3. RADIAL NEUROPATHY.pdf

ANATOMY, CAUSES OF INJURY, SIGN & SYMPTOMS, INVESTIGATION , SURGICAL & PHYSIOTHERAPY TREATMENT

1. RADIAL
NEUROPATHY
P/B :-DR NIYATI PATEL 1

2. ANATOMY
ROOT VALUE –C5-T1
Arising from posterior cord of spinal cord
MOTOR SUPPLY
1.Triceps Brachii
2.Brachioradialis
3.Anconeus
4.Supinator
5.Extensor Carpi RadialisLongus
6.Extensor Carpi RadialisBrevis
7.Extensor Digitorum
8.Extensor DigitiMinimi
9.Extensor Carpi Ulnaris
10.Abductor PollicisLongus
11.Extensor PollicisBrevis
12.Extensor PollicisLongus
13.Extensor Indicis
SENSORY SUPPLY
P/B :-DR NIYATI PATEL 2

3. P/B :-DR NIYATI PATEL 3

4. CAUSES
Axilla
• Crutch palsy
• Deep penetrating injury in the
axilla
• Diphtheria involving the radial
nerve in the axilla
• Lead poisoning which generally
causes bilateral involvement of the
radial nerve
• Saturday night palsy.
Upper Arm
• Tourniquet’s palsy involving all
three nerves
• Fracture shaft humerus
• Injection palsy
• Gun shot or glass cut injury
• Supracondylar palsy
At the Elbow
• Tennis elbow
• Inflammation of the common extensor
tendon may heal by fibrosis and compress the
radial nerve
• Fracture of the upper end of radius and
ulna
• Direct blow to the posterior interosseous
nerve
• A fibrous arch covers the posterior
interosseous nerve as its passes through the
supinator muscles and can gets compressed
during forceful contraction of the muscles.
• Two layers of supinator can also compress
the nerve against the
aponeurosisof extensor carpi radialisbrevis.
• Compression of the posterior interosseus
nerve due to ganglia, neoplasm, bursae, VIC
and fibrosis after trauma.
P/B :-DR NIYATI PATEL 4

5. SATURDAY NIGHT
PALSY
Sleeping in an armchair
with the limb hanging
by the side of the chair
(Saturday night palsy)
All the muscles are
affected which are
supplied by radial
nerve except triceps
brachhi
P/B :-DR NIYATI PATEL 5

6. POSTERIOR INTEROSEOUS NERVE SYNDROME
The posterior interosseous nerve is a pure motor nerve
and sequentially innervatessupinator extensor carpi
radialisbrevis, extensor digitorumcommunis, extensor
digitiminimi, extensor carpi ulnaris,abductor pollicis,
extensor pollicisbrevis, extensor pollicislongus, and
extensor indicis
In the case of a posterior interosseous nerve
entrapment, the compression occurs within the
musculotendinousradial tunnel.
Motor function is lost but sensory function is remaining
P/B :-DR NIYATI PATEL 6

7. SIGNS AND SYMPTOMS
Sensory
There will be loss of sensation over the following areas
depending
upon the level of lesion.
• Posterior part of the upper arm
• Lower lateral part of the arm
• Posterior part of the forearm
• Posterior part of the hand and the fingers up to the nail beds.
The autonomous zone for the radial nerve is the first web
space.
When the posterior interosseous nerve only is involved then the
patient will not have anesthesiaof the autonomous zone as the
posterior interosseous nerve is a purely motor nerve.
P/B :-DR NIYATI PATEL 7

8. Motor Loss
The following muscles will be involved depending upon
the level of lesion: Triceps, brachioradialis, extensor
carpi radialislongusand brevis, extensor carpi ulnaris,
extensor digitorum, extensor digiti minimi, supinator,
anconeus, abductor pollicieslongus, extensor pollicies
longusand brevis, extensor indicis.
Loss of supination, wrist extension, fingers extension
and thumb extension
Reflex –triceps reflex diminished
Gait assessment –arm swing absent
P/B :-DR NIYATI PATEL 8

9. DEFORMITIES
WRIST DROP
FINGER DROP
THUMB DROP
P/B :-DR NIYATI PATEL 9

10. FUNCTIONAL DISABILITY
The patient generally will have a poor grip due to lack
of wrist extensor as fixator and cannot put objects like
glasses or cups flat on the table.
Following activities are not able to do –combing,
eating, dressing, bathing, gripping, holding small and
large objects
P/B :-DR NIYATI PATEL 10

11. INVESTIGATION
RADIOGRAPH :-shows whether there is presence of fracture
MRI :-To delineate complete avulsion of nerve roots
SD CURVE:-abnormality in conduction can be verified.
Sharp curve, long chronaxie, low rheobaseand the absence
of contraction with repetitive stimuli indicates
denervation. If it is done 2-3 weeks after injury, it shows
the sign of denervation and to find out whether it is
moderate or severe injury
NCV:-To find out the severance of nerve fiberswith
walleriandegeneration.
EMG:-it will help to find out reversible and irreversible
nerve damage and will help map out whether it pre
ganglionic/ post ganglionic lesion
P/B :-DR NIYATI PATEL 11

12. TYPES OF INJURIES
In Neuropraxia pain, numbness, muscle
weakness, minimal muscle wasting is present.
Recovery occurs within minutes to days
In Axonotmesis there is pain, evident
muscle wasting, complete loss of motor,
sensory and sympathetic functions. Recovery
time–months (axon regeneration at 1-1.5
mm/day)
In Neurotmesis no pain, complete loss of
motor, sensory and sympathetic functions.
Recovery time –months and only with
surgery
P/B :-DR NIYATI PATEL 12

13. SPECIAL TESTS
PALM TO PALM TEST
TINEL’S SIGN
P/B :-DR NIYATI PATEL 13

14. SURGICAL MANAGEMENT
Surgery indicated, when there is no improvement by 16 weeks
Complete paralytic injury of more than 2 years duration, need tendon transfer
Limb is immobilised for 5 weeks after surgery
The requirement for restoration of wrist and hand function are:
• Wrist extension
• Finger metacarpophalangealextension
• Thumb extension
• Stability of the carpometacarpal joints of the thumb.
TENDON TRANSFER SURGERIES
Transfer of pronator teresfoe ECRL & ECRB
Transfer of FCR for APL
Transfer of FCU for long finger extensors
Robot jones transfer
Pronator teresfor ECRL & ECRB
FCU for Ext Digitorum
FCR for EPL/EPB/APL
P/B :-DR NIYATI PATEL 14

15. PHYSIOTHERAPY
Pain reduction TENS
Reduced inflammation and oedema keep affected
limb elevated
To maintain muscle properties AROM & PROM For
affected and unaffected limb
IG Current to the paralysed muscles
Massage
Splinting for functional position
Cock up splint
Robert jones splint
P/B :-DR NIYATI PATEL 15