From the Guidelines
Radial nerve injury after anterior subcoracoid glenohumeral dislocation is a less common complication, but prompt recognition and management are crucial to optimize outcomes and minimize long-term morbidity. The initial management of anterior subcoracoid glenohumeral dislocation should focus on prompt reduction of the dislocation under appropriate sedation or anesthesia, as younger patients are more likely to have labroligamentous injury and persistent instability after dislocation compared with older patients 1. For the radial nerve injury specifically, a thorough neurological examination should be performed to document the extent of deficit, including wrist and finger extension, thumb abduction, and sensation over the dorsal aspect of the hand.
- Key considerations in the management of radial nerve injury after anterior subcoracoid glenohumeral dislocation include:
- Immobilization in a sling for 1-3 weeks depending on patient factors and injury severity
- Passive range of motion exercises, progressing to active exercises as pain allows
- Use of a wrist splint to prevent wrist drop and maintain hand function
- Electromyography and nerve conduction studies if no improvement is seen after 3 months, or if initial examination suggests a more severe nerve injury (neurotmesis)
- Surgical exploration may be considered in cases of severe nerve injury or lack of improvement with conservative management The mechanism of radial nerve injury in these cases typically involves traction on the nerve during the dislocation event, as the humeral head displaces anteriorly and stretches the posterior cord of the brachial plexus from which the radial nerve originates 1. Most radial nerve injuries associated with shoulder dislocations are neurapraxias that resolve spontaneously within 3-6 months, highlighting the importance of careful monitoring and follow-up to guide management decisions.
From the Research
Radial Nerve Injury After Anterior Subcoracoid Glenohumeral Dislocation
- The incidence of nerve injury accompanied by anterior dislocation of the glenohumeral joint is 21%, with radial nerve palsy being very rare 2.
- A case report described a 56-year-old man who presented with an anterior dislocation of the left shoulder and radial nerve palsy, which was diagnosed through neurological examination and magnetic resonance imaging 2.
- The management of radial nerve palsy associated with anterior dislocation of the shoulder is crucial, as it has serious implications on activity morbidity 2.
- Anterior glenohumeral dislocations can be classified into subcoracoid, subglenoid, subclavicular, and intrathoracic subtypes, with the subcoracoid subtype being relevant to radial nerve injury 3.
- Injuries of the terminal branches of the infraclavicular brachial plexus, including the radial nerve, can occur due to various patterns of injury, such as anterior glenohumeral dislocation, axillary nerve injury, and displaced proximal humeral fracture 4.
- The management of radial nerve injuries has evolved, with recent advances in nerve repair techniques, conduits, wraps, autograft, and allograft allowing for tension-free coaptations and improved outcomes 5.
- Radial nerve injuries can be challenging to manage, and their etiology, workup, diagnosis, management, and outcomes have been reviewed in the literature 6.
Patterns of Injury and Management
- The patterns of injury to the terminal branches of the infraclavicular brachial plexus, including the radial nerve, can vary, with anterior glenohumeral dislocation being one of the common causes 4.
- The management of radial nerve injuries depends on the pattern of injury, with surgical intervention not always necessary in cases of infraclavicular injury associated with dislocation of the shoulder 4.
- Early exploration of the nerves should be considered in patients with axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy 4.
- Nerve repair techniques and tendon transfers are the mainstays of management for radial nerve injuries, with recent advances in nerve repair techniques offering improved outcomes 5.