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Radial Nerve Injury Early and Late Management
Dr Sumer YadavMch- Plastic and Reconstructive Surgery
Introduction
Loss of radial nerve function in the hand creates a significant disability
Patient can not extend the fingers and thumb and therefore has great difficulty in grasping objects.
Loss of active wrist extension robs grasp and power grip
Anatomy
The radial nerve is the largest branch of the brachial plexus
Continuation of the posterior cord, with nerve fibers from C6, C7, C8, and, occasionally, T1.
The radial nerve innervates the extensor and supinator musculature located in the arm and forearm and provides distal sensation.
Lies first in the posterior compartment of the arm,
Anterior compartment of the arm,
Continues in the posterior compartment of the forearm.
Course
Passes across the LD deep to the axillary artery.
Winds around the medial side of the humerus,
And enters the triceps muscle between the long and medial heads.
Course
It follows the spiral groove of the humerus, piercing the lateral intermuscular septum (10 cm proximal to the lateral epicondyle) from posterior to anterior,
Runs between the brachialis and brachioradialis to lie anterior to the lateral condyle of the humerus.
The nerve then divides into a superficial branch and a deep branch.
The superficial branch, purely sensory, Runs under cover of the brachioradialis
in the forearm. Innervates the radial wrist, dorsal radial
hand, and dorsum of the radial 3.5 digits
The deep branch of the radial nerve, the posterior interosseous nerve,
winds to the dorsum of the forearm, around the lateral side of the radius, and through the muscle fibers of the
supinator.
Motor supply
All extensor muscles:1. Abductor pollicis longus1. Extensor pollicis brevis2. Extensor carpi radialis
longus2. Extensor carpi radialis brevis3. Extensor pollicis longus4. Extensor digitorum
communis4. Extensor indicis proprius5. Extensor digiti minimi quinti6. Extensor carpi ulnaris
Cutaneous innervation
Posterior cutaneous nerve of arm (originates in axilla)
Inferior lateral cutaneous nerve of arm (originates in arm)
Posterior cutaneous nerve of forearm (originates in arm)
The superficial branch of the radial nerve provides sensory innervation to much of the back of the hand, including the web of skin between the thumb and index finger.
Topography
In the proximal part of the nerve monofascicular pattern is seen. Each fasicle cointains a mixture of motor and sensory fibres.
In the distal forearm, the fascicles contain nearly pure motor or pure sensory axons.
Generally, the sensory fascicles are considered to sit more superficially and the motor fibers more dorsal.
Topography – Radial Nerve
Divides into the superficial radial nerve and the posterior interosseous nerve at the level of the supinator
But they can be neurolysed proximally for 7 to 9 cm without any interconnections,
Remaining fairly separate to the level of the spiral groove
The distal sensory fibres are identified and excluded from the repair or harvested and used as a graft.
Etiology
Penetrating injury
Compression injury Saturday night palsy
Crush injury Avulsion or traction injuries,
Ischemia and other non-mechanical factors thermal injury, electric shock, radiation, percussion.
EtiologyHolstein-Lewis fracture
Most commonly caused by fracture of the humerus,
at the junction of the middle and distal thirds. (Holstein-Lewis fracture)
Radial nerve in particular jeopardy The proximal spike of this radial # breaks
through the lateral cortex at a point where the nerve is most closely apposed to the bone
High Radial– Proximal to Spiral Groove
High Radial– AT, or Distal to, Spiral Groove
Posterior Interosseous Neuropathy
Superficial Radial Neuropathy
FractureCallus formationCrutches
“Saturday night palsy”FractureCallus formationLipomaRadial artery aneurysm
Radial tunnel syndromeSupinator syndromeMonteggia fractureGangliaFibromaPostsurgical
Cheiralgia parestheticaFracturePostsurgicalVenous canulationLacerationBlunt trauma
EXAMINATION OF THE RADIAL NERVE
Physical Examination Sensory pinprick light touch testing, Sites posterior arm posterior forearm posterior lateral hand and thumb.
Improper technique may incorrectly suggest median or ulnar weakness.
Inability to stabilize the wrist results in decreased strength in grip (median nerve),
key pinch (ulnar nerve), and thumb palmar adduction (median nerve).
Location Motor Sensory
High Radial– Proximal to Spiral Groove
Weak elbow, loss of wrist, and finger and thumb extension (WRIST DROP)
Sensory loss over posterior arm, forearm, and posterolateral hand
High Radial– At, or Distal to, Spiral Groove
Elbow normalLoss of Wrist, finger, and thumb extensors
Normal sensation over posterior arm and forearm. Sensory loss over posterolateral hand
Location Motor Sensory
Posterior Interosseous Neuropathy
Normal elbow and wrist extensors. Weak finger and thumb extensors
Normal sensation over posterior arm, forearm, and posterolateral hand
Superficial Radial Neuropathy
Normal extensors Sensory loss over posterolateral hand.Normal sensation over posterior arm and forearm
Work up
Radiographs– Radial nerve injury in the arm, X ray of arm to
detect or rule out a fracture– In Posterior interosseous nerve injury, X ray
radius and ulna– rule out elbow or forearm fractures, dislocations
or instabilities, and arthrosis. MRI is useful in detecting tumors such as lipomas
and ganglions
Electro-myographic (EMG) and nerve conduction velocity (NCV)
Help to locate the site of injury Help to monitor the nerve recovery over time. EMGs may not be positive for 3-6 weeks following
injury. EMG may be performed initially to provide a
baseline, but unless the nerve is severed, no changes will be observed for 3-6 weeks.
Timing of nerve repairs
Open injuries Require early exploration. Sharp lacerations can be repaired immediately and
directly. Wound must be relatively clean and free of gross
contamination. A primary repair is not recommended with injuries secondary to a crush injury significant soft tissue damage.
At 3 weeks (or when the wound permits), the nerve is re-explored, and definitive repair or graft can be performed.
At the time, the zone of injury is apparent based on the extent of scar formation.
Open injuries
Gunshot wound
Exception to the general rule of early exploration of open injuries.
Mechanisms of nerve damage are predominantly heat and shock effects.
They are treated as closed trauma.
Closed injuries
In closed or blunt trauma, initial management is expectant with close observation.
If complete recovery is not observed within 6 weeks,
Electrodiagnostic studies should be obtained
for baseline evaluation.
Monthly clinical and EMG evaluation If motor unit potentials are seen with EMG,
► spontaneous reinnervation is anticipated,
Lack of clinical or electrical evidence of reinnervation at 3 months requires operative exploration.
Intra operative nerve conduction study.
Electric activity is present
Grade 2 or 3 injury Neurolysis is done
No electrical activity Grade 4 or 5 injury Injured nerve is excised and nerve is grafted
RNP with Fracture Humerus
Incidence 1.8% to 18% Managed in three ways Early exploration of the nerve Exploration at 6 to 8 weeks Exploration after longer waiting
Early exploration of the nerve
Advantages Can know the status of the nerve. Stabilization of the fracture protects the nerve Technically easyDisadvantages No lesions in more than 95% patients explored Accurate assessment cannot be madeNonoperative management is the treatment of
choice in the initial period.
Exploration at 6 to 8 weeks
An unnecessary operation is avoided No interference with fracture healing
Absence of advancing Tinels sign is an added indication for exploration at 6 to 8 weeks
Exploration after longer waiting
Initial signs of recovery may take 4 or 5 months
Time for recovery can be calculated.
Distance from the fracture site to the point of innervation of Brachioradialis ( 2 cm above the lateral epicondyle)
Sufficient time
Regeneration start in about 21 to 30 days after the repair.
Proceeds at the rate of 1mm/ day About 21 to 30 days to establish neuro-
muscular continuity.
Choice of management
Patients are treated non operatively initially Exploration only after a realistic waiting
period Indications for early exploration Open fractures Operative intervention for # reduction Associated with vascular injuries Patients with multiple trauma.
Epineurial versus group fascicular repair
In a prospective clinical study, no significant differences were observed between fascicular repairs and epineurial repairs.
Tension on the repair
Gapping at the repair, ischemia, and scar formation.
Postural maneuvers to decrease tension should be avoided.
Extensive mobilization should be avoided. Mobilization of the nerve for 1 to 2 cm can
provide some relief of tension.
Management of a nerve gap
Methods of reconstruction significant nerve gap
Grafting with non-vascularized, autogenous nerve- Gold standard
Vascularized nerve grafting Conduit interposition Nerve allograft
Nerve transfers to reconstruct the radial nerve
Redundant portion of the median nerve supplying the FDS.
The triceps branch of the radial nerve.
Postoperative management
Early range of motion is critical. On Day 3, Dressings are removed,
wounds are examined. The repair sites are protected
using splints for 2 weeks.
Postoperative management
After the short period of protection, restricted movements are started.
Goals are to regain full passive range of motion prevent joint stiffness and contractures. Later-stage rehabilitation is focused on motor
or sensory re-education.
REQUIREMENTS IN RNP
Irreparable RNP needs to be provided with 1. Wrist extension2. Finger ( MCP) extension3. Combination of thumb extension and
abduction Motors available includes extrinsic muscles innervated by the median and ulnar
nerves
Nerve repair verses tendon transfers
Time since injury is critical factor If prognosis of nerve repair is poor it would
be prudent to proceed directly to tendon transfers
Nerve grafts can be used if the gap is too great
Results are better if grafts are less than 5 cm
Correction of contractures
All joints must be kept supple Easier to prevent than to correct Maximum motion must be present before a
tendon transfer No tendon transfer can move a stiff joint, Impossible for a joint to have more active motion
post-op than passive motion pre-op [email protected]
Adequate strength
Avoid a muscle that was previously denervated and now has returned to function
A muscle will usually loose one grade of strength after transfer
Amplitude of motion
Wrist flexors and extensors : 33 mm Finger extensors and EPL : 50 mm Finger flexors : 70 mm Impossible for a wrist flexor with an
excursion of 33 mm to substitute fully for a finger extensor that requires an amplitude of 50 mm
Tenodesis effect
Convert from monoarticular to biarticular FCU transferred to EDC is converted to
multiarticular Effective amplitude of tendon is increased by
active volar flexion of wrist. Thereby allowing the transferred wrist flexors
to extend the fingers fully
Straight line of pull
One tendon - one function If inserted into two tendons, the force and
amplitude of the donor tendon will be dissipated and will be less effective.
Expendable donor Removal of tendon must not result in
unacceptable loss of function
Tissue equilibrium
It implies that No soft tissue induration Wounds are mature Joints are supple The scars are soft Consider providing new tissue cover with
flaps.
Tissue equilibrium
Tendon transfer works best when passed between subcutaneous fat and deep fascial layer
Least likely to work in the pathway of scar Skin incisions should be planned so as to
place tendon junctures beneath flaps rather than directly beneath incisions
Timing of tendon transfers
Early - when there is questionable or poor prognosis of nerve repair.
Nerve gap is more than 5 cm Large wound Extensive scaring Skin loss over the nerve
Timing of tendon transfers
In other cases consider doing nerve repair. If good nerve repair has been accomplished
wait a sufficient time before transfers. Which is determined by Seddon’s figures for
nerve regeneration about 1 mm per day.
Timing of tendon transfers
Little support for Bevins concept Proceed directly to tendon transfer and never
repairing the nerve Results of radial nerve repair are good to
warrant routine repair in all cases.
History
Evolved during the two world wars
Sir Robert Jones major inventor of radial nerve transfers.
Classic Jones transfer
1916PT – ECRL and ECRBFCU – EDC 3-5FCR – EIP, EDC 2 and EPL1921PT – ECRL and ECRBFCU – EDC 3-5FCR – EIP, EDC 2, EPL, EPB and [email protected]
History
Jones used both strong wrist flexors. Zachary showed that it is desirable to leave
to leave atleast one wrist flexor intact. PL alone is not adequate to provide for wrist
flexion.
Scuderi rerouted the PL to EPL.
History
Evolved into standard set of transfers for radial nerve palsy:
PT to ECRB FCU to EDC 2-5 PL to rerouted EPL
Tendon transfer
INFINITE NUMBER OF POSSIBLE COMBINATIONS AVAILABLE
THREE SETS OF TRANSFERS ARE WIDELY USED USING FCU BOYES’ PROCEDURE—UTILISES SUPERFICIALIS TENDON
FOR FINGER EXTENSION STARR’S METHOD –UTILISES FCR INSTEAD OF FCR
IN POSTERIOR INTEROSSEOUS NERVE PALSY, PT TRANSFER IS NOT NECESSARY THE INDICATION FOR FCR TRANSFER
FCU Transfer
The first incision The FCU tendon is
transected from the pisiform
Detached as far proximally as the incision allows.
SEPARATED FROM DENSE FASCIAL ATTACHMENTS► CARROLL TENDON STRIPPER
WHEN STRIPPER IS NOT AVAILABLE ► EXTEND FIRST INCISION PROXIMALLY
The second incision Begins 2 inches below the
medial epicondyle and angles across the dorsum of the proximal forearm, moving directly toward the Lister tubercle.
The rest of the fascial attachments to FCU muscle is incised.
The third incision begins on the volar-radial
aspect of the mid forearm, passes dorsally around the radial border of the forearm in the region of insertion of the pronator teres (PT) muscle, and angles back on the dorsum of the distal forearm towards the Lister tubercle.
TENDON OF PT IS IDENTIFIED
ITS INSERTION IS FREED UP WITH AN INTACT LONG STRIP OF PERIOSTEUM TO ENSURE SUFFICIENT LENGTH
The PT tendon is passed subcutaneously around the radial border of the forearm,
Superficial to the BR and ECRL
Inserted into the ECRB muscle just distal to its musculotendinous junction.
ECRL NOT INCLUDED WRIST IN 45 DEGREE
EXTENSION
The FCU muscle is pulled subcutaneously over the ulnar border.
THE FCU TENDON is weaved through the EDC tendons at 45 degree angles.
Suture FCU tendon into each EDC slip separately with 4-0 non absorbable suture
Adjust the tension in each EDC tendon individually so that all 4 MP joints can extend synchronouly & evenly
Wrist & MP joints in neutral (0 degrees) & FCU under maximum tension.
The EPL is divided and rerouted toward the volar aspect.
The PL tendon is transected at the wrist and detached proximally to allow a straight line of pull between the PL and EPL tendons.
Keep wrist in neutral & with maximum tension on both EPL & PL.
SETTING THE PROPER TENSION IN THE SUTURES IS ESSENTIAL
SUTURES SHOULD BE TIGHT ENOUGH --- CONSIDERING THE FACT THAT
EXTENSORS GET STRETCHED WITH TIME TO PROVIDE FULL EXTENSION, YET NOT
SO TIGHT AS TO RESTRICT FULL FLEXION
POST OPERATIVE MANAGEMENT
LONG ARM SPLINT – FOREARM IN 15-30 DEGREES
PRONATION, WRIST IN 45 DEG EXTENSION, MP JOINTS IN 10-15 DEG FLEXION THUMB IN MAXIMUM ABDUCTION. PIP JOINTS ARE LEFT FREE. Remove SPLINT after 4 weeks.
POST OPERATIVE MANAGEMENT
Planned Exercise Program –To begin at 4 weeks.
Instruct to work in synergistic movements Maximum recovery occurs in 3-6 months
POTENTIAL PROBLEMS
Excessive radial Deviation -Due to removal of FCU -Aggravated if PT is inserted in ECRL In patients with PIN palsy FCU transfer is
contraindicated Do Boyes’ superficialis transfers or FCR
transfer.
Absence of Palmaris Longus
Compromises FCU set of transfers. Include the EPL into the FCU to EDC transfer,
limits the abduction component of the transfer. BR( brachioradialis )can be used only in Post
interosseous nerve palsy FDS 3 or 4 can be substituted for absent PL
(Tsug& Goldner) Boyes superficialis transfer is the preferred
method in absent PL
SUPERFICIALIS TRANSFER(Boyes transfer)
In 1960 Boyes offered a reasonable alternative to the standard set of transfer.
FCU is a more important wrist flexor to preserve Normal axis of wrist motion is from dorsiradial to
volar-ulnar FCU is too strong and its excursion too short for
transfer to the finger extensors Prime ulnar stabilizer of wrist is too important to
sacrifice.
SUPERFICIALIS TRANSFER(Boyes transfer)
Despite the clinical concerns, studies have shown no functional loss of power grip with FCU transfer.
SUPERFICIALIS TRANSFER(Boyes transfer)
Full active extension of fingers with an FCU or FCR transfer can be achieved only by simultaneous volar flexion of the wrist, relying on the tenodesis effect of the transfer.
Boyes concluded that because of the greater excursion (70mm) FDS was a ideal motor for finger extensors
New transfer provided for independent control of thumb and index finger
SUPERFICIALIS TRANSFER(Boyes transfer)
The combination of transfer are PT to ECRL and ECRB FCR to ECB and APL FDS ring to EDC (via interosseous
membrane) FDS long to EPL and EIP (via interosseous
membrane)
SUPERFICIALIS TRANSFER(Boyes transfer)
The PT to ECRB transfer is done. Expose superficialis of long & ring finger
through distal palm transverse incision . Make opening in interosseous membrane. Protect both anterior & posterior
interosseous vessels Divide tendons & deliver them through
forearm wound
SUPERFICIALIS TRANSFER
FDS 2 routed to radial side of profundus mass through the interossous membrane
FDS 3 routed to ulnar side of profundus mass Avoid injury to median nerve FDS 2 is intervowen into tendons of EIP,EPL FDS 3 into EDC
SUPERFICIALIS TRANSFER
FCR tendon at the base of the thumb is divided and detached.
And sutured to APL and EPB tendons.
Summary of Boyes transfer
PT to ECRB
FDS long to EPI and EPL FDS ring to EDC
FCR to APL and EPB
FCR transfer
PT to the ECRB transfer is performed. The FCR tendon is exposed through a longitudinal incision on
the volar-radial aspect of the forearm. The tendon is divided at the wrist and redirected around the
radial border of the forearm to the wrist dorsally via a subcutaneous tunnel.
The finger extensor tendons are withdrawn distally and sutured to the flexor carpi radialis.
After that, reroute the PL to the EPL.
CHOICE OF SURGERY
RADIAL OR INTEROSSEOUS N PALSY— FCR SET OF TRANSFERS
LEAVES THE FCU INTACT WHICH IS A PRIME ULNAR STABILIZER OF THE WRIST
BOYE’S SET BEST FOR PTS WITH NO PL FCU SET OF TRANSFERS
CONTRAINDICATED IN PTS WITH POSTERIOR INTEROSSEOUS N PALSY
NONOPERATIVE TRETMENT
Maintenance of full passive range of movement in all joints of wrist and hand
Prevention of contractures mainly thumb and index web
Physiotherapy has to be thought and closely monitored
Splints Dynamic and static Stabilizing the wrist in extension imparts
good temporary function.
INTERNAL SPLINT (Early transfers) Early PT to ECRB transfer to eliminate the need for an
external splint and to restore some amount of power grip Indications1. Substitute during regeneration of the nerve to eliminate
the need for splintage2. Act as helper by adding power of normal muscle to the
reinnervated muscles3. Substitute in cases in which nerve repair results are
poor
INTERNAL SPLINT
PRICIPLES OF TRANSFERS Do not decrease remaining function in hand Do not create deformity Be a phasic transfer or capable of phase
conversion Early PT to ECRB transfer fulfills all these
indications and principals so can be done at the time of radial nerve repair or soon thereafter
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