[RADIAL TUNNEL SYNDROME].

INTRODUCTION: The radial tunnel syndrome (RTS) is an entrapment of the radial nerve in the forearm. It is characterized by pain focused on the trapping area in the proximal forearm as well as pain radiated down the forearm. The syndrome is more common in men and in our estimation, there is a circumstantial connection to the continuous use of the computer keyboard. Radial tunnel syndrome is a consequence of nerve entrapment in the tunnel, which is formed from a covering consisting of the supinator muscle and the distal margins of this muscle. There is a clear association between radial tunnel syndrome and the occurrence of tennis elbow. The sensitivity in nearby locations along with the lack of familiarity of some of the clinicians with RTS lead to misdiagnosis and therefore, even to mistreatment in some cases. The physical examination is the most important means of making the correct diagnosis. The treatment of radial tunnel syndrome is divided into the conservative one in which emphasis is placed on physiotherapy and mobilizations of the nerve and the surgical one during which decompression of the radial canal is performed and in fact release of pressure at the exact anatomical location.

Acute compressive radial neuropathy and wrist drop due to the repetitive overuse of the arm.

OBJECTION: Entrapment neuropathies are common in clinical practice. Early diagnosis and management of nerve compression is necessary to maintain limb function and to improve the patient's quality of life. CASE REPORT: In this article, we reported a woman presenting with wrist drop as a result of acute radial nerve compression following strenuous activity involving the arms. The diagnosis was based on clinical and ultrasonographic findings. Once the diagnosis was made, activity modifications and systemic steroid were prescribed, and the patient made a near-complete recovery. CONCLUSION: Patients with acute wrist drop and sensorial loss should be examined in terms of arm overuse, and radial nerve compression should be confirmed by peripheral nerve ultrasound.

Radial nerve injuries.

Radial nerve injuries continue to challenge hand surgeons. The course of the nerve and its intimate relationship to the humerus place it at high risk for injury with humerus fractures. We present a review of radial nerve injuries with emphasis on their etiology, workup, diagnosis, management, and outcomes.

Low profile radial nerve palsy orthosis with radial and ulnar deviation.

Individuals who sustain damage to the radial nerve experience a significant loss in functional use of the hand. Traditional orthoses have been effective in providing assistance with wrist stabilization and finger/thumb MP extension. These authors adapted a low profile orthosis to provide the necessary support while allowing radial and ulnar deviation of the wrist, thus increasing functional use of the hand.--Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

Bilateral radial nerve compression neuropathy in the newborn.

PURPOSE: This study aims to discuss the diagnosis and management of radial nerve compression neuropathy in the newborn. METHODS: A personal case is presented, followed by a review and analysis of clinically similar cases identified via a PubMed search of published medical literature. RESULTS: We report a case of a term newborn with bilateral radial neuropathy at the humerus level. Despite severe axonal involvement in the electrophysiological evaluation, the patient showed complete bilateral recovery after 3 months of follow-up. CONCLUSIONS: Isolated radial nerve palsy is a rare event in the newborn. The condition does not require surgical treatment and usually proceeds to full and rapid spontaneous recovery.

Posterior interosseous neuropathy in the distal radial tunnel in a contrabassoon musician.

OBJECTIVE: Bassoonists seem to have a high recorded prevalence of performance-related upper limb symptoms. Yet, the background for their symptoms has not been established. This study aimed to diagnose and treat the pathology that caused severe upper limb symptoms in a bassoon/contrabassoon musician in order to allow him to continue his professional career in a symphony orchestra. METHODS: A detailed neurological bedside examination was undertaken and targeted physiotherapy offered. RESULTS: The physical examination demonstrated weakness, atrophy, and nerve trunk soreness, indicating an affliction of the posterior interosseous nerve (radial tunnel syndrome) or its muscular branches. The risk factors during bassoon playing are comparable to those reported from industrial exposures. The patient was able to resume playing after treatment by nerve mobilisation.

Secondary radial nerve palsy after internal fixation of humeral shaft fractures.

OBJECTIVE AND BACKGROUND: There was no agreement with regard to the treatment for secondary radial nerve palsy. This study aimed to investigate at what point should exploration of the nerve be considered. METHODS: One hundred and twenty-five patients with fracture of the diaphyseal humerus treated with internal fixation at our hospital from February 2000 to February 2010 were reviewed retrospectively. There were six cases of secondary radial nerve palsy occurred soon after humeral internal fixation. No recognized intraoperative injuries to the radial nerve were recorded. Initial conservative observation was carried out in all six cases. RESULTS: Follow-up period averaged 28 months (range 24-37 months). In four cases, the beginning of electromyography recovery averaged 3.5 months (range 1-5 months), the meantime of onset of clinical recovery was 4.8 months (range 1-6 months), and the average time to full recovery of wrist and finger extension was 8.5 months (range 3-12 months). In other two cases, nerve exploration was made when there was no nerve recovery 3 months after internal fixation of humeral fracture at the request of patients. There were no macroscopic lesions of the radial nerve. At 2-year follow-up, extension of wrist and finger recovered to nearly normal in these two cases. CONCLUSIONS: For treatment for secondary radial nerve palsy, it seems reasonable to consider watchful waiting for about 5 months before nerve exploration if the decision as to the period of waiting was based on the clinical recovery onset time.

Radial nerve palsy in the newborn combined with congenital radial head dislocation: Case report and literature review.

RATIONALE: Radial nerve palsy in the newborn and congenital radial head dislocation (CRHD) are both rare disorders, and early diagnosis is challenging. We reported a case of an infant with concurrent presence of these 2 diseases and provide a comprehensive review of the relevant literature. The purpose of the study is to share diagnostic and treatment experiences and provide potentially valuable insights. PATIENT CONCERNS: A newborn has both radial nerve palsy and CRHD, characterized by limited wrist and fingers extension but normal flexion, normal shoulder and elbow movement on the affected side, characteristic skin lesions around the elbow, and an "audible click" at the radial head. The patient achieved significant improvement solely through physical therapy and observation. DIAGNOSES: The patient was diagnosed with radial nerve palsy in the newborn combined with CRHD. INTERVENTIONS: The patient received regular physical therapy including joint function training, low-frequency pulse electrical therapy, acupuncture, paraffin treatment, as well as overnight splint immobilization. OUTCOMES: The child could actively extend the wrist to a neutral position and extend all fingers. LESSONS: If a neonate exhibits limited extension in the wrist and fingers, but normal flexion, along with normal shoulder and elbow movement, and is accompanied by skin lesions around the elbow, there should be a high suspicion of radial nerve palsy in the newborn.

Radial Tunnel Syndrome: Review and Best Evidence.

Radial tunnel syndrome (RTS) is caused by compression of the posterior interosseous nerve and consists of a constellation of symptoms that have previously been characterized as aspects of other disease processes, as opposed to a distinct diagnosis. First described in the mid-20th century as "radial pronator syndrome," knowledge regarding the anatomy and presentation of RTS has advanced markedly over the past several decades. However, there remains notable controversy and ongoing research regarding diagnostic imaging, nonsurgical treatment options, and indications for surgical intervention. In this review, we will discuss the anatomic considerations of RTS, relevant physical examination findings, potential diagnostic modalities, and outcomes of several treatment options.

Management of humeral shaft fractures.

Humeral shaft fractures account for approximately 3% of all fractures. Nonsurgical management of humeral shaft fractures with functional bracing gained popularity in the 1970s, and this method is arguably the standard of care for these fractures. Still, surgical management is indicated in certain situations, including polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical options include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing. Each of these techniques has advantages and disadvantages, and the rate of fracture union may vary based on the technique used. A relatively high incidence of radial nerve injury has been associated with surgical management of humeral shaft fractures. However, good surgical outcomes can be achieved with proper patient selection.

Differential diagnosis and physical therapy management of a patient with radial wrist pain of 6 months' duration: a case.

STUDY DESIGN: Case report. BACKGROUND: Differential diagnosis for patients with radial wrist pain requires consideration of systemic disease, referred pain to the radial aspect of the wrist, and local dysfunction. The list of possible local dysfunctions should include De Quervain syndrome, as well as entrapment neuropathy of the superficial radial nerve. CASE DESCRIPTION: The patient was a 57-year-old man with right radial wrist pain of 6 months' duration. The referral diagnosis was De Quervain syndrome, but a previous course of electrophysical agents-based physical therapy management had been unsuccessful. The physical examination ruled out the cervical, shoulder, elbow, and wrist joints as possible sources of pain. In this case, the diagnosis of entrapment neuropathy of the superficial radial nerve, rather than De Quervain syndrome, was primarily based on the symptom provocation resulting from a modified radial bias upper limb nerve tension test. Based on this diagnosis, treatment consisted of active and passive exercises using neurodynamic techniques. OUTCOMES: After 1 treatment session, the patient noted changes with regard to current pain intensity and function that exceeded the minimal clinically important difference and the minimal detectable change, respectively. After only 2 treatment sessions, the patient reported a complete resolution of symptoms and a full return to work. DISCUSSION: This case report critically evaluates the diagnostic process for patients with radial wrist pain and suggests neuropathy of the superficial sensory branch of the radial nerve as a differential diagnostic option. LEVEL OF EVIDENCE: Therapy, level 4.J Orthop Sports Phys Ther 2010;40(6):361-368, Epub 22 April 2010. doi:10.2519/jospt.2010.3210.

High radial nerve palsy.

High radial palsy is primarily associated with humeral shaft fractures, whether primary due to the initial trauma, or secondary to their treatment. The majority will spontaneously recover, therefore early surgical exploration is mainly indicated for open fractures or if ultrasonography shows severe nerve damage. Initial signs of nerve recovery may appear between 2 weeks and 6 months. Otherwise, the decision to explore the nerve is based on the patient's age, clinical examination and electroneuromyography, as well as ultrasonography findings. If recovery does not occur, an autograft is indicated only in younger patients, before 6 months, if local conditions are suitable. Otherwise, nerve transfers performed by an experienced team give satisfactory results and can be offered up to 10 months post-injury. Tendon transfers are the gold standard treatment and the only option available beyond 10 to 12 months. The results are reliable and fast.

Effect of dry needling on radial tunnel syndrome: A case report.

This case report describes a 45-year-old male who presented with chronic right lateral elbow pain managed unsuccessfully with conservative treatment that included anti-inflammatory medication, injection, massage, exercise, bracing, taping, electro-physical agents, and manual therapy. Diagnosis of radial tunnel syndrome (RTS) was based on palpatory findings, range of motion testing, resisted isometrics, and a positive upper limb neural tension test 2b (radial nerve bias). Conventionally, the intervention for this entrapment has been surgical decompression, with successful outcomes. This is potentially a first-time report, describing the successful management of RTS with dry needling (DN) using a recently published DN grading system. Immediate improvements were noted in all the outcome measures after the first treatment, with complete pain-resolution maintained at a 6-month follow-up. A model is proposed describing the mechanism by which DN could be used to intervene for nerve entrapment interfaces.

Isolated spontaneous posterior interosseous nerve palsy: a review of aetiology and management.

Isolated posterior interosseous nerve palsy is an uncommon condition and its management is controversial. Existing literature is sparse and a treatment algorithm based on existing best evidence is absent. A comprehensive review was undertaken to elucidate the causes of spontaneous posterior interosseous nerve palsy and suggest a management strategy based on the current evidence. Posterior interosseous nerve palsy can be broadly categorized as compressive and non-compressive, and the existing evidence supports surgical intervention for compressive palsy. For posterior interosseous nerve pathology with no compressive lesion on imaging, conservative management should be tried first. Surgery is therefore reserved for compressive lesions and for failure of conservative management. The commonly performed operative procedures include decompression and neurolysis, neurorrhaphy and nerve grafting, and tendon transfers with or without nerve grafting performed as a salvage procedure. The prognosis is poorer in patients aged > 50 years, those with a delay to surgery, and those who have had long-standing compression with severe fascicular thinning.

Management of clinical radial nerve palsy with closed fracture shaft of humerus--a postal questionnaire survey.

The management of radial nerve palsy associated with fracture shaft of humerus is still a matter of debate. Various studies based on surgical and conservative management of this clinical problem have shown good results. After a recent systematic review by Shao et al. we felt that it was timely to survey the current practice among trauma and orthopaedic surgeons in England. Postal questionnaires were sent to orthopaedic surgeons in the north of England. The response rate was 64%. The survey showed that surgeons still differ in the ways of management of radial nerve palsy associated with fracture shaft of humerus, with a slightly higher percentage of surgeons preferring conservative treatment. The study also reveals the current practice of immobilisation, investigations and the duration of expectant treatment before surgical exploration among surgeons in the north of England.

Compression neuropathies of the upper extremity.

Nerve compression syndromes of the upper extremity occur at predicable locations. The diagnosis of nerve compression or nerve entrapment is based on the neurologic and electrodiagnostic examinations. The anatomy, neurophysiology, and electrodiagnosis of nerve compression are discussed. Common and uncommon compression and entrapment syndromes of the upper extremity are described. Errors in diagnosis occur when the neurologic or electrodiagnostic examinations are incomplete or inaccurate.

Acupuncture treatment of compression neuropathy of the radial nerve: a single case report of "Saturday Night Palsy".

PURPOSE: Evidence that acupuncture is effective for any type of motor nerve injury is limited to case reports and case series but these findings indicate benefit. Observation that the radial nerve has the most rapid recovery of all peripheral nerves suggests that acupuncture might benefit treatment of "Saturday Night Palsy," a syndrome of radial-nerve compression. TREATMENT: A 41-year-old female with a 1-week history of inability to write or extend the right wrist received 1 acupuncture treatment utilizing the Lung and Large Intestine meridians in the forearm, with the 2 meridians interconnected using the Luo and Yuan points. A cockup wrist splint was then applied. CONCLUSIONS: Wrist motion with gravity neutralized returned immediately after treatment. As the day progressed, the patient reported increasing strength in wrist and finger extension. The next day, the patient cancelled the second acupuncture treatment, as her hand had recovered. Examination 4 months later revealed normal wrist and finger extension, sensation, and return of the brachioradialis reflex. The patient was symptom-free 1-year postinjury. Acupuncture potentially facilitates recovery and may enhance treatment of peripheral motor nerve injury.