Radial nerve palsy in patients presenting with fentanyl/xylazine wounds of the dorsal forearm: A case series

Introduction: The presence of synthetic compounds like xylazine in the illicit opioid supply of the United States has led to presentations of unique upper extremity wounds in persons who inject drugs. As an alpha-2 adrenergic receptor agonist, xylazine causes local vasoconstriction of blood vessels as well as central nervous system depression. With increased vasoconstriction, patients experience more issues with adequate perfusion which is hypothesized to cause nerve deficiencies near injection sites. Methods: Three patients presenting with a history of deep upper extremity forearm wounds secondary to injection with xylazine and fentanyl had clinically significant radial nerve palsies. Each patient's presentation and clinical course was observed and reported. Results: In all three cases, patients presented with chronic necrotic forearm wounds that required repeated surgical debridement and wound care. There was evidence of weakness in the radial nerve distribution, with patients exhibiting dysfunction of the extrinsic digital and wrist extensors. Conclusion: Providers should be aware of a common manifestation of radial nerve deficiency in upper extremity wounds in patients with a history of fentanyl-xylazine injections. While surgical management of nerve palsies such as tendon transfers are options for treatment, successful long-term treatment must also rely on multidisciplinary care for addiction and psychosocial support for ideal functional outcomes.