Bilateral Wrist Pain and Nexplanon: Likely Nerve Injury from Implant Complications
The bilateral wrist pain, numbness, and tingling in this patient is most likely related to nerve injury from the Nexplanon implant itself or from previous removal attempts, particularly given the history of a bent implant requiring removal and the anatomical distribution of symptoms suggesting median and ulnar nerve involvement.
Direct Nexplanon-Related Nerve Injury
Mechanism of Nerve Involvement
Deep or migrated Nexplanon implants can cause direct nerve compression or injury, particularly affecting the median, ulnar, or radial nerves when the device is placed too deeply or migrates into muscle tissue 1, 2.
The patient's left arm symptoms (sharp pain radiating to the wrist with constant soreness) are consistent with median nerve irritation from a deeply embedded or intramuscularly placed implant 1.
Median nerve neuropathy from Nexplanon presents with abnormal sensations, numbness in the hand, and pain that can radiate distally to the wrist and thumb—matching this patient's right-sided symptoms 1.
The fact that symptoms improve with hand extension suggests nerve compression that is position-dependent, which occurs when implants are placed adjacent to or compress peripheral nerves 1.
Evidence from Removal Complications
Blind removal attempts of impalpable or deeply placed implants can cause iatrogenic nerve injury and local muscle irritation, leading to worsening neurologic symptoms 1, 2.
This patient had a bent implant removed in April 2023 with replacement 3 days later—the original bent configuration and subsequent manipulation may have caused the implant to migrate deeper or be placed incorrectly during reinsertion 1.
Ulnar nerve palsy has been documented from attempted in-office removal of deeply implanted Nexplanon devices, requiring surgical exploration and nerve grafting 2.
Incorrect insertion (non-insertion, partial insertion, or deep insertion) occurs in 12.6 per 1000 insertions, and deep insertions are the primary risk factor for nerve complications 3.
Clinical Correlation with Laboratory Findings
Normal Labs Rule Out Systemic Causes
The patient's complete blood count, comprehensive metabolic panel, and liver function tests are all within normal limits, effectively ruling out systemic inflammatory conditions, metabolic disorders, or infectious etiologies that could cause bilateral neuropathy 4.
Slightly elevated absolute neutrophils (7.5) and alkaline phosphatase (121) are minimal and non-specific, not suggesting any systemic inflammatory or infectious process that would explain bilateral nerve symptoms 4.
Normal glucose (77 mg/dL) and renal function (eGFR 111) exclude diabetic neuropathy and uremic neuropathy as alternative explanations for the bilateral symptoms 4.
Immediate Management Recommendations
Imaging and Localization
Obtain imaging immediately to localize the current Nexplanon implant before any removal attempts—radiographs or ultrasound can determine depth and proximity to neurovascular structures 1, 2.
If the implant is non-palpable, deep, or has migrated, refer for fluoroscopic-guided removal by a specialist (orthopedic surgeon or peripheral nerve surgeon familiar with the procedure) rather than attempting blind in-office removal 1, 2.
MRI of the left arm may be appropriate if nerve injury is suspected to evaluate for implant location relative to the median nerve and assess for nerve compression or damage 4.
Urgent Referral Criteria
Any patient with neurologic symptoms after Nexplanon placement or attempted removal requires prompt diagnosis and referral to a peripheral nerve surgeon 2.
This patient meets criteria for urgent referral given:
- Progressive symptoms since August (4+ months)
- Bilateral involvement suggesting either bilateral nerve injury or referred pain from unilateral deep implant
- Numbness and tingling during activity
- Pain severity (8/10 burning pain on right side)
Surgical Exploration Indications
Implants placed intramuscularly, adjacent to nerves, or causing persistent neurologic symptoms require surgical exploration and removal under fluoroscopic guidance 1.
Symptoms of median nerve neuropathy and local muscle irritation from intramuscularly migrated implants typically resolve gradually after proper surgical removal 1.
Common Pitfalls to Avoid
Do Not Attempt Blind Removal
Never attempt blind removal of a non-palpable or deeply placed Nexplanon—this causes iatrogenic nerve injury and worsening symptoms 1, 2.
Encasement within fibrotic tissue is the most common challenge during removal and increases risk of nerve injury with blind attempts 3.
Do Not Delay Referral
Patients with impalpable contraceptive implants should be referred immediately to specialists familiar with the procedure to prevent further deterioration of adjacent neurovascular structures 1.
The 4-month delay since symptom onset (August to current) may have allowed progressive nerve compression or injury.
Do Not Attribute to Unrelated Causes
- While the right arm symptoms began after venipuncture at the antecubital site, the bilateral nature, chronicity, and specific nerve distribution patterns are more consistent with Nexplanon-related nerve injury than simple phlebotomy complications 1, 2.
Alternative Considerations (Less Likely)
Carpal tunnel syndrome or other primary wrist pathology would not explain the temporal relationship to Nexplanon placement/removal or the upper arm pain 4.
The ACR Appropriateness Criteria for chronic wrist pain recommend MRI as the next study after normal radiographs, but in this case, imaging should focus on the upper arm implant site first given the clear temporal and anatomical relationship 4.