Delayed posterior interosseous nerve palsy

DELAYED

POSTERIOR

INTEROSSEOUS

NERVE

PALSY

An unusual presentation of a forgotten glass injury R. SHARMA, R. K. DIMRI and J. DIAS

From Leicester Royal Infirmary, Leicester, UK A case in which a glass foreign body caused a delayed posterior interosseous nerve palsy is described.

Journal of Hand Surgery (British and European Volume, 1998) 23B." 3:418-419 Delayed nerve injury due to a retained foreign "body is rare. Median nerve injuries due to retained foreign bodies have been reported (Browett and Fiddian, 1985; Faithfull and Petchell, 1995; Fisher and Bryan, 1971). Our case concerns a posterior interosseous nerve palsy that developed 2 months after a minor injury, totally forgotten by the patient CASE R E P O R T

A 16-year-old male student presented with inability to extend the thumb and all fingers of the right hand. He denied any injury at the first visit. The onset of symptoms was gradual. He was unable to straighten the little and ring fingers at first and 2 weeks later the middle and index fingers and the thumb as well. Examination showed minimal wasting on the extensor aspect of the forearm. Sensation in the hand was normal. Extension of the fingers at the metacarpophalangeal joints was MRC grade 1. The extensor pollicis longus was grade 1 and the thumb abductors grade 2. The clinical diagnosis at this stage was a right posterior interosseous nerve palsy due to an unknown cause. The nerve conduction study was consistent with right posterior interosseous nerve palsy. At this stage he was lost to follow-up for 18 months. On reappearing again at the clinic he recalled that 2 months before the onset of symptoms he had broken a glass door, sustaining bruises only. On fresh examination he now had a firm, non-tender 2 cm diameter swelling on the extensor aspect of the forearm, with no recovery of power in the hand. A plain X-ray showed a glass foreign body approximately 3 cm long. An MRI scan confirmed a foreign body granuloma containing a 3 cm piece of glass within the subcutaneous tissue lateral to the radial head. The posterior interosseous nerve was explored at this stage by an anterior approach and its proximal normal part identified. The swelling with its thick walled bursa containing the glass piece was excised through a second posterior incision. The triangular glass piece measured 20 mm in length, 5 mm at the base and 2 mm in thickness. The proximal and distal ends of the posterior interosseous nerve were completely divided (Fig 1), and we performed an epineural repair with loupe magnification. There was good recovery of all the extensors of the fingers and the thumb to MRC grade 4 at follow-up 18 months later.

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Fig 1 Cut ends of the posterior intcrosseous nerve shown with the glass flagrnent.

DISCUSSION An unnoticed injury by a large glass fragment is unusual, and for it to migrate a few months later and cause a nerve injury is also rare. Delayed injury of the superficial radial nerve due to a foreign body 30 years after the original event has been reported by Fisher and Bryan (1971). The patient had a foreign body in the substance of the median nerve and another tenting the superficial radial nerve. Delayed median nerve palsy due to a foreign body has also been reported by Browett and Fiddian (1985), and Southworth and Hartwig (1990). An unnoticed foreign body, in this case a wood splinter, compressing the median nerve at the wrist has been reported by E1-Adwar (1972). Sterling et al (1972) reported an acute carpal tunnel syndrome due to a glass foreign body in the wrist. Traumatic aneurysm is another cause for delayed nerve palsy (Rahimizadeh, 1992). M R I is recommended for localizing non-metallic foreign bodies and investigating suspicious swellings in the extremities (Monu et al, 1995). References Browett JR Fiddian NJ (1985). Delayed median nerve injury due to retained glass fragments: A report of two cases. Journal of Bone and Joint Surgery, 67B: 382 384. E1-Adwar LI (1972). A rare case of wrist injury: A case report. Injury, 3: 183-184. Faithfull DK, Petchell JF (1995). Occult injury of the median nerve. Journal of H a n d Surgery, 20B: 210-211. Fisher DE, Bryan RS (1971). Neuropathy from old retained foreign bodies (glass) in the forearm: Report of a case. Clinical Orthopaedics and Related Research, 74:146 148. 418

DELAYED PIN PALSY Monu JUV, McManus CM, Ward WG, Haygood TM, Pope TL, Bohrer SP (1995). Soft-tissue masses caused by long-standing foreign bodies in the extremities: M R Imaging findings. American Journal of Roentgenology, 165:395 397. Rahimizadeh A R (1992). Unusual delayed radial nerve palsy caused by a traumatic aneurysm of a collateral radial artery: Report of two cases. Neurosurgery, 30: 628-630. Southworth SR, Hartwig R H (1990). Foreign body in the median nerve: A complication of acupuncture. Journal of H a n d Surgery, 15B: 111 112. Sterling AP, Eshragbi A, Anderson WJ, Habermann ET (1972). Acute carpal

419 tunnel syndrome secondary to a foreign body within the median nerve. Bulletin of the Hospital for Joint Diseases, 33: 130-134.

Received: 19 September 1997 Accepted after revision: 26 November 1997 Mr J. Dias, Department of Orthopaedics, LeicesterRoyal Infirmary, infirmary Square, LeicesterLE1 5WW,UK. © 1998The Brit!sh Society for Surgery of the Hand