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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 50  |  Issue : 6  |  Page : 220-222

Ulnar nerve injury due to lateral traction device during shoulder arthroscopy: Was it avoidable?


Department of Orthopedics, Kasturba Medical College, Manipal University, Manipal, Karnataka, India

Date of Submission06-Feb-2017
Date of Decision17-Mar-2017
Date of Acceptance08-Jun-2017
Date of Web Publication08-Dec-2017

Correspondence Address:
Dr. Sandesh Madi
Department of Orthopedics, Kasturba Medical College, Manipal University, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_12_17

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  Abstract 


Most of the nerve injuries reported during shoulder arthroscopy in a beach chair, or lateral position is related to inappropriate patient positioning or excess traction. The lateral decubitus position is more vulnerable for traction-related neuropraxia. The present case serves as an important lesson from an avoidable situation of “having a one track mind” of the surgical team during the arthroscopic repair of shoulder instability performed in the lateral decubitus position. The operating surgeon must supervise the appropriate positioning of the patient on operation table and adequate padding of vulnerable bony points before beginning of shoulder arthroscopy to prevent any position-related nerve injuries. This is probably the first case to illustrate an unusual cause of ulnar nerve compression particularly related to the use of an additional traction device in the arthroscopic repair of shoulder instability performed in lateral decubitus position, which has not been previously defined.

Keywords: Arthroscopy, lateral decubitus, lateral jack, neuropraxia, ulnar nerve


How to cite this article:
Pandey V, Madi S, Acharya K. Ulnar nerve injury due to lateral traction device during shoulder arthroscopy: Was it avoidable?. Formos J Surg 2017;50:220-2

How to cite this URL:
Pandey V, Madi S, Acharya K. Ulnar nerve injury due to lateral traction device during shoulder arthroscopy: Was it avoidable?. Formos J Surg [serial online] 2017 [cited 2019 Mar 21];50:220-2. Available from: http://www.e-fjs.org/text.asp?2017/50/6/220/220345




  Introduction Top


Arthroscopic repair of the shoulder instability can be accomplished with patient in either beach chair or lateral decubitus position depending on the surgeons' preferences. Neurological complications have been described in both of these positions. In the lateral decubitus position, a 10%–30% incidence rate of transient neuropraxia has been observed.[1] Moreover, it was observed that the musculocutaneous nerve is the most vulnerable.[1] The documented risk factors include patient positioning and limb traction during anesthesia, capsular distension, and local compression as a result of irrigation fluid.[2] We report perhaps the first case of an ulnar nerve compression injury related to the use of an additional traction device that is utilized in the arthroscopic repair for recurrent shoulder dislocations in the lateral decubitus position.


  Case Report Top


A 30-year-old male presented to our shoulder clinic with recurrent episodes of dislocation of his left shoulder. Clinical examination revealed no muscle wasting or ligament laxity. Apprehension and relocation-release test were positive. The distal neurovascular examination was normal. An arthroscopic Bankart repair was contemplated.

The patient was taken up for surgery under general anesthesia. He was positioned in the sloppy lateral decubitus position with longitudinal traction device (Spider 2, Smith-Nephew, Andover, USA) attached. Another device called “Lateral Jack” (TENET, Canada) [Figure 1] was employed during the arthroscopic procedure to increase the working space inside the joint in the anteroinferior aspect. Standard arthroscopic Bankart repair using four bioabsorbable anchors was accomplished in 90 min, traction devices were removed, and the patient was shifted out of operating room.
Figure 1: The “Lateral Jack” device (TENET, Canada)

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On first postoperative day, the patient complained of tingling and paresthesia over the ulnar border of his hand and forearm. Clinical examination revealed minimal tenderness over the course of ulnar nerve near the elbow on the medial side without any swelling or bruise over the skin. Movement of the elbow was full and painless. Sensory examination of ulnar nerve revealed mild hypoesthesia over the medial border of the little finger. Motor function of the ulnar nerve was found to be intact. Examination of other peripheral nerves in the limb was found to be intact. Cervical spine examination was normal. The patient refused the nerve conduction studies to confirm further the lesion. He was prescribed oral pregabalin (75 mg) and methylcobalamin (750 mcg) once daily for 6 weeks. In subsequent follow-ups, his sensory deficit gradually improved and completely recovered at the end of 3 months.


  Discussion Top


During arthroscopic Bankart repair, the anteroinferior labrum needs to be properly visualized and liberated from the neck of glenoid to achieve a proper repair with appropriate tensioning of the inferior glenohumeral ligament over the glenoid using suture anchors. Often, a common difficulty observed during arthroscopic Bankart repair is constrained space in the inferior aspect of glenoid to work on the labrum. This may limit the access to the inferior glenohumeral space and jeopardize the work over the labrum compromising a successful labral repair. To overcome this difficulty, use of lateral jack is quite helpful in the lateral decubitus position. Lateral jack is a low profile, well-cushioned, surgeon-controlled lateral traction device recommended for arthroscopic shoulder instability surgeries. It acts by abutting against upper third-middle third of arm on the medial aspect and levers the arm laterally and thereby distracts the glenohumeral joint. This increases the inferior working space and provides an excellent inferior view that eases anteroinferior labral liberation and further repair. Lateral jack is not a lateral traction device, which offers lever arm effect of the upper extremity because the hand is fixed by the longitudinal traction device (Spider 2). Hence, how much compression force over the upper arm is important and it should be used intermittently to avoid nerve injury. The Spider 2 can support up to 50 lb. At full extension. However, it is imperative to determine the longitudinal traction force and lateral distraction force applied to the arm which usually varies case to case. Conventionally, 10–15 lb of longitudinal traction in applied in shoulder surgeries. However, the lateral distraction force required for Bankart repair is adjusted according to the visibility of the anteroinferior part of the joint.

The upper one-third-middle one-third area of the arm is well cushioned by muscles and protects the ulnar nerve against any pressure. However, the ulnar nerve is practically bare without any muscle cover around in the lower third of the arm and it remains vulnerable to any external compression such as that of lateral jack below middle third of the arm. Hence, as long as the lateral traction jack is placed at the upper third-middle third junction of the arm, the ulnar nerve is well protected within the cushions of muscle cover. If the jack slips to the lower position closer to the elbow, it may end up compressing the ulnar nerve.

In the index case, retrospectively, we realized that the lateral traction jack was placed too close to the elbow for prolonged duration and this would be the most likely culprit for the subsequent complication. We overlooked this fact as the team was preoccupied with the surgical procedure to be performed. Furthermore, during the procedure, surgical assistant was asked to manually distract the joint by pushing the lateral jack up to further visualize the inferior aspect of the joint. This could have put undue pressure on the ulnar nerve near the elbow.

Another factor that could have contributed in nerve compression is the position of the limb with respect to pronation-supination. Prielipp et al. have demonstrated that change in the arm position affects the external pressure transmitted to the ulnar groove. Supination of the forearm produces the least amount of pressure at the ulnar groove; pronation produces the most, and a neutral forearm position results in an intermediate value.[3] In the case of usage of lateral traction device, pronation of the limb brings the ulnar nerve closer to the traction device, and this will put the ulnar nerve at more risk to compression by the traction device than supination [Figure 2]a and [Figure 2]b. However, we cannot recall the exact position of limb regarding pronation-supination in the index case. Hence, it is prudent to position the lateral jack against the upper third of arm with the forearm in supination to avoid undue pressure on the ulnar nerve [Figure 3]a and [Figure 3]b.
Figure 2: Representation image. (a) Complete pronation of the limb brings the ulnar nerve closer to the traction device. (b) Supination of the limb moves ulnar nerve away from the traction device

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Figure 3: (a and b) Representation image. Ideal positioning of the lateral jack is at upper third mid third junction of arm with longitudinal traction

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Common pharmacological treatment prescribed for the sensory symptoms of nerve compression (neuropraxia) includes nonsteroidal anti-inflammatory drug, anticonvulsants, antidepressants, and opioids (as a last resort). Methylcobalamin (activated form of Vitamin B12) is an another potential pain killer besides, improving nerve conduction, promoting the regeneration of injured nerves, and inhibiting ectopic spontaneous discharges of injured primary sensory neurons.[4] Recently, the role of gabapentin in the treatment of neuropathic pain caused by traumatic or postsurgical peripheral nerve injury has been evaluated and found to be effective and well-tolerated.[5] These medications either single or as combination (depending on severity of symptoms and patients' response) should be continued for minimum 6–12 weeks. Our patient received combination of oral methylcobalamin (750 mcg) along with pregabalin (75 mg) once a day for 6 weeks. Symptoms gradually disappeared by the end of 3 months without any long-term disability.

Perioperative peripheral nerve injury is a rare but important perioperative complication resulting in significant patient disability, functional loss, and the potential for litigation.[6] We believe that many cases do not come to light because of underreporting of this complication, and the actual incidence might be much higher.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pitman MI, Nainzadeh N, Ergas E, Springer S. The use of somatosensory evoked potentials for detection of neuropraxia during shoulder arthroscopy. Arthroscopy 1988;4:250-5.  Back to cited text no. 1
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2.
Stanish WD, Peterson DC. Shoulder arthroscopy and nerve injury: Pitfalls and prevention. Arthroscopy 1995;11:458-66.  Back to cited text no. 2
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3.
Prielipp RC, Morell RC, Walker FO, Santos CC, Bennett J, Butterworth J. Ulnar nerve pressure: Influence of arm position and relationship to somatosensory evoked potentials. Anesthesiology 1999;91:345-54.  Back to cited text no. 3
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4.
Zhang M, Han W, Hu S, Xu H. Methylcobalamin: A potential vitamin of pain killer. Neural Plast 2013;2013:424651.  Back to cited text no. 4
    
5.
Gordh TE, Stubhaug A, Jensen TS, Arnèr S, Biber B, Boivie J, et al. Gabapentin in traumatic nerve injury pain: A randomized, double-blind, placebo-controlled, cross-over, multi-center study. Pain 2008;138:255-66.  Back to cited text no. 5
    
6.
Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve injury associated with anesthesia: A closed claims analysis. Anesthesiology 1999;90:1062-9.  Back to cited text no. 6
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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