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Axillary nerve injury caused by intradeltoid muscular injection: A case report
Axillary nerve injury caused by intradeltoid muscular injection: A case report Ho-Rim Choi, MD,a Seiji Kondo, MD,a Shinji Mishima, MD,a Takuya Shimizu, MD,a Yukiharu Hasegawa, MD,a Kunio Ida, MD,a Masaaki Hirayama, MD,b and Hisashi Iwata, MD,a Nagoya, Japan
R
ecently we experienced a rare case of axillary nerve injury caused by intradeltoid muscular injection. Moreover, the injury was selective to the branch of the axillary nerve that runs to the middle of the deltoid muscle, and only the middle one-third of the deltoid was paralyzed characteristically. We review the anatomy of the axillary nerve and warn of the possibility of such injury by intradeltoid injection.
CASE REPORT A 25-year-old man got an intradeltoid muscular injection of 1 mL (0.5 mg) of atropine and 1 mL (50 mg) of hydroxyzine hydrochloride in his right shoulder as a premedication for operation on his right ear. A 25-gauge needle was used for the injection at 3-finger width below the acromion. Two days after the injection, he complained of dull pain and weakness of his shoulder. Four days after the injection, he was referred to the orthopaedic department. At the time of injection, he had neither pain nor numbness on his shoulder and arm. He was a professional dancer but could not dance well because of the weakness of his shoulder. There was no other specific trauma nor injection history to his shoulder. On physical examination, his right shoulder looked normal in the resting position but, because of the contraction of the anterior and posterior fibers, only the middle portion of the deltoid bulged out like a balloon (Figure 1, A and B) with activity. A slight decrease in abduction power was found, but there was neither tenderness nor sensory change. The affected shoulder had a normal range of motion with a stable glenohumeral joint. The radiographic examination was within normal limits. Two weeks after the injection, magnetic resonance imaging showed no pathologic changes. The electromyography and nerve conduction velocity (NCV) were checked 4 weeks after the injury. The electromyography showed positive sharp wave at rest. During voluntary contraction, polyphasic potentials and lower Surgerya
Neurology,b
From the Departments of Orthopaedic and Nagoya University School of Medicine, Nagoya, Japan. Reprint requests: Ho-Rim Choi, MD, Department of Orthopaedic Surgery, Nagoya University School of Medicine, 65 Tsurumaicho Showa-ku Nagoya, 466-8550 Japan (E-mail: choinagoya@ yahoo.co.kr). J Shoulder Elbow Surg 2001;10:493-5. Copyright © 2001 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2001/$35.00 + 0 32/4/114682 doi:10.1067/mse.2001.114682
A
B Figure 1 Patient’s right shoulder appears normal in resting position (A). When he puts stress on his shoulder, paralyzed middle deltoid bulges out by contraction of anterior and posterior fibers (B).
interference pattern were seen with no high voltage potentials (Figure 2, A, and Figure 3, A). Low amplitude and normal distal latency of the axillary nerve were observed on the NCV (Figure 4). Eight weeks after the injury, followup electromyography showed positive sharp wave at rest
493
494
Choi et al
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B
J Shoulder Elbow Surg September/October 2001
A
B
Figure 2 Positive sharp wave pattern of electromyography at rest. A, Four weeks after injury; B, 8 weeks after injury.
and normal interference during voluntary contraction (Figure 2, B, and Figure 3, B). From these electromyographic and NCV findings, we concluded this injury was an incomplete axonotmesis of the axillary nerve. After 3 months’ follow-up with physiotherapy, the middle deltoid showed good contraction without any bulging out, and there was no complaint of pain. The patient refused repeat electromyography/NCV testing.
DISCUSSION Intramuscular injection is one of the most common procedures used in hospitals. Occasionally, however, this causes unexpected neuromuscular complications such as radial and sciatic nerve palsies2,11,13,14 or contracture of the deltoid and quadriceps muscles.5,8,15 Peripheral nerve damage by intramuscular injection can result from a needle, chemical irritation and toxic action of the injected solution, or neuritis from progressive inflammatory and fibrotic changes.2,11,13,14 Many kinds of therapeutic and prophylactic agents have been reported as a cause of injection paralysis.11,13,14 However, there is no report of atropine and hydroxyzine hydrochloride, which do not have specific neurotoxicity.4
Figure 3 Electromyography of voluntary contraction. Polyphasic potentials with lower interference pattern at 4 weeks after injury (A) have improved to normal interference pattern 8 weeks after injury (B).
When a nerve injury is caused directly by a needle, most patients complain of immediate pain at the time of injection. However, in this case, the patient had no immediate injection pain. We hypothesize that the injury was limited to the pure motor branch of the axillary nerve that runs to the middle deltoid. Many authors suggest faulty sites of injection as the most important factor responsible.2,11,13 Various textbooks describe the position of the axillary nerve as coursing transversely at approximately 5 cm distal to the origin of the deltoid muscle on its deep surface.3,6,7,10 Hollinshead6 notes that the nerve lies only approximately 1.5 to 2 inches below the acromion. Kulkarni et al10 studied cadavers of 66 adults and noted that the axillary nerve ran a course on the deep surface of the deltoid muscle approximately 2.2 to 2.6 cm above the midpoint on the vertical plane of the muscle. Kido et al7 analyzed 46 cadaveric shoulders
Choi et al
J Shoulder Elbow Surg Volume 10, Number 5
and found that the average level of the axillary nerve was 5.29 cm and 5.01 cm below the anterolateral and posterolateral corner of the acromion, respectively. Burkhead et al3 also dissected 102 cadaveric shoulders and found that the distance from the midportion of the acromion to the axillary nerve ranged from 4.3 to 7.4 cm. In this case, the injection was done approximately 3-finger width below the acromion. In many textbooks, the recommended site for injection of the deltoid muscle is at the midpoint of the deltoid muscle or at approximately 5 cm or 3-finger width below from the acromion.1,9,12 However, these injection points are approximately 4 to 6 cm from the acromion, which can be hazardous to the nerve. When an intramuscular injection is performed, the relation of the nerve to the preferred site of injection should be kept in mind. Because of the possibility of axillary nerve injury by intradeltoid injection, we suggest avoidance of using it indiscriminately.
495
A
REFERENCES 1. Beecroft PC, Redick SA. Intramuscular injection practices of pediatric nurses: site selection. Nurse Educ 1990;15:23-7. 2. Bhatia M, Jindal AK. Injection induced nerve injury: an iatrogenic tragedy. J Assoc Physicians India 1996;44:532-3. 3. Burkhead WZ Jr, Scheinberg RR, Box G. Surgical anatomy of the axillary nerve. J Shoulder Elbow Surg 1992;1:31-6. 4. Goodman and Gilman’s the pharmacological basis of therapeutics. Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG, editors. 9th ed. New York: McGraw-Hill; 1996. p. 141-60, 581-600. 5. Groves RJ, Goldner JL. Contracture of the deltoid muscle in the adult after intramuscular injections. J Bone Joint Surg Am 1974;56:817-20. 6. Hollinshead WH. Anatomy for surgeons. 3rd ed. Vol. 3. Philadelphia: Harper & Row; 1982. p. 309. 7. Kido M, Matuzaki A, Nakamura H, Irie Y, Kato K, Koga T. Position of the axillary nerve in the deltoid muscle [in Japanese]. Shoulder Joint 1996;20:27-30. 8. Konkel KF, Lucas GL. Abduction contracture of the shoulders: a case report. Clin Orthop 1974;104:224-7. 9. Kozier B, Erb G, Berman AJ, Burke K. Fundamentals of nursing concepts, process, and practice. 6th ed. Upper Saddle River (NJ): Prentice Hall Health; 2000. p. 785. 10. Kulkarni RR, Nandedkar AN, Mysorekar VR. Position of the axillary nerve in the deltoid muscle. Anat Rec 1992;232:316-7. 11. Ling CM, Loong SC. Injection injury of the radial nerve. Injury 1976;8:60-2. 12. Perry AG, Potter PA. Clinical nursing skills and technique. 4th ed. St. Louis: Mosby; 1998. p. 631. 13. Sobel E, Huang EY, Wieting CB. Drop foot as a complication of acupuncture injury and intragluteal injection. J Am Podiatr Med Assoc 1997;87:52-9. 14. Streib EW, Sun SF. Injection injury of the sciatic nerve: unusual
B
Figure 4 NCV findings 4 weeks after injury. Affected side has normal distal latency but low amplitude compared with unaffected side. A, Affected side (distal latency, 4.3 ms); B, unaffected side (distal latency, 3.8 ms).
anatomic distribution of nerve damage. Eur Neurol 1981;20: 481-4. 15. Yamaguchi M, Izumida S, Murakami T, Kumagai S. Three cases of contracture of the deltoid muscle possibly caused by injection [in Japanese]. Seikei Geka 1970;21:1105-11.
R
ecently we experienced a rare case of axillary nerve injury caused by intradeltoid muscular injection. Moreover, the injury was selective to the branch of the axillary nerve that runs to the middle of the deltoid muscle, and only the middle one-third of the deltoid was paralyzed characteristically. We review the anatomy of the axillary nerve and warn of the possibility of such injury by intradeltoid injection.
CASE REPORT A 25-year-old man got an intradeltoid muscular injection of 1 mL (0.5 mg) of atropine and 1 mL (50 mg) of hydroxyzine hydrochloride in his right shoulder as a premedication for operation on his right ear. A 25-gauge needle was used for the injection at 3-finger width below the acromion. Two days after the injection, he complained of dull pain and weakness of his shoulder. Four days after the injection, he was referred to the orthopaedic department. At the time of injection, he had neither pain nor numbness on his shoulder and arm. He was a professional dancer but could not dance well because of the weakness of his shoulder. There was no other specific trauma nor injection history to his shoulder. On physical examination, his right shoulder looked normal in the resting position but, because of the contraction of the anterior and posterior fibers, only the middle portion of the deltoid bulged out like a balloon (Figure 1, A and B) with activity. A slight decrease in abduction power was found, but there was neither tenderness nor sensory change. The affected shoulder had a normal range of motion with a stable glenohumeral joint. The radiographic examination was within normal limits. Two weeks after the injection, magnetic resonance imaging showed no pathologic changes. The electromyography and nerve conduction velocity (NCV) were checked 4 weeks after the injury. The electromyography showed positive sharp wave at rest. During voluntary contraction, polyphasic potentials and lower Surgerya
Neurology,b
From the Departments of Orthopaedic and Nagoya University School of Medicine, Nagoya, Japan. Reprint requests: Ho-Rim Choi, MD, Department of Orthopaedic Surgery, Nagoya University School of Medicine, 65 Tsurumaicho Showa-ku Nagoya, 466-8550 Japan (E-mail: choinagoya@ yahoo.co.kr). J Shoulder Elbow Surg 2001;10:493-5. Copyright © 2001 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2001/$35.00 + 0 32/4/114682 doi:10.1067/mse.2001.114682
A
B Figure 1 Patient’s right shoulder appears normal in resting position (A). When he puts stress on his shoulder, paralyzed middle deltoid bulges out by contraction of anterior and posterior fibers (B).
interference pattern were seen with no high voltage potentials (Figure 2, A, and Figure 3, A). Low amplitude and normal distal latency of the axillary nerve were observed on the NCV (Figure 4). Eight weeks after the injury, followup electromyography showed positive sharp wave at rest
493
494
Choi et al
A
B
J Shoulder Elbow Surg September/October 2001
A
B
Figure 2 Positive sharp wave pattern of electromyography at rest. A, Four weeks after injury; B, 8 weeks after injury.
and normal interference during voluntary contraction (Figure 2, B, and Figure 3, B). From these electromyographic and NCV findings, we concluded this injury was an incomplete axonotmesis of the axillary nerve. After 3 months’ follow-up with physiotherapy, the middle deltoid showed good contraction without any bulging out, and there was no complaint of pain. The patient refused repeat electromyography/NCV testing.
DISCUSSION Intramuscular injection is one of the most common procedures used in hospitals. Occasionally, however, this causes unexpected neuromuscular complications such as radial and sciatic nerve palsies2,11,13,14 or contracture of the deltoid and quadriceps muscles.5,8,15 Peripheral nerve damage by intramuscular injection can result from a needle, chemical irritation and toxic action of the injected solution, or neuritis from progressive inflammatory and fibrotic changes.2,11,13,14 Many kinds of therapeutic and prophylactic agents have been reported as a cause of injection paralysis.11,13,14 However, there is no report of atropine and hydroxyzine hydrochloride, which do not have specific neurotoxicity.4
Figure 3 Electromyography of voluntary contraction. Polyphasic potentials with lower interference pattern at 4 weeks after injury (A) have improved to normal interference pattern 8 weeks after injury (B).
When a nerve injury is caused directly by a needle, most patients complain of immediate pain at the time of injection. However, in this case, the patient had no immediate injection pain. We hypothesize that the injury was limited to the pure motor branch of the axillary nerve that runs to the middle deltoid. Many authors suggest faulty sites of injection as the most important factor responsible.2,11,13 Various textbooks describe the position of the axillary nerve as coursing transversely at approximately 5 cm distal to the origin of the deltoid muscle on its deep surface.3,6,7,10 Hollinshead6 notes that the nerve lies only approximately 1.5 to 2 inches below the acromion. Kulkarni et al10 studied cadavers of 66 adults and noted that the axillary nerve ran a course on the deep surface of the deltoid muscle approximately 2.2 to 2.6 cm above the midpoint on the vertical plane of the muscle. Kido et al7 analyzed 46 cadaveric shoulders
Choi et al
J Shoulder Elbow Surg Volume 10, Number 5
and found that the average level of the axillary nerve was 5.29 cm and 5.01 cm below the anterolateral and posterolateral corner of the acromion, respectively. Burkhead et al3 also dissected 102 cadaveric shoulders and found that the distance from the midportion of the acromion to the axillary nerve ranged from 4.3 to 7.4 cm. In this case, the injection was done approximately 3-finger width below the acromion. In many textbooks, the recommended site for injection of the deltoid muscle is at the midpoint of the deltoid muscle or at approximately 5 cm or 3-finger width below from the acromion.1,9,12 However, these injection points are approximately 4 to 6 cm from the acromion, which can be hazardous to the nerve. When an intramuscular injection is performed, the relation of the nerve to the preferred site of injection should be kept in mind. Because of the possibility of axillary nerve injury by intradeltoid injection, we suggest avoidance of using it indiscriminately.
495
A
REFERENCES 1. Beecroft PC, Redick SA. Intramuscular injection practices of pediatric nurses: site selection. Nurse Educ 1990;15:23-7. 2. Bhatia M, Jindal AK. Injection induced nerve injury: an iatrogenic tragedy. J Assoc Physicians India 1996;44:532-3. 3. Burkhead WZ Jr, Scheinberg RR, Box G. Surgical anatomy of the axillary nerve. J Shoulder Elbow Surg 1992;1:31-6. 4. Goodman and Gilman’s the pharmacological basis of therapeutics. Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG, editors. 9th ed. New York: McGraw-Hill; 1996. p. 141-60, 581-600. 5. Groves RJ, Goldner JL. Contracture of the deltoid muscle in the adult after intramuscular injections. J Bone Joint Surg Am 1974;56:817-20. 6. Hollinshead WH. Anatomy for surgeons. 3rd ed. Vol. 3. Philadelphia: Harper & Row; 1982. p. 309. 7. Kido M, Matuzaki A, Nakamura H, Irie Y, Kato K, Koga T. Position of the axillary nerve in the deltoid muscle [in Japanese]. Shoulder Joint 1996;20:27-30. 8. Konkel KF, Lucas GL. Abduction contracture of the shoulders: a case report. Clin Orthop 1974;104:224-7. 9. Kozier B, Erb G, Berman AJ, Burke K. Fundamentals of nursing concepts, process, and practice. 6th ed. Upper Saddle River (NJ): Prentice Hall Health; 2000. p. 785. 10. Kulkarni RR, Nandedkar AN, Mysorekar VR. Position of the axillary nerve in the deltoid muscle. Anat Rec 1992;232:316-7. 11. Ling CM, Loong SC. Injection injury of the radial nerve. Injury 1976;8:60-2. 12. Perry AG, Potter PA. Clinical nursing skills and technique. 4th ed. St. Louis: Mosby; 1998. p. 631. 13. Sobel E, Huang EY, Wieting CB. Drop foot as a complication of acupuncture injury and intragluteal injection. J Am Podiatr Med Assoc 1997;87:52-9. 14. Streib EW, Sun SF. Injection injury of the sciatic nerve: unusual
B
Figure 4 NCV findings 4 weeks after injury. Affected side has normal distal latency but low amplitude compared with unaffected side. A, Affected side (distal latency, 4.3 ms); B, unaffected side (distal latency, 3.8 ms).
anatomic distribution of nerve damage. Eur Neurol 1981;20: 481-4. 15. Yamaguchi M, Izumida S, Murakami T, Kumagai S. Three cases of contracture of the deltoid muscle possibly caused by injection [in Japanese]. Seikei Geka 1970;21:1105-11.