We present a case of painful radial nerve palsy following application of a humeral lengthening frame. At re-operation, the radial nerve was found to be compressed against a distal pin. This was re-sited providing immediate pain relief and a gradual resolution of the radial nerve palsy. Pain in association with a nerve palsy should alert the clinician to the possibility of nerve compression that may benefit from urgent decompression

Halliday, Jane

Hems, Tim

Simpson, Hamish

PubMed

Springer - Publisher Connector

CASE REPORT
Beware the painful nerve palsy; neurostenalgia, a diagnosis
not to be missed
Jane Halliday • Tim Hems • Hamish Simpson
Received: 11 April 2012 / Accepted: 24 September 2012 / Published online: 4 October 2012
 The Author(s) 2012. This article is published with open access at Springerlink.com
Abstract We present a case of painful radial nerve palsy
following application of a humeral lengthening frame. At
re-operation, the radial nerve was found to be compressed
against a distal pin. This was re-sited providing immediate
pain relief and a gradual resolution of the radial nerve
palsy. Pain in association with a nerve palsy should alert
the clinician to the possibility of nerve compression that
may benefit from urgent decompression.
Keywords Neurostenalgia  Limb lengthening 
Decompression  Radial nerve
Introduction
Neuropathic pain, arising from a lesion of the nervous
system, is defined as persistent intractable pain dispropor-
tional between the extent of the lesion and the severity of
the pain. It is associated with sensory and/or motor dis-
turbance [1]. Neurostenalgia is a neuropathic pain that
results from continuing irritation of an anatomically intact
nerve by a noxious agent [1]. It may be chronic or acute
and is not associated with excess sudomotor or vasomotor
activity. Common causes include compression, distortion,
ischaemia or tethering of the nerve. Removal of the caus-
ative agent typically results in immediate relief of pain and
a more gradual recovery of nerve function. If the cause
persists, irreversible changes in the affected nerve may
occur with the nerve lesion worsening from that of a
conduction block to a degenerative lesion [1]. It is there-
fore important that pain in relation to nerve palsy is
recognised and acted upon quickly to prevent significant
nerve damage from occurring.
Case report
A 10-year-old girl underwent application of a humeral
lengthening frame of her right humerus to correct severe
humeral shortening gradually. The shortening was second-
ary to osteomyelitis of the right proximal humerus aged
10 weeks. This had left her with a 10-cm discrepancy
between the lengths of the right and left humeri, resulting in
significant functional difficulties. The lengthening frame
was applied with the elbow extended without any intra-
operative complications. In recovery, her right hand was
warm and well perfused with full sensation and movement
of the wrist and small hand joints. On the first post-operative
day, however, she complained of severe burning pain in her
right arm and hand requiring significant opiates for relief
and a pain team review. Examination revealed evidence of a
partial right radial nerve palsy; weakness of right wrist
extension, an inability to extend the fingers and diminished
sensation on the dorsum of the first webspace. She dis-
played evidence of hyperalgesia with an exaggerated
response to pin-prick on the dorsum of the first webspace.
There was no mechanical allodynia. All other hand and
wrist movements and sensation were intact.
An ultrasound scan of the right arm was performed. This
revealed no haematoma or collection. The radial nerve was
not visualised.
J. Halliday (&)  H. Simpson
Department of Trauma and Orthopaedics, Edinburgh Royal
Infirmary, 51 Little France Crescent, Old Dalkeith Road,
Edinburgh EH16 4SA, UK
e-mail: jane.halliday@cantab.net
T. Hems
Department of Trauma and Orthopaedics, Glasgow Royal
Infirmary, 84 Glasgow St, Glasgow G4 0SF, UK
123
Strat Traum Limb Recon (2012) 7:177–179
DOI 10.1007/s11751-012-0143-6
On the second post-operative day, her symptoms
decreased slightly. However, on the third post-operative
day, her symptoms did not settle further and the patient was
taken back to theatre for exploration of the radial nerve due
to ongoing severe pain. The radial nerve was found to be in
continuity without any bruising or contusion. Distally, it
was found to pass tightly against the most distal external
fixator pin such that, with the elbow flexed the nerve
became tightly pressed against the pin. The distal pin was
removed and re-sited slightly proximal.
Post-operatively, there was complete resolution of the
right arm pain and hyperalgesia. Sensation to the first
webspace recovered on the second post-operative day with
motor function returning more gradually. There was full
recovery of radial nerve motor function at 4 months post-
operatively.
Discussion
In 1943, Seddon [2] introduced a classification of nerve
injuries based on three main types of nerve fibre injury and
whether there was continuity of the nerve: neurotmesis,
axonotmesis and neurapraxia [2]. Neurotmesis is the most
severe injury. It is a lesion in which the axon and its
encapsulating connective tissue lose their continuity,
resulting in Wallarian degeneration. Axonotmesis is also a
degenerative lesion in which the relative continuity of an
axon and its myelin sheath is lost, with preservation of its
connective tissue framework. Neurapraxia is a non-
degenerative lesion in which there is a local conduction
block, typically of large myelinated fibres. Anatomical
continuity is preserved with selective demyelination.
Neurology may deteriorate as a result of progressive
damage to the nerve. Neurapraxia commonly results from
compression and/or ischaemia of peripheral nerves.
Recovery occurs by Schwann cell repair, which occurs
over weeks to months [1].
Neurapraxia can occur with or without pain. Normal
sensory function is the product of an actively maintained
equilibrium between neurons and their environment [3].
Any disruption of this equilibrium that results from chan-
ges in sensitivity, excitability, transmission, growth status
and survival can initiate profound changes in sensory
function, which explains why diverse diseases can manifest
as pain.
Transient nerve compression, stretch or distortion, such
as the radial neuropathy of ‘Saturday night palsy’, may
result in transient nerve palsy but is typically not associated
with pain. Closed nerve injuries may be managed by
observation for a few months or by early exploration of the
nerve. The decision is based on an assessment of the
probability that the nerve has been disrupted or is under
compression. Chronic nerve compression, distortion and
ischaemia results in pain, termed neurostenalgia. Neurost-
enalgia is neuropathic pain provoked by the continuing
action of the agent responsible for the lesion of the nerve,
which is anatomically intact. Removal of the agent results
in resolution of the pain. Chronic nerve compression can
result from a wide variety of aetiologies and can equally
produce a wide variety of symptoms and signs, such as
muscle weakness and altered sensation in the distribution
of the affected nerve. Careful history taking, examination
and investigation are essential in guiding the clinician as to
the cause. In all cases, the presence of intractable pain
should alert the clinician to a compressive cause.
A famous case of neurostenalgia was that of the first
Lord Nelson who suffered constant stump pain years after
amputation of his right upper limb. Loosening and dis-
charge of a suture round the median nerve years later
resulted in a sudden resolution of the pain [1]. Birch and
Strange [4] published a series of case reports describing
neurostenalgia. They describe a case of compression of the
lateral part of the sciatic nerve by a screw, resulting in
neurostenalgia and common peroneal nerve palsy. The pain
resolved 1 day post-screw removal, and within 6 weeks,
the common peroneal nerve palsy had resolved. Birch [1]
describes the case of an 11-year-old who suffered excru-
ciating post-operative pain in his upper limb following
vascular surgery to control major haemorrhage. A suture
was found to pass through the sheath of the ulnar nerve at
re-exploration. This was removed with complete resolution
of the pain. He also reports the case of a 43-year-old
woman who underwent ligation of the short saphenous
vein. This was complicated post-operatively by foot drop
and intense posture-related pain. The common peroneal
nerve was found to be encircled by a suture at re-explo-
ration. Suture removal resolved the pain. A literature
review using Google Scholar and PubMed reveals isolated
case reports on relief of neurostenalgia by operation years
after injury [5–7].
In this case, the patient reported persistent burning pain
and an exaggerated response to pin-prick sensation fol-
lowing application of her humeral lengthening frame 1 day
post-operatively. The cause of the stimulation was con-
firmed as the most distal external fixator pin compressing
the radial nerve because complete and immediate pain
resolution occurred when the pin was re-sited. The varia-
tion in the level of symptoms was likely to have been due
to a change in elbow position when the elbow was in a
semi-flexed position, the nerve was compressed against the
pin but with the arm fully extended the pressure was
reduced. Nociceptor fibres, widely distributed in skin,
muscle, joints and the walls of blood vessels, pass to fine
myelinated A-delta fibres and non-myelinated C fibres.
Stimulation of A-delta fibres results in sharp, well-localised
178 Strat Traum Limb Recon (2012) 7:177–179
123
pain. Stimulation of C fibres causes a dull, burning and
poorly localised pain that typically is delayed [1]. This
would suggest that stimulation of both C and A-delta fibres
occurred in this patient.
We would recommend that clinicians consider neurost-
enalgia in all cases of nerve palsy associated with severe
pain. This is particularly pertinent post-operatively when
pain out of proportion to the procedure associated with
nerve dysfunction should make the clinician consider nerve
compression. A diagnosis of neurostenalgia warrants early
exploration. It suggests a cause for the pain, which needs to
be removed to resolve the intractable pain and prevent
irreversible changes in the affected nerve.
Conflict of interest There are no real or apparent conflict of interest
that may have a direct bearing on the subject matter of the article.
Open Access This article is distributed under the terms of the
Creative Commons Attribution License which permits any use, dis-
tribution, and reproduction in any medium, provided the original
author(s) and the source are credited.
References
1. Birch R, Wynn Parry CB (1998) Surgical disorders of the
peripheral nerves. Churchill Livingstone, Edinburgh
2. Seddon H (1943) Three types of nerve injury. Brain 66:237–288
3. Woolf CJ, Mannion RJ (1999) Neuropathic pain:aetiology, symp-
toms, mechanisms, and management. The Lancet 353:1959–1964
4. Birch R (1990) A new type of peripheral nerve lesion. J Bone Jt
surg 72:312–313
5. Montgomery AS, Birch R, Malone A (2005) Sciatic neurostenal-
gia: caused by total hip arthroplasty, cured by late neurolysis.
J Bone Jt Surg Br 87:410–411
6. Stenning M, Drew S, Birch R (2005) Low-energy arterial injury at
the shoulder with progressive or delayed nerve palsy. J Bone Jt
Surg Br 87-B:1102–1106
7. Camp SJ, Milani R, Sinsi M (2008) Intractable neurostenalgia of
the ulnar nerve abolished by neurolysis 18 years after injury.
J Hand Surg (European Volume) 33:45–46
Strat Traum Limb Recon (2012) 7:177–179 179
123


Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed

Jane Halliday

Tim Hems

Hamish Simpson

Crossref

Strategies in Trauma and Limb Reconstruction

Edinburgh Research Explorer

     Edinburgh Research Explorer                                      Beware the painful nerve palsy; neurostenalgia, a diagnosis notto be missedCitation for published version:Halliday, J, Hems, T & Simpson, H 2012, 'Beware the painful nerve palsy; neurostenalgia, a diagnosis not tobe missed' Strategies in trauma and limb reconstruction, vol 7, no. 3. DOI: 10.1007/s11751-012-0143-6Digital Object Identifier (DOI):10.1007/s11751-012-0143-6Link:Link to publication record in Edinburgh Research ExplorerDocument Version:Publisher's PDF, also known as Version of recordPublished In:Strategies in trauma and limb reconstructionPublisher Rights Statement:Copyright © The Author(s) 2012General rightsCopyright for the publications made accessible via the Edinburgh Research Explorer is retained by the author(s)and / or other copyright owners and it is a condition of accessing these publications that users recognise andabide by the legal requirements associated with these rights.Take down policyThe University of Edinburgh has made every reasonable effort to ensure that Edinburgh Research Explorercontent complies with UK legislation. If you believe that the public display of this file breaches copyright pleasecontact openaccess@ed.ac.uk providing details, and we will remove access to the work immediately andinvestigate your claim.Download date: 28. Apr. 2017CASE REPORTBeware the painful nerve palsy; neurostenalgia, a diagnosisnot to be missedJane Halliday • Tim Hems • Hamish SimpsonReceived: 11 April 2012 / Accepted: 24 September 2012 / Published online: 4 October 2012 The Author(s) 2012. This article is published with open access at Springerlink.comAbstract We present a case of painful radial nerve palsyfollowing application of a humeral lengthening frame. Atre-operation, the radial nerve was found to be compressedagainst a distal pin. This was re-sited providing immediatepain relief and a gradual resolution of the radial nervepalsy. Pain in association with a nerve palsy should alertthe clinician to the possibility of nerve compression thatmay benefit from urgent decompression.Keywords Neurostenalgia  Limb lengthening Decompression  Radial nerveIntroductionNeuropathic pain, arising from a lesion of the nervoussystem, is defined as persistent intractable pain dispropor-tional between the extent of the lesion and the severity ofthe pain. It is associated with sensory and/or motor dis-turbance [1]. Neurostenalgia is a neuropathic pain thatresults from continuing irritation of an anatomically intactnerve by a noxious agent [1]. It may be chronic or acuteand is not associated with excess sudomotor or vasomotoractivity. Common causes include compression, distortion,ischaemia or tethering of the nerve. Removal of the caus-ative agent typically results in immediate relief of pain anda more gradual recovery of nerve function. If the causepersists, irreversible changes in the affected nerve mayoccur with the nerve lesion worsening from that of aconduction block to a degenerative lesion [1]. It is there-fore important that pain in relation to nerve palsy isrecognised and acted upon quickly to prevent significantnerve damage from occurring.Case reportA 10-year-old girl underwent application of a humerallengthening frame of her right humerus to correct severehumeral shortening gradually. The shortening was second-ary to osteomyelitis of the right proximal humerus aged10 weeks. This had left her with a 10-cm discrepancybetween the lengths of the right and left humeri, resulting insignificant functional difficulties. The lengthening framewas applied with the elbow extended without any intra-operative complications. In recovery, her right hand waswarm and well perfused with full sensation and movementof the wrist and small hand joints. On the first post-operativeday, however, she complained of severe burning pain in herright arm and hand requiring significant opiates for reliefand a pain team review. Examination revealed evidence of apartial right radial nerve palsy; weakness of right wristextension, an inability to extend the fingers and diminishedsensation on the dorsum of the first webspace. She dis-played evidence of hyperalgesia with an exaggeratedresponse to pin-prick on the dorsum of the first webspace.There was no mechanical allodynia. All other hand andwrist movements and sensation were intact.An ultrasound scan of the right arm was performed. Thisrevealed no haematoma or collection. The radial nerve wasnot visualised.J. Halliday (&)  H. SimpsonDepartment of Trauma and Orthopaedics, Edinburgh RoyalInfirmary, 51 Little France Crescent, Old Dalkeith Road,Edinburgh EH16 4SA, UKe-mail: jane.halliday@cantab.netT. HemsDepartment of Trauma and Orthopaedics, Glasgow RoyalInfirmary, 84 Glasgow St, Glasgow G4 0SF, UK123Strat Traum Limb Recon (2012) 7:177–179DOI 10.1007/s11751-012-0143-6On the second post-operative day, her symptomsdecreased slightly. However, on the third post-operativeday, her symptoms did not settle further and the patient wastaken back to theatre for exploration of the radial nerve dueto ongoing severe pain. The radial nerve was found to be incontinuity without any bruising or contusion. Distally, itwas found to pass tightly against the most distal externalfixator pin such that, with the elbow flexed the nervebecame tightly pressed against the pin. The distal pin wasremoved and re-sited slightly proximal.Post-operatively, there was complete resolution of theright arm pain and hyperalgesia. Sensation to the firstwebspace recovered on the second post-operative day withmotor function returning more gradually. There was fullrecovery of radial nerve motor function at 4 months post-operatively.DiscussionIn 1943, Seddon [2] introduced a classification of nerveinjuries based on three main types of nerve fibre injury andwhether there was continuity of the nerve: neurotmesis,axonotmesis and neurapraxia [2]. Neurotmesis is the mostsevere injury. It is a lesion in which the axon and itsencapsulating connective tissue lose their continuity,resulting in Wallarian degeneration. Axonotmesis is also adegenerative lesion in which the relative continuity of anaxon and its myelin sheath is lost, with preservation of itsconnective tissue framework. Neurapraxia is a non-degenerative lesion in which there is a local conductionblock, typically of large myelinated fibres. Anatomicalcontinuity is preserved with selective demyelination.Neurology may deteriorate as a result of progressivedamage to the nerve. Neurapraxia commonly results fromcompression and/or ischaemia of peripheral nerves.Recovery occurs by Schwann cell repair, which occursover weeks to months [1].Neurapraxia can occur with or without pain. Normalsensory function is the product of an actively maintainedequilibrium between neurons and their environment [3].Any disruption of this equilibrium that results from chan-ges in sensitivity, excitability, transmission, growth statusand survival can initiate profound changes in sensoryfunction, which explains why diverse diseases can manifestas pain.Transient nerve compression, stretch or distortion, suchas the radial neuropathy of ‘Saturday night palsy’, mayresult in transient nerve palsy but is typically not associatedwith pain. Closed nerve injuries may be managed byobservation for a few months or by early exploration of thenerve. The decision is based on an assessment of theprobability that the nerve has been disrupted or is undercompression. Chronic nerve compression, distortion andischaemia results in pain, termed neurostenalgia. Neurost-enalgia is neuropathic pain provoked by the continuingaction of the agent responsible for the lesion of the nerve,which is anatomically intact. Removal of the agent resultsin resolution of the pain. Chronic nerve compression canresult from a wide variety of aetiologies and can equallyproduce a wide variety of symptoms and signs, such asmuscle weakness and altered sensation in the distributionof the affected nerve. Careful history taking, examinationand investigation are essential in guiding the clinician as tothe cause. In all cases, the presence of intractable painshould alert the clinician to a compressive cause.A famous case of neurostenalgia was that of the firstLord Nelson who suffered constant stump pain years afteramputation of his right upper limb. Loosening and dis-charge of a suture round the median nerve years laterresulted in a sudden resolution of the pain [1]. Birch andStrange [4] published a series of case reports describingneurostenalgia. They describe a case of compression of thelateral part of the sciatic nerve by a screw, resulting inneurostenalgia and common peroneal nerve palsy. The painresolved 1 day post-screw removal, and within 6 weeks,the common peroneal nerve palsy had resolved. Birch [1]describes the case of an 11-year-old who suffered excru-ciating post-operative pain in his upper limb followingvascular surgery to control major haemorrhage. A suturewas found to pass through the sheath of the ulnar nerve atre-exploration. This was removed with complete resolutionof the pain. He also reports the case of a 43-year-oldwoman who underwent ligation of the short saphenousvein. This was complicated post-operatively by foot dropand intense posture-related pain. The common peronealnerve was found to be encircled by a suture at re-explo-ration. Suture removal resolved the pain. A literaturereview using Google Scholar and PubMed reveals isolatedcase reports on relief of neurostenalgia by operation yearsafter injury [5–7].In this case, the patient reported persistent burning painand an exaggerated response to pin-prick sensation fol-lowing application of her humeral lengthening frame 1 daypost-operatively. The cause of the stimulation was con-firmed as the most distal external fixator pin compressingthe radial nerve because complete and immediate painresolution occurred when the pin was re-sited. The varia-tion in the level of symptoms was likely to have been dueto a change in elbow position when the elbow was in asemi-flexed position, the nerve was compressed against thepin but with the arm fully extended the pressure wasreduced. Nociceptor fibres, widely distributed in skin,muscle, joints and the walls of blood vessels, pass to finemyelinated A-delta fibres and non-myelinated C fibres.Stimulation of A-delta fibres results in sharp, well-localised178 Strat Traum Limb Recon (2012) 7:177–179123pain. Stimulation of C fibres causes a dull, burning andpoorly localised pain that typically is delayed [1]. Thiswould suggest that stimulation of both C and A-delta fibresoccurred in this patient.We would recommend that clinicians consider neurost-enalgia in all cases of nerve palsy associated with severepain. This is particularly pertinent post-operatively whenpain out of proportion to the procedure associated withnerve dysfunction should make the clinician consider nervecompression. A diagnosis of neurostenalgia warrants earlyexploration. It suggests a cause for the pain, which needs tobe removed to resolve the intractable pain and preventirreversible changes in the affected nerve.Conflict of interest There are no real or apparent conflict of interestthat may have a direct bearing on the subject matter of the article.Open Access This article is distributed under the terms of theCreative Commons Attribution License which permits any use, dis-tribution, and reproduction in any medium, provided the originalauthor(s) and the source are credited.References1. Birch R, Wynn Parry CB (1998) Surgical disorders of theperipheral nerves. Churchill Livingstone, Edinburgh2. Seddon H (1943) Three types of nerve injury. Brain 66:237–2883. Woolf CJ, Mannion RJ (1999) Neuropathic pain:aetiology, symp-toms, mechanisms, and management. The Lancet 353:1959–19644. Birch R (1990) A new type of peripheral nerve lesion. J Bone Jtsurg 72:312–3135. Montgomery AS, Birch R, Malone A (2005) Sciatic neurostenal-gia: caused by total hip arthroplasty, cured by late neurolysis.J Bone Jt Surg Br 87:410–4116. Stenning M, Drew S, Birch R (2005) Low-energy arterial injury atthe shoulder with progressive or delayed nerve palsy. J Bone JtSurg Br 87-B:1102–11067. Camp SJ, Milani R, Sinsi M (2008) Intractable neurostenalgia ofthe ulnar nerve abolished by neurolysis 18 years after injury.J Hand Surg (European Volume) 33:45–46Strat Traum Limb Recon (2012) 7:177–179 179123

     Edinburgh Research Explorer                                      Beware the painful nerve palsy; neurostenalgia, a diagnosis notto be missedCitation for published version:Halliday, J, Hems, T & Simpson, H 2012, 'Beware the painful nerve palsy; neurostenalgia, a diagnosis not tobe missed', Strategies in trauma and limb reconstruction, vol. 7, no. 3. https://doi.org/10.1007/s11751-012-0143-6Digital Object Identifier (DOI):10.1007/s11751-012-0143-6Link:Link to publication record in Edinburgh Research ExplorerDocument Version:Publisher's PDF, also known as Version of recordPublished In:Strategies in trauma and limb reconstructionPublisher Rights Statement:Copyright © The Author(s) 2012General rightsCopyright for the publications made accessible via the Edinburgh Research Explorer is retained by the author(s)and / or other copyright owners and it is a condition of accessing these publications that users recognise andabide by the legal requirements associated with these rights.Take down policyThe University of Edinburgh has made every reasonable effort to ensure that Edinburgh Research Explorercontent complies with UK legislation. If you believe that the public display of this file breaches copyright pleasecontact openaccess@ed.ac.uk providing details, and we will remove access to the work immediately andinvestigate your claim.Download date: 28. Nov. 2025CASE REPORTBeware the painful nerve palsy; neurostenalgia, a diagnosisnot to be missedJane Halliday • Tim Hems • Hamish SimpsonReceived: 11 April 2012 / Accepted: 24 September 2012 / Published online: 4 October 2012 The Author(s) 2012. This article is published with open access at Springerlink.comAbstract We present a case of painful radial nerve palsyfollowing application of a humeral lengthening frame. Atre-operation, the radial nerve was found to be compressedagainst a distal pin. This was re-sited providing immediatepain relief and a gradual resolution of the radial nervepalsy. Pain in association with a nerve palsy should alertthe clinician to the possibility of nerve compression thatmay benefit from urgent decompression.Keywords Neurostenalgia  Limb lengthening Decompression  Radial nerveIntroductionNeuropathic pain, arising from a lesion of the nervoussystem, is defined as persistent intractable pain dispropor-tional between the extent of the lesion and the severity ofthe pain. It is associated with sensory and/or motor dis-turbance [1]. Neurostenalgia is a neuropathic pain thatresults from continuing irritation of an anatomically intactnerve by a noxious agent [1]. It may be chronic or acuteand is not associated with excess sudomotor or vasomotoractivity. Common causes include compression, distortion,ischaemia or tethering of the nerve. Removal of the caus-ative agent typically results in immediate relief of pain anda more gradual recovery of nerve function. If the causepersists, irreversible changes in the affected nerve mayoccur with the nerve lesion worsening from that of aconduction block to a degenerative lesion [1]. It is there-fore important that pain in relation to nerve palsy isrecognised and acted upon quickly to prevent significantnerve damage from occurring.Case reportA 10-year-old girl underwent application of a humerallengthening frame of her right humerus to correct severehumeral shortening gradually. The shortening was second-ary to osteomyelitis of the right proximal humerus aged10 weeks. This had left her with a 10-cm discrepancybetween the lengths of the right and left humeri, resulting insignificant functional difficulties. The lengthening framewas applied with the elbow extended without any intra-operative complications. In recovery, her right hand waswarm and well perfused with full sensation and movementof the wrist and small hand joints. On the first post-operativeday, however, she complained of severe burning pain in herright arm and hand requiring significant opiates for reliefand a pain team review. Examination revealed evidence of apartial right radial nerve palsy; weakness of right wristextension, an inability to extend the fingers and diminishedsensation on the dorsum of the first webspace. She dis-played evidence of hyperalgesia with an exaggeratedresponse to pin-prick on the dorsum of the first webspace.There was no mechanical allodynia. All other hand andwrist movements and sensation were intact.An ultrasound scan of the right arm was performed. Thisrevealed no haematoma or collection. The radial nerve wasnot visualised.J. Halliday (&)  H. SimpsonDepartment of Trauma and Orthopaedics, Edinburgh RoyalInfirmary, 51 Little France Crescent, Old Dalkeith Road,Edinburgh EH16 4SA, UKe-mail: jane.halliday@cantab.netT. HemsDepartment of Trauma and Orthopaedics, Glasgow RoyalInfirmary, 84 Glasgow St, Glasgow G4 0SF, UK123Strat Traum Limb Recon (2012) 7:177–179DOI 10.1007/s11751-012-0143-6On the second post-operative day, her symptomsdecreased slightly. However, on the third post-operativeday, her symptoms did not settle further and the patient wastaken back to theatre for exploration of the radial nerve dueto ongoing severe pain. The radial nerve was found to be incontinuity without any bruising or contusion. Distally, itwas found to pass tightly against the most distal externalfixator pin such that, with the elbow flexed the nervebecame tightly pressed against the pin. The distal pin wasremoved and re-sited slightly proximal.Post-operatively, there was complete resolution of theright arm pain and hyperalgesia. Sensation to the firstwebspace recovered on the second post-operative day withmotor function returning more gradually. There was fullrecovery of radial nerve motor function at 4 months post-operatively.DiscussionIn 1943, Seddon [2] introduced a classification of nerveinjuries based on three main types of nerve fibre injury andwhether there was continuity of the nerve: neurotmesis,axonotmesis and neurapraxia [2]. Neurotmesis is the mostsevere injury. It is a lesion in which the axon and itsencapsulating connective tissue lose their continuity,resulting in Wallarian degeneration. Axonotmesis is also adegenerative lesion in which the relative continuity of anaxon and its myelin sheath is lost, with preservation of itsconnective tissue framework. Neurapraxia is a non-degenerative lesion in which there is a local conductionblock, typically of large myelinated fibres. Anatomicalcontinuity is preserved with selective demyelination.Neurology may deteriorate as a result of progressivedamage to the nerve. Neurapraxia commonly results fromcompression and/or ischaemia of peripheral nerves.Recovery occurs by Schwann cell repair, which occursover weeks to months [1].Neurapraxia can occur with or without pain. Normalsensory function is the product of an actively maintainedequilibrium between neurons and their environment [3].Any disruption of this equilibrium that results from chan-ges in sensitivity, excitability, transmission, growth statusand survival can initiate profound changes in sensoryfunction, which explains why diverse diseases can manifestas pain.Transient nerve compression, stretch or distortion, suchas the radial neuropathy of ‘Saturday night palsy’, mayresult in transient nerve palsy but is typically not associatedwith pain. Closed nerve injuries may be managed byobservation for a few months or by early exploration of thenerve. The decision is based on an assessment of theprobability that the nerve has been disrupted or is undercompression. Chronic nerve compression, distortion andischaemia results in pain, termed neurostenalgia. Neurost-enalgia is neuropathic pain provoked by the continuingaction of the agent responsible for the lesion of the nerve,which is anatomically intact. Removal of the agent resultsin resolution of the pain. Chronic nerve compression canresult from a wide variety of aetiologies and can equallyproduce a wide variety of symptoms and signs, such asmuscle weakness and altered sensation in the distributionof the affected nerve. Careful history taking, examinationand investigation are essential in guiding the clinician as tothe cause. In all cases, the presence of intractable painshould alert the clinician to a compressive cause.A famous case of neurostenalgia was that of the firstLord Nelson who suffered constant stump pain years afteramputation of his right upper limb. Loosening and dis-charge of a suture round the median nerve years laterresulted in a sudden resolution of the pain [1]. Birch andStrange [4] published a series of case reports describingneurostenalgia. They describe a case of compression of thelateral part of the sciatic nerve by a screw, resulting inneurostenalgia and common peroneal nerve palsy. The painresolved 1 day post-screw removal, and within 6 weeks,the common peroneal nerve palsy had resolved. Birch [1]describes the case of an 11-year-old who suffered excru-ciating post-operative pain in his upper limb followingvascular surgery to control major haemorrhage. A suturewas found to pass through the sheath of the ulnar nerve atre-exploration. This was removed with complete resolutionof the pain. He also reports the case of a 43-year-oldwoman who underwent ligation of the short saphenousvein. This was complicated post-operatively by foot dropand intense posture-related pain. The common peronealnerve was found to be encircled by a suture at re-explo-ration. Suture removal resolved the pain. A literaturereview using Google Scholar and PubMed reveals isolatedcase reports on relief of neurostenalgia by operation yearsafter injury [5–7].In this case, the patient reported persistent burning painand an exaggerated response to pin-prick sensation fol-lowing application of her humeral lengthening frame 1 daypost-operatively. The cause of the stimulation was con-firmed as the most distal external fixator pin compressingthe radial nerve because complete and immediate painresolution occurred when the pin was re-sited. The varia-tion in the level of symptoms was likely to have been dueto a change in elbow position when the elbow was in asemi-flexed position, the nerve was compressed against thepin but with the arm fully extended the pressure wasreduced. Nociceptor fibres, widely distributed in skin,muscle, joints and the walls of blood vessels, pass to finemyelinated A-delta fibres and non-myelinated C fibres.Stimulation of A-delta fibres results in sharp, well-localised178 Strat Traum Limb Recon (2012) 7:177–179123pain. Stimulation of C fibres causes a dull, burning andpoorly localised pain that typically is delayed [1]. Thiswould suggest that stimulation of both C and A-delta fibresoccurred in this patient.We would recommend that clinicians consider neurost-enalgia in all cases of nerve palsy associated with severepain. This is particularly pertinent post-operatively whenpain out of proportion to the procedure associated withnerve dysfunction should make the clinician consider nervecompression. A diagnosis of neurostenalgia warrants earlyexploration. It suggests a cause for the pain, which needs tobe removed to resolve the intractable pain and preventirreversible changes in the affected nerve.Conflict of interest There are no real or apparent conflict of interestthat may have a direct bearing on the subject matter of the article.Open Access This article is distributed under the terms of theCreative Commons Attribution License which permits any use, dis-tribution, and reproduction in any medium, provided the originalauthor(s) and the source are credited.References1. Birch R, Wynn Parry CB (1998) Surgical disorders of theperipheral nerves. Churchill Livingstone, Edinburgh2. Seddon H (1943) Three types of nerve injury. Brain 66:237–2883. Woolf CJ, Mannion RJ (1999) Neuropathic pain:aetiology, symp-toms, mechanisms, and management. The Lancet 353:1959–19644. Birch R (1990) A new type of peripheral nerve lesion. J Bone Jtsurg 72:312–3135. Montgomery AS, Birch R, Malone A (2005) Sciatic neurostenal-gia: caused by total hip arthroplasty, cured by late neurolysis.J Bone Jt Surg Br 87:410–4116. Stenning M, Drew S, Birch R (2005) Low-energy arterial injury atthe shoulder with progressive or delayed nerve palsy. J Bone JtSurg Br 87-B:1102–11067. Camp SJ, Milani R, Sinsi M (2008) Intractable neurostenalgia ofthe ulnar nerve abolished by neurolysis 18 years after injury.J Hand Surg (European Volume) 33:45–46Strat Traum Limb Recon (2012) 7:177–179 179123

English

A new type of peripheral nerve lesion.

Intractable neurostenalgia of the ulnar nerve abolished by neurolysis 18 years after injury. J Hand Surg (European Volume) 33:45–46 Strat Traum Limb Recon

Low-energy arterial injury at the shoulder with progressive or delayed nerve palsy.

Neuropathic pain:aetiology, symptoms, mechanisms, and management.

Surgical disorders of the peripheral nerves. Churchill

Three types of nerve injury.

http://dx.doi.org/10.1007/s11751-012-0143-6

Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed

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