What is the best course of action for a patient with numbness and tingling in the right lower extremity (RLE) after a previous trauma?

Management of Numbness and Tingling in Right Lower Extremity After Trauma

In a patient with numbness and tingling in the right lower extremity following trauma, immediately assess for spinal injury risk factors and nerve/vascular compromise, then initiate appropriate imaging and specialist referral based on severity indicators.

Immediate Assessment for Spinal Injury

Suspect spinal injury if the patient has any of the following risk factors 1:

• Tingling in the extremities (directly applicable to this case) 1
• Sensory deficit or muscle weakness involving the torso or extremities 1
• Pain or tenderness in the neck or back 1
• Fall from greater than standing height 1
• Motor vehicle, motorcycle, or bicycle crash 1
• Age ≥65 years 1
• Altered mental status or intoxication 1

If spinal injury is suspected, manually stabilize the head to minimize motion of the head, neck, and spine 1. Do not use immobilization devices unless properly trained, as they may be harmful 1.

Evaluate for Compartment Syndrome

In severe limb trauma, compartment syndrome is a critical time-sensitive diagnosis 1:

Assess repetitively (every 30 minutes to 1 hour during the first 24 hours) for the "four P's" 1:

• Pain (spontaneous or with passive stretch/flexion-extension) 1
• Paraesthesia (numbness/tingling) 1
• Paresis (weakness) 1
• Pressure (tense compartment on palpation) 1

Note that pulselessness and pallor are late signs indicating irreversible damage 1. If compartment syndrome is suspected, measure compartment pressure: pressure ≥30 mmHg or differential pressure (diastolic BP minus compartment pressure) <30 mmHg indicates compartment syndrome 1.

Assess for Vascular and Nerve Injury

Examine for 1, 2:

• Absent or diminished pulses 2
• Pallor or coolness of the extremity 2
• Active hemorrhage 2
• Specific distribution of sensory loss (helps localize nerve injury) 3, 4
• Motor weakness patterns 3, 5

Determine Need for Trauma Center Transfer

The presence of Vittel criteria mandates admission to a specialized Trauma Centre 1. For limb trauma specifically, severity indicators include 1:

• Two or more long bone fractures 1
• Proximal amputation above wrist/ankle 1
• Degloving, crushing, or acute limb ischemia 1

Diagnostic Workup

Immediate Imaging

• Plain radiographs to assess for fractures 1
• CT or MRI if nerve injury or plexopathy suspected, particularly if progressive symptoms 6

Laboratory Testing for Peripheral Neuropathy Evaluation

If trauma was remote and symptoms are persistent/progressive, evaluate for underlying neuropathy 7:

• Fasting blood glucose and hemoglobin A1c (diabetes is the most common cause) 7
• Vitamin B12 level 7
• Thyroid function tests (TSH, free T4) 7
• Consider hepatitis B, C, and HIV testing if clinically indicated 7

Electrodiagnostic Studies

Electromyography (EMG) and nerve conduction studies help differentiate radiculopathy, plexopathy, and peripheral nerve entrapment 3, 6.

Treatment Approach

Acute Management

• If compartment syndrome confirmed: immediate fasciotomy with wide incision of skin, subcutaneous tissue, and fascia 1
• If vascular injury: urgent vascular surgery consultation 1, 2
• Do not move or straighten an injured extremity 1
• If far from definitive care, stabilize with padded splint in position found 1

Pharmacological Management for Neuropathic Pain

If symptoms persist beyond acute phase 7:

• First-line: Duloxetine 60 mg once daily (can increase to 120 mg if needed) 7
• Alternative: Pregabalin or gabapentin 7
• Avoid opioids due to adverse event profile 8

Non-Pharmacological Interventions

• Physical activity to improve neuropathic pain 7
• Acupuncture and cognitive behavioral therapy as adjuncts 7

Critical Pitfalls to Avoid

• Do not dismiss tingling as minor: it is a specific indicator of potential spinal injury requiring immediate assessment 1
• Do not wait for pulselessness or pallor to diagnose compartment syndrome—these are late, irreversible signs 1
• Do not delay fasciotomy if compartment syndrome is established, as timing is critical for limb salvage 1
• Do not rely solely on symptoms for neuropathy diagnosis, as up to 50% may be asymptomatic initially 8

Follow-Up and Monitoring

• Monitor for rhabdomyolysis if crush injury: check CPK (>1000 IU/L indicates rhabdomyolysis), plasma myoglobin, and potassium 1
• Initiate VTE prophylaxis with LMWH within 36 hours after hemorrhage control 1
• Reassess neurologic status regularly during first 24-48 hours 1