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![ A patient with irreparable 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.
Requirements in a Patient with Radial Nerve
Palsy](https://image.slidesharecdn.com/radialnervepalsy-160706134024/75/Radial-nerve-palsy-30-2048.jpg)
Uploaded bymanoj das
Radial nerve palsy
The document provides information about the radial nerve including its anatomy, course, branches and clinical presentations of radial nerve palsies. It discusses the radial nerve's origin from the brachial plexus and branches in the arm and forearm. Common causes of radial nerve palsy include fractures and entrapment in the radial tunnel. Clinical features, investigations, treatment including splinting and tendon transfers, and postoperative management are outlined. Surgical techniques for nerve repair and reconstructive procedures are also described.
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Radial nerve palsy
- 1. RADIAL NERVE PALSY Dr ManojDas Ortho Resident Institute Of medicine, TUTH, Nepal
- 2. • Largest branchof the brachial plexus • Arises from the posterior cord of the brachial plexus (C5–T1) • Mixed nerve Radial Nerve Anatomy
- 3. Course of RadialNerve (RN) in the arm In the axilla, RN lies anterior to subscapularis, teres major and LD • Sensory supply: Posterior cutaneous nerve of arm RN leaves the axilla via the triangular space • Motor supply: long head of Triceps It then comes to lie along spiral groove on posterior aspect of humeral shaft along with arteria profunda brachii • Motor: medial and lateral heads of triceps, Anconeus • Sensory: posterior cutaneous nerve of forearm, lower lateral cutaneous nerve of arm
- 4. RN then leavesthe spiral groove by piercing the lateral intermuscular septum to enter the anterior compartment of the arm, 10-12 cm above the lateral epicondyle • Motor supply: Brachialis (lateral part), BR, ECRL Anterior to lateral epicondyle, RN divides into its terminal branches • Terminal branches: Posterior Interosseous Nerve (PIN) and Dorsal or Superficial radial sensory nerve Here it lies b/w brachialis and BR
- 5. Deep terminal branch→ Posterior interosseous nerve (PIN) Supinator EIP EDC and EDM ECU ECRB Superficial terminal branch Radial Nerve Proper EPL EPB APL PIN reaches the back of forearm by passing around the lateral aspect of the radius b/w the superficial and deep heads of the Supinator to supply all extensor compartment muscles Finally, PIN ends by supplying carpal joint sensation
- 6. BR ECRL Dorsal Radial Sensory Nerve Dorsaldigital nerves Radial styloid 8 cm Dorsal radial nerve courses through the forearm immediately deep to the BR It emerges b/w tendons of BR and ECRL ≈ 8 cm proximal to radial styloid, to become subcutaneous It crosses the anatomical snuffbox b/w EPB and EPL, dividing into multiple branches to supply sensation to hand Course of Radial Nerve (RN) in the forearm
- 7. Lower lateral cutaneous nerveof arm Posterior cutaneous nerve of arm Posterior cutaneous nerve of forearm Dorsal radial sensory nerve Gives sensibility to the 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
- 8. - crutch palsy -aneursysm of axillary vessels Total palsy Aetiology and clinical features Very high radial nerve palsy Clinical features
- 9. - # shaftof humerus -prolonged application of tourniquet -pressure on arm as in Saturday night paralysis -injections -from excessive callus formation of old fracture impinging on the nerve - Elbow extension spared - Lost: Wrist, thumb and finger extension; sensation over 1st web space High radial nerve palsy Clinical features
- 10. -Dislocation of elbow -#neckof radius -Enlarged bursae -Rheumatoid synovitis of elbow -During operation for excision of radius head - Elbow extension spared with weak wrist extension and radial deviation - Lost – thumb , finger extension: sensory over dorsum of 1st web space Low radial nerve palsy Clinical features
- 11.
- 12. Mechanism of injury(e.g. sharp penetrating vs. blunt trauma) Timing of injury Loss of motor and sensory function Presence of pain Interval recovery of function in patients presenting late History
- 13. Assessment of motorfunction Assessment of sensory function Assessment of involved joints Physical Examinatio n Individual muscles innervated by the nerve are tested to determine what is functioning and what is not: ▪Helps to determine the level of injury ▪Guides future surgical planning ▪Elicitation of Tinel’s sign ▪Specific sensory testing Each joint is taken through its passive range of motion to assess for suppleness → presence of fixed joint contractures in delayed presentations is associated with poor treatment outcomes
- 14. Specific sensory tests TestPerception Main receptor Comments Static 2 point discrimination (2PD) Tactile Merkel cell ▪Evaluates sensory receptor innervation density ▪Normal distance: 6mm Moving 2PD Tactile Meissner corpuscle ▪Normal distance: 3mm Tuning fork (250 Hz) Vibration Pacinian corpuscle Tuning fork (30 Hz) Vibration Meissner Semmes-Weinstein monofilament test Pressure Merkel Ten test (moving light touch) Pressure Merkel ▪Reliability comparable to monofilament test Cold-heat test Temperature Free nerve endings•Changes in Vibration and Pressure thresholds are seen in early nerve compression but are unreliable for evaluating nerve lacerations •Changes in sensory receptor innervation density (2PD) are seen in chronic nerve compression but are reliable for evaluating nerve lacerations
- 15. Commonly used EDT -Electromyography(EMG) -Nerve conduction studies (NCS) 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 Electrodiagnostic testing
- 16. Limitations of EDT: ▪Evaluatesonly large myelinated fibres → smaller axons conveying pain and temperature are not assessed ▪Changes in unmyelinated nerve fibres, which are the first to be affected in nerve compressions, are not evaluated ▪Performing the test before 3-6 weeks post injury can give inaccurate results ▪Very proximal or distal nerve injuries are difficult to assess ▪Unreliable assessment of multi-level injuries ▪Examiner dependant
- 17. Nerve conduction studies(NCS) 2 electrodes are placed along the course of the nerve. The first electrode stimulates the nerve to fire, and the second electrode records the generated action potential Amplitude • represents the size of the response • proportional to the number of depolarizing axons in the nerve Latency • the delay in response following stimulation Conduction velocity Sensory nerve action potential (SNAP) • Response obtained when the recording electrodes is placed proximally along the sensory nerve, toward the spinal cord Compound motor action potential (CMAP) • Response obtained when the recording electrodes is placed distally at the target muscle
- 18. Electromyography (EMG) • Activityobserved when a needle electrode is inserted into the muscle Insertional activity • Seen when the muscle is at rest • Absent in normal muscles▪Fibrillation potentials ▪Fasciculations • Generated by the muscle during a voluntary contraction • Evaluates the integrity of neuro- muscular junction Motor unit potentials (MUPs)
- 19. Sequence of eventsin nerve compression Focal demyelination Axonal damage at the compression site Further axonal loss Axonal sprouting producing collateral re-innervation Remyelination following decompression ▪↑Latency ▪↓Nerve conduction velocity Associated Electrodiagnostic findings ▪↓SNAP ▪↓CMAP ▪↑Insertional activity ▪Fibrillation potentials and fasciculations ▪’Giant’ MUPs ▪Normalization of NCV ▪Loss of ‘giant’ MUPs
- 20. Non-operative -full passiverange of motion in all joints of the wrist and hand and prevention of contractures, including that of the thumb-index web - splints 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 TREATMENT
- 21. INTERNAL SPLINT Burkhalterproposed early transfer of PT-ECRB to restore wrist extension as an adjunct to nerve repair. It restores the power grip quickly and effectively since wrist extension is restored 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 Green’s operative hand
- 22. In asharp injury exploration is indicated for diagnostic, therapeutic and prognostic purposes In avulsion , blasting injures –to identification of the nerve injury and making the ends of the nerve with sutures for later repair. When a nerve 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. INDICATIONS FOR SURGERY
- 23. -primary repair givesthe best result with respect to motor,sensory recovery, is indicated in clean sharp nerve injuries and carried out in first 6-8 hours. -delayed,primary repair carried out between 7-18days - primary repair fascicular alignment because of minimal excision of the nerve ends. -Secondary repair-preferable only in crushed,avulsed injuries where patients life is seriously endangered.it is done at delay of 3-6 wks. Time of surgery
- 24. Seddon hassuggested the maximum length of time that may be required for motor recovery to first manifest itself can easily be calculated by measuring the distance on the x-ray from the fracture site to the point of innervation of the brachioradialis muscle (approximately 2 cm above the lateral epicondyle) Green's Operative Hand Surgery Nerve Exploration If No Return After a Longer Waiting Period
- 28. SURGICAL TECHNIQUES Techniquesof neurorrhaphy -partial neurorrhaphy -epineural neurorrhaphy -perineural neurorrhaphy -epiperineural neurorrhaphy -interfasicular nerve grafting
- 29. Tendon transfers Arthodesis Tendon transfers work to correct: instability imbalance lack of co-ordination restore function by redistributing remaining muscular forces RECONSTRUCTIVE PROCEDURES
- 30. A patientwith irreparable 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. Requirements in a Patient with Radial Nerve Palsy
- 31. Robert jonesdescribed 2 sets of tendon transfers 1916: PT - ECRL and ECRB FCU - EDC III,IV,V FCR - EDCII,EIP and EPL 1921: PT - ECRL and ECRB FCU - EDC III,IV,V FCR - EDCII,EIP , EPL,APL ,EPB TENDON TRANSFER
- 32. Green’s operative handsurgery
- 33.
- 34. a long armsplint is applied that immobilizes the forearm in 15 to 30degrees of pronation. the wrist in approximately 45 degrees of extension. the MP joints in slight (10 to 15 degrees) flexion. the thumb in maximum extension and abduction. The proximal interphalangeal joints of the fingers are left free. The cast is removed 4 weeks postoperatively; removable short arm splints to hold the wrist, fingers, and thumb in extension are made, which the patient wears for an additional 2 weeks, removing them only for exercise. Postoperative Management
- 35.
- 36. Wartenberg’s syndrome • Aka:Cheiralgia paresthetica • D/t compression of Superficial radial nerve as it emerges b/w ECRL and BR, 8 cm proximal to radial styloid
- 37. 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 extended periods → in pronation, the tendons of BR and ECRL approximate and may compress the nerve ▪In WS, pain is exacerbated by pronation, while in DQT pain is elicited with changes in thumb and wrist position ▪DQT - normal sensation in the dorso-radial hand ▪DQT - pain on percussion over the 1st extensor compartment Electrodiagnostic testing is of limited value in Wartenberg’s syndrome
- 38. 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
- 39. The radial tunnelis a 5 cm space bounded by: ▪Dorsally: capsule of the radiocapitellar joint ▪Volarly: the BR ▪Laterally: the ECRL and ECRB muscles ▪Medially: the biceps tendon and brachialis muscles Within radial tunnel, there are 5 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 of Fröhse) ▪the distal edge of the Supinator BR Supinator arcade of Fröhse ECRL PIN
- 40. Diagnosis loss of fingerand 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
- 41. 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
- 42. 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
- 43.
- 44. Posterior (Henry orThompson Approach)
- 45.
- 46.
Editor's Notes
- #21 Many types of splints have been designed for patients with radial nerve palsy, most of which offer some type of extension assist.A, In one of the less cumbersome designs, passive MP extension is provided by simple elastic webbing beneath the proximal phalanges.B, Active flexion of the PIP joints is not impeded
- #34 Transfer of pronator teres (PT) to extensor carpi radialis brevis (ECRB), transfer of flexor carpi radialis (FCR) to extensor digitorum communis (EDC), and palmaris longus (PL) to rerouted extensor pollicis longus (EPL). A and B, Volar and dorsal incisions used in combination of transfers. Note short transverse incisions over thumb metacarpal joint dorsally and wrist volarly used in rerouting EPL. C, Transfer of PT into more centralized ECRB. PT insertion is harvested with 2- to 3-cm periosteal extension strip. D, FCR transfer to EDC. FCR motor tendon attachment at 45-degree angle into recipient tendon. E and F, Transfer of PL to rerouted EPL. By rerouting EPL out of its third extensor compartment, combination of thumb abduction and extension can be achieved.