Objective: To report a case of focal hand dystonic tremor secondary to distal post-traumatic peripheral nerve injury with a review of relevant literature.

Background: Post-traumatic dystonias (PTD) present with heterogeneity of location, injury severity, and time of onset.[1-4] They are thought to occur due to maladaptive cortical changes in reaction to aberrant peripheral inputs.[3] Peripheral nerve injury has been experimentally shown to induce dystonic movement disorders in animal models.[5] Complex regional pain syndrome (CRPS) is often comorbid.[1,3] PTD are often mistaken for a functional movement disorder.[2-4]

Method: We report the case of a focal dystonic hand tremor, which developed a few months after distal ulnar traumatic injury. Informed consent was obtained for case report and media.

Results: A 25-year-old male patient suffered a traumatic left hand injury in 2023 when his fingers were mutilated by a small propeller. He underwent digit reconstruction surgery and skin grafting for the 3rd and 4th digits. Post operatively he developed allodynia and hyperesthesia of the 4th finger. Six months after the injury, he developed a coarse left hand tremor involving the 3rd through 5th fingers. EMG/NCS demonstrated a mild left carpal tunnel syndrome and mild left cubital tunnel syndrome. Left endoscopic carpal tunnel release did not provide improvement. He was diagnosed with possible CRPS, partially relieved by left stellate ganglion block. On our examination 18 months after injury, he showed a coarse, 9Hz flapping ​tremor of the 3rd-5th fingers at the metacarpophalangeal joints. Tremor was triggered by active flexion of the involved fingers, particularly when applying grip force and was not present at rest or while holding a posture. Propranolol and clonazepam were ineffective. Onabotulinum toxin A injection into the affected muscles was ineffective in controlling tremor.

Conclusion: PTD is an under recognized complication of peripheral nerve injury. Injuries of the ulnar nerve at the elbow [6] and wrist [1] have been associated with the development of hand tremor, but rarely an injury of the distal ulnar innervation is implicated. PTD is frequently medication resistant.[7] Botulinum toxin injections may provide relief of muscular spasm, but it rarely improves limb function.[1]

References: [1] Jankovic, J., & Van der Linden, C. (1988). Dystonia and tremor induced by peripheral trauma: predisposing factors. Journal of Neurology, Neurosurgery & Psychiatry, 51(12), 1512-1519.
[2] Lenka, A., & Jankovic, J. (2023). Peripherally-induced movement disorders: an update. Tremor and Other Hyperkinetic Movements, 13, 8.
[3] Luca, C, Singer, C. (2004) Peripheral dystonia. – MedLink Neurology
[4] Ercoli, T., Defazio, G., Geroin, C., Marcuzzo, E., Fabbrini, G., Bono, F., … & Italian Registry of Adult Dystonia Study Group. (2021). Sudden onset, fixed dystonia and acute peripheral trauma as diagnostic clues for functional dystonia. Movement Disorders Clinical Practice, 8(7), 1107-1111.
[5] Reinhold, C., Knorr, S., McFleder, R. L., Harder-Rauschenberger, L., Gräfenhan, T., Schlosser, A., … & Ip, C. W. (2025). Peripheral nerve injury induces dystonia-like movements and dysregulation in the energy metabolism: A multi-omics descriptive study in Thap1+/− mice. Neurobiology of Disease, 205, 106783.
[6] Little, J. W., Burchiel, K., & Nutter, P. (1986). Tremor and peripheral nerve entrapment: case report. Journal of neurosurgery, 64(1), 145-147.
[7] Cardoso, F., & Jankovic, J. (1995). Peripherally induced tremor and parkinsonism. Archives of neurology, 52(3), 263-270.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/focal-dystonic-hand-tremor-secondary-to-distal-traumatic-peripheral-nerve-injury/