Intraneural Nodular Fasciitis of the Radial Nerve: A Case Report.

CASE: We report a case of intraneural nodular fasciitis in the forearm initially suspected as a schwannoma, emphasizing the importance of accurate diagnosis. A 40-year-old woman presented with mass on the lateral aspect of her right forearm and radial neuropathy symptoms for 2 months. An excisional biopsy and histopathological examination confirmed nodular fasciitis. Postoperative evaluation at 4.5 years found no pain, paralysis, or recurrence. CONCLUSION: Awareness of nodular fasciitis is crucial to prevent misdiagnosis and unnecessary treatment. Despite its rapid growth, nodular fasciitis generally has an excellent prognosis without long-term consequences.

Rare Variant of the Radial Artery Causing Compression of the Superficial Radial Nerve: A Case Report.

CASE: This case report describes a patient with paresthesia in the distribution of the superficial sensory branch of the radial nerve that was treated with surgery. Intraoperatively, there was a unique cause of internal compression by a rare superficial radial artery variant running adjacent to it. The nerve was mobilized from the artery with fascial releases. The patient had symptom resolution postoperatively. CONCLUSION: To our knowledge, this cause of compression has not been described before and should be considered in a differential diagnosis. In addition, clinicians should be aware of this anatomical variant during venipunctures and surgical approaches.

Superficial thrombophlebitis in the forearm leading to entrapment of the radial nerve branch: a first case report and literature review.

This article reports a case of a female patient admitted with swelling and subcutaneous mass in the right forearm, initially suspected to be multiple nerve fibroma. However, through preoperative imaging and surgery, the final diagnosis confirmed superficial thrombophlebitis. This condition resulted in entrapment of the radial nerve branch, leading to noticeable nerve entrapment and radiating pain. The surgery involved the excision of inflammatory tissue and thrombus, ligation of the cephalic vein, and complete release of the radial nerve branch. Postoperative pathology confirmed the presence of Superficial Thrombophlebitis. Through this case, we emphasize the importance of comprehensive utilization of clinical, imaging, and surgical interventions for more accurate diagnosis and treatment. This is the first clinical report of radial nerve branch entrapment due to superficial thrombophlebitis.

Radial Nerve Palsy in the Setting of Humeral Shaft Fracture.

The upper limb has a complex anatomy comprised of many nerve and vascular structures, making humeral shaft fractures extremely important. Injury to the humeral shaft commonly occurs due to trauma and affects younger male or older female patients. The radial nerve travels along the spiral groove of the humerus, placing it at an increased risk of damage in humeral shaft fractures. If injured, there are a variety of classifications of radial nerve injury, different indications for exploration, and treatment methods that orthopedic surgeons have available in treating these injuries. This review aims to discuss the etiology of humeral shaft fracture-associated radial nerve palsy, tools for diagnosis, and treatment.

Ancient Schawanoma of radial nerve: a rare case report.

Soft tissue swellings on the forearm can present with a range of clinical and histopathological diagnosis. Ancient Schawanoma is a rare benign condition that can develop over the flexor surface of the forearm as a cystic swelling and can involve the median or the ulnar nerve. However, the presentation of this condition on the extensor surface with involvement of the radial nerve is an extremely uncommon diagnosis. A 69 year old female presented at the outpatient department with a swelling on the extensor aspect of her right forearm for the past 2 years. Ultrasound examination showed a mixed cystic solid mass and MRI report revealed a complex predominantly cystic mass in the extensor compartment of the forearm, measuring 4.3 x 5.3 x 7.2 cm size. After obtaining informed consent, the patient was operated under tourniquet control and the mass was removed sparing the radial nerve that was adherent to its capsule. The final histopathological report confirmed the diagnosis as Ancient Schawanoma.

Comparison of nerve versus tendon transfer for radial nerve palsy.

OBJECTIVE: This study aims to investigate the choice of intervention time and operation mode between nerve and tendon transfer for the treatment of radial nerve palsy (RNP). METHODS: 46 RNP patients underwent nerve transfer (n = 22) and tendon transfer (n = 24). The intraoperative blood loss, main incision length, operation duration, and length of hospital stay and follow-up period of patients in these two groups were recorded and compared. The range of motion (ROM) of the elbow, wrist, fingers, and thumb, the hand grip and pinch strength, the Disabilities of Arm, Shoulder, and Hand (DASH) and the 36-Item Short Form Health Survey (SF-36) scores were measured and compared preoperatively and postoperatively between the two groups. RESULTS: The ROM of thumb and the hand grip strength of patients in the nerve transfer group were greater than that in the tendon transfer (P < 0.05). Both of the two groups indicated significant improvements in the ROM of elbow, wrist, finger, thumb and the hand grip and pinch strength (P < 0.05) postoperatively. The DASH scores decreased significantly at 6 months (P < 0.05) and 12 months (P < 0.05) after surgery in both groups, while the postoperative SF-36 scores significantly increased (P < 0.05). There was no significant difference in postoperative DASH and SF-36 scores between the two groups (P > 0.05). CONCLUSION: In summary, both nerve and tendon transfer techniques are effective treatments for RNP. Nerve transfer is particularly advantageous for early RNP, while tendon transfer is suitable for patients with radial nerve injury more than one year.

A postoperative heterotopic ossification leading to radial palsy.

We report the case of a 58-year-old man who developed radial palsy three months after surgical reinsertion of the distal biceps brachii through a single anterior approach. Radiographs and ultrasound examinations revealed heterotopic ossification compressing the deep branch of the radial nerve. Surgical excision and neurolysis were performed. At the two-month follow-up, the patient was asymptomatic. Practitioners and orthopedic surgeons should be aware of the risk of heterotopic ossification after distal biceps reinsertion and its possible atypical clinical presentation.

The Epidemiology of Radial Tunnel Syndrome and Its Overlap With Lateral Epicondylitis.

PURPOSE: Radial tunnel syndrome (RTS) is characterized by nerve compression affecting the posterior interosseous nerve branch in the forearm, and its symptoms often overlap with those of lateral epicondylitis (LE). The purpose of this study was to examine the epidemiology of RTS, frequency of injections and surgical release, and overlap of RTS with LE. METHODS: We queried the PearlDiver database to identify RTS in patients older than 18 years. Demographic data, diagnostic or therapeutic injection within 30 days of diagnosis, surgical release within 1 year of diagnosis, and 90-day postoperative complication rates were evaluated. Using International Classification of Diseases, 10th Revision, laterality codes, we also determined the number of patients who had same-side RTS and LE and the proportion of patients who subsequently underwent simultaneous RT release and LE debridement. RESULTS: The prevalence of RTS in a representative United States insurance database was 0.091%, and the annual incidence was 0.0091%. There were 75,459 patients identified with an active RTS diagnosis. The mean age at the time of diagnosis was 52 years (range, 18-81 years), 55% were women, and 1,833 patients (2.4%) underwent RT release within 1 year. Fewer than 3% of the patients received an injection within 30 days of RTS diagnosis. The 90-day postoperative complication rates were low: 5% of the patients required hospital readmission and 2.1% underwent revision surgery. Approximately 5.7% of the patients with RTS also had a diagnosis of LE on the same side within 6 months of RTS diagnosis. In patients with ipsilateral RTS and LE who underwent surgery, 59.1% underwent simultaneous RT release and LE debridement, whereas 40.9% underwent isolated radial tunnel release. CONCLUSIONS: The analysis of a large insurance database showed that the diagnosis of RTS is rarely assigned, suggesting that the incidence of this nerve compression is low. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Spontaneous radial nerve palsy with hourglass-like constriction.

Hourglass-like constriction (HLC) is an uncommon spontaneous mononeuropathy that is typically characterised by a sudden onset of pain followed by palsy, affecting branches of the radial (posterior interosseous nerve) and median nerves (anterior interosseous nerve). HLC of the radial nerve (RN) is rare, with only a few reported cases. Here, we report a case of a man who presented with acute wrist and finger drop due to the HLC of the RN. Surgery was recommended 5 months after clinical observation, when the lesion was resected and primarily repaired, resulting in satisfactory recovery. There is still much that remains unknown about HLC, especially for RN. The current understanding points out an inflammatory disease that should be treated conservatively for 3-7 months. The surgical technique depends mostly on the severity and extent of constriction; however, considering only RN constrictions, primary repair by neurorrhaphy or nerve grafts resulted in better functional outcomes.

Median to Radial Nerve Transfer: An 8-Year Experience From a Lower-Middle Income Country.

INTRODUCTION: With an incidence of 2-16%, radial nerve palsy is one of the common forms of nerve injuries globally. Radial nerve palsy causes debilitating effects including loss of elbow extension, wrist drop and loss of finger extension. Reparative surgical pathways range from primary repair and neurolysis, to nerve grafting, nerve transfers, and tendon transfers. Due to ease of performance and acceptability and reproducibility of outcomes, tendon transfers are considered the gold standard of radial nerve palsy repair. However, independent finger function cannot be achieved and as such may not give truly desirable results. In lower-middle income countries, the question of nerve transfer versus tendon transfer for patients who are keen to get back to work is key. While tendon transfer recovery is faster, the functional loss is often considered devastating for fine hand function due to loss of grip secondary to lack of wrist and finger extension. In this study, we present our experience of performing median nerve transfers for radial nerve palsy in Pakistan. METHODS: We performed a retrospective case-series of patients undergoing median to radial nerve transfer for radial nerve palsy over a period of 6 y, from 2012 to 2019. Patients with radial nerve palsy were diagnosed via electromyography and nerve conduction studies. The procedure involved coapting the branches of the flexor carpi radialis and flexor digitorum superficialis (long and ring finger) nerves to the posterior interosseous nerve and extensor carpi radialis brevis, respectively. Patients were assessed using the Medical Research Council scale for muscle strength of wrist, finger and thumb extension separately at 1 y time. Our results were then compared to results from similar nerve transfer studies. RESULTS: We operated on 10 right-hand dominant patients, eight males and two females with a median age of 33 y (6-63 y). four sustained injury to the right hand and six to the left. Causes of the injuries included road traffic accident (n = 3), firearm injury (n = 4), shrapnel (n = 1), iatrogenic injury (injection in deltoid region (n = 1) and fall (n = 1). Types of fracture included mid humerus fracture, fracture of the surgical neck of the humerus, and supracondylar fracture of the humerus. Median time to surgery since injury was 4 mo (1-8 mo). Independent wrist extension was M4+ in all patients and independent finger extension was M4+ in seven and M4-in two patients. However, a patient who presented late at 8 mo had poorer finger outcomes with extension at M2-. All patients had independent movement of fingers. CONCLUSIONS: Nerve transfer is a reliable method of post traumatic nerve repair and reinnervation, particularly in lower-middle income countries, even in cases where the nerve damage is severe and extensive and up to 6 mo may have elapsed between injury and presentation. Timely median to radial nerve transfer is a highly recommended option for radial nerve palsy, with regular follow-ups and physical therapy added to ensure positive outcomes.

Tendon Transfer for Correction of the Radial Deviation Deformity of the Wrist and Centralization in Posterior Interosseous Nerve Palsy.

There are very few descriptions of tendon transfers designed specifically to address the reconstruction of posterior interosseous nerve palsy (PINP). Unlike a radial nerve palsy (RNP), a patient with a PINP is able to extend their wrist but in radial deviation, because of the preserved innervation of the extensor carpi radialis longus (ECRL). Tendon transfers to restore finger and thumb extension in PINP have been extrapolated from tendon transfers to restore these functions in RNP, specifically using flexor carpi radialis, not flexor carpi ulnaris, so as not to further exacerbate the distinctive radial deviation deformity of the wrist. However, the standard pronator teres to extensor carpi radialis brevis transfer for a RNP fails to address or correct the radial deviation deformity in PINP. We present a simple tendon transfer specifically to address this radial deviation deformity in a PINP, by performing a side-to-side tenorrhaphy of the ECRL tendon to the extensor carpi radialis brevis tendon, followed by transection of the ECRL insertion onto the base of the index finger metacarpal distal to the tenorrhaphy. This technique converts a functioning ECRL from a radially deforming force, transferring its vector of pull onto the base of the middle finger metacarpal and so producing centralization of wrist extension in axial alignment with the forearm.

Decompression with Brachioradialis Tenotomy Improves Pain and Quality of Life in Patients with Radial Sensory Nerve Compression.

BACKGROUND: Decompression of the superficial sensory branch of the radial nerve (SBRN) with complete brachioradialis tenotomy may treat pain in both simple and complex cases of SBRN compression neuropathy. METHODS: A retrospective chart review was performed of consecutive patients undergoing this procedure between 2008 and 2020 including postoperative outcomes within 90 days. Data were collected and analyzed, including patient and injury demographics, pain descriptors, and patient-reported pain questionnaire, including reported pain severity and impact on quality of life using visual analogue scale (VAS) instruments. Within-group presurgical and postsurgical analyses and between-group statistical analyses were performed. RESULTS: Thirty-three of 58 patients met inclusion criteria. Median time from symptom onset to surgery was 300 days, and median postoperative follow-up time was 37 days. Twenty-five percent of patients ( n = 8) underwent isolated SBRN decompression. The remainder had concomitant decompression of another radial [ n = 16 (48%) or peripheral [ n = 12 (36%)] entrapment point. Ten of 33 patients (30%) had resolution of pain at final follow-up ( P = 0.004). Median change in worst pain over the previous week was -4 ( P < 0.001), and average pain over the last month was -2.75 ( P < 0.001) on the VAS. The impact of pain on quality of life showed a median change of -3 ( P < 0.001) on the VAS. CONCLUSION: Decompression of the sensory branch of the radial nerve including a complete brachioradialis tenotomy improves pain and quality-of-life VAS scores in patients with both simple compression neuropathy syndrome and complex nerve compression syndrome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Nerve Conditions of the Upper Limb: How Not to Miss or Mismanage.

There are several issues associated with nerve compression syndromes of the upper limb; ultrasonography is a useful diagnostic tool. The orthopaedic surgeon should know how to evaluate and treat patients who do not obtain expected relief following carpal or cubital tunnel release, and also be knowledgeable about the workup and evaluation of patients with conditions of debatable pathology and treatment, such as radial tunnel syndrome or pronator syndrome. Recent studies on suprascapular neuropathy include discussions about the pathophysiology and etiology of the condition, its natural history, and who might benefit from surgery.

Distal Nerve Transfer to Restore Wrist and Finger Extension - A Systematic Review.

Background: There are numerous options available for restoration of wrist and finger extension following radial nerve palsy. The aim of this study is to conduct a systematic review of the effectiveness of nerve transfer for radial nerve palsy. Methods: Electronic literature research of PubMed, Cochrane, Scopus and Lilacs database was conducted in June 2021 using the terms 'Distal nerve transfer' AND 'Radial nerve injury' 'Radial nerve palsy' OR 'Radial nerve paresis' OR 'Median nerve transfer' OR 'wrist extensor' OR 'finger extension' OR 'thumb extension' OR 'wrist motion'. The data extracted included the study details, demographic data, procedure performed and final functional outcome according to the muscle research council scale. Results: A total of 92.59% and 56.52% had satisfactory outcome following distal nerve transfer of median nerve to restore wrist and finger extension respectively. No significant correlation was found between time to injury duration and satisfactory outcomes. Conclusions: Outcomes of nerve transfers are comparable to tendon transfers. Multi-centric studies are needed to compare the results amongst various surgical procedures described. Level of Evidence: Level III (Therapeutic).

Radial nerve entrapment after fracture of the supracondylar humerus: a rare case of a 6-year-old.

Supracondylar fracture of the humerus is one of the most common fractures seen in children, and posteromedial displacement of the distal fragment in extension-type supracondylar humerus fractures can cause injury to the radial nerve. A 6-year old girl who presented with symptoms of radial nerve injury after a supracondylar fracture of the right humerus with complete posteromedial displacement of the distal fragment (Gartland type III) underwent surgery where closed reduction and percutaneous pinning was performed. The patient was routinely followed up and at 6 months postoperatively no neurological improvement was seen. Exploratory surgery revealed complete discontinuation of the radial nerve at the fracture site and entrapment of the nerve stumps in healed bone callus. A gap of 2 cm was observed between nerve stumps, and sural nerve cable grafting was performed with good results. If neurological symptoms do not improve over time, appropriate differential diagnosis and, if necessary, exploratory surgery should be considered. Despite limited reports and their conflicting outcomes, sural nerve cable grafting could be a useful option to bridge the gap of discontinued nerve injury. Level of Evidence: Level IV, Case Report.

Ultrasound-Guided Hydrodissection Provides Complete Symptom Resolution in Radial Tunnel Syndrome: A Case Series and Scoping Review on Hydrodissection for Radial Nerve Pathology.

ABSTRACT: This study analyzes the effectiveness of ultrasound-guided hydrodissection (HD) perineural as a treatment for radial tunnel syndrome (RTS). A literature search was performed along with retrospective analysis of local cases to assess outcomes and safety of this procedure. In the case series, surgical candidates, defined as cases with over 80% but temporary relief after diagnostic injection, were treated with ultrasound-guided HD. Of 22 patients who received ultrasound-guided diagnostic injections, 11 proceeded to HD. All HD patients experienced complete and lasting symptom resolution for a minimum of 2 years, and none required surgery. Thorough literature review provided seven studies, which fulfilled inclusion criteria. Sixty-one patients are represented in the literature. All studies reported significant benefit to pain symptoms with HD of radial nerve, with five specifying over 90% improvement. No adverse effects from HD were noted in any study. Ultrasound-guided HD of the radial tunnel has potential to be a surgery sparing treatment for RTS.

Outcomes of Rerouting the Palmaris Longus to Extensor Pollicis Longus Tendon Transfer through the Second Extensor Compartment for Radial Nerve Palsy.

Background: A palmaris longus (PL) to extensor pollicis longus (EPL) is a standard tendon transfer used to restore thumb extension in patients with radial nerve palsy. This transfer is done by withdrawing the EPL from the third compartment and passing it subcutaneously to reach the PL. We modified this transfer by rerouting the EPL through the second extensor compartment to improve the retropulsion of the thumb. The aim of this study is to report the outcomes of this modified transfer. Methods: Four patients with traumatic radial nerve palsy underwent the modified PL to EPL transfer. They also underwent transfer of the pronator teres (PT) to extensor carpi radialis brevis (ECRB) and flexor carpi radialis (FCR) to extensor digitorum communis (EDC). Patients were followed up for at least 1 year after surgery. The data with regard to age, gender, cause of radial nerve palsy, duration between injury and surgery, and duration of follow-up was recorded. At final follow-up, the arc of motion at the interphalangeal joint (IPJ), metacarpophalangeal joint (MCPJ), palmar and radial abduction and retropulsion were measured for the reconstructed thumb and contralateral normal thumb. Results: All patients were male, with a mean age of 34.3 (range, 19-46) years. The mean duration between the injury and surgery was 15.9 (7-27) months, and the mean post-operative follow-up period was 16.8 (12-25) months. All patients recovered good thumb function. The mean arc of motion of the affected and contralateral thumb were IPJ flexion: 52°/80°; IPJ extension: 21°/14°; MCPJ flexion: 30°/33°; MCPJ extension:24°/31°; radial abduction: 70°/74°; palmar abduction: 68°/75° and retropulsion: 4.8cm/5.0cm. Conclusion: Rerouting the PL to EPL tendon transfer through the second extensor compartment in radial nerve palsy can restore good thumb function especially retropulsion. Level of Evidence: Level IV (Therapeutic).

Anterolateral Thigh Flap for Low-Voltage Fourth-Degree Electrical Burn Injury With Immediate Radial Nerve Palsy at the Elbow: A Case Report.

While high-voltage electrical injuries usually cause severe burn wounds and axonal polyneuropathy, low-voltage electrical injuries cause limited cutaneous wounds and demyelinating mononeuropathy, of which the median and ulnar nerves are the most commonly involved. We present the case of a 42-year-old man who suffered a 480-voltage electrical injury at his right elbow, resulting in a 24 × 10 cm fourth-degree burn wound and immediate radial nerve palsy. The burn wound was debrided with confirmation and preservation of radial nerve continuity. The wound was covered with a free anterolateral thigh flap and it healed uneventfully. The Tinel's sign continued to advance at follow-up, and electrodiagnostic studies showed progressive reinnervation. His radial nerve function recovered completely in 9 months. This is a rare case of low-voltage electrical injury with a fourth-degree burn wound and immediate radial nerve palsy. We treated the wound aggressively with early debridement and prompt flap coverage, but conservatively treated the radial nerve injury. The nerve recovery course indicates that it had a "shocked-cooked" injury and served itself as a well-placed nerve graft for the subsequent regeneration. We believe that our successful outcome in this case can provide more insights into the management of such injuries.