A rare case of progressive and late onset posterior interosseous nerve palsy following distal biceps tendon repair (original) (raw)
Medical Science Monitor
Departmental sources Background: Although iatrogenic posterior interosseous nerve (PIN) palsy is an uncommon complication of ruptured distal biceps brachii tendon surgical anatomical reinsertion, it is the most severe complication leading to functional limitation. The present study investigated possible types of PIN palsy as a postoperative complication of anatomical distal biceps tendon reinsertion, and aimed to clinically assess patients at 2 years after its surgical treatment. Material/Methods: The studied sample comprised 7 male patients diagnosed with an iatrogenic PIN palsies after anatomical reinsertion of the distal biceps tendon, who were referred to the reference center for management of a peripheral nervous system injury. The nerve injury was intraoperatively evaluated. The clinical assessment used the Medical Research Council (MRC) System for motor recovery, and the Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) was performed before the surgical treatment of the PIN injuries and at 2 years postoperatively. In all studied cases, electromyography was performed preoperatively and postoperatively. Results: The comparison of the preoperative (x=1.43±0.53) and postoperative (x=4.71±0.49) results of the motor recovery of the PIN demonstrated a statistically significant improvement (p<0.001). Moreover, the results of functional assessments with the use of the Quick DASH questionnaire significantly improved (p<0.001) postoperatively (x=6.14±6.86) compared to the preoperative evaluations (x=54.29±12.05). Conclusions: The PIN palsies as complications of the surgical anatomical reinsertion of ruptured distal biceps brachii resulted from mechanical nerve compression or direct intraoperative damage. The 2-year outcomes justified the clinical use of surgical management for iatrogenic PIN palsy.
The supinator muscle and radial nerve entrapment: historical note and modern anatomical insight
Due to its deep location, close to the elbow joint, the supinator muscle requires special dissection skills. This fact enhanced our interest for a more accurate knowledge of the anatomical relations of the muscle with the elbow joint and with the posterior branch of the radial nerve. There are many clinical consequences of these anatomic relations, such as epicondylar impingement syndromes. There resides an open field of research on the anatomical basis of radial nerve entrapment syndromes. In 1618, Da Cortona published a clear reference to the passage of the nerve in close relation to the deeper side of the supinator muscle. All the material here presented, corresponds to careful dissection work on embalmed corpses, prepared at our dissection lab, with original techniques. The classical approach through ventral dissection demonstrates the relation between the supinator muscle arcade (Fröhse) and the radial nerve, with its natural sliding adipose cushion sheath. The dorso-lateral surgical approach, allows deep dissection of the forearm muscles, in relation to the lateral epicondylar bundle, and the elbow joint capsule. Stereoscopic microscopy completed our macroscopic observations. Future histological and microscopic analysis of the nature of the supinator arcade; of the intricate relation of the supinator muscle fibers and the capsular fibers of the elbow; and also, the importance of the vascular elements of the muscle arcade and of the adipose bursa that surrounds the radial nerve, will further provide rich interesting research towards the improvement of pathogenic knowledge of the regional impingement, and compressive radial nerve syndromes.
Compression of the radial nerve at the elbow by a ganglion: two case reports
2009
Introduction: Radial nerve compression by a ganglion in the radial tunnel is not common. Compressive neuropathies of the radial nerve in the radial tunnel can occur anywhere along the course of the nerve and may lead to various clinical manifestations, depending on which branch is involved. We present two unusual cases of ganglions located in the radial tunnel and requiring surgical excision. Case presentation: A 31-year-old woman complained of difficulty in fully extending her fingers at the metacarpophalangeal joint for 2 weeks. Before her first visit, she had noticed a swelling and pain in her right elbow over the anterolateral forearm. The extension muscle power of the metacarpophalangeal joints at the fingers and the interphalangeal joint at the thumb had decreased. Sonography and magnetic resonance imaging of the elbow revealed a cystic lesion located at the area of the arcade of Frohse. A thin-walled ovoid cyst was found against the posterior interosseous nerve during surgical excision. Pathological examination was compatible with a ganglion cyst. The second case involved a 36-year-old woman complaining of numbness over the radial aspect of her hand and wrist, but without swelling or tumor in this area. The patient had slightly decreased sensitivity in the distribution of the sensory branch of the radial nerve. There was no muscle weakness on extension of the fingers and wrist. Surgical exposure defined a ganglion cyst in the shoulder of the division of the radial nerve into its superficial sensory and posterior interosseous components. There has been no disease recurrence after following both patients for 2 years. Conclusion: Compression of nerves by extraneural soft tissue tumors of the extremities should be considered when a patient presents with progressive weakness or sensory changes in an extremity. Surgical excision should be promptly performed to ensure optimal recovery from the nerve palsy.
Open Journal of Orthopedics, 2012
Background: The etiology and treatment of spontaneous paralysis variants of anterior interosseous nerve (AIN) syndrome remains controversial. Variation and multiple sites of potential compression complicate the successful performance of neurolysis. This anatomic study of the AIN and sites of potential compression in the proximal forearm facilitates critical steps involved in neurolytic procedures and management. Methods: Upper extremities of twelve cadavers were examined to evaluate potential sites of AIN compression in the proximal forearm. Potential sites of musculoaponeurotic compression were evaluated, including: lacertus fibrosus; inferior fibrous arch of the humeral head of the pronator teres (PT) muscle; inferior fibrous arch of the ulnar head of the PT muscle; fibrous arch in the flexor digitorum superficialis (FDS) muscle; Gantzer's muscle; and vascular structures near the AIN and median nerve. Results: The AIN arose at a mean distance of 54.5 mm distal to the elbow from the posterior (n = 9) or ulnar side (n = 3) of the median nerve. Relative positions of AIN branches were variable. A fibrous arch was found between the lacertus fibrosus and the PT in two cases. Nine cadavers had two fibrous arches in the PT and FDS, and three cadavers had one arch. An accessory head in the FDS was found to be a risk of AIN compression. Gantzer's muscle was present in six cases, crossing the AIN superficially. Two potentially compressive vascular arches were identified. Conclusions: Our observations confirm that multiple musculoaponeurotic and/or vascular structures can contribute to AIN compression in the proximal forearm. Understanding the complex anatomic relationships of this nerve is crucial to improving outcomes of neurolysis in cases of non-regressive AIN paralysis.
Injury of the Radial Nerve in the Arm: A Review
Cureus, 2018
Compression of the radial nerve is most commonly described at the supinator muscle (i.e., arcade of Frohse). However, radial nerve compression can occur in the arm. Therefore, the purpose of this article is to review both etiologies of radial nerve entrapment and the sites at which this can occur in the arm. The clinical presentation of radial nerve entrapment in the arm and how it differs from that of entrapment at other sites is reviewed and the conditions potentially predisposing to nerve entrapment are described. Particular attention is paid to the nerve's course and potential variants of the anatomical structures in the arm. In each case, the recommended course of management for the neuropathy is described. Injury of the radial nerve can arise from a varied set of pathologies including trauma, tumors, anomalous muscles, and intramuscular injections. Physicians should have a good working knowledge of the anatomy and potential mechanisms for radial nerve injury.
International Journal of Morphology, 2016
Nerve compression by anomalous muscles located at the wrist and distal forearm is an infrequent condition. Accessory muscles may compress underlying structures in the Carpal Tunnel region or ulnar canal , producing pain and paresthesia. Two cases of ulnar and median nerve compression, caused by prominent accessory muscles at the distal forearm, are described. Literature review is presented.
Ulnar nerve injury with martin-gruber anastomosis
European Journal of Plastic Surgery, 1987
A patient with a traumatic ulnar nerve interruption at the level of the elbow is presented; the motor function of the hand remained intact. Electromyographic studies demonstrated a functional median-to-ulnar motor nerve anastomosis in the forearm. The literature on this aberration of innervation is reviewed, and problems of diagnosis and the treatment are discussed.
Plastic and Reconstructive Surgery, 2011
The origin of the flexor pollicis longus muscle can vary, causing compression of the anterior interosseous nerve in the forearm. The topographic relationship of the flexor pollicis longus to the median and anterior interosseous nerves must be considered when these nerves are decompressed. The anterior interosseous nerve is a motor nerve supplying the flexor pollicis longus, the flexor digitorum profundus, and the pronator quadratus. Unusual etiologic conditions can occasionally cause isolated neuropathy of the flexor pollicis longus branch from the anterior interosseous nerve. Methods: Six patients presented with isolated paralysis of the flexor pollicis longus, four following venipuncture in the cubital fossa and two following arthroscopy of the elbow joint. Cadaveric dissections were performed to examine any anatomy clinically relevant to the above techniques. The structure of the flexor pollicis longus nerve branch at different levels was examined with macroscopic and microscopic dissections and immunohistochemistry. Results: In each case, clinical symptoms resolved completely with conservative treatment. Dissection of cadaver arms showed that the nerve branch to the flexor pollicis longus joins the anterior interosseous nerve in the proximal third of the forearm and shares a common epineurium, but has its own fascicle up to the proximal aspect of the elbow. The branch to the flexor pollicis longus has no proximal interneural cross-connections up to the main trunk of the median nerve. Conclusion: The variable relationship of the superficial cubital veins to the underlying muscles and minimally invasive approaches to the elbow joint may cause an isolated neuropathy in the motor branch to the flexor pollicis longus, with a resultant solitary paralysis of the muscle. (Plast. Reconstr. Surg.
Hand (New York, N.Y.), 2009
Surgical repair of distal biceps tendon rupture is a technically challenging procedure that has the potential for devastating and permanently disabling complications. We report two cases of posterior interosseous nerve (PIN) injury following successful biceps tendon repair utilizing both the single-incision and two-incision approaches. We also describe our technique of posterior interosseous nerve repair using a medial antebrachial cutaneous nerve graft (MABC) and a new approach to the terminal branches of the posterior interosseous nerve that makes this reconstruction possible. Finally, we advocate consideration for identification of the posterior interosseous nerve prior to reattachment of the biceps tendon to the radial tuberosity.
Medicinski glasnik : official publication of the Medical Association of Zenica-Doboj Canton, Bosnia and Herzegovina, 2021
Aim To report clinical, functional and radiographic results of oneincision distal biceps tendon repair with Toggle Loc (Zimmer-Biomet, Warsaw, Indiana, USA) at an average 4-year follow-up and to assess posterior interosseous nerve injury complications after reconstruction. Methods We conducted a retrospective review of 58 consecutive distal biceps tendon repairs performed at our department between 2010 and 2018. Disabilities of Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) scale and elbow range of motion (ROM) were recorded at each follow-up and an ultrasound examination was also performed to assess the repaired biceps brachii tendon. Results Clinical evaluation showed good and excellent results at medium- and long-term follow-up. A temporary posterior interosseous nerve (PIN) palsy developed in four (6.81%) patients and always resolved in 8 weeks. PIN palsy prevalence is in accordance with the results of the previous studies. Conclusion Distal biceps tendon repai...
Journal of neurological surgery, 2013
Background and Study Aims Little information can be found in the literature regarding the relationships of the posterior interosseous nerve (PIN) while it traverses the supinator muscle. Because compression syndromes may involve this nerve at this site and researchers have investigated using branches of the PIN to the supinator for neurotization procedures, the authors' aim was to elucidate information about this anatomy. Materials and Methods Dissection was performed on 52 cadaveric limbs to investigate branching patterns of the PIN within the supinator muscle. Results On 29 sides, the PIN entered the supinator muscle as a single nerve and from its medial side provided two to four branches to the muscle. On 23 sides, the nerve entered the supinator muscle as two approximately equal-size branches that arose from the radial nerve on average 2.2 cm from the proximal edge of this muscle. In these cases, the medial of the two branches terminated on the supinator muscle, and the lateral branch traveled through the supinator muscle; in 13 specimens, it provided additional smaller branches to the supinator muscle. The length of PIN within the supinator muscle was 4 cm on average, and the diameter of its branches to the supinator muscle ranged from 0.8 to 1.1 mm. In 10 specimens, the PIN left the supinator muscle before the most distal aspect of the muscle. In two specimens with a single broad PIN, muscle fibers of the supinator muscle pierced the PIN as it traveled through it. Conclusion This knowledge of the anatomy of the PIN as it passes through the supinator muscle may be useful to neurosurgeons during decompressive procedures or neurotization.
Imaging of Posterior Interosseous Neuropathy following Distal Biceps Repair: A Report of 3 Cases
Case Reports in Radiology, 2015
Three cases of PIN palsy following biceps repair are presented with clinical and imaging correlation. The imaging findings in these cases will be discussed and the orthopedic literature, as regards possible surgical approaches and technical factors believed to predispose to or prevent this complication, will be reviewed. It is important for radiologists to serve as consultants in these uncommon but sometimes devastating complications, helping to quickly and accurately recognize the imaging findings corresponding to the clinical symptoms and aiding the surgeon in diagnosis and treatment by identifying the possible causes and sites of nerve compression.
Nerve transfers in distal forearm and in the hand
Plastic and Aesthetic Research , 2020
Nerve transfers were used, originally, to restore shoulder and elbow function in brachial plexus lesions. This concept has been developed over the years and applied to distal nerve injuries in which lower functionality was expected because of the gap between the injury site and the target muscle. The aim of this review is to describe nerve transfers in the distal forearm and hand for isolated lesions of the median, ulnar and radial nerves. The different advantages achieved by transposition of a functional nerve stump near the effector muscle have opened up new options for the management of nerve lesions. Some of these alternatives have only been recently reported and a few are exclusively case reports.
Histomorphometry of the ulnar nerve and of its branches
Surgical and Radiologic Anatomy, 1998
A morphometric study has shown that 10% of the fibers of the ulnar nerve should suffice to reinnervate the biceps muscle in brachial plexus palsies. The aim of this study was to evaluate, by a morphometric study using computerized microanalysis, the cross-sectional surface areas of the different collateral and terminal branches of the ulnar nerve. This was expressed in terms of percentage of the cross-sectional surface area of the main trunk of the ulnar nerve. The study revealed that the branch to the flexor digitorum profundus bellies to the ring and little fingers formed 9.5% of the cross-sectional area of the ulnar nerve. Thus use of these fascicles destined for the flexor digitorum profundus, identified by intra-operative nerve stimulation, at the level of the arm would be sufficient for neurotisation of the nerve to the biceps. This has been confirmed by the initial clinical results in patients operated upon using this technique.