radial nerve palsy

radial nerve palsy

1. Radial Nerve Injury
Early and Late Management
Dr Sumer Yadav
Mch- Plastic and Reconstructive Surgery
[email protected]

2. 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
[email protected]

3. [email protected]

4. 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.
[email protected]

5. 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.
[email protected]

6. 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.
[email protected]

7. 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.

[email protected]

8. 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
[email protected]

9. 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.
[email protected]

10. [email protected]

11. Motor supply
All extensor muscles:
1. Abductor pollicis longus
1. Extensor pollicis brevis
2. Extensor carpi radialis
longus
2. Extensor carpi radialis
brevis
3. Extensor pollicis longus
4. Extensor digitorum
communis
4. Extensor indicis proprius
5. Extensor digiti minimi quinti
6. Extensor carpi ulnaris
[email protected]

12. Motor supply
Triceps (long, medial, lateral)
Anconeus
Brachioradialis
Supinator
[email protected]

13. 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.
[email protected]

14. 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.
[email protected]

15. 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.
[email protected]

16. 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.
[email protected]

17. Etiology
Holstein-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
[email protected]

18. High Radial–
Proximal to
Spiral Groove
High Radial– AT,
or Distal to,
Spiral Groove
Posterior
Interosseous
Neuropathy
Superficial
Radial
Neuropathy
Fracture
Callus
formation
Crutches
“Saturday night
palsy”
Fracture
Callus
formation
Lipoma
Radial artery
aneurysm
Radial tunnel
syndrome
Supinator
syndrome
Monteggia
fracture
Ganglia
Fibroma
Postsurgical
Cheiralgia
paresthetica
Fracture
Postsurgical
Venous
canulation
Laceration
Blunt trauma
[email protected]

19. EXAMINATION OF THE RADIAL
NERVE
Physical Examination
Sensory
pinprick
light touch testing,
Sites
posterior arm
posterior forearm
posterior lateral hand and thumb.
[email protected]

20. 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).
[email protected]

21. 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 normal
Loss of Wrist,
finger, and thumb
extensors
Normal
sensation over
posterior arm
and forearm.
Sensory loss over
posterolateral
hand
[email protected]

22. 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
[email protected]

23. [email protected]

24. 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
[email protected]

25. 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.
[email protected]

26. Acute injury and its management
[email protected]

27. 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.
[email protected]

28. 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
[email protected]

29. 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.
[email protected]

30. 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.
[email protected]

31. 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.
[email protected]

32. 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
`
[email protected]

33. 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
[email protected]

34. Early exploration of the nerve
Advantages
Can know the status of the nerve.
Stabilization of the fracture protects the nerve
Technically easy
Disadvantages
No lesions in more than 95% patients explored
Accurate assessment cannot be made
Nonoperative management is the treatment of
choice in the initial period.
[email protected]

35. 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
[email protected]

36. 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)
[email protected]

37. 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.
[email protected]

38. 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.
[email protected]

39. Nerve Repair
[email protected]

40. Types of repair- epineural
[email protected]

41. Group fascicular Fascicular
[email protected]

42. Epineurial versus group fascicular repair
In a prospective clinical study, no
significant differences were observed
between fascicular repairs and epineurial
repairs.
[email protected]

43. 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.
[email protected]

44. 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
[email protected]

45. Nerve transfers to reconstruct the radial
nerve
Redundant portion of the median nerve
supplying the FDS.
The triceps branch of the radial nerve.
[email protected]

46. 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.
[email protected]

47. 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.
[email protected]

48. Tendon transfer
[email protected]

49. REQUIREMENTS IN RNP
Irreparable RNP needs to be provided with
1.Wrist extension
2.Finger ( MCP) extension
3.Combination of thumb extension and
abduction
Motors available includes
extrinsic muscles innervated by the median
and ulnar nerves
[email protected]

50. 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
[email protected]

51. PRINCIPALS OF TENDON
TRANSFERS
[email protected]

52. 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]

53. 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
[email protected]

54. 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
[email protected]

55. 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
[email protected]

56. 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.
[email protected]

57. Expendable donor
Removal of tendon must not result in
unacceptable loss of function
[email protected]

58. 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.
[email protected]

59. 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
[email protected]

60. 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
[email protected]

61. 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.
[email protected]

62. 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.
[email protected]

63. History
Evolved during the two
world wars
Sir Robert Jones major
inventor of radial nerve
transfers.
Classic Jones transfer
1916
PT – ECRL and ECRB
FCU – EDC 3-5
FCR – EIP, EDC 2 and
EPL
1921
PT – ECRL and ECRB
FCU – EDC 3-5
FCR – EIP, EDC 2, EPL,
EPB and APL
[email protected]

64. 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.
[email protected]

65. History
Evolved into standard set of transfers for
radial nerve palsy:
PT to ECRB
FCU to EDC 2-5
PL to rerouted EPL
[email protected]

66. 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
[email protected]

67. FCU Transfer
The first incision
The FCU tendon is
transected from the
pisiform
Detached as far
proximally as the
incision allows.
[email protected]

68. SEPARATED FROM
DENSE FASCIAL
ATTACHMENTS ►
CARROLL TENDON
STRIPPER
WHEN STRIPPER IS NOT
AVAILABLE ► EXTEND
FIRST INCISION
PROXIMALLY
[email protected]

69. 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.
[email protected]

70. 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.
[email protected]

71. TENDON OF PT IS IDENTIFIED
ITS INSERTION IS FREED UP WITH
AN INTACT LONG STRIP OF
PERIOSTEUM TO ENSURE
SUFFICIENT LENGTH
[email protected]

72. 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
[email protected]

73. The FCU muscle is
pulled subcutaneously
over the ulnar border.
THE FCU TENDON is
weaved through the
EDC tendons at 45
degree angles.
[email protected]

74. 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.
[email protected]

75. 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.
[email protected]

76. Summary of repair
PT to ECRB
FCU to EDC
PL to the EPL
[email protected]

77. 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
[email protected]

78. 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.
[email protected]

79. POST OPERATIVE MANAGEMENT
Planned Exercise Program –To begin at 4
weeks.
Instruct to work in synergistic movements
Maximum recovery occurs in 3-6 months
[email protected]

80. 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.
[email protected]

81. 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
[email protected]

82. 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.
[email protected]

83. SUPERFICIALIS TRANSFER
(Boyes transfer)
Despite the clinical concerns, studies
have shown no functional loss of power
grip with FCU transfer.
[email protected]

84. 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
[email protected]

85. 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)
[email protected]

86. 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
[email protected]

87. 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
[email protected]

88. SUPERFICIALIS TRANSFER
FCR tendon at the base of the thumb is
divided and detached.
And sutured to APL and EPB tendons.
[email protected]

89. Summary of Boyes transfer
PT to ECRB
FDS long to EPI and EPL
FDS ring to EDC
FCR to APL and EPB
[email protected]

90. 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.
[email protected]

91. The finger extensor
tendons are withdrawn
distally and sutured to
the flexor carpi radialis.
After that, reroute the
PL to the EPL.
[email protected]

92. 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
[email protected]

93. 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
[email protected]

94. Splints
Dynamic and static
Stabilizing the wrist in extension imparts
good temporary function.
[email protected]

95. [email protected]

96. 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
Indications
1.Substitute during regeneration of the nerve
to eliminate the need for splintage
2.Act as helper by adding power of normal
muscle to the reinnervated muscles
3.Substitute in cases in which nerve repair
results are poor
[email protected]

97. 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
[email protected]

98. THANK YOU
THANK YOU
[email protected]