What is the best course of action for a 31-year-old female patient experiencing intermittent sharp pain and constant soreness in her left upper arm, radiating to her wrist, thumb, and medial anterior wrist, with numbness and tingling sensations, after having a Nexplanon (etonogestrel) implant inserted and removed due to complications?

Nexplanon Implant Removal and Nerve Injury Evaluation

This patient requires urgent removal of the Nexplanon implant with concurrent evaluation for nerve injury, specifically median nerve compression or injury, given the constellation of symptoms including radiating pain, burning sensation, numbness, and tingling in a median nerve distribution. 1

Immediate Clinical Assessment

The symptom pattern strongly suggests nerve injury or compression related to the implant:

• Pain radiating from upper arm to wrist and thumb indicates median nerve involvement, as the thumb is specifically innervated by the median nerve 1
• Burning sensation (8/10) with activity and numbness/tingling that resolves with hand extension are classic signs of nerve compression or irritation 1
• Symptoms worsening after phlebotomy on the right arm suggests the patient may have bilateral nerve sensitivity or systemic nerve irritation 1

The timing is critical: symptoms began approximately 3-4 months after the April 2023 insertion, which aligns with potential nerve injury from improper placement or migration 1.

Recommended Diagnostic Workup

Ultrasound is the initial imaging modality of choice for this 31-year-old patient with suspected implant-related nerve complications 1:

• Ultrasound can identify the implant location and assess for migration, bending (as occurred with her previous implant), or proximity to neurovascular structures 1
• Ultrasound can visualize nerve compression and assess for any fluid collections or inflammatory changes around the implant 1
• This is operator-dependent, so ensure an experienced sonographer performs the examination 1

If ultrasound is equivocal or non-diagnostic, MRI without contrast should be obtained to evaluate for nerve injury, inflammation, or other soft tissue complications 1.

Nerve conduction studies (NCS) and electromyography (EMG) should be considered to objectively document median nerve dysfunction and establish baseline severity before intervention 1.

Management Algorithm

Step 1: Immediate Pain Management

• Acetaminophen and NSAIDs should be offered as first-line analgesics, avoiding opioids when possible 1
• Duloxetine 30 mg daily for one week, then 60 mg daily is specifically indicated for neuropathic pain with numbness and tingling, showing 30-50% pain reduction in clinical trials 1
• Ice application and activity modification to reduce nerve irritation 1

Step 2: Implant Removal

The implant should be removed urgently given the severity of symptoms (8/10 burning pain) and functional impairment 1:

• Removal should be performed by an experienced provider familiar with difficult extractions 1
• Intraoperative assessment of the nerve should be performed if accessible during removal 1
• Document the implant's position relative to neurovascular structures 1

Step 3: Post-Removal Evaluation

• Reassess symptoms 2-4 weeks after removal to determine if nerve injury is resolving 1
• If symptoms persist beyond 4 weeks, referral to a peripheral nerve specialist or hand surgeon is warranted 1, 2
• Consider physical therapy for nerve gliding exercises and functional recovery 1

Critical Pitfalls to Avoid

Do not delay implant removal in the setting of progressive neurologic symptoms—early intervention improves outcomes for nerve injuries 2, 3.

Do not assume symptoms will resolve spontaneously—the patient already has a 4-month history of worsening symptoms, indicating this is not a transient issue 1.

Do not perform repeat insertion until nerve symptoms have completely resolved and alternative contraceptive methods have been discussed 4, 5.

Document the bilateral nature of symptoms (left arm implant site with right arm phlebotomy reaction) as this may indicate underlying nerve sensitivity or systemic factors affecting nerve function 1.

Alternative Contraception Counseling

Given the patient's history of two complicated Nexplanon experiences (bent implant in March 2023, nerve injury in August 2023), she should be counseled about alternative long-acting reversible contraception 4:

• 52-mg levonorgestrel IUD has demonstrated excellent efficacy and may avoid upper extremity complications 6
• Other hormonal methods without implantation risk should be discussed 5, 7

The etonogestrel levels from Nexplanon become undetectable within one week of removal, allowing rapid transition to alternative contraception 4, 8.