It describes about Radial nerve its injury clinical evaluation and tests and then management in simple way

1. RADIAL NERVE INJURY AND ITS
MANAGEMENT
BY DR.M.IMRAN ASHRAF

2. RADIAL NERVE
• The radial nerve, a continuation of the
posterior cord of the
• brachial plexus, consists of fibers from C6, C7,
and C8 and
• sometimes T1. It is primarily a motor nerve
that innervates
• the triceps; the supinators of the forearm; and
the extensors
• of the wrist, fingers, and thumb.

3. MUSCLES SUPPLIED BY RADIAL NERVE
• the triceps brachii, brachioradialis, extensor
• carpi radialis, extensor digitorum communis,
extensor carpi
• ulnaris, abductor pollicis longus, and extensor
pollicis longus.

4. LEVEL OF INJURY
• The radial nerve may be injured
• at the elbow,
• in the upper arm
• in the axilla
• PIN compression syndrome
• Radial Tunnel Syndrome

5. • PIN compression syndrome is a compressive
neuropathy of the PIN which affects the nerve
supply of the forearm extensor compartment
• Presents with pain in forarm and wrist can be
diagnosed with resisted pronation test that
will inrease pain
• TX is conservative and surgical decompression

6. five potential sites of compression
fibrous tissue anterior to the radiocapitellar joint
• between the brachialis and brachioradialis
• “leash of Henry”
• are recurrent radial vessels that fan out across the PIN at
the level of the radial neck
• extensor carpi radialis brevis edge
• medio-proximal edge of the extensor carpi radialis brevis
• "arcade of Fröhse"
• which is the proximal edge of the superficial portion of the
supinator
• supinator muscle edge
• distal edge of the supinator muscle

8. • Radial Tunnel Syndrome is a compressive neuropathy of the
posterior interosseous nerve (PIN) at the level of proximal forearm
(radial tunnel)
• Radial Tunnel
• 5 cm in length from the level of the radiocapitellar joint, extending
distally past the proximal edge of the supinator
• boundaries
• lateral
• Brachioradialis,ECRL,ECRB
• medial
• biceps tendon,brachialis
• floor
• capsule of the radiocapitellar joint

10. CLINICAL FEATURES
• Low lesions are usually due to fractures or dislocations
• at the elbow, or to a local wound. Iatrogenic lesions
• of the posterior interosseous nerve where it winds
• through the Supinator muscle are sometimes seen
• after operations on the proximal end of the radius.
• The patient complains of clumsiness and, on testing

11. Low lesions
• cannot extend the metacarpophalangeal joints of the
• hand. In the thumb there is also weakness of extension
• and retroposition. Wrist extension is preserved
• because the branch to the extensor carpi radialis
longus
• arises proximal to the elbow. The wrist is seen to
• extend into radial deviation without the balance of
• the extensor carpi radialis brevis.

12. • High lesions occur with fractures of the humerus
• or after prolonged tourniquet pressure. There is an
• obvious wrist drop, due to weakness of the radial
• extensors of the wrist, as well as inability to extend
• the metacarpophalangeal joints or elevate the
• thumb Sensory loss is limited to a
• small patch on the dorsum around the anatomical
• snuffbox

13. • Very high lesions may be caused by trauma or
operations around the shoulder.
• More often they are due to chronic compression in the
axilla
• this is seen in drink and drug addicts who fall into a
stupor with the arm dangling over the back of a chair
• (‘Saturday night palsy’) or in thin elderly patients
• using crutches (‘crutch palsy’). In addition to weakness
• of the wrist and hand, the triceps is paralyzed and the
triceps reflex is absent

14. Sensory examination
• Sensory examination is relatively unimportant, even
• when the nerve is divided in the axilla, because usually
there
• is no autonomous zone. When present, the autonomous
zone
• usually is over the first dorsal interosseous muscle,
between
• the first and second metacarpals. It usually is too
inconsistent
• to afford more than confirmatory evidence of complete
interruption
• of the nerve proximal to its bifurcation at the elbow

15. Treatment
• Open injuries should be explored and the
nerve repaired or grafted as soon as possible.

16. Treatment
• Closed injuries are usually neurapraxia or
conduction block lesions, and function eventually
returns. In patients with fractures of the humerus
it is important to examine for a radial nerve injury
on admission, before treatment and again after
manipulation or internal fixation.
• If the palsy is present on admission, one can
afford to wait for 12 weeks to see if it starts to
recover. If it does not, then EMG should be
performed; if this shows denervation potentials
and no active potentials, a neurapraxia is excluded
and the nerve should be explored. The results,
even with delayed surgery and quite long grafts,
can be gratifying as the radial nerve has a
straightforward motor function

17. • If it is certain that there was no nerve injury on
admission, and the signs appear only after
manipulation or internal fixation, then the
chances of an iatrogenic injury are high and the
nerve should be explored and if necessary
repaired or grafted without delay.
• Surgical exploration in the absence of
• nerve recovery or advancing Tinel sign may be
indicated at 3 months after injury.
• The results of nerve repair seem to be better
when done before rather than after 6 months

18. • If recovery does not occur, the disability can
be largely overcome by tendon transfers:
• When a nerve repair is performed, and
suitable recovery is anticipated, tendon
transfers generally should be delayed for 6
months

19. • Burkhalter outlined three indications for early tendon
transfer:
• (1) to act as a substitute during regrowth of the nerve,
avoiding use of external splints,
• (2) to act as a helper as reinnervation proceeds,
• (3) to intervene when the results of the nerve repair
are
• considered poor or the nerve is irreparable.
• the transfer of the pronator teres to establish wrist
• extension early creates no disability and that the
transferred unit still functions as a forearm pronator.

20. • In radial nerve injury
• There is loss of following movements
• Elbow extension which achieved by (Elbow
extension Deltoid, latissimus dorsi, or biceps to
Triceps)
• Wrist extension which is achieved by(Pronator
teres to ECRB)
• Finger extensions ..achieved by (FDS, FCR, or
FCU to EDC)
• Thumb extension (Palmaris longus or FDS toEPL)

21. • Radial Nerve Tendon Transfers
• Distinguish High Versus Low Injury
• High (Radial Nerve Proper): Triceps, Brachioradialis,
ECRL (Wrist extension is preserved with a tendency
toward radial deviation secondary to preserved
extensor carpi radialis longus function)
• Low (Posterior Interosseous Nerve): (Supinator, ECRB,
EDC, ECU, EDM/Q, APL, EPL, EPB, EIP
• i.e. Loss of finger extension at MP joints and Thumb IP
extension

24. • Brand (most common)
• Wrist Extension: Pronator Teres (PT) to the Extensor Carpi
Radialis Brevis (ECRB) Tendon Transfer
• Finger Extension: Flexor Carpi Radialis to Extensor
Digitorum Communis Tendon Transfer for Finger Extension
• Thumb Extension Palmaris Longus to Extensor Pollicis
Longus Tendon Transfer
• Perform transfers in sequence: wrist, fingers then thumb

25. Jones
• Wrist Extension: PT to ECRB
• Finger Extension: FCU* to EDC
• Thumb Extension: PL to EPL

26. Boyes
•
• Wrist Extension: PT to ECRB
• Thumb/Finger Extension
• FDS (ring) to EIP/EPL
• FDS (long) to EDC/EDM
• FDS taken through IOM

27. •THANK YOU