A rare case of progressive and late onset posterior interosseous nerve palsy following distal biceps tendon repair (original) (raw)
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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.