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![ Tendon transplant in radial nerve palsy
needs to be provided with
(1) wrist extension.
(2) finger (metacarpophalangeal [MP] joint) extension.
(3) a combination of thumb extension and abduction.](https://image.slidesharecdn.com/radialnerveentrapment-200601154618/85/Radial-nerve-entrapment-48-320.jpg)
Uploaded byYash Oza
Radial nerve entrapment
1. The radial nerve is a major branch of the brachial plexus that provides motor innervation to muscles of the posterior arm and extensor compartment of the forearm. 2. It is susceptible to entrapment at several points along its course, most commonly in the radial tunnel where the posterior interosseous nerve passes. 3. Radial nerve entrapment causes weakness of wrist and finger extension and can be diagnosed through history, physical exam including Tinel's sign, and electrodiagnostic testing. Conservative treatment includes splinting and steroid injections while surgery involves nerve decompression.
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Radial nerve entrapment
- 1. Presented by :Dr Yash Oza Moderator : Dr Pradip Patil
- 2. Radial Nerve e • Largestbranch of the brachial plexus • Arises from the posterior cord of the brachial plexus (C5–T1) • Mixed nerve Anatomy
- 3. Course of RadialNerve • The Axilla • The Axilla to the Spiral Groove • The Spiral Groove to the Supinator Muscle • Branches • The Posterior Interosseous Nerve • The Superficial Sensory Radial Nerve
- 4. • The Axilla •Radial nerve in the distal axilla. • The radial nerve lies superficial to three muscles • (from proximal to distal): 1. the subscapularis 2. the latissimus dorsi tendon 3. the teres major • The radial nerve enters the arm anterior to the long head of the triceps. • It soon dives into a cleft between the long triceps head and the medial triceps head. • Within this cleft, the nerve runs toward the spiral groove.
- 5. • The Axillato the Spiral Groove • The radial nerve passes down the spiral groove between the origins of the lateral and medial heads of the triceps. • It remains in contact with the humerus and is covered by the lateral head of the triceps. • Then it pierces the lateral intermuscular septum, about halfway down the arm.
- 6. • The SpiralGroove to the Supinator Muscle • Upon entering the flexor compartment at midarmlevel, the radial nerve runs under three muscles, which sequentially arcade over the nerve. • This anatomical arrangement has been referred to as the radial tunnel. • ECRB loops over it; that may predispose the radial nerve to irritation. • Distal to the elbow joint, the radial nerve bifurcates into the, 1. posterior interosseous and 2. superficial sensory radial nerves. And enter supinator muscle.
- 7. • The supinatorhas a deep and a superficial head. • The superficial head forms a pocket, into which the posterior interosseous nerve descends. The edge of this pocket can be fibrous and is termed the arcade of Fröhse. • The superficial sensory radial nerve remains superficial to both heads of the supinator.
- 8. • The PosteriorInterosseous Nerve • After emerging from between the two heads of the supinator muscle, the PIN lies between extensor digitorum communis the abductor pollicis longus. • It then ramifies into a large number of unnamed branches, which are often called the cauda equina of the forearm. • It gives of muscular branches to following muscle. • PIN Deep Group: • Abductor Pollicis longus • Extensor pollicis longus • Extensor pollicis brevis • Extensor indicis • PIN Superficial Group • Extensor carpi Ulnaris • Extensor digitorum communis • Extensor digiti minimi
- 9. • The SuperficialSensory Radial Nerve • It remains deep to the brachioradialis muscle until 2/3rd of the way down the forearm. • In the lower 1/3rd it becomes superficial when the BR and ECRL form their tendons. • Then nerve passes to the dorsal aspect of the wrist, branches upon the dorsolateral aspect of the hand, and remains superficial to the extensor retinaculum. • The superficial sensory radial nerve usually has four or more terminal sensory branches. Dorsal digital nerves ECRL Dorsal Radial Sensory BR Nerve 8 cm Radial styloid
- 10. Lower lateral cutaneous nerveof arm Posterior cutaneous nerve of arm Posterior cutaneous nerve of forearm Dorsal radial sensory nerve dorsum of the hand over the radial two-thirds, the dorsum of the thumb, and the index, middle finger proximal to the distal interphalangeal joint. Cutaneous innervation from radial nerve
- 11.
- 12. MOTOR Innervation OfRadial Nerve Radial nerve Innervated muscle Triceps brachii Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis
- 13. Radial nerve Innervated muscle Tricepsbrachii Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis
- 14. Radial nerve Innervated muscle Tricepsbrachii Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis
- 15. PIN Supinator Extensor carpi ulnaris Extensordigitorum Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis
- 16. PIN Supinator Extensor carpi ulnaris Extensordigitorum Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis
- 17. PIN Supinator Extensor carpi ulnaris Extensordigitorum Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis
- 18. PIN Supinator Extensor carpi ulnaris Extensordigitorum Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis
- 19. PIN Supinator Extensor carpi ulnaris Extensordigitorum Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis
- 20. PIN Supinator Extensor carpi ulnaris Extensordigitorum Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis EPB – Resistance applied at prox phalanx EPL – Resistance applied at distal phalanx
- 21. PIN Supinator Extensor carpi ulnaris Extensordigitorum Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis
- 22. Radial Nerve Entrapment •Entrapment neuropathies refer to isolated nerve injury occurring at specific location where a nerve is mechanically constricted in a fibrous/ fibro osseous tunnel • Mechanism is : Compression, constriction, angulation or streatching • Common cause : • External : cast brace, tourniquet • Internal : Bony callous, ganglion, tumours, fibrous tissue, normal or abberent muscle • Compression may be acute or intermittent or continuous.
- 23. Pathophysiology of entrapment •Nerve is surrounded by loose connective tissue called adventia nevosum – it is regional vascular bundle in nerve circumference • Normally, Movement of extremity slightly alters this vascular circulation • Stretch or traction beyond certain limit will affect this circulation and obstruction to outflow. • Create positive pressure to endoneurium • Leading to intrafascicular edema & nerve damage • It’s termed as miniature closed compartment syndrome • Histologically – segmental demyelination & remyelination seen It is type of a Neuropraxia
- 24. • General conditionthat may predispose to Neuropathy • DM • GB Syndrome • Double crush hypothesis – nerves are more susceptible to compression if fibers are damaged proximally • Tomoculous Neuropathy – a hereditary pressure sensitive neuropathy . d/t abnormal myelination
- 25. Radial Entrapment • Commonsite A) Axialla : • Crutch palsy – d/t pressure with ill- adjusted crutches whithout proper handgrip • Aneurism of axillary vessels B) Shoulder • # - D/L of upper humerus & attempt to their reduction C) Radial Groove : • # shaft Humerus • Prolonged application of tourniquet • Ill-applied cast • Saturday Night Palsy & Honeymoon palsy • Excessive callus of an old fracture • Infection & Iatrogenic
- 26. D) B/w Spiralgroove & Lat. Epicondyle • # Shaft Humerus • # Supracondylar humerus • # lateral condyle • Cubitus vulgus deformity E)Elbow : • Dislocation • # neck of radius • Enlarged burase • RA Elbow • Radial head excision surgery • Radial tunnel syndrome/ PIN syndrome F) Forearm • Cheiralagia Parasthetica / Wartnberg Disease
- 27. Saturday night palsy: • radial nerve compression in the arm resulting from direct pressure against a firm object. Honeymoon Palsy : • When bed partner’s head compresses radial nerve while resting in crook of partner’s arm Radial tunnel syndrome : • Entrapment of PIN in in radial tunnel Cheiralagia Parasthetica / Wartnberg Disease: • compression of Superficial radial nerve as it emerges b/w ECRL and BR, 8 cm proximal to radial styloid
- 29. Type Location MotorSensory Very High Above spiral groove Total Palsy Post Cut.N. of Arm spared High B/w Spiral groove & Lat Epicondyle Triceps spared BR involevd Lower Lat.CN of Arm & Post.CN of Forearm (+/-?) (both emerges from spiral groove) Low At Elbow Elbow, Wrist extensor spared Lost over dorsum of 1st web space PIN - Elbow, Wrist extensor spared Spared Type of Radial nerve injuries according to location
- 30. Clinical Features • Sign& Symptoms – according to the level of involvement MOTOR : • Clumpsiness, weakness, wasting or fasciculation of muscle • Paralysis, loss of tone, atrophy, areflexia, insensitivity to compression SENSORY : • Numbness, paresthesia, tingling, prickling, burning over affected area AUTONOMIC : • Atrophy, ulcer, skin changes, hyperesthesia
- 31. •TINEL SIGN : •Gentle percussion by finger hammer from distal to proximal direction along the course of nerve gives transient tingling sensation in distribution of nerve • Sensation should persist for several seconds
- 32. Diagnosis • History taking •Motor- sensory examination • Electrophysiological studies – EMG & NCV • CT scan • MRI
- 33.
- 34. Lower lateral cutaneous nerveof arm Posterior cutaneous nerve of arm Posterior cutaneous nerve of forearm Dorsal radial sensory nerve Cutaneous innervation from radial nerve
- 35. EMG • Indicates thatthe muscle is innervated or not • But gives no specific indication as to the level of injury to nerve • Denervated muscle show sharp positive consistent waves. • This waves will last until the muscle has become reinvervated or fibrotic.
- 37. NSC • In nerveconduction velocity studies there will be slowed conduction time at a specific point along the course of the nerve
- 39. • Use ofElectrodiagnostic Testing 1. Documentation of injury 2. Location of insult 3. Severity of injury 4. Recovery pattern 5. Prognosis 6. Objective data for impairment documentation 7. Pathology 8. Selection of optimal muscles for tendon transfer procedure
- 40. CT scan &MRI • Used to identify causative factor & site for nerve compression by an anatomical object. • Not always indicated.
- 41. Treatment • Most ofentrapment injuries are managed conservatively with good to excellent result. • Important function to be regained are 1. Wrist extension 2. Metacarpophalangeal joint extension 3. Thumb Extension
- 42. SPLINTS NSAIDS Ultrasound Therapy Gradual rehabilitation programme Removal external offending compression Steroid injection Conservative Treatment
- 43. SPLINTS fullpassive range of motion in all joints of the wrist and hand and prevention of contractures, including that of the thumb- index wrist drop can be treated successfully by splints Barkhalter has observed that grip strength may be increased by 3 to 5 times by simply stabilizing the wrist with splints Many types of splints have been described & Each patient individual need should be addressed Conservative Treatment
- 44. EMG studiesevery 4 week is indicated during conservative treatment If clinical or EMG evidence of recovery ensues within 12 weeks of onset surgical exploration is most likely not indicated
- 45. When anerve deficit follows blunt or closed trauma, and no clinical or electrical evidence of regeneration has occurred after an appropriate time, exploration of the nerve is indicated. If no sign of recovery seen after 12 weeks of conservative therapy, Surgical exploration & Neurolysis with release of all possible offending structure is needed Surgical Exploration
- 46. It providesinternal splint. It restores the power quickly and effectively Advantages are: It works as a substitute during nerve regrowth and largely eliminates an external splint Subsequently the transfer aids the newly innervated and weak wrist extensor It continues to act as a substitute in case nerve regeneration is poor or absent Tendon Transplant
- 47. Tendon transferswork to correct: instability imbalance lack of co-ordination restore function by redistributing remaining muscular forces
- 48. Tendon transplantin radial nerve palsy needs to be provided with (1) wrist extension. (2) finger (metacarpophalangeal [MP] joint) extension. (3) a combination of thumb extension and abduction.
- 49. Radial nerve compressionsyndromes
- 50. Wartenberg’s syndrome /Cheiralgia paresthetica • compression of Superficial radial nerve as it emerges b/w ECRL and BR, 8 cm proximal to radial styloid Dorsal digital nerves ECRL Dorsal Radial Sensory BR Nerve 8 cm Radial styloid
- 51. isolated pain orparesthesias over the dorsoradial aspect of the hand preceding history of trauma to the area (i.e., handcuffs, forearm fracture) Differentiating Wartenberg’s syndrome from de Quervain’s tenosynovitis A Tinel’s sign over the superficial sensory radial nerve is the most common exam finding Clinical features presence of motor weakness suggests a more proximal site of compression Also seen in patients who use forearms in pronated position for extendedperiods → in pronation, the tendons of BR and ECRLapproximate and may compress the nerve ▪In WS, pain is exacerbated by pronation, while in DQT pain is elicited with changes in thumb andwrist position ▪DQT - normal sensation in the dorso-radialhand ▪DQT - pain on percussion over the 1st extensor compartment Electrodiagnostic testing is of limited value in Wartenberg’s syndrome
- 52. Finkelsetein sign Palmar flexion& ulnar deviation increases the sympopms Treatment - Removal of encircling structure ( Wristwatch, Handcuff) - Local Inj.of steroid - Exploration & Neurolysis
- 53. Posterior interosseous nerve(PIN) syndrome • D/t compression of PIN in the radial tunnel • Most common causes include: ▪Tumors such as lipomas, ganglia ▪Rheumatoid synovitis ▪Septic arthritis ▪Vasculitis
- 54. The radial tunnelis a 5cm space bounded by: ▪Dorsally: capsule ofthe radiocapitellar joint ▪Volarly: the BR ▪Laterally: the ECRL and ECRB muscles ▪Medially: the biceps tendon and brachialis muscles Within radial tunnel, there are5 potential sites of compression: ▪fibrous bands to the radiocapitellar joint between the brachialis and BR ▪the recurrent radial vessels (leash of Henry) ▪the proximal edge of the ECRB ▪the proximal edge of the Supinator (arcade ofFröhse) ▪the distal edge of theSupinator BR arcade of Fröhse Supinator ECRL PIN
- 55. Diagnosis • loss offinger and thumb extension • Weak wrist extension with radial deviation (since ECRL innervation is intact) • Intact passive tenodesis effect (rules out extensor tendon rupture) • EMG testing is helpful to confirm the diagnosis and monitor motor recovery
- 56. Radial Tunnel syndrome •Similar to PIN syndrome, it is also d/t compression of PIN in the radial tunnel • Not considered a true compression neuropathy by some
- 57. Radial Tunnel Syndromeis a clinical diagnosis Radial Tunnel Syndrome Tenderness over radial tunnel (lateral proximal forearm, 3-4 cm distal to lateral epicondyle over the mobile wad) Pain at ECRB origin with resistance of middle finger extension Pain with resisted forearm supination ↑ Pain on combined elbow extension, forearm pronation, and wrist flexion