A closer look at Saturday Night Palsy

I was reading James’ post on Saturday Night Palsy and thought about having a closer look.

Saturday night palsy occurs due to pressure on the radial nerve by keeping the arm over the handle of a chair or in some unusual position while sleeping, usually following heavy drinking. The palsy occurs due to injury to the radial nerve in the radial groove of the humerus (bone of the arm). The radial nerve, also known as the musculospiral nerve, lies in the radial groove in the posterior aspect of the humerus. The resulting paralysis from the injury is usually temporary, neuropraxia in type and resolves by itself but in some unfortunate cases, rhabdomyolysis may occur due to prolonged immobilization of the musculature as reported by Brian M. Devitt et al.  in a case report.

Radial Groove on humerus. Modified from Wikipedia

They reported a case of a 18 year male who suffered from Saturday Night Palsy after binge drinking and subsequently sleeping with his right arm wrapped around a suitcase. He woke up with paralysis of the right arm, severe pain and swelling. He also suffered from rhabdomyolysis. The course was not good. Total debridement of the biceps and brachialis muscle and partial debridement of brachioradialis muscle had to be done. All because of falling asleep while drunk!

Saturday night palsy is characterized by wrist drop. Injury to the radial nerve in the radial groove causes motor paralysis of the extensor muscles of the wrist, resulting in wrist drop. The patient is unable to lift up his wrist and it hangs down. Extensor muscles of all the joints of the thumb are paralyzed hence the patient is unable to extend his thumb. Extensor muscles of the fingers as a whole are not affected because the interossei muscles and lumbrical muscles which are responsible for extension remain unaffected as they are supplied by the ulnar nerve and the median and ulnar nerves respectively. The supinator and brachioradialis muscles are paralysed but supination movement of the forearm is possible by the intact biceps muscle.

The triceps muscle escapes paralysis although it is supplied by the radial nerve because nerve supply to all the three heads of the muscle arises before the radial nerve enters in the radial groove.

Sensory loss is present on the back of the hand, on the lateral side of the thumb and adjacent part of the palm. There is sensory loss on the medial side of the thumb and adjoining sides of the index, middle and lateral side of the ring finger. Anesthesia of the back of the fingers also occurs up to the proximal interphalangeal joint except over the thumb where it reaches up to the nail.

Saturday night palsy is usually managed conservatively with removal of compression, physical therapy and wrist splints.

Reference:

Devitt, B., Baker, J., Ahmed, M., Menzies, D., & Synnott, K. (2010). Saturday night palsy or Sunday morning hangover? A case report of alcohol-induced Crush Syndrome Archives of Orthopaedic and Trauma Surgery DOI: 10.1007/s00402-010-1098-z

Going for fishing: What’s the catch?

It is very unfortunate to have a leisurely activity end in a disaster. A recent case report by Inchingolo F et al. published in the Head and Face Medicine journal illustrates this. When you go for fishing, you may end up with more than what you would have bargained for; the catch may be your very own eye, or in this case, the eyelid.

The authors describe a case of a young 32 year old male fisherman in whom the fish-hook he was using got embedded in his right eyelid. When he was reeling the hook back, it hit him in the face and attached to his right eyelid. He was fortunate that the eye was not injured. The hook was removed under local anesthesia by making a small incision and the patient made a full recovery. He even wanted to resume fishing.

Fish-hook injury to the eyelid. From Head and face medicine.

Fish-hook injuries to the eye would be considered as penetrating injuries to the eye. If you look at the figure, the ends of the fish-hook are curve backwards with a barb. Now I am no expert on fish-hooks, but I would guess they are designed to keep the fish hooked, the more the fish struggles to get it off, the more deeply it attaches. Same thing happens in case of an accidental injury. If you try to get it off forcibly, it will cause even more damage.

Penetrating injuries of the eye are potentially dangerous and they should receive prompt treatment. They are dangerous due to –

• Immediate effect of the trauma.
• Infections may be introduced.
• Sympathetic ophthalmitis.

Layers of the eye. From Patient UK.

Immediate effects of trauma may be on the lid and conjunctiva and they are common as they serve to protect the eye. In lid injury, the site of the injury must be stitched meticulously. Even then, there may notching of the eyelid upon healing, but it was not there in this case. The cornea may also be injured, having a linear wound or a lacerated wound. The corneal endothelium swells up as a result of the injury and the cornea becomes cloudy. In case of large injuries to the cornea, there may be prolapse of the iris and it becomes adherent to the cornea upon recovery. The eyeball itself may rupture in severe cases. The lens may also be involved in the injury. In minor injuries to the lens, a traumatic cataract is formed with subsequent loss of vision. This is treated by removing the cataract. In severe injury to the lens, there is a large wound at the anterior capsule of the lens and the cortical matter of the lens comes out in the anterior chamber as white floccules.

The fish-hook can also cause infection of the eye. Purulent keratitis, that is, pus forming corneal inflammation can occur. This can give rise to frank purulent corneal ulcer which forms a corneal opacity on healing and impairs vision. Endophthalmitis, inflammation of the inner coats of the eyeball and panophthalmitis, inflammation of all the layers of the eyeball can also occur. Panophthalmitis is a dangerous condition with poor prognosis and the eye may have to be removed.

Another dangerous condition that may occur is sympathetic ophthalmitis. In sympathetic ophthalmitis, the uninjured normal eye also becomes involved in inflammation, in addition to the injured eye. Vision becomes impaired in both the eyes. It is thought to be autoimmune in origin, in which antibodies produced against the uveal pigments, uveal proteins and retinal proteins of the injured eye attack the normal eye.

How can fish-hook injuries be prevented? Simple precautions will suffice. Protective goggles will suffice in protecting the eye. Caution while handling the hooks will also be protective.

Reference :

Inchingolo F, Tatullo M, Abenavoli FM, Inchingolo AD, Inchingolo AM, & Dipalma G (2010). Fish-hook injuries: a risk for fishermen. Head & face medicine, 6 (1) PMID: 21156039