I read the case report by Brown and Britton [
[1]
] with interest. I have several points to make.
- 1.The Summary of Product Characteristics for Implanon was revised and recommendations as to insertion site were changed in 2007/2008 in response to repeated reports of nerve injury [[2]], deleting reference to using the biceps/triceps groove. As the authors show in their anatomical diagram, the neurovascular bundle runs quite superficially in the groove proximal to the medial epicondyle. Surgically trained authors have commented in no uncertain terms on how unwise it is to insert implants over the groove [3,4].
- 2.Sensory disturbance of the medial cutaneous nerve of the forearm has been described in relation to removal of an implant in one other case [[5]].
- 3.It remains to be seen whether Nexplanon's redesigned applicator reduces the risk of deep insertion [[6]]. The redesign does not have any influence over a clinician's selection of an insertion site. Clinicians need to be aware that insertion near to the neurovascular bundle can injure nerves or even the brachial artery [[2]], especially in thin women. Important lessons need to be learned from cases of injury to all three nerves running superficially in the medial aspect of the upper arm [[2]].
- 4.Non-surgically trained clinicians removing impalpable implants even under ultrasound guidance should know their limitations and have a low threshold for referring to an upper limb surgeon.
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References
- Neuropathy associated with etonogestrel implant insertion.Contraception. 2012; 86: 591-593
- Legal aspects of contraceptive implants.J Fam Plann Reprod Health Care. 2010; 36: 243-248
- Nerve injury caused by removal of an implantable hormonal contraceptive.Am J Obstet Gynecol. 2006; 195: 323-326
- Implantable contraceptive devices: primum non nocere.J Fam Plann Reprod Health Care. 2006; 32: 190-192
- Focal brachial cutaneous neuropathy associated with Norplant® use: suggests careful consideration of the recommended site for inserting contraceptive implants.J Fam Plann Reprod Health Care. 2001; 27: 155-156
- A risk management approach to the design of contraceptive implants.J Fam Plann Reprod Health Care. 2010; 36: 191-195
Article info
Publication history
Published online: December 06, 2012
Accepted:
October 22,
2012
Received:
October 9,
2012
Identification
Copyright
© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
