15. Distal Radius Fracture with Median Nerve Transection

OBJECTIVE: Distal radius fractures may be accompanied by severe complications like median nerve transection, especially in cases involving the distal third of the radius. These injuries can be subtle and often overlooked during initial assessments focused solely on the fracture. Symptoms such as numbness in the median nerve distribution may be attributed to typical traumatic sequelae. Given the nerve’s proximity to the distal radius, it’s prone to injury during trauma, requiring a high level of suspicion. We present a case of closed high-energy distal radius fracture with concurrent median nerve transection to emphasize the importance of promptly recognizing and addressing this complication. METHODS/CASE: A 28-year-old healthy right-hand dominant male sustained a significant crush injury directly to his right distal forearm while operating heavy machinery at work. Evaluation at the local emergency department revealed dorsally angulated fracture of the right distal radius and mildly displaced fracture of the right distal ulna. Closed reduction with long arm splinting was initially performed, resulting in improved alignment on post-reduction imaging. Subsequent referral to our hand surgery practice occurred for further management. Upon evaluation one-week post-injury, X-ray imaging demonstrated re-displacement of the radial fracture, accompanied by complaints of numbness and tingling in the median nerve distribution of the right hand. Subsequent treatment involved placement in a thumb spica cast and scheduling for surgery. The patient underwent open reduction internal fixation of the right distal radius, coupled with open carpal tunnel release, 12 days following the injury. During the initial surgical intervention, the nerve was immediately identified as transected. Primary repair of the median nerve was not feasible, due to retraction of approximately 5cm. This necessitated delayed nerve reconstruction. A subsequent surgical procedure was undertaken two weeks later (26 days post-injury), during which the median nerve was repaired using Axogen Avance® Nerve Graft. Due to retraction and scarring, an allograft was used to fashion an end-to-end anastomosis. RESULTS: During the follow-up visit, the patient reported decreased pain in the right wrist. Wrist X-rays revealed anatomical alignment of the distal radius and ulna with intact hardware. A comprehensive physical examination was conducted in the clinic, encompassing the following observations: A well-healed volar surgical incision. Median nerve distribution numbness. CONCLUSION: The literature highlights the rarity but significance of median nerve transection in distal radius injuries, often misdiagnosed as carpal tunnel syndrome or median nerve stretch injuries. Due to potential implications on patient outcomes, timely and accurate diagnosis is crucial. Further research and clinical vigilance are needed to improve understanding, recognition, and treatment strategies. Enhancing comprehension of the mechanisms and clinical presentations can lead to better patient care and reduced risk of long-term complications. CORRESPONDING AUTHOR: Daniel Zarif, 1265 Washington Blvd, Apt 1004. Detroit, MI 48226, Email: [email protected], (610) 416 7053.