Iatrogenic nerve injury during upper limb surgery (excluding the hand) - 01/12/24

Doi : 10.1016/j.otsr.2024.104056

Laurent Obert ^a, Sophie Spitael ^a, François Loisel ^a, Matthieu Mangin ^a, Victor Rutka ^b, Christophe Lebrun ^a, Frédéric Sailhan ^c,^d, Philippe Clavert ^e,⁎
^a Service d’Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main. Université de Franche-Comté, Faculté de médecine et CHU de Besançon LNIT (UR 4662), 25000 Besançon, France
^b Service d’Orthopédie, de Traumatologie, de Chirurgie de la Main. CHU Edouard Herriot, 5 place d'Arsonval, 69003 Lyon, France
^c Service d’Orthopédie et Traumatologie, CHU Cochin, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
^d Hôpital Privé Arago - Almaviva santé – 187 A Rue Raymond Losserand, 75014 Paris, France
^e Service de chirurgie du membre supérieur, CHRU Strasbourg – Hautepierre, 2, Av. Molière, 67200 Strasbourg, France

^⁎Corresponding author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Sunday 01 December 2024

Abstract

Nerve injury is the most feared complication of upper limb surgery. In about 17% of cases, the injury is iatrogenic and the potential for recovery is poor. In this context, patients file for compensation in about a quarter of cases. Defective patient installation or locoregional anaesthesia are rarely the cause of nerve injury. Nerves may be injured during creation of the surgical approach, implantation of the material or reduction of a traumatic injury. The injury is usually related to nerve release, retractor positioning or inappropriate limb-segment lengthening. Stretching and/or compression of a nerve trunk or branch is thus often the main cause.

Among diagnostic tools, imaging studies (ultrasonography, computed tomography, and magnetic resonance imaging) provide information on nerve structure but not on the potential for recovery. Electromyography combined with a neurological examination establishes the diagnosis, guides the management strategy, allows nerve-function monitoring, and indicates when nerve repair or palliative surgery is indicated. Electromyography also has prognostic value, both at diagnosis and during follow-up, by showing whether nerve regeneration is taking place. When creating the surgical approaches, thorough familiarity with anatomic safe zones and nerve trajectories is crucial to ensure full control of the zones at highest risk for nerve injury.