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Flashcards in Radial nerve compression Deck (35):
1

Define PIN compression syndrome?

 Compressive neuropathy of PIN effective the muscular supply of the forearm EXTENSOR compartment

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2

What is the epidemiology of PIN compression syndrome?

  • 3 per 100,000 people pa
  • More common in
    • manual labourers
    • males
    • bodybuilders

3

Describe the aetiology of PIN compresison syndrome?

  • Trauma- fracture/dislocation monteggia/radial head fr
  • Microtrauma- repitive pronosupination movements
  • Space filling lesions- ganglions/lipomas
  • Inflammation - rheumatoid synovitis
  • Iatragenic- surgery

4

Describe the pathoanatomy of PIN compression syndrome?

  • 5 potential sites of compression= FLEAS
  • Fibrous tissue ant to radiocapitellar joint
    • between brachialis/brachioradialis
  • Leash of Henry
    • recurrent radial vessels fan out across PIN at level of radial necl
  • Extensor carpi radialis brevis edge
    • mediporx edge of ECRb
  • Arcade of Frohse
    • prox edge of superficial portion of Supinator
  • Supinator Muscle edge
    • Distal edge of supinator muscle

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5

Decribe the anatomy of PIN?

  • Branch of radial nerve
  • Provides motor innervation EXTENSOR compartment

Course

  • Passes between 2 heads of supinator muscle
  • Direct contact with radial neck 
  • Passes over Abductor pollicis longus to reach interosseous membrane
  • transverses along posterior interossesous membrane

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6

What does PIN supply?

Common extensors

  • ECRB
  • EDC
  • EDM
  • ECU

Deep Extensors

  • Supinator
  • Abductor pollicis longus
  • Extensor pollicis brevus
  • Extensor pollicis longus
  • Extensor incidis proprius

Sensory

  • sensory fibres to dorsal wrist capsule- by terminal branch
  • Located on floor of 4th EXTENSOR COMPARTMENT 

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7

What are the symptoms and signs of PIN compression syndrome?

Symptoms

  • Insidous onset
  • Pain in forearm & wrist- location depends on site of compression
  • Weakness with finger, wrist and thumb movements

Signs

  • Chronic compression- muscle atrophy
  • Weakness- finger metacarpal extension
  • Wrist extension weakness
  • inability to extend wrist in neutral/ulna deviation.
  • Wrist will extend with RADIAL deviation due to intact ERCL ( radial N) and absent ECU ( PIN)
  • ​​Provocation test
    • RESISTED SUPINATION- Increase Pain
    • Normal Tenodesis effect - Ra ext tendons won't

8

Are any investigations helpful in PIN compression syndrome?

  • Yes MRI- maybe helpful to deliniate the soft tissue mass responsible for compression
  • EMG- may be helpful to identify level of compresion adn rule out differential diagnosis of neuropathy

9

What is the DDX of forearm pain and weakness?

  • PIN compression syndrome
  • Brachial plexus compression
  • Cervical spine nerve compression
  • Peripheral neuropathy

10

Describe the TX of PIN compression syndrome?

Non operative

  • Rest, activity modification, stretch, splinting, NSAIDS
  • Cortiosteriod injection if compressive mass ruled out and isolated tenderness distal to lateral epicondyle
    • single injection 3-4 cm to lat epicondyle at site of compression

Operative

  • Surgical decompression
    • symptoms >3mo of non op tx
    • compressive mass detected on investigations
    • Outcomes variable- spontaneous recovery of motor function seen in 75-97% of non traumatic cases
    • may continue to improve for up to 18 mo

11

Describe the technique for surgical decompression of PIN syndrome?

Approach

  • Anterolateral to elbow most common
  • Release first..
    •  Fibrous band connecting Brachialis and brachioradialis
    • leash of Henry
    • Fibrous edge of ERCB
    • Radial tunnel inc arcade of Frosche and distal supinator

12

Name the complications of PIN compression syndrome?

  • Muscle fibrosis of PIN innervated muscles -> tendon transfer procedures to establish funciton
  • Chronic Pain

13

What is the last muscle to recover in PIN compression syndrome?

  • Extensor indicis Proprius

14

What is radial tunnel syndrome?

  • A compressive neuropathy of PIN with PAIN ONLY
  • No motor or sensory dysfunction

15

Describe the pathophysiology of radial tunnel syndrome?

involves the same sites as PIN compression syndrome

  • Fibrous band between Brachialis and brachoradialis, anterior to radiocapitellar joint
  • Leash of Henry- radial recurrent vessels 
  • ECRB  medial border
  • Arcade of Frohse prox edge of supinator- most frequent site of entrapment
  • Supinator distal border edge

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16

Can you describe any associated conditions of radial tunnel syndrome?

  • Lateral Epicondylitis
  • RTS is difficult to distinguish from lateral epicondylitis and coexts in 5% pts

17

Describe the anatomy of the radial tunnel?

  • 5cm in length
  • Extends from level of radiocapitellar joint extending distally past the proximal edge of supinator
  • Boundaries
    • lateral
      • Brachioradialis
      • ECRB
      • ECRL
    • medial
      • Biceps tendon
      • Brachialis
    • Floor
      • capsule of radiocapitellar joint

18

Describe the signs and symptoms of radial tunnel syndrome?

Symptoms

  • Deep aching pain in DORSAL RADIAL PROXIMAL forearm
    • From lateral elbow to wrist
    • increased during forearm rotation/lifting
    • muscle weakness due to pain

Signs

  • Tenderness over wad in supinator arch
  • Max tenderness 3-5cm distal to Lat epicondyle
  • Resisted long finger extension->pain at tunnel
  • Resisted supination ( elbow/wrist in extension)
  • Passive pronation-> pain
  • Radial tunel injection test- positive= PIN palsy, PAIN relief

 

19

Investigations in radial tunnel syndrome?

  • MRI usually negative
  • EMG- inconclusive as PIN carries Group IV fibres- (C fibres, nioception) and small myelinated Group IIA afferent fibres( temperature)
    • Pressure on these nerves causes pain
    • these fibres can't be evaluated by EMG
    • large myelinated PIN fibres remain normal so EMG normal
  • Diagnostic injection into area of local tenderness

20

What is the DDX of lateral forearm pain?

  • Radial tunnel syndrome- tenderness 305cm distal to lat epi
  • Lateral epicondylitis- tenderness directly over Lat epicondyle
  • Cervical radiculopathy C6-7

21

What is Tx of the radial tunnel syndrome?

Non operative

  • Activity modification, temporary splinting, nsaids
  • Corticosteriods

70% improvement at 6 weeks

60% painfree at 2 years

Operative

  • Radial tunnel release
  • Disappointing outcomes only 50-90% gd-ex recovery
  • delayed max recovery up to 9-18 months
  • lower success in concomitant lat epicondylitis, multiple entrapment neuropathies and workers compensation

 

22

Describe the technique for radial tunnel release?

Approach

  • Dorsal approach to PIN
    • 3 planes have been described
    • between ERCB and EDC
    • Between brachioradialis and ERCL
    • Transmuscular brachioradialis spliting
  • ​Anterior approach to PIN
    • ​Between brachioradilis and biceps
  • ​Release

    • fibroud bands superificial to radiocapitellar joint 


    • arcade of Frohse

    • distal edge of supinator
  • Outcomes= success rate decompression 70-90%

 

23

What is Wartenberg's syndrome?

  • Compressive neuropathy of Superficial radial nerve
  • aka Cheiralgia paresthetica
  • Sensory manifestation only
  • no motor deficit

24

What is the epidemiology of Wartenberg's syndrome?

  • Rare
  • Female : Male 4:1
  • Age 20-70 years

25

Describe the pathoanatomy of Wartenberg's syndrome?

  • Superficial radial nerve compressed by SCISSORING action of Brachioradialis & ERCL tendons during forearm PRONATION
  • also fascial bands at its exit site in subcutaneous tissue

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26

Name any associated conditions with Wartenberg's syndrome?

  • De Quervain's Disease in 20-50%

27

What is the prognosis of Wartenberg's syndrome?

  • Spontaneous resolution is common
  • 74% success after surgical decompression

28

Describe the course of the superificial radial nerve?

  • Arises from the bifircation of the radial nerve in the proximal forearm
  • travels DEEP to brachioradialis in forearm
  • emerges from BETWEEN Brachioradialis & ERCL 9cm Proximal to RADIAL STYLOID
  • Bifurcates proximal to wrist
    • dorsal branch lies 1-3cm radial to lister's tubercle
    • supplied 1st /2nd web space
    • palmar branch passes 2cm of 1st dorsal compartment directly over EPL- supplies dorsolat thumb

29

Describe the Signs and symptoms of Warternberg's syndrome?

Hx

  • maybe of trauma- forearm fracture
  • handcuffs
  • tight wrist band/ wrist watch , bracelet or pop

Symptoms

  • ILL defined pain over DORSALRADIAL  hand- no watch!!
  • Paresthesia over dorsalradial hand
  • Numbness
  • worse w repetitive wrist flexion/ulnar deviation
  • no motor weakness

​Signs

  • Tinel's signover superficial sensory radial nerve
  • Wrist flexion, ulnar deviation & pronation for 1 min
  • Finklestein test

Investigaitons limited- emg limited, diagnostic wrist block

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30

What is the DDX of ill-defined forearm pain and parathesia?

  • De Quervain's Tenosynovitis- Pain not aggrevated by wrist pronation
  • Lateral antebrachial cutaneous nerve neuritis- positive tinels over LACN mistaken for SSR nerve
  • Intersection syndrome- dorsoradial swelling, crepitus on wrist flexion/extension
  • Wartenberg's syndrome

31

Describe the tx of Wartenberg's syndrome?

Non operative

  • Rest, activity modification, nsaids, wrist splints
  • Corticosteriod injections - linited evidence

Operative

  • Surgical decompresion- symptoms >6 months

 

32

Describe the surgical decompression technique?

Approach

  • longitudinal incision volar to Tinsel's sign
    • to avoid Lateral antebrachial cutaneous nerve
    • to avoid tethering of incision scar over sup radial Nerve
  • Neurolysis 
  • Release fascia betwen Brachioradialis and ERCL

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33

What are the complications of Wartenberg's syndrome?

  • Failed Decompression
  • Persistent Pain and numbness
  • wound dehiscence
  • Infection

34

35

Describe the course of the radial nerve?

  • Arises posterior cord brachial plexus C5-8 roots
  • descends anteriorly to Subscapularis, teres major, lat dorsi
  • continues lateral and posterior to run in spiral groove of proximal humerus
  • passes beneath LATERAL head of TRICEPS to PIERCE LATERAL INTERMUSCULAR SEPTUM as it courses from POST to ANT compartments
  • IN cubital fossa - emits muscular branches to BRACHIALIS, BRACHIORADIALIS, ERCL.
  • Then divides into PIN and SENSORY RADIAL NERVE
  •  Level of RADIOHUMERAL joint PIN enters radial tunnel.

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