Parálisis del nervio radial neonatal: relato de un caso / Isolated radial nerve palsy in a newborn: case report

La parálisis radial neonatal aislada (PRNA) es un cuadro clínico infrecuente que debe distinguirse de otras entidades más frecuentes, como la parálisis braquial obstétrica (PBO). Debemos sospechar una PRNA en neonatos que presentan incapacidad para la extensión de muñeca y de dedos, pero mantienen intacta la función del deltoides, del bíceps, y del tríceps, así como la flexión de muñeca y de dedos. Mientras la PBO tiene una evolución clínica variable dependiendo de la extensión de la lesión neurológica, la PRNA presenta una resolución espontánea, independientemente del grado de afectación inicial. Presentamos el caso de un recién nacido con PRNA cuyo diagnóstico inicial fue de PBO.

Isolated radial nerve palsy (IRNP) in the newborn is a rare clinical condition that must be distinguished from entities that are more common, such brachial plexus birth palsy (BPBP). It should be suspected in newborns presenting with absent wrist and digital extension but intact deltoid, biceps, and triceps function, as well as wrist and digital flexor function. Whereas BPBP is highly variable depending on the extent of the neurological involvement, IRNP resolves spontaneously, regardless of the severity of the initial presentation. We herein present a case of newborn with IRNP whose initial diagnosis was of BPBP.

Effectiveness of electrophysical modalities in the sensorimotor rehabilitation of radial, ulnar, and median neuropathies: A meta-analysis.

INTRODUCTION: People with ulnar, radial or median nerve injuries can present significant impairment of their sensory and motor functions. The prescribed treatment for these conditions often includes electrophysical therapies, whose effectiveness in improving symptoms and function is a source of debate. Therefore, this systematic review aims to provide an integrative overview of the efficacy of these modalities in sensorimotor rehabilitation compared to placebo, manual therapy, or between them. METHODS: We conducted a systematic review according to PRISMA guidelines. We perform a literature review in the following databases: Biomed Central, Ebscohost, Lilacs, Ovid, PEDro, Sage, Scopus, Science Direct, Semantic Scholar, Taylor & Francis, and Web of Science, for the period 1980-2020. We include studies that discussed the sensorimotor rehabilitation of people with non-degenerative ulnar, radial, or median nerve injury. We assessed the quality of the included studies using the Risk of Bias Tool described in the Cochrane Handbook of Systematic Reviews of Interventions and the risk of bias across studies with the GRADE approach described in the GRADE Handbook. RESULTS: Thirty-eight studies were included in the systematic review and 34 in the meta-analysis. The overall quality of evidence was rated as low or very low according to GRADE criteria. Low-level laser therapy and ultrasound showed favourable results in improving symptom severity and functional status compared to manual therapy. In addition, the low level laser showed improvements in pinch strength compared to placebo and pain (VAS) compared to manual therapy. Splints showed superior results to electrophysical modalities. The clinical significance of the results was assessed by effect size estimation and comparison with the minimum clinically important difference (MCID). CONCLUSIONS: We found favourable results in pain relief, improvement of symptoms, functional status, and neurophysiological parameters for some electrophysical modalities, mainly when applied with a splint. Our results coincide with those obtained in some meta-analyses. However, none of these can be considered clinically significant. TRIAL REGISTRATION: PROSPERO registration number CRD42020168792; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168792.

Post-operative rehabilitation in a traumatic rare radial nerve palsy managed with tendon transfers: a case report.

Radial nerve is a frequently injured nerve. Radial nerve palsy result from direct trauma, neuropathies, and fracture over the humerus, malignant tumor and neuritis. A case of 26-year male is presented in this report who had a road traffic accident resulting in injury over the right shoulder, wrist joint and diagnosed of radial nerve palsy, consequently was operated with soft tissue reconstruction with tendon transfers which resulted into pain over wrist joint and loss of extensors muscle function of the wrist joint, which led to difficulty in performing activities of daily living. Surgical history and rehabilitation is mentioned in the case report. We report that there were significant improvements in muscle strength, range of motion, relief from pain, and exceptional improvements in the patient´s functional independence with physiotherapy interventions post-operative tendon transfers.

Analyzing the functional effects of dynamic and static splints after radial nerve injury.

The radial nerve is a commonly injured upper extremity peripheral nerve. The inability to extend the wrist results in a loss of hand function and dexterity that affects patients' ability to perform their activities of daily living. There is no strong evidence to support a particular splint design for improving dexterity. This cohort study compared whether a static or dynamic splint can improve hand dexterity when assessed with the 9-hole peg test (9-HPT) after radial nerve injury. Thirty-four subjects with radial nerve palsy participated in the study. The test was repeated three times for each subject, first without the splint, and then while wearing the control static wrist splint, and finally while wearing the dynamic splint. The 9-HPT was used as the outcome measure. The 9-HPT times were 36.4±4.8seconds without a wrist splint and improved when using the static and the dynamic splints to 33.5±4.5seconds (P<0.01) and 25.7±3.5seconds (P<0.01) respectively. The use of a dynamic splint after radial nerve palsy can provide the patient with greater manual dexterity when compared to using no splint or a static splint.

Late-Onset Radial Nerve Palsy After Closed Treatment of a Periprosthetic Humerus Fracture: A Case Report.

CASE: A 58-year-old woman underwent successful reverse total shoulder arthroplasty for a proximal humerus fracture. Three years later, she sustained a periprosthetic humerus fracture after a fall and was treated conservatively. She healed with an abundance of callus and subsequently developed delayed-onset radial nerve palsy at 3 months, despite minimal change in humeral alignment and avoidance of the use of any compressive external braces or splints. CONCLUSIONS: Minimally displaced periprosethetic humerus fractures can lead to delayed radial nerve palsy from callus entrapment, and there should be increased awareness of this potential complication when counseling and treating patients conservatively.

Transient neonatal radial nerve palsy. A case series and review of the literature.

Transient neonatal radial nerve palsy manifests at birth by wrist drop and intact elbow and shoulder function. Spontaneous resolution is universal. We present a case series, including two bilateral cases, and a review of the cases found in the English literature, hypothesizing how this condition is probably misdiagnosed as brachial plexus injury.

Median to radial nerve transfers for restoration of wrist, finger, and thumb extension.

Radial nerve injury results in loss of wrist, finger, and thumb extension. Traditionally, radial nerve palsies that fail to recover spontaneously have been reconstructed with tendon transfers or nerve grafts. Nerve transfers are a novel approach to the surgical management of Sunderland grade IV and V radial nerve injuries. We describe our technique for median to radial nerve transfers. In this procedure, the flexor digitorum superficialis nerve is transferred to the extensor carpi radialis brevis nerve for wrist extension, and the flexor carpi radialis nerve is transferred to the posterior interosseous nerve for finger and thumb extension. Our experience with these nerve transfers has demonstrated excellent outcomes up to 10 months after injury. Indeed, unlike tendon transfers, median to radial nerve transfers have the potential to restore normal radial nerve function, including independent finger motion. Tension-free nerve coaptation and postoperative motor re-education are critical factors to achieving these successful outcomes.

[Functional magnetic resonance imaging. What are the benefits expected in hand surgery?]. / IRM fonctionnelle. Quels apports en chirurgie de la main ?

Functional MRI (fMRI) allowed considerable advances upon understanding of cerebral functioning. Cortical plasticity, which allows the voluntary command of a restored function by a transferred muscle remains to be investigated in its intimacy. The authors present here the round table held at the 48th annual meeting of the French Society for Surgery of the Hand on December 22nd, 2012. It tries to review the analysis of the phenomenon observed during multiple tendinous transfers for restoration of proximal radial nerve palsy. Were successively approached: 1) Methods of acquisition and analysis of the signals (C. D-M.); 2) Movement reorganization (O.M.); 3) Motor plasticity after hand allograft (A. S.); 4) The potential interest of the fMRI in hand rehabilitation (F. D.); 5) The analysis of cerebral plasticity in general (H. B.). A rather philosophical conclusion opens other fields to f MRI (A.M.).

Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy.

OBJECTIVE: To assess the inter-rater and intra-rater reliability and validity of the original and a modified Medical Research Council scale for testing muscle strength in radial palsy. DESIGN: Prospective, randomized validation study. PATIENTS: Thirty-one patients with peripheral paresis of radial innervated forearm muscles were included. METHODS: Wrist extension, finger extension and grip strength were evaluated by manual muscle testing. Dynamometric measurement of grip strength was performed. Pair-wise weighted kappa coefficients were calculated to determine inter-rater and intra-rater reliability. The 2 scores were compared using the signed-rank test. Spearman's correlation coefficients of the maximal relative force measurements with the median (over-raters) Medical Research Council and modified Medical Research Council scores were calculated to determine validity. RESULTS: Inter-rater agreement of the Medical Research Council scale (finger extension: 0.77; wrist extension: 0.78; grip strength: 0.78) and the modified Medical Research Council scale (finger extension: 0.81; wrist extension: 0.78; grip strength: 0.81) as well as intra-rater agreement of the Medical Research Council scale (finger extension: 0.86; wrist extension: 0.82; grip strength: 0.84) and the modified Medical Research Council scale (finger extension: 0.84, wrist extension: 0.81; grip strength: 0.88) showed almost perfect agreement. Spearman's correlation coefficients of the maximal relative force measurements with the median Medical Research Council and modified Medical Research Council score were both 0.78. CONCLUSION: Medical Research Council and modified Medical Research Council scales are measurements with substantial inter-rater and intra-rater reliability in evaluating forearm muscles.

Primary radial nerve palsy in patients with acute humeral shaft fractures.

OBJECTIVE: The primary aim was to report on the recovery of radial nerve function in patients with acute closed humeral shaft fractures and associated primary radial nerve palsy. The secondary aim was to report on the long-term functional outcome and health-related quality of life (HRQoL) in patients with this specific injury. SETTING: Six major hospitals in Stockholm County. DESIGN: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome and HRQoL. PATIENTS: Thirty-three patients with acute radial nerve palsy and a closed humeral shaft fracture in a population of 358 patients with 361 humeral shaft fractures. INTERVENTION: Nonoperative or operative treatment as per decision of the attending orthopedic surgeon. MAIN OUTCOME MEASUREMENTS: Recovery of the radial nerve, fracture healing, functional outcome according to the Short Musculoskeletal Function Assessment (SMFA) and the Disabilities of the Arm, Shoulder and Hand (DASH). HRQoL according to Short Form 36 (SF-36). RESULTS: Among the 18 patients treated nonoperatively, 16 (89%) displayed a complete recovery from their radial nerve palsy while 2 (11%) presented minor sequelae. In 11 (73%) of the 15 patients treated primarily operatively, the nerve function recovered completely while 2 patients (13%) had minor sequelae and 2 (13%) had major sequelae, i.e. 1 partial nerve palsy and 1 total radial nerve palsy. Sixteen patients (48%) were available for assessment of the long-term functional outcome and HRQoL at a mean of 7 years (range, 6 to 8 years). The range of motion and the muscular strength of the injured arm, the functional outcome according to the SMFA, and HRQoL according to the SF-36 showed results comparable to those previously reported for patients with healed humeral shaft fractures without associated radial nerve palsy. CONCLUSION: This study confirms the high spontaneous recovery rate of primary radial nerve palsies in patients with closed humeral shaft fractures. Primary radial nerve palsy should not be regarded as an isolated indication for primary surgical intervention.

Tenodesis extension splinting for radial nerve palsy.

Injuries to the radial nerve or posterior interosseous nerve can lead to significant functional limitation. Inability to extend the wrist and/or digits prevents the hand from being positioned properly for functional tasks. Therapy after radial nerve injury is geared toward maintaining passive extension of the wrist and digits. Sensory reeducation can also be performed but often not necessary since the distribution of the nerve distally is on the dorsoradial surface of the hand. Since nerve regeneration is often a lengthy process and the extent of recovery is variable, splinting the involved extremity is used to prevent contractures and maximize function. This article introduces a new splint that allows patients to extend the fingers and thumb via a tenodesis effect at the wrist. In early trials, it has produced excellent results for enhancing functional use of the injured extremity while nerve regeneration occurs or until tendon transfers have been performed.

Transfer of a single flexor carpi ulnaris tendon for treatment of radial nerve palsy.

Between 1993 and 2002, 108 patients with isolated and persisting radial nerve palsy, underwent transfer of the flexor carpi ulnaris tendon alone to extensor digitorum communis, extensor indicis proprius and extensor pollicis longus. Only patients with sufficient flexor carpi ulnaris muscle power (grade M5) underwent this procedure. Long-term functional results were reviewed at a mean postoperative follow up of 48 (range 3-120) months. In comparison with the contralateral hand, the range of extension of the wrist was less but extension of the fingers and the MCP joints were similar to that of the normal hand. All patients improved functionally and could cope with their routine activities. Most were able to return to their previous jobs. There was no obvious difference in the end result of using this single transfer from our previous results using the three tendon transfers which are commonly used to treat radial nerve palsy. The single flexor carpi ulnaris tendon transfer has some advantages in terms of simplicity, shorter operation time, less morbidity and less surgical scars.

Isolated radial nerve palsy in a newborn: report of two cases.

Two newborns with history of difficult birth were diagnosed within 24 hours after birth with isolated radial nerve palsy. Both newborns recovered completely. Awareness and multidisciplinary approach is essential.

Splinting and radial nerve palsy: a single-subject experiment.

This study examines which of three splint designs most effectively improved hand function in a patient with radial nerve palsy, and demonstrates the application of a single-subject experimental design. The static volar wrist cock-up splint (splint 1), dynamic tenodesis suspension splint (splint 2), and dorsal wrist cock-up with dynamic finger extension splint (splint 3) were evaluated. Each splint was worn for 3 weeks, and hand function was assessed by means of standardized measures of function and disability. Statistical significance was calculated using the minimal level of detectable change (MDC) at the 95% confidence level. Only with splints 2 and 3 did a true change in function occur, compared with baseline scores (no splint). In addition, the patient completed all tasks while using splints 2 and 3 but did not complete three tasks while using splint 1. The hand therapists' goal is to fabricate a splint that improves function and that the patient will wear. Only splint 3 met these criteria. This experiment highlights the need to evaluate both the statistical and the clinical significance of treatment interventions.

Long-term results of tendon transfers for radial nerve palsy in patients with limited rehabilitation.

The authors reviewed the long-term functional results of 22 patients who underwent tendon transfer for isolated radial nerve palsy. The average number of postoperative visits was eight (range of postoperative visits, 3-16), and the mean follow-up was 6.3 years. All but 1 patient had improved function after the tendon transfers, and could cope with the activities of daily living. Radial deviation of the wrist at rest was present in 10 of the 15 patients with flexor carpi ulnaris transfer and in 2 of 7 patients with flexor carpi radialis transfer, with a mean of 14.5 deg (range of radial deviation, 5-30 deg). Although a global decrease in wrist power and power grip was noted, 13 of 17 previously employed patients were able to work after transfer; however, only 1 of 7 heavy manual laborers was able to return to his previous employment. Despite the poor clinic attendance, the overall functional results compared favorably with other published series. It appears that tendon transfer for radial nerve palsy is a viable option, even in patients with limited rehabilitation.

Radial nerve palsy after simple fracture of the humerus.

Radial nerve palsy is a common complication of simple fracture of the humerus. The aim of this retrospective study was to assess the degree of spontaneous recovery and the need for exploration and repair of the nerve. The study included 26 patients with radial nerve palsy after simple fracture of the humerus. The male:female ratio was 3:1 and the median age was 21 years (range 9-79). Three patients had early exploration of the radial nerve in connection with osteosynthesis, and no appreciable damage to the nerve was found. Two other patients were explored later because they failed to recover. This exploration showed damage to the nerve which required further operation. Twenty-one patients were treated conservatively and all recovered well. None needed later operation. Because of the low incidence of nerve lesions we recommend an expectant policy initially.