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* From the Department of Anesthesiology and Intensive Care,
and Department of Orthopedics, Kyoto Prefectural University of Medicine, Kyoto, Japan.
Address correspondence to: Dr. Nobuaki Shime, Department of Anesthesiology and Intensive Care, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan. Phone: +81-75-251-5633; Fax: +81-75-251-5843; E-mail: shime{at}koto.kpu-m.ac.jp
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Abstract |
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Clinical features: A one-month-old baby was found to have bilateral wrist and finger drop after the removal of splints that has been applied to the right hand for 14 days and to the right hand for six days during perioperative management of Blalock-Taussig shunt surgery. The hand splints had been applied to the forearms with adhesive silky tape to keep peripheral vascular lines in place. The patient also suffered from several episodes of cardiogenic shock, hypoxemia and generalized edema relating to cardiac dysfunction during this fine period. Given the findings of no impairment of median or ulnar nerves and brachioradial muscle, it was suspected that bandaging with adhesive tapes caused peripheral radial nerve damage at the level of posterior interosseus nerve on forearm. Diminished oxygen delivery and edema may additionally have contributed to peripheral nerve ischemia. The aforementioned neurologic symptoms resolved spontaneously after several days.
Conclusion: Prolonged compression by bandaging of splints on forearm may have resulted in ischemic damage to the posterior interosseus nerve branch combined with extensor carpi radialis longus nerve branch of the radial nerve. We should attempt to reduce the frequency and duration of splinting of the extremities, especially in sedated, paralyzed babies, given the potential risk of compression neuropathy.
PERIPHERAL nerve palsy is a well-described complication of general anesthesia.1,2 External nerve compression from inappropriate positioning in sedated and paralyzed patients is believed to be a cause of ischemic nerve injury.3 Given their small size and inability to respond to sensory changes such as numbness or paresthesia, infants are at much greater risk for developing compression neuropathy. We encountered bilateral radial nerve palsies in an infant after undergoing Blalock-Taussig shunt surgery in the setting of prolonged forearm bandages with splints.
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Perioperative course of the two surgeries
No abnormalities in the patient's nervous system had been detected preoperatively. An intravenous catheter was placed in the right dorsal metacarpal vein preoperatively. His right hand had been bandaged by a silky elastic adhesive tape (Silkypore®, Sumitomo-3M, Tokyo, Japan) with an aluminium-based splint (Alfence®, Alcare, Tokyo, Japan) to ensure sufficient drip infusion (Figure 1
). During the surgery, he was positioned with his bilateral shoulder joints abducted to 90 and elbow joints flexed to 90 with soft pads placed beneath the upper limbs to avoid excess shoulder extension.
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Seven days after the first surgery, he underwent a second surgery for replacement of the shunt graft with a smaller size in order to reduce pulmonary blood flows and relieve ventricular overload. An arterial line was placed in the left radial artery, and the left hand was bandaged by adhesive tape, with a splint similar to the one primarily applied to the right hand, in order to monitor the appropriate arterial waveform. The patient suffered an episode of transient severe hypoxemia (SpO2 below 60%) during the second surgery. The postoperative general status was uneventful. No abnormality was detected in his level of consciousness after the withdrawal from sedatives.
Detection of radial nerve palsy
Thirteen days after the first surgery, the bilateral hand splints were removed. The splints remained attached for a total of 14 days on the right hand and six days on the left. When the splints were removed, bilateral wrist and finger drop was noted (Figure 2). Extension movements of the wrist and fingers were completely absent. Elbow movements and flexion movements in the fingers were intact.
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Three days later, right wrist extension movement was detected with grade 2/5 to 3/5 power. Clinical recovery, with the 5/5 extension on the right hand, was detected on the 4th day after the initial appearance of palsy, followed by recovery of the left hand on the 9th day.
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Discussion |
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The site of injured radial nerve can be diagnosed by assessing clinical signs.7 In our patient, the presence of impaired extension of both wrists and fingers, with normal movement at the elbow joints and normal finger flexion indicates peripheral radial nerve injury at or distal to the spiral groove. The prolonged splinting of the hands was suspicious for causing compression nerve damage. An elevation in pressure of the posterior compartment of the forearm due to tightening by adhesive tape could have resulted in damage in the posterior interosseus nerve as it travels through the spinator muscle.7,8 The presence of wrist drop might also indicate concurrent damage to the extensor carpi radialis longus nerve.9 The other possible site of damage was at the posterior part of the humerus, due to pressure from inflation of the blood pressure cuff or the edge of the splint, causing similar symptoms. If we had obtained sensory examination or electrodiagnostic studies, those would have been helpful for determination of the precise site of injury.
Repeated episodes of diminished peripheral oxygen delivery in this patient with cyanotic, congenital cardiac disease are also likely to have exacerbated nerve damage.2 Interstitial edema occurring during and after cardiopulmonary bypass or during venous infusion would have resulted in additional increase in compression of the nerve fibres.10 The presence of bilateral occurrence of nerve injury suggests the participation of these factors.
It should be noted that nerve injury in children has the potential to cause psychological trauma for parents, despite the fact that spontaneous remission is the usual outcome.2 We should attempt to reduce the frequency and duration of splinting of the extremities, especially in sedated, paralyzed babies.
Accepted for publication October 13, 2000.
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2 Muller-Vahl H, Munte TF, Vahl CF. Postoperative ulnar nerve palsy: is it an unpreventable complication? Anesth Analg 1993; 77: 404–5.
3 Ciulla TA, Frederick AR Jr, Kelly C, Amrein R. Postvitrectomy positioning complicated by ulnar nerve palsy. Am J Ophthalmol 1996; 122: 739–40.[Medline]
4 Guzman F, Naik S, Weldon OG, Hilton CJ. Transient radial nerve injury related to the use of a self retaining retractor for internal mammary artery dissection. J Cardiovasc Surg 1989; 30: 1015–6.[Medline]
5 Tollner U, Bechinger D, Pohlandt F. Radial nerve palsy in a premature infant following long-term measurement of blood pressure. J Pediatr 1980; 96: 921–2.[Medline]
6 Hayman M, Roland EH, Hill A. Newborn radial nerve palsy: report of four cases and review of published reports. Pediatr Neurol 1999; 21: 648–51.[Medline]
7 Carlson N, Logigian EL. Radial neuropathy. Neurol Clin 1999; 17: 499–523.[Medline]
8 Eaton CJ, Lister GD. Radial nerve compression. Hand Clin 1992; 8: 345–57.[Medline]
9 Hashizume H, Nishida K, Nanba Y, Shigeyama Y, Inoue H, Morito Y. Non-traumatic paralysis of the posterior interosseous nerve. J Bone Joint Surg Br 1996; 78: 771–6.
10 Salisbury RE, Dingeldein GP. Peripheral nerve complications following burn injury. Clin Orthop 1982; 163: 92–7.
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