Learning from errors: Iatrogenic ulnar nerve injury resulting from a venous cut down procedure

doi:10.1136/bcr.06.2008.0264

BMJ Case Rep. 2008; 2008: bcr0620080264.

Published online 2008 November 20. doi: 10.1136/bcr.06.2008.0264

PMCID: PMC3124750

Learning from errors

Iatrogenic ulnar nerve injury resulting from a venous cut down procedure

Ravi Kumar Gupta, Rajiv Kansay, Varun Aggarwal, and Parmanand Gupta

Government Medical College Hospital, Department of Orthopaedics, Chandigarh, 160047, India

Email: ravikgupta2000/at/yahoo.com

Abstract

We present a case of an iatrogenic left ulnar nerve injury caused during the basilic vein cut down in a 25-year-old woman presenting with a ruptured ectopic pregnancy and requiring an emergency laparotomy. Two months after her discharge from the hospital, the patient presented to the hand surgery clinic with a weak grip strength and paraesthesias in the left hand, diagnosed to be resulting from a deficient ulnar nerve function. Surgical exploration of the nerve showed a complete section of the nerve. End to end repair and anterior transposition of the nerve was done. At 10 months follow up, the patient showed recovery in the flexor digitorum profundus and flexor carpi ulnaris, thus partially improving the grip strength. The patient was still under follow-up at the time this report was prepared.

BACKGROUND

Venous cut down is an important procedure for providing venous access. The procedure is usually carried out by the junior doctors under local anaesthesia in the emergency rooms/wards. Being a minor adjunct procedure to the main treatment, the complications caused by it, especially major ones, can land the treating team in embarrassing situations. We present a rare case of iatrogenic section of the left ulnar nerve which occurred during the basilic vein cut down.

CASE PRESENTATION

A 25-year-old woman presented to the hand clinic of our institution in July 2007 with weak grip strength and paraesthesias in the left hand. She said that her symptoms developed after an emergency laparotomy performed on her for a ruptured ectopic pregnancy 2 months earlier. Examination revealed a complete loss of the ulnar nerve function below the elbow and the presence of a transverse surgical scar in the supratrochlear region (fig 1). She informed us that the surgical scar resulted from the performance of a cut down procedure conducted in the emergency room before the laparotomy.

Figure 1

Transverse surgical scar of venous cut down.

INVESTIGATIONS

Electrodiagnostic studies confirmed a complete blockage of the conduction beyond the elbow.

TREATMENT

Exploration of the patient’s ulnar nerve revealed a complete section of the nerve with both the stumps having bulbous swellings at the ends (fig 2). The bulbous ends of the nerve were resected until the normal nerve fibrils became visible at both the ends (fig 3). The resection resulted in a gap of approximately 1 inch (2.5 cm) between the two ends. End to end repair of the nerve was possible after mobilisation of both the ends and anterior transposition of the nerve at the elbow (fig 4). The patient has since visited the clinic on regular monthly follow-up.

Figure 2

Bulbous ends of the cut ulnar nerve.

Figure 3

Normal nerve fibrils seen after resection of the bulbous ends.

Figure 4

Anterior transposition and end to end suture.

OUTCOME AND FOLLOW-UP

During a recent visit, at 10 months follow-up in May 2008, the patient showed complete recovery in the function of the muscles of the forearm innervated by ulnar nerve—that is, the flexor carpi ulnaris and medial half of the flexor digitorum profundus. The patient is still under the follow-up of our clinic.

DISCUSSION

All invasive procedures carry some degree of risk of damage to the normal structures in the proximity of the region where the procedure is performed.¹ Both percutaneous (venepuncture) and cut down (venesection) techniques have been routinely employed on the patients with varying complications; however, the cut down procedure has been reported to be comparatively safe.²^,³

The majority of the complications related to nerves have been attributed to the injury to the cutaneous nerves resulting from the blind access of the venepuncture.¹^,⁴^,⁵ Jablon et, in a retrospective study on implantable venous devices, have reported the rate of complications of cephalic vein cut down as 11%.² There is only one isolated case in the literature, reported in 1989, mentioning injury to the ulnar nerve caused during a cut down procedure on the basilic vein.⁶ We therefore feel that probably the complications resulting from cut down procedures are under reported. As the procedure is usually carried out by junior doctors in an emergency situation in casualty/wards, conditions such as lighting, instrumentation, assistance, etc, are not as optimum as in an operating room. Furthermore, the overcrowding of patients in public hospitals, especially in developing countries, usually leads to physical exhaustion of the team of residents working around the clock. All these factors working in unison could lead to an increased rate of such preventable complications. However, an awareness of the complications and a high level of caution during the procedure can be helpful in avoiding such events arising.

LEARNING POINTS

Venous cut down is a common minor surgical procedure.
Knowing the complications helps to avoid them.
Ulnar nerve injury is a major complication.
A high level of caution during the procedure is important.
Early diagnosis and repair of the cut ulnar nerve is important for the best results

Footnotes

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication

REFERENCES

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2. Jablon LK, Ugolini KR, Nahmias NC. Cephalic vein cut-down verses percutaneous access: a retrospective study of complications of implantable venous access devices. Am J Surg 2006; 192: 63–7. [PubMed]

3. Shukla NK, Das DK, Deo SV, et al. An analysis of long-term venous access catheters in cancer patients: experience from a tertiary care centre in India. J Postgrad Med 2002; 48: 21–4. [PubMed]

4. Rayegani SM, Azadi A. Lateral antebrachial cutaneous nerve injury induced by phlebotomy. J Brachial Plex Peripher Nerve Inj 2007; 2: 6. [PMC free article] [PubMed]

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6. Mathur SN, Meena JL, Kriplani A, et al. Ulnar nerve injury: an unusual complication of basilic vein cut open. J Indian Med Assoc 1989; 87: 164–5. [PubMed]

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