his right arm when he was hit by a piece of metal roofing during storm-force winds in a cyclone, which hit his island community. He was able to access initial medical treatment at the central hospital where the wound was cleaned and an external fixator was applied to stabilise a multi-fragmentary, midshaft humeral fracture. As he was otherwise medically stable, he was discharged and asked to attend rehabilitation as an outpatient the following week for wound assessment and rehabilitation.

Subjective Assessment[edit | edit source]

Subjective assessment is difficult, as Mahmoud is in severe pain and distressed that he has been unable to locate his wife or two children since the cyclone.

Social History[edit | edit source]

Currently living in a temporary shelter set up by an International NGO and attends the clinic alone.

Prior to the cyclone, he supported his small family by providing a taxi service in the local area.

Past Medical History[edit | edit source]

Mahmoud has no past medical history or mobility issues.

Presenting Condition[edit | edit source]

Mahmoud reports severe pain (VAS 10/10) along the back of his arm, combined with numbness to the top of his hand, around the thumb area. The pain is particularly bad at night and he experiences difficulty sleeping.

Since his injury, he has experienced difficulty moving the right arm but reports that this has become more isolated to extending the wrist and digits since the surgery. Although it is difficult, Mahmoud reports he has been using only his left arm as he has been worried about the symptoms and thinks something has gone wrong with his right arm.

Examination Findings[edit | edit source]

Observation[edit | edit source]

Patient seated with right arm supported by left across his body (protective posture).

External fixator to right humerus with clean pin sites and healed wound with no evidence of infection.

Slight swelling present to right hand but normal temperature and colour to skin throughout right arm

Sensation[edit | edit source]

Total loss of sensation to top of right thumb. All other areas sensate but hyperalgesia present

Active Movement[edit | edit source]

Full movement of neck and unaffected left upper limb.

Right shoulder movement limited by stiffness and pain but motor function intact.

  • Elbow extension, forearm supination, wrist extension, finger and thumb extension M0 (Muscle strength score = 0 MRC Scale).
  • All other muscles throughout the right upper limb M4 limited by pain (Muscle strength score = 4 MRC Scale)

Passive Movement[edit | edit source]

Stiff End Range of Movement of elbow, wrist, finger and thumb extension

Functional Assessment[edit | edit source]

Unable to position right hand to grip any item with pressure

Clinical Impression[edit | edit source]

26-year-old, right-hand dominant patient with multi-fragmentary, open, midshaft humeral fracture of his non-dominant left upper limb, managed with external fixator. Suspected radial nerve injury potentially sustained at time of initial injury or intra-operatively. Neurotmesis suspected due to location and mechanism of injury, total numbness and motor loss in radial nerve distribution.

High pain levels limiting rehabilitation options currently with ongoing potential to significantly impact function and mental health. Lack of active wrist, finger and thumb extension limiting ability to position hand to grasp objects, despite ability to flex digits. Significant risk for secondary joint contracture, allodynia and long-term reduced function.

Treatment[edit | edit source]

Goals[edit | edit source]

Short-term[edit | edit source]

  • Decrease pain and adequate pain management to aid sleep.
  • Improve ability to accurately assess patient and improve patient’s ability to follow a treatment plan.
  • Improve patient’s understanding of peripheral nerve function and why he is experiencing his current symptoms to improve trust and allow him to participate in his rehabilitation without fear of further harm. Make the patient aware of the safety implications of the loss of sensation to the back of the hand.
  • Regain full passive Range of Movement at all joints in the right arm. Provide a splint to improve wrist position and allow functional grip. Encourage patient to use right hand/arm without fear of harm.
  • Organise re-assessment in the next six weeks to review any evidence of radial nerve recovery; i.e. neuropraxia or neurotmesis.

Long-term[edit | edit source]

  • Resolve or manage nerve pain effectively if this pain has continued.
  • Prevent flexion contractures at the elbow, wrist, fingers and thumb to maintain any function and improve outcome if secondary surgery is available within the next two years, as neurotmesis suspected.
  • Maintain splint to assist in function.

Approach[edit | edit source]

  • Advice on positioning for comfort with arm supported and hand elevated to reduce potential for swelling. Patient not to sustain this protected position for long periods, as flexion contracture is a risk.
  • Advice to take nerve pain medications as prescribed, to improve ability to sleep, manage rehabilitation and permit functional use his hand and arm.
  • Desensitisation techniques, once nerve pain medication started.
  • Wrist extension splint with advice to remove regularly to prevent loss of wrist flexion.
  • ROM and Power: Teach functional grips with splint on and encourage use of right arm.
  • Passive ROM and active ROM exercises to treat initial stiffness, prevent contracture and build strength in unaffected muscles. Link with medical team to communicate evidence of radial nerve injury.
  • Establish plans for timescales for removal of external fixator.

Education[edit | edit source]

  • Explanation of radial nerve injury and nerve pain as patient only aware of fracture. Re-evaluation in 6-8 weeks important to determine neuropraxia or neurotmesis, but patient should be aware that the chances of long-term injury are high.
  • Accessing nerve pain medication extremely important to manage sleep and ability to comply with rehabilitation. This medication may not work immediately but the effects will build up over time.
  • Regaining passive movement and preventing flexion contracture at elbow, wrist, fingers and thumb. Maintaining full ROM and power of unaffected muscles will not cause harm. Use of a wrist splint to assist with function and help prevent contracture. Advice regarding regular removal of splint to monitor any pressure areas (particularly at numb base of thumb) and to allow full active wrist flexion. Continue exercises at least three times daily.

Outcome[edit | edit source]

  • After the rehabilitation session, Mahmoud understands the two parts of his injury; the humeral fracture and the radial nerve injury.
  • He understands the nerve pain he is experiencing and has a plan of how to source specific nerve-pain medication with the medical team.
  • Mahmoud will work on his ROM himself, now he is no longer worried about causing more damage and wants to prevent any further complications.
  • He is able to put his wrist splint on himself and can see that he is now able to make a fist and grasp objects.
  • He understands he needs to return to the clinic for another assessment to see if his nerve is showing any signs of recovery, but he is aware there is a significant chance he will be unable to actively extend his elbow, wrist, fingers and thumb long-term.

Resources[edit | edit source]

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion

References [edit | edit source]

  1. Lathia C, Skelton P, Clift Z, Chapter.5 Early Rehabilitation of Peripheral Nerve Injuries. Lathia C, Skelton P, Clift Z. Early Rehabilitation in Conflicts and Disasters. London, UK: Handicap International. 2020. p110-112