Posterior Interosseous Nerve Palsy Research Articles

Posterior Interosseous Nerve Palsy in Rheumatoid Arthritis: A Systematic Review.

The purpose of this systematic review is to describe the pathoanatomy, presentation, diagnostic workup, treatment modalities, and outcomes of posterior interosseous nerve (PIN) palsy in patients with rheumatoid arthritis (RA). All reported cases of PIN palsy in patients with RA were reviewed to yield 72 cases of PIN palsy in 70 patients. The male-to-female ratio was 1:2.7. Pain involving the elbow was very common (20/33 cases reporting this information), and paralysis or weakness of digit extension was noted in 27/33 cases and 6/33 cases, respectively. Only 1 of the 54 cases undergoing surgical intervention reported persistent weakness, and this 1 patient had undergone a 3-month trial of conservative management. In conclusion, Appropriate pharmacologic management in conjunction with magnetic resonance imaging (MRI) and ultrasound monitoring may be used for conservative management, but surgical decompression should still be utilized for patients with a compressive disease pathology who fail to improve with 6 weeks of conservative treatment, or for those with advanced disease on initial presentation.

Nomenclature of the radial nerve: distinguishing between the deep branch of the radial nerve and the posterior interosseous nerve.

To address an inconsistency in the nomenclature of the anatomy and compressive syndromes of the deep branch of the radial nerve, we advocate for a single compression syndrome that presents along a spectrum from pain to posterior interosseous nerve palsy.

Anconeus Muscle Transfer to Correct or Prevent Wrist Radial Deviation in Radial and Posterior Interosseous Nerve Injuries

Wrist radial deviation is a possible complication of tendon transfer for restoration of wrist extension in cases of radial nerve paralysis. In posterior interosseous nerve (PIN) injury, this is because of the imbalance caused by the intact extensor carpi radialis longus and paralysis of the extensor carpi ulnaris (ECU). This deformity may also occur following transfer of the pronator teres (PT) to the extensor carpi radialis brevis (ECRB) for radial nerve palsy. To address wrist radial deviation, we propose transferring the anconeus muscle, extended by the intermuscular septum between the ECU and the flexor carpi ulnaris (FCU), to the ECU tendon. Through an incision over the ulna, the intermuscular septum between the ECU and FCU is harvested at the level of the periosteum and left attached to the anconeus proximally. The anconeus muscle is then released from the ulna, and the intramuscular septum extension is sutured to the ECU tendon under maximal tension. Anconeus muscle transfer was performed on two patients to correct chronic wrist radial deviation following PT to ECRB tendon transfer for radial nerve injury, as well as on two patients with PIN paralysis. In four patients, transfer was performed in addition to standard tendon transfers for radial nerve paralysis to prevent radial wrist deviation deformity. Wrist radial deviation was corrected or prevented in all but one patient at an average follow-up of 10 months. Patients with PIN lesions and those who had anconeus transfer concomitantly with radial nerve tendon transfers were capable of active ulnar deviation. No patient experienced elbow extension weakness, pain, or instability. Anconeus muscle transfer extended by intermuscular septum presents a viable alternative for addressing radial deviation of the wrist in cases of PIN nerve lesions or following PT to ECRB tendon transfer in radial nerve paralysis. Therapeutic V.

Distal biceps tendon rupture: a comprehensive overview

Distal biceps tendon (DBT) is a relatively rare injury mainly occurring in middle-aged men while in eccentric biceps muscle contraction. Clinical appearance with proximal avulsion of the muscle and specific clinical tests are most of the time sufficient for diagnosing DBT, but if needed ultrasonography and MRI, most often in FABS view, can be used to ensure diagnosis of DBT and partial DBT. Surgical anatomical reinsertion has shown to be a successful method of treatment, although conservative treatment can be initiated in older patients. Two different approaches are described in literature: single- and double-incision techniques with different fixation methods proving to have similarly good results. Major complications of surgical intervention are posterior interosseous nerve palsy and symptomatic heterotropic ossification. Overall outcome of surgical intervention has shown high subjective satisfaction with slight weakness in flexion and supination but mostly without loss in range of motion.

Rate of Complications After Capitellum Fracture Fixation: A Systematic Review and Meta-Analysis

This systematic review aimed to determine the incidence of complications following surgical fixation of an acute capitellum fracture. We secondarily aimed to compare the complication rate between anterior-to-posterior (A-P) versus posterior-to-anterior (P-A) screw insertion. PubMed, EMBASE, and Scopus were searched to identify studies on surgical fixation of capitellum fractures in skeletally mature patients. The main outcome was the rate of complication after fracture fixation. Subgroup analysis was performed to assess the impact of the fixation technique on the outcomes after surgery. An inverse variance method using random or fixed effects models was used to perform a meta-analysis based on the degree of heterogeneity between studies. Study heterogeneity was evaluated using Q statistics to calculate the I2 index. We included 42 studies in the final analysis. The most reported complications after surgical fixation of capitellum fractures included elbow pain (21%), radiocapitellar arthritis (19%), hardware removal (17%), and heterotopic ossification (13%). When groups were stratified based on the direction of screw insertion, the mean rate of avascular necrosis was higher in the P-A direction (29% vs 11%). In comparison, the rate of revision fixation (2.9% vs 6.7%) and heterotopic ossification (7.3% vs 22%) were higher in the A-P direction. Transient posterior interosseous nerve palsy was reported in four patients in four studies, of whom three patients had A-P screw fixation. Fixation of a displaced capitellum fracture is recommended when possible. However, patients should be counseled about the potential risk of complications and chances of undergoing an unplanned surgery. Therapeutic IV.

Minimally invasive distal biceps tendon repair: a case series.

Distal biceps tendon repairs are commonly performed using open techniques. A minimally invasive distal biceps tendon repair technique using a speculum and hooded endoscope was developed to improve visualization, reduce soft-tissue dissection, and minimize complications. This paper describes the technique and reports the outcomes of 75 minimally invasive distal biceps tendon repairs. The operation reports and outcomes of 75 patients who underwent distal biceps tendon repair using this technique between 2011 and 2021 were retrospectively reviewed. Median time to follow-up was 12 months (interquartile range [IQR], 6-56 months). Primary outcomes were function as measured by the Disabilities of Arm, Shoulder and Hand Score (DASH) questionnaire, and rate of complications. Median DASH score was 1.7 of 100 (IQR, 0-6.8). There were 2 of 75 (2.7%) re-ruptures of the distal tendon. There were no cases of vascular injury, proximal radius fracture, or posterior interosseous nerve, median, or ulnar nerve palsy. In this series, minimally invasive distal biceps repair was safe and effective with a low rate of major complications. Recovery of function, as indicated by low DASH scores, was satisfactory, and inconvenience during recovery was minimized. Level of evidence: IV.

Posterior interosseous nerve paralysis secondary to an extraneural ganglion cyst from a radial neck pseudarthrosis: illustrative case.

Many benign and malignant tissue or bony lesions have been reported as causes of extrinsic or intrinsic posterior interosseous nerve (PIN) neuropathy at the proximal forearm/elbow region. The authors describe an unusual cause of external compression of the PIN due to a ganglion cyst arising from a radial neck pseudarthrosis (a false joint). Decompression of the PIN with the release of the arcade of Frohse was performed with resection of the radial head and the ganglion cyst. By 6 months postoperatively, the patient had a complete neurological recovery. This case illustrates a previously unreported cause of extraneural compression of the PIN from a pseudarthrosis. The mechanism for compression in this case from the radial head pseudarthrosis is likely attributable to the sandwich effect, in which the PIN is sandwiched between the arcade of Frohse at the supinator from above and the cyst below.

90-day outcomes and factors for complications following radial head arthroplasty for Mason Type III and IV radial head fractures.

The aim of this study is to evaluate 90-day outcomes and complications following radial head arthroplasty (RHA) for Mason Type III and IV radial head fractures (RHFs) and determine factors predisposing patients to early complications and revision surgery. Patients undergoing RHA for Mason Type III and IV RHFs were identified retrospectively from an institutional database. Postoperative complications, reoperations, elbow range of motion, radiographs and concomitant injuries on the ipsilateral upper extremity were reviewed. Additionally, injuries were sub-classified as low-energy trauma (LET) or high-energy trauma (HET). Univariate logistic regression was performed to evaluate the risk for complications using patient factors not limited to the presence of concomitant ligamentous or bony injuries. P values < 0.05 were considered statistically significant. Seventy four patients were included in our study with an average follow-up time of 12.7months. Complications within 90-days of operation occurred in 8.1% of patients: heterotopic ossification (4.1%), superficial wound dehiscence (2.7%), and posterior interosseous nerve palsy (1.4%). No patients required readmission or revision surgery in the 90-day postoperative period. Univariate regression analysis did not demonstrate a significant association between diabetes, ASA status, HET versus LET, or the presence of concomitant injury. Concomitant injuries were found in 92% of patients. Radial head arthroplasty for RHFs demonstrates a low complication rate in the short-term. Diabetes, ASA class, high versus low energy trauma, and presence of concomitant injury were not found to be associated with higher complication rates in the 90-day postoperative period. Level of evidence IV, retrospective case series.

Posterior interosseous Nerve Palsy after Corticosteroid Injection for Tennis Elbow

A 47-year-old healthy male was treated for his tennis elbow with a steroid injection elsewhere. In the affected forearm, he was surgical treated for a forearm fracture, thirty years previously. After the injection, he developed posterior interosseous nerve palsy. He was treated with neurolysis of the nerve from the radial tunnel and distal to the supinator, where it was found to be adherent to the healed fracture site. Most of the motor nerve function returned within two years. We believe this to be an example of a “double crush” phenomenon of the radial nerve. Injection of steroids to treat lateral epicondylitis is extremely common and previous injury or surgery to the extremity should be considered before its administration.

Posterior interosseous nerve palsy due to lipoma: A rare case report

The posterior interosseous nerve is the terminal motor branch of the radial nerve without a sensory component. The nerve may be compressed for various reasons along the course of the forearm. Two different clinical pictures occur due to compression of the nerve in the forearm. In radial tunnel syndrome, entrapment of the nerve in the radial tunnel, pain in the elbow is at the forefront, while in the second clinical picture, posterior interosseous nerve syndrome, wrist and finger extension are affected. Posterior interosseous nerve syndrome is rare and develops due to many causes such as trauma, previous surgeries around the elbow, neurologic diseases and abnormal anatomical structures. A rare condition in the etiology of posterior interosseous nerve syndrome is mass lesions causing compression of the forearm.

Short-term outcome of unicortical, intramedullary repair of distal biceps ruptures – A retrospective cohort study

Modern distal biceps reconstruction techniques generally have satisfactory outcomes, but are not without complications. Posterior interosseous nerve (PIN) palsy is a rare but potentially devastating complication of bicortical metal button fixation. Recently, a unicortical, intramedullary, repair technique utilizing a suture anchor has been described. The primary aim of this study was to compare short-term functional and patient-reported outcomes and complication rates in patients receiving unicortical intramedullary repair (UR) with suture anchor against those receiving bicortical repair (BR) with metallic button. We hypothesized that UR would have equally satisfactory outcomes without the complication profile. Retrospective chart review was conducted for all patients undergoing operative fixation of distal biceps tendon ruptures from 2015 to 2021 at our tertiary referral center. Twenty patients received BR, and eight patients received UR. Patient demographics and surgical complications were compared. QuickDASH scores at two-month and latest in-person and telehealth postoperative visits, as well as elbow and forearm range of motion at last clinical visit, were collected and analyzed. Average patient age in the BR & UR cohorts were 49.3±9.3 and 42.1±6.2 years, respectively, with a male predominance. There was no statistical difference in patient age, sex, hand dominance, injury laterality, injury chronicity, and follow-up duration. Range of motion was comparable and excellent in both groups. Latest follow-up was 3.0±0.5 years in the BR and 1.5±0.4 years in the UR cohorts. QuickDASH scores improved between the two-month and latest time points in each cohort however did not differ significantly in head-to-head comparison. Complications included a case of PIN palsy, distal biceps tendon rerupture, and lateral antebrachial cutaneous nerve (LABC) neuropraxia in the BR group and two cases of LABC neuropraxia in the UR group. The number needed to treat (NNT) for the prevention of one additional case of PIN palsy using UR is 22 patients. Short-term functional and patient-reported outcomes in traditional BR and newly reported UR of distal biceps tendon ruptures are comparable and excellent. UR did not have higher failure rate despite follow-up periods beyond what is typically reported for tendon reruptures. In this limited retrospective cohort study, UR also did not encounter postoperative PIN palsy and had an NNT of 22 patients. In the appropriate clinical setting, this provides early evidence supporting the utilization of unicortical intramedullary suture anchor fixation of distal biceps tendon ruptures as well as associated perioperative interventions such as preoperative nerve blocks.

Brachioradialis to Extensor Carpi Ulnaris Transfer - An Additional Transfer to Prevent Radial Deviation Deformity of the Wrist following Tendon Transfers for Posterior Interosseous Nerve Palsy.

The usual recommendation in posterior interosseous nerve (PIN) palsy is to use the flexor carpi radialis instead of the flexor carpi ulnaris (FCU) for restoration of digital extension. The use of FCU takes away the only remaining ulnar deviator of the wrist. Although preserving the FCU prevents severe radial deviation deformity, we found that some patients still develop a radial deviation deformity, especially during wrist extension. We have used a brachioradialis (BR) to extensor carpi ulnaris (ECU) transfer to prevent the development of a radial deviation deformity and find that it restores the normal radio-ulnar balance of the wrist by providing a dynamic ulnar stabiliser. It is a simple addition to the standard two tendon transfers for PIN palsy with minimal donor morbidity. We have used this triple transfer for PIN palsy in seven patients with satisfactory results and no complications. Level of Evidence: Level V (Therapeutic).

Posterior Interosseous Nerve Palsy Associated with Multiple Epiphyseal Dysplasia

AbstractMultiple epiphyseal dysplasia is a condition that courses with a retarded epiphyseal development and may cause joint dysmorphia. We report a case of posterior interosseous nerve palsy in a child with dysplasia. After a physical examination and complementary diagnostic tests that revealed posterior interosseous nerve compression neuropathy, surgical neurolysis og the posterior interosseous nerve was performed at level of the the arcade of Frohse. The satisfactory evolution of the patient confirmed our diagnosis. Attention must be paid to the onset of signs or symptoms of nerve compression in these patients.

A case report of surgical treatment of traumatic drop hand by quadruple tendons transfer.

IntroductionDrop hand is the case of inability to dorsiflexion of the hand and fingers according to radial nerve palsy (complete syndrome) or PIN (Posterior Interosseous Nerve) palsy (partial syndrome). Therefore, the patient loses part of the normal function of his/her hand causing life problems especially if it is the dominant hand. Tendon transfer is the main surgical treatment.Case reportWe present a case of a young male who sustained multiple traumatic war injuries especially in the left upper limb; open humerus fracture, open ulna fracture, open radius fracture with a clear drop hand syndrome. After quadruple tendons transfer, he got a very good result especially in thumb movements with good ROM (Range Of Motions) in the wrist.DiscussionSince it is difficult to restore full ROM and full muscular strength in the wrist and fingers of a drop hand with triple tendon transfer routinely, especially in the case of multiple injury to the upper extremity with the pronator teres being nonfunctional, we decided to perform quadruple tendon transfer depending on the tendons; FCR, PL, 3rdFDS, 4thFDS for stronger extension of the wrist, thumb, and other fingers.ConclusionOur aim here is to confirm that the drop hand does not have standard findings in all cases. It may be a challenge, and may have atypical findings especially in the case of ipsilateral multiple traumatic limb, which in turn may have weakness or restriction in some important movements, so, it is important to keep in mind alternatives of tendon transfer.

Intramedullary, unicortical repair of distal biceps tendon rupture

Historically-used bicortical repair of distal biceps tendon rupture are at risk for posterior interosseous nerve palsy. Here we present a technique, and associated case report, utilizing unicortical repair with a suture cortical button device for this injury. The described technique provides robust fixation and avoids the rare, but potentially devastating complication of posterior interosseous nerve palsy.

The Window Test: A Simple Bedside Method to Detect Radial Deviation of the Wrist Commonly Seen in Posterior Interosseous Nerve Palsy

Posterior interosseous nerve palsy (PINP) is a disorder caused by damage to the posterior interosseous nerve, resulting in weak extension of the wrist and fingers as well as radial deviation of the wrist. This study analyzed a new type of evaluation for PINP in hopes of increasing ease of diagnosis and earlier detection of the disorder. The window test is performed by the examiner laying hands on the ulnar aspect of the patient's pronated forearm while the patient tries to extend the wrist. A positive test is obtained when a gap (window) appears between the examiner's forearm and the patient's hand. Laypeople, medical students, residents, and practicing providers were assessed prospectively on their ability to correctly diagnose PINP by observing one hand, by observing both hands and by using the window test. The window test was consistently found to be the most effective method of evaluation, as it increased the accuracy of diagnosis in all groups surveyed. Additionally, case studies were performed using the window test on patients, further demonstrating the efficacy of the test by confirming wrist radial deviation. The window test introduces a reference frame making it easier to assess wrist radial deviation and offering a simple evaluation that can be administered by virtually anyone. These findings indicate that the implementation of the window test will increase the accuracy and effectiveness of PINP diagnosis, thus allowing early diagnosis and better management.

Neuralgic amyotrophy.

This review focuses on the current insights and developments in neuralgic amyotrophy (NA), an auto-immune multifocal peripheral nervous system disorder that leaves many patients permanently impaired if not recognized and treated properly. NA is not as rare as previously thought. The phenotype is broad, and recent nerve imaging developments suggest that NA is the most common cause of acute anterior or posterior interosseous nerve palsy. Phrenic nerve involvement occurs in 8% of all NA patients, often with debilitating consequences. Acute phase treatment of NA with steroids or i.v. immunoglobulin may benefit patients. Long-term consequences are the rule, and persisting symptoms are mainly caused by a combination of decreased endurance in the affected nerves and an altered posture and movement pattern, not by the axonal damage itself. Patients benefit from specific rehabilitation treatment. For nerves that do not recover, surgery may be an option. NA is not uncommon, and has a long-term impact on patients' well-being. Early immunomodulating treatment, and identifying phrenic neuropathy or complete nerve paralysis is important for optimal recovery. For persistent symptoms a specific treatment strategy aiming at regaining an energy balance and well-coordinated scapular movement are paramount.

Treatment of diaphyseal forearm fracture with interlocking intramedullary nailing: A pilot study

IntroductionThe present study was done to assess the functional outcome and complications of interlocking intramedullary (IM) radius ulna nailing to treat radio-ulna fractures in adults. MethodologyThirty adult patients with diaphyseal or segmental fractures of radius and ulna were included and treated with IM nailing. Grace and Eversmann rating system was used to assess functional evaluation and grip strength was measured using grasp dynamometer. ResultsMean age of the 30 eligible patients was 33.5 years, and males comprised 77% of the study population. Intra-operative complications like nail impaction and proximal screw locking problem for radius was present in one patient each. Increased swelling in three patients (10%) and posterior interosseous nerve palsy in one patient (3%) were observed post-operatively. In the post-operative period, all patients were able to move fingers, had 100° elbow range of motion and good grip strength. Pronation and supination till 80° was present in 80% and 57% of the patients respectively. Wrist flexion and dorsiflexion till 90° was present in 80% and 57% of the patients. Fracture union was confirmed radiologically in all cases at a mean of 3.6 weeks. Functional outcome was excellent in 73% and good in 13%. Grip strength was judged to be excellent in all cases. ConclusionsExcellent and good functional outcomes were obtained in 86%, and no case developed mal-union or delayed union. Based on our results, IM nail for surgical treatment of radial and ulnar diaphyseal fractures can be used.

Management of posterior interosseous nerve (PIN) palsies after distal biceps tendon repair using a single incision technique- a conclusive approach to diagnostics and therapy

Complete distal ruptures of the biceps brachii tendon are rather rare and surgical reinsertion is the gold standard. Recently, one incision approaches for the refixation of the distal biceps tendon have been popularized with the introduction of a single-incision approach employing a trans-radial cortical button fixation. Since the introduction of this fixation technique we have seen more iatrogenic lesions to the posterior interosseous nerve (PIN) after not having seen any PIN lesions with 2 incision biceps refixation techniques over the last 5 years. Several patients with iatrogenic PIN affections after one incision refixation techniques of the distal biceps tendon were referred to our level 1 department of Plastic surgery and hand surgery from different orthopedic surgeons. Over the course of 6 months we saw 5 patients with a similar history. We decided to analyze this problem and propose a course of action to regain function of the PIN innervated muscles as good and fast as possible. If there is a loss of function in the PIN innervated muscles after distal biceps refixation a neurological evaluation including electrophysiology needs to be conducted. An ultrasound assessment of the nerve itself should guide the clinician in the decision between a conservative and a surgical treatment in the early postoperative phase. If surgical exploration is warranted intraoperative neurography should be the basis on which ground (partial) grafting or solely neurolysis is performed. Postoperatively all patients need to follow a rehabilitation protocol to help with nerve regeneration and regaining of motor function.

Nerve Grafting for Chronic PIN Palsy Due to Radiocapitellar Joint Entrapment 2 Years Following Closed Reduction of a Pediatric Monteggia Fracture-Dislocation: A Case Report With 1-Year Follow-up

This article describes the first case of successful nerve grafting for posterior interosseous nerve (PIN) palsy secondary to radiocapitellar joint entrapment 2 years following closed reduction (CR) of a pediatric Monteggia fracture-dislocation (MFD). Patient notes were examined. The literature was reviewed to determine whether similar cases or techniques had been reported. A 5-year-old girl presented with a PIN palsy 2 years following CR of an MFD, demonstrating Medical Research Council (MRC) grade 4 wrist and MRC grade 2 finger and thumb extension. Nerve exploration at 27 months revealed a PIN crushed in the radiocapitellar joint with a proximal neuroma-in-continuity and no response to electrical stimulation. Neurolysis and lateral antebrachial cutaneous nerve cable grafting were performed. The decision to pursue nerve grafting was based on the intraoperative appearance of an atrophic PIN with no response to stimulation, but with minimal muscle atrophy, short distance to target muscles, and pediatric patient with extended reinnervation timeline. Full recovery (MRC grade 5 wrist extension and MRC grade 4+ finger and thumb extension) was achieved at 1-year follow-up. We present the first case of successful nerve grafting for PIN palsy secondary to radiocapitellar joint entrapment 2 years following CR of a type III MFD. Even with significant treatment delay, nerve reconstruction should be considered in the pediatric population.