Involuntary arm movements post-pacemaker insertion – real or Reel syndrome?

Background Twiddler syndrome, and the variant Reel syndrome, are rare but important complications of pacemaker implantation.Case summary We describe a rare complication of conventional permanent pacemaker implantation of rhythmic arm twitching secondary to brachial plexus stimulation from a displaced pacing lead caused by Reel syndrome.Discussion Twiddler syndrome and its variants are rare but important complications of pacemaker insertion. Holistic planning of cardiac procedures in elderly patients should identify those at risk to allow for targeted education and post-procedural care.