Ischaemic Monomelic Neuropathy and Compartment Syndrome: A Spectrum of Ischaemia

Case Report

Austin Surg Case Rep. 2025; 10(1): 1064.

Ischaemic Monomelic Neuropathy and Compartment Syndrome: A Spectrum of Ischaemia

Tom Challoner¹*; Mei Sien Liew¹; Rajive Jose²

1Registrar, Plastic Surgery, All of Queen Elizabeth Hospital Mindelsohn Way Birmingham B15 2GW, UK

2Consultant, Plastic Surgery, All of Queen Elizabeth Hospital Mindelsohn Way Birmingham B15 2GW, UK

*Corresponding author: Tom Challoner, Registrar, Plastic Surgery, All of Queen Elizabeth Hospital Mindelsohn Way Birmingham B15 2GW, UK. Email: Tom.challoner@gmail.com

Received: December 13, 2024; Accepted: December 31, 2024; Published: January 07, 2025

Abstract

Ischaemic Monomelic Neuropathy (IMN) is a rare sequelae of arteriovenous fistula formation in the upper limb. It typically presents with sensory disturbance and represented ischaemic to peripheral nerves. A case of ischaemia following fistula revision is presented and ongoing ischaemic leading to acute compartment syndrome. The pathophysiology of IMN is unclear, however the ischaemic insult to the nerves must also affect the other structures in the forearm, including muscles, and should be recognised as spectrum of ischaemia. Progression to compartment syndrome is a significant risk with devastating consequences and should therefore be considered in any neurovascular disturbance following fistula formation.

Keywords: Compartment Syndromes; Vascular fistula; Ischemia

Introduction

Ischaemic Monomelic Neuropathy (IMN) is a rare peripheral neuropathy complication secondary to an ischaemic injury following the creation of Arteriovenous (AV) fistulae of the upper limb providing access for haemodialysis. The estimated incidence rate of IMN is 0.5% following vascular access procedure, but the exact pathophysiology of IMN is poorly understood [1]. Still, it is caused by an arterial steal, and poor perfusion of vasa nervorum, resulting in multiple axonal loss mononeuropathies in the distal limb [2]. The symptoms commonly occur immediately postoperatively with predominantly neurological signs, but often without notable clinical ischaemia affecting the limb. IMN can lead to permanent functional loss of the affected limb and irreversible chronic pain. Whilst recognised amongst transplant surgeons, a spectrum of ischaemic insults can occur with all forearm structures at risk. We present a case of acute compartment syndrome associated with the revision of the brachiocephalic fistula for haemodialysis access which the diagnosis was delayed.

Case Presentation

A 35-year-old, right-handed male underwent revision of a brachiocephalic fistula for haemodialysis. He had previously undergone a live donor kidney transplant which had failed, and the flow in his existing right-sided fistula had reduced, requiring revision. Under general and regional supraclavicular block anaesthesia, a 6mm GORE® ACUSEAL Vascular Graft (Gore Medical, Arizona, USA) was anastomosed proximal to the previous cephalic vein anastomosis in the upper arm with an end-to-side anastomosis. It was tunnelled distally and anastomosed to the cephalic vein. The hand was perfused following the procedure, and radial artery flow confirmed with handheld doppler.

The patient was reviewed 4 hours postoperatively due to significant pain in the forearm which had been present since the procedure. The right forearm was warm, but the hand slightly cooler, with a digital capillary refill time of 3 seconds. Further analgesia was prescribed.

The patient was reviewed overnight with the same complaint of significant pain which was improved at rest. There was sensory disturbance to the entire hand in all territories distal to the wrist, and weakness of both the intrinsics and long flexors and extensors to the digits. The capillary refill time was <2 seconds and the hand warm, however the radial pulse could not be palpated. There was no collection at the surgical site. A fentanyl PCA was commenced, with a diagnosis of IMN considered and the sensory disturbance was considered a consequence of the regional block wearing off.The following morning, approximately 18 hours postoperatively, due to persistent sensory disturbance, pain, and a contracture of the digits, the patient was returned to theatre for exploration. It was identified that there was no flow in the radial and ulnar arteries whilst the graft was patent. When clamped, normal flow was restored, demonstrating a significant vascular steal. The graft was tied off and wounds were closed.The patient was referred to the upper limb service following this secondary procedure as his symptoms had not improved. On examination, the right hand was held in a clawed position, with pain on passive extension of the digits, a tense volar compartment of the forearm, and paraesthesia to the entire hand distal to the wrist crease, suggestive of median, ulnar, and superficial branch of radial nerve palsy involvement. Creatinine kinase was 5894 (Figure 1). A clinical diagnosis of compartment syndrome was made, and the patient planned for return theatre for right forearm fasciotomy.

Citation: Challoner T, Liew MS, Jose R. Ischaemic Monomelic Neuropathy and Compartment Syndrome: A Spectrum of Ischaemia. Austin Surg Case Rep. 2025; 10(1): 1064.