Radial nerve injury

anatomy , what is it , classification , clinical features , associated syndromes , diagnosis , treatment

1. RADIAL NERVE INJURY Eunice Susan Thomson -40

2. INJURY TO RADIAL NERVE RADIAL NEUROPATHY OR RADIAL NERVE PALSY Neuropraxia – compression Axonotmesis – disruption of axon Neurotmesis –complete disruption of nerve

3. ANATOMY Largest branch Arises from – posterior cord of brachial plexus

4. COURSE

5. Motor supply : long head of triceps Motor supply : medial and lateral head of triceps, aconeus Sensory supply : post. Cutaneous nerve of forearm,lower lateral cutaneous nerve of forearm Motor supply : brachialis , brachioradialis Posterior interosseous nerve and superficial radial sensory nerve

6. ETIOLOGY Humeral fractures – during fracture or during surgery Gun shot injury Injuries with sharp object Iatrogenic – upper limb surgery

7. Prolonged application of tourniquet Crutch palsy Intramuscular injections Compression neuropathies Saturday night paralysis

8. CLINICAL FEATURES

9. MOTOR DEFICIT Wrist drop Inability to extend and radially abduct the thumb Difficulty in straightening elbow Difficulty in making a fist Inability to grasp

10. SENSORY LOSS Numbness Weakness B urning sensation

11. CLASSIFICATION OF INJURY High radial nerve palsy - in radial groove Low radial nerve palsy –around the elbow

12. RADIAL NERVE COMPRESSION SYNDROMES

13. WARTENBERG SYNDROME Compression of superficial branch of radial nerve Between extensor carpi radialis longus and brachioradialis Numbness – posterior aspect of the thumb

14. POSTERIOR INTEROSSEOUS NERVE SYNDROME Compression of PIN – radial tunnel Causes : Trauma Lipoma Septic arthritis Pain and weakness of extensors of digits

15. RADIAL TUNNEL SYNDROME Compression of PIN Pain T enderness

16. DIAGNOSIS Muscle strength and function Triceps Brachioradialis TESTING FOR TRICEPS STRENGTH

17. Wrist extensors – Unable to extend Partial paralysis - contraction of Extensor carpi radialis and Extensor carpi ulnaris Extensor digitorum - metacarpo -phalangeal joints Extensor policis longus – inter-phalangeal joint of thumb

18. Electromyography Recording electric activity of muscle Nerve conduction studies Velocity of conduction of impulse in nerve

19. TREATMENT CONSERVATIVE Splintage of paralysed limb : Radial nerve palsy – Cock-up splint

20. COCK-UP SPLINT

21. Preserve mobility of joints – full ROM once daily Maintain hygiene – skin and nails

22. Physiotherapy Massage of paralysed muscles Passive exercises Developing partially affected muscles Analgesics

23. SURGERY- indications High impact nerve injury Severe neuropathic pain Lack of response to conservative management Indif ference to Tinnel test

24. SURGERY Nerve repair Neurolysis Tendon transfer

25. NERVE REPAIR Primary nerve repair Secondary nerve repair

26. Nerve repair Primary nerve repair (1 week) Immediate primary nerve repair : clean nerve cut with limited injury Delayed primary nerve repair : wound contaminated Wound is debrided 2 nerve ends are approximated with fine silk sutures prevent retraction Definitive repair (2 weeks)

27. SECONDARY NERVE REPAIR INDICATIONS : Nerve lesions presenting some time after injury Syndrome of incomplete interruption Syndrome of nerve irritation Failure of conservative treatment (3 weeks)

28. TECHNIQUES NERVE SUTURE NERVE GRAFT

29. NERVE SUTURE Epi -neural suture Epi - perineural suture Perineural suture Group fascicular repair

30. NERVE GRAFTING Nerve gap > 10cm Expandable nerve ( Sural nerve) is sutured to 2 ends

31. NEUROLYSIS Nerve freed from enveloping scar – PERINEURAL FIBROSIS Longitudnal dissection to relieve pressure from fibrous tissue within nerve – INTRANEURAL FIBROSIS

32. RECONSTRUCTIVE SURGERIES Tendon transfers Arthrodesis Muscle transfer

33. TENDON TRANSFERS Correct : Instability Imbalance Lack of co-ordination Redistributing muscular forces – restore function

34. ARTHRODESIS Surgically immobilising a joint by fusing the bones Not preferred

35. PROGNOSIS Age Tension at suture line Time since injury Location of injury Condition of nerve ends Associated condition – infection , ischemia

36. REFERENCE NATARAJAN ‘S TEXTBOOK OF ORTHOPAEDICS AND TRAUMATOLOGY MAHESHWARI ‘S ESSENTIAL ORTHOPAEDICS

37. Eunice Susan Thomson