P123 Peripheral nerve injury following brachial plexus block and tourniquet use: a case report

<h3>Background and Aims</h3> Although rare, peripheral nerve injuries represent significant complications in orthopedic surgery, often arising from multiple perioperative factors including patient positioning, regional anesthesia techniques, tourniquet pressures, and inflation duration. We aim to report a case of multifactorial upper limb neuropathy following wrist surgery under combined regional and general anesthesia, discussing its potential etiologies and clinical outcome. <h3>Methods</h3> We present the case of a 44-year-old healthy male who underwent open and arthroscopic fixation of a scaphoid fracture with bone graft interposition. An ultrasound-guided axillary brachial plexus block was performed with 25 ml of 0.5% ropivacaine, followed by balanced general anesthesia. A pneumatic tourniquet was inflated to 220 mmHg for 2 hours and 8 minutes, while the patient‘s intraoperative systolic blood pressure averaged 90 mmHg, consistent with his usual baseline values. The procedure was uneventful, with no intraoperative complications reported. <h3>Results</h3> The patient was discharged from the post-anesthesia care unit with partial regression of the brachial plexus block. At 60 hours postoperatively, by which time complete resolution would have been expected, he continued to exhibit difficulty flexing the elbow, paresthesia in the median and ulnar nerve territories, and weak biceps contraction. Electromyography confirmed mild lesions of the musculocutaneous, median, and ulnar nerves. A multifactorial etiology was considered, involving the nerve block, prolonged tourniquet inflation, and mechanical compression. He required intensive physiotherapy and achieved near-complete neurological recovery within five months. <h3>Conclusions</h3> Peripheral nerve injury following upper limb orthopedic surgery can result from a combination of factors, including nerve blocks and tourniquet use. Tourniquet pressures should not exceed 100 mmHg above systolic blood pressure, and application time should be limited to 2 hours. Early diagnosis and multidisciplinary management are essential for recovery. This case highlights the importance of preventive strategies and careful intraoperative planning to minimize nerve injury risk.