11486396 /90/2703-0397902.00/0 Nivaomc ncn CCopsight 190 hy the Congress of Neurological Surgeons Vol. 27. No, 3.1990 Prnied in USA Posterior Interosseous Nerve Palsies George Cravens, M.D., and David G. Kline, M.D. Department of Nearosurgers; Louisiana State University Medical Center. and Charity Hospital and Ochsner Foundation Hospital New Orleans, Louisiana ‘One hundred seventy patients with radial nerve disorders were reviewed at the Louisiana State University Medical Center over a 15-year period. Of these, 32 had involvement of the posterior interosseous nerve exclusively. Findings. included weak wrist extension with a radial drift, inability 10 extend the fingers, paralysis of thumb extension, and weak ‘thumb abduction, Causes included entrapment at the arcade of Froshe (14 patients). laceration (6 patients). fracture (6 patients), compression or contusion (3 patients), and loss associated with tumor (3 patients). The ratio of men to women, \was 2:1. and the right arm was involved twice as often as the left, Preoperative evaluation included physical examination, electrophysiological testing (electromyogram /nerve conduction velocity). and roentgenograms of the elbow and forearm. Of the 30 patients (2 patients had bilateral lesions), 26 underwent operation. In the operative series, all 28 nerves had a function of Grade 3 or more of a possible 5 after 4 years of follow-up. Seventeen had achieved Grade 4/5. and 7 had obtained Grade 5/5. At operation, 23 nerves were found 1o be in continuity. Fourteen lesions of nerves in continuity were associated with entrapment and, not unexpectedly. transmitted a nerve action potential with slowed conduction and low amplitude across the lesion. Four nerves in continuity that had lesions caused by injury had nerve action potentials and were treated by neurolysis. and another 4 had no nerve action potentials and were treated by graft or suture repair. Five injured nerves were not in continuity. Two could be repaired by end-to-end suture. and 3 required graft repair. A large ganglion cyst involving the posterior interosscous nerve was also resected. (Neurosurgery 27:397= 402. 1990) Key words: Arcade of Froshe, Extensor carpi radialis, Extensor carpi ulnaris, Posterior interosseous nerve, Supinator muscle entrapment INTRODUCTION Isolated weakness of muscles innervated by the posterior interosseous nerve (PIN) is rare (20). Diagnosis can often be missed because wrist drop is not a feature. The patient presents with weak wrist extension and radial drift, inability to extend the fingers at the metacarpophalangeal joints. and weakness ‘or loss of thumb extension and abduction. There is no sensory deficit, although diffuse deep forearm pain and/or discomfort may be associated symptoms. Electrodiagnostic studies can yield false negative results on nerve conduction tests. or partial denervation may be seen on the electromyogram. which suggests a partial radial nerve lesion rather than a posterior interosseous nerve palsy. Careful clinical examination, in addition to knowledge of distal radial nerve anatomy. is, essential for a correct diagnosis. MECHANISMS OF POSTERIOR INTEROSSEOUS: NERVE PALSY ‘Traumatic paralysis of the PIN may follow open injuries to the proximal forearm. for example. lacerations and gunshot wounds (14, 30). Closed injuries due to fractures of the proximal radius or fracture of both radius and ulna can also result in paralysis (9, 12. 17, 29), Iatrogenic causes include radial head resection and injury associated with tumor re- ‘moval (16. 30. 31), Chronic repeated trauma related to siress- ful supination and pronation has been reported in swimmers. frisbee players. tennis players. violinists, and orchestra con- ductors (22). Nontraumatic progressive paralysis of the PIN may also be caused by inflammatory conditions such as rheumatoid ar- thritis (5. 19. 23). Compression of a nerve by a local mass is not uncommon (1. 14). Lipomas causing compression of the posterior interosseous nerve have been reviewed by Wu et al (33). Other causes of compression include fibromas, gan- lions, and traumatic ancurysms of the posterior interosseous artery (2. 8). Intrancural tumors include neurofibromas and schwannomas (16). Amyloid neuropathy associated with mul- tiple myeloma has also been reported (26). Nonetheless. spon- taneous entrapment at the level of the supinator muscle or arcade of Froshe is the most frequent cause of posterior interosseous nerve palsy (3. 7. 10. 11. 15. 21. 27). The anat- omy of the PIN and its relationship to mechanisms of injury are reviewed. Clinical presentations and the methods used for preoperative evaluation, as well as the results, are discussed SELECTED ANATOMICAL POINTS Close to the joint line of the elbow, the radial nerve branches, to the brachial. brachioradial, and extensor carpi radialis Jongus muscles and to the periosteum of the lateral epicon- dyle. anterior radiohumeral joint, and the annular ligament (24). At variable levels distal to the elbow, the main trunk divides into the PIN and superticial sensory radial (SSR) branches, The extensor carpi radialis brevis muscle arises from the lateral epicondyle of the humerus and lies anterolateral 10 the PIN beneath the extensor carpi radialis longus, Spinner (28) has described how the edge of the muscle can impinge on the PIN during pronation. Just before passing between the two heads of the supinator. the PIN branches to the extensor carpi radialis brevis and supinator muscles. Some think that the vascular arcade over and under the PIN, proximal to its course under the volar supinator. can be a source of entrapment. Immediately distal 10 the origin of the extensor carpi radialis brevis muscle, the PIN passes beneath the often fibrous edge of the superficial oblique portion of the supinator muscle to enter the muscle itself. This is the arcade ‘of Froshe. which was initially described by Froshe and Frankel in 1908 (30),398 CRAVENS and KLINE The most proximal part of the superficial head of the supinator muscle may be tendinous and forms a fibrous arch. Arising in a semicircular manner from the tip of the lateral epicondyle, supinator fibers arch downward approximately 1 em and then attach to the medial aspect of the lateral epicon- dyle of the humerus just lateral to the articular surface of the capitulum. The PIN passes under the edge of this fibrous arch (Fig. 1). Spinner, in his 1968 anatomical studies (28), demonstrated that in 70% of specimens, the medial half of the arcade was, ‘membranous, whereas in the remaining 30% the arcade was of the same firm consistency as the lateral half, As the nerve winds laterally 10 meet the extensor compartment of the forearm, it lies close to the neck of the radius. Upon leaving, the distal border of the supinator muscle, deep to the super= ficial layer of extensor muscles, the PIN arborizes into short branches that supply the medial extensor musculature (the extensor carpi ulnaris, extensor digitorum communis, exten- sor digiti minimi) and two long branches that supply the extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus, and extensor indicis muscles. Although the PIN is primarily a motor nerve, it also gives off terminal sensory branches to the ligaments and articula- tions of the carpal joints as well as sensory innervation to the periosteum of the radius and interosseous membrane of the forearm. Entrapment of a motor nerve may cause a diffusely localized, dull, aching pain (25). A motor nerve such as the PIN contains not only larger efferent fibers that are myeli- nated, but also many thinly myelinated and nonmyelinated afferent fibers of muscular and extramuscular origin. Many Of these fibers are nociceptive and therefore responsible for the pain in some cases of PIN palsy. Lateral elbow pain (or “tennis elbow") on pronation/supination is probably the most frequently noted sensory discomfort (32), although this symp- tom, when not associated with paresis in PIN distribution, is usually caused by mechanisms other than impingement on the PIN (24, 25). The SSR, which branches from the radial nerve as the PIN is formed, ‘continues its course in the forearm above the extensor carpi radialis longus and beneath the brachioradialis. The SSR supplies the skin over the radial side of the dorsum Of the wrist and hand and terminates on the dorsal surface of the radial three and one-half fingers. This nerve, which is anatomically separate from the PIN, is not involved in the PIN syndrome. CLINICAL FEATURES Each of the patients reported on in this paper had serious motor loss in the distribution of the PIN. Complete injury to the PIN produced paralysis of the extensor muscles of the Recurrent radial Vascular prcade—_areade of Froshe ~~ vor Brachioradialis m. Fic. 1, Drawing of the relationship of anatomical structures at the level of the elbow, ECR, extensor carp radials branch: ECL {extensor carpi ulnars branch: PIN. posterior interasseous nerve: SSR. cial sensory radial nerve: BR. brachioradialis branch Neurosurgery, Vol. 27, No. 3 forearm. except for extensor carpi radials brevis and longus. ‘The hallmark was wrist extension with radial drift caused by paralysis of the extensor carpi ulnaris. Finger and. thumb extension were absent, Less severe involvement of the PIN or an incomplete injury or lesion produced paresis of extensor carpi ulnaris so that ulnar extension was weak. In addition, finger extension, although present, was weak, and some fin- gers extended further than others. Thumb extension was almost always either very weak of. more often, absent, Elec- tromyographic studies showed reduced or absent insertional activity and denervational changes, such as fibillations in the forearm extensor muscles except for the extensor carpi radi- alis brevis and longus). Each of the nerves injured by fracture. laceration. contusion, or previous operation, and operated on in this series. had complete loss by clinical and electromyo- aphic criteria, With entrapment, loss in the distribution of the PIN was more variable and usually less complete than with injury Often, some fingers extended farther than others, but thumb extension was almost always very weak or totally absent (Figure 2), Despite these observations, loss was complete in $ of the 14 cases of entrapment scen and operated on in this series. Loss inthe other 9 limbs in 7 patient with entrapments was incomplete but severe, according to our grading system, including Grade | of a possible 5 (I patient), Grade 2/5 (3 patients), and Grade 3/5 (5 patients). Most patients with ‘entrapment and some with traumatic injury to the PIN com- plained of some diffuse pain in either the elbow or forearm Such discomfort was sometimes exacerbated by pronation, supination, or wrist extension Noninvasive computer recordings of nerve action potentials, (NAPS) as well as electromyograms and conduction studies, were done in all patients with entrapments (6, 14, 22). None: theless, the decision to operate was based primarily on the findings at physical examination and the patients’ histones. The one tumor found in this operative series was a mod crately large ganglion cyst compressing the PIN. Neural loss preoperatively was Grade 3/5. PIN function in two other patients having had previous removal of a neurofibroma and ‘a schwannoma was initially Grades 2/5 and 4/5, respectively, but improved to Grades 4/5 and 5/5 over time. SURGICAL APPROACH Surgery was carried out under general anesthesia. The patient was placed in a supine position on the operating table with the affected arm partially abducted at the shoulder and Fic, 2, Characteristic weak wrist dorsiflevion with radial drift and variabie"abilty to extend ihe fingers (lett hand) as compared ith normal function (right hand}September 1990 the forearm in supination. A curvilinear incision, approxi- mately 8 to 10 cm long, was made over the anterior surface of the forearm just distal to the elbow crease, and extended along the groove medial to the bulk of the brachioradialis muscle. The fascia was exposed, using blunt and sharp dissection. The brachioradial muscle was retracted radially or laterally after adequate exposure. Beneath this muscle, the radial nerve. including. its branches to the brachioradial, extensor carpi radialis longus and brevis muscles, as well as its division into the SSR and the PIN, was then exposed. ‘The exact level at which the PIN and the SSR branched from the radial nerve was variable, but usually occurred about to 1.5 inches distal to the antecubital flexion crease. Just distal to this branching point, a number of small vessels from the recurrent radial artery and accompanying veins formed a vascular arcade over the Volar or anterior surface of the PIN These vessels were dissected away from the nerve and then coagulated. using bipolar forceps. The SSR branch was usually dissected distally, anterior 10, the extensor carpi radialis brevis muscle. The PIN was then traced distally as it passed beneath the edge of the superficial (or volar part of the supinator (Figs. 3 and 4), By longitudinally Gividing the superficial head of the supinator, the PIN was ‘exposed as it passed through the arcade of Froshe and entered the extensor compartment of the forearm, Care was taken 10 preserve all branches to the extensor musculature. Where the PIN was in continuity, intraoperative stimulation and record ing of NAPs was done. If'an NAP was recorded acrossa lesion in continuity, a neurolysis was done. If no NAP was recorded, then the lesion was resected and a repair was done, Graft ‘material was usually harvested by sectioning the SSR proxi- mally and resecting the length needed distally. The proximal end of the SSR was then buried deep to the brachioradial muscle after “sealing” cach proximal fascicle. using fine tipped bipolar forceps, There was no incidence of painful forearm or symptomatic neuroma connected with using SSR asa donor grait in this series of patients. RESULTS, ‘The Department of Neurosurgery at the Louisiana State University Medical Center evaluated 170 cases of radial nerve disorders not associated with injury to another nerve over a 15-year period (1968-1983). Patients seen after 1983 were not Fic, 3. Operative dissection. showing the superficial sensory branch (SSR) and the posterior interosseous nerve (PLN). The volue supinator has been sectioned. Recording electrodes are on the PIN (Go the right) distal to the level ofthe arcade of Froshe. and stimulating electrodes are on the proximal PIN (1o the lef) POSTERIOR INTEROSSEOUS NERVE PALSIES 399 included, because we wanted to have several years’ follow-up data on each patient. During this period. 30 patients with 32 isolated PIN palsies were seen. This constituted 19% of the isolated radial nerve injuries studied. There were 1] women, ranging in age from 19 to 49 (average age, 32.8 years), and 19 ‘men, ranging in age from 12 to 72 (average age. 29 years), for aan approximate 2:1 ratio of men to women (Table 1), The right side was involved twice as often as the left (22 vs. 10) (Table 1). The tendency of involvement of the right sid when compared in the two sexes, was more marked in women. ‘The male population had a greater proportion of traumatic injuries, often involving the left side, which gave a more equal distribution (Table 2). [Fone looks at only entrapment lesions, however, the right versus left predominance becomes more apparent (R/L, 9:5) (Table 2). Mechanisms of injury for both FiG, 4. Close-up view showing the posterior interosseous nerve (PIN) passing beneath the arcade of Froshe, formed by the volar supinator() Tame Louisiana State University Medical Center Series of 32 Posterior Interosseous Nerve Palsies in 30 Patient Women Men Average age (9) 328 290 Age range (2) 19-49 12-72 Palsies/patients nyt 20/19 Right/lef 10/02 08 “Two patients (1. man, | woman) had bilateral posterior interos seous nerve palsy due to entrapme Tamer 2 Cause andl Handedness of Posterior Interosseons Nerve Pals Women Me Total Cause —— Right eft Right Leh Right Left Lacerations roo 3 2 4 2 Fractures > 1 3 0 5 4 Contusions 1 0 0 2 41 2 ‘compression Tumors 2 0 1 0 3 0 Entrapment $4 8 4 9 Totals 0 Roos 0 Posterior interosseous nerve palsy associated with the placement, of a plate for fracture in 2 cases: 3 previous operations in another Tumors included 1 ganglion cyst. 1 schwannoma. and | neuro- fibroma,400 CRAVENS and KLINE men and women are also given in Table 2 the time of orthopedic manipulation and pla matic cases. including 14 entrapmems (2 bilat tumors (Table 2), Tape 3 Grading of Posterior Imerosseous Nerve Function Grade Criteria 0 NoECU, EC. or EPL muscle function 1 Trace or against gravity of ECU only, absent EC and EPL. musele funetion 2 Recovery of ECU. absent or trace only’ of EC and/or EPL muscle 3 Recovery of ECU, some EC, weak or absent EPL muscle function 4 Recovery of maderate strength of EC and EPL. {ull strength in ECU muscle function S$ Recovery of full strength of EPL, EC. and ECU, muscle function “ECU. extensor carpi ulnaris: EC. extensor communis: EPL. x ‘tensor pollicus longus. Operative Cause of Injury Findings" Injury® Lacerations—‘Transection Glass ‘Transection Giass Transoction Mexal Transection Glass Incontinuity Kote Prior pri Kote Fractures Incontinuity Radius Fi: plated Transection| Radius Fix} plated Incontinuity Radius Fis) Incontinuity Radius Fis) elbow dis location Incontinuity —— Ragius/ulna Fis 3 previous ‘operations Contusions In continuity Brick Incontinuity Pool cue ~ Preoperative loss complete Fe, fracture (2) absent: (4), present Tendon transfer helped recovery All_patients operated upon had symptoms less than I year in duration. Traumatic causes included lacerations (6 patients), fractures (6 patients). and contusions (3 patients). for a total of 15 injuries, OF the 6 fractures. ? involved injury of the nerve at ment of a plate. and another probably sustained contusion during a third operative attempt at fracture repair. There were 17 nontrau- al) and 3 The three tumors included one ganglion Newrosurgerv. Vol. 27, No. 3 cyst and two tumors of neural origin, a schwannoma and a neurofibroma. The method used to grade PIN loss pre- and postoperatively is outlined in Table 3 Table 4 shows the data for injured PIN nerves operated on. Lacerating injuries transected the PIN in 4 patients. One was repaired within 72 hours by suture, and three were repaired aller a delay. two by suture and one by graft repair. with good results. Despite injuries by sharp objects and complete pre- ‘operative loss. two nerves were in continuity. Neither trans- mitted an NAP. and both required repair. eventually showing 00d results. Five patients with PIN palsies associated with fracture, usually of the radius, were operated on. Each had complete lossin distribution ofthe PIN preoperatively. In three ofthese patients, previous operative manipulation and, usually, plat- ing of the fracture. played a role in the origin of the PIN injury. One of these patients had had three operations in an attempt to stabilize fractures of both the radius and the ulna Im one patient with a radius fracture that had been plated there was no continuity of the nerve. After the stumps were ‘rimmed to healthy tissue, there was @ 2.S-inch gap, which necessitated a graft. The PINs of the other four patients with fractures associated with PIN injuries who underwent surgery were in-continuity, Two transmitted NAPs and underwent neurolysis, but two did not and required grat repair. Again, the results were good. although the graft repair in the patient with three previous operations led to only a Grade 3/5 out- come. Tendon transfer was necessary 10 provide elective finger and thumb extension. The two patients with PIN palsies associated with contu- Result Follow-up oe (Grade) ra (Transection) Secondary 4s 2 suture (Transection) Secondary ays 1s (Transection) Secondary aise 3 arafts Primary 55 3 suture o Secondary ays Ls o Secondary s/s 3S rafts o Grats 4s 28 (Transeetion) Grafts 4s 25 w Neurolysis 4/5 2 ira Neurolysis 4/510 5/5 2 oO Gratis ys" 3 w Neurolssis 4/5 3 ra Neurolssis s/s 45September 1990 Tanur $ Enwrapped Posterior Intevosseous Nerve Results _ Preoperative Postoperative Number of Grade Grade Patients o/s s/s 3 o/s 4/5 1 o/s 3/5 H ys 5/5 1 2s 4s 3 3/5 4/5 L 3/5 5/5 4 “Tendon transfer helped recovery in patient. Tame 6 Nomoperated Posterior Inverosseous Nerve Resuls Grade when First Evaluated to Final Grade 2sw4/s HSwa/s A/S S/S Prior tumor removal 1 1 Sleep compression 1 (contusion) Fracture L sions had transmitted NAPs and required only a neurolysis. Both have recovered well. Table 5 shows the results for patients with entrapped PIN nerves and Table 6 for 4 patients with injured nerves not operated on. Despite entrapment as a mechanism, loss was complete preoperatively in 5 of these patients, and in another 4 was quite severe (Grade 1/5 or 2/5). In each instance, intraoperative recording showed an NAP across the entrap- ment site, which was al the arcade of Froshe. Conduction was slowed and the amplitude of the NAP was usually low Thirteen of the 14 entrapped nerves recovered to either Grade 4/5 (5 patients) or 5/5 (8 patients): one, in which loss had been complete preoperatively. recovered to Grade 3/5 and ‘was helped by a tendon transfer, Patients with palsies that ‘were the result of previous tumor removal, sleep compression, and fracture treated without operation had incomplete losses when seen initially and improved with time. DISCUSSION Because of is unique anatomical configuration. the radial nerve is vulnerable 10 injury at several locations in its course through the arm and forearm. Lesions involving the radial nerve before it divides into the terminal motor (PIN) and sensory branches give rise to consistent clinical findings (4 18), Lesions involving the PIN, however. can often be missed. as complete wrist drop is not a feature. Instead. presenting symptoms are weak wrist extension with radial deviation. ‘variable ability to extend the fingers. and ether complet loss or severe weakness of thumb extension and abduction. There is often associated elbow pain. which may be exacerbated by pronation or supination. Such symptoms might suggest a partial injury to the whole radial nerve: however. they are Usually due to PIN involvement, Of the 170 cases of radial nerve disorders reviewed at Louisiana State University Med- ical Center, 32 (19%) involved the PIN. It is therefore impor- tant to suspect PIN palsy: when examining patients. with suspected radial nerve involvement. At the level of the arcade of Froshe. the PIN is vulnerable POSTERIOR INTEROSSEOUS NERVE PALSIES 401 to compression and entrapment. Chronic repetitive irritation exacerbated by alternating pronation and supination may play a role in the development of the palsy. Acute injury. with compression is also common. These chronic and acute forms of entrapment of the PIN accounted for 14 of the palsies seen in the present series. Neurolysi of the nerve, with release of the arcade of Froshe, led to good recovery All patients with lacerations, fractures. or contusions should have clinical evaluations that include careful physical exami- nation, radiographic views of the elbow and forearm, and clectrodiagnostic studies such as electromyograms and non- invasive conduction recordings to document the level and extent oF injury. Sharp-object injuries are candidates for early or primary repair. Blunt injuries are usually followed for several months for signs of improvement. Those who show no improvement require an operation for definitive treat ment, Timing of surgery and type of repair have been reviewed elsewhere (13. 14, 22, 30). Surgical intervention that included external neurolysis, re- pair by end-to-end suture, or interfascicular grafting led to 00d or excellent results (atleast Grade 3/5) in all 28 patients. Fifteen of these reached Grade 4/5. and 1 achieved a Grade 5/5 level, Although strong wrist extension is important for power grip, complete recovery of finger and thumb extension Js not required for a useful hand, The importance of regaining ‘maximal wrist, finger, and thumb extension to avoid major disability of the hand cannot be overemphasized Intraoperative nerve stimulation and recording are very portant in making a decision for or against resection in patients with injuries that leave the PIN in continuity. In the present series, 4 of 8 injured nerves that remained in conti- nuity had negative nerve action potentials and thus required resection and subsequent repair by suture or graft rather than neurolysis. Four injured nerves with positive NAPs had neu- rolysis and recovered well, Injured nerves that were not in continuity (5) could sometimes be repaired by suture (2) with g00d results, although those that required interfescicular grafts G)also did well. Patients who are awaiting reinnervation should receive physiotherapy that includes range of motion exercises. Many patients also benefitted from the use ofa dynamic dorsiflexion splint with outrigger. subber bands. and finger pads in order 10 maintain flexibility and mobility of all finger and thumb joints CONCLUSIONS Lesions involving the posterior interosseous nerve may give clinical picture that simulates a more proximal, partial radial nerve injury. Neurosurgeons should be aware ofthe possibility ‘of posterior interosseous nerve palsy in injury involving the elbow and forearm. Patients who do not have a return of function either clinically or with electrical testing after 3 ‘months are candidates for surgical exploration. In the present series. neurolysis or surgical repair utilizing direct suture or interfascicular grafts provided good to excellent results in almost all cases. Intraoperative recordings were helpful in making a decision for or against resection concerning th injured nerves remaining in continuity seen in this series of patients, Received for publication, August 30. 1989: accepted. final form. pal 9. 1990, Reprint requests: David G., Kline. M.D.. Department of Neurosur gery, Louisiana State University School of Medicine. New Orleans, LA 70112402 CRAVENS and KLINE REFERENCES, Blakemore ME: Posterior interosseous nerve paralysis caused by ‘lipoma, J R Coll Surg Edinb 24C2:1 13-116. 1979. Bower TL, Stone KH: Posterior interosscous nerve paralysis, caused by a ganglion atthe elbow. J Bone Joint Surg [Br] 38°77 776, 1966, Brsan FS, Miller LS, Panjaganond P: Spontaneous paralysis of the posterior interosseous nerve: A case report and review of the ature. Clin Orthop 809-12. 197 Capener N The vulnerability of the posterior interosseous nerve ‘of the forearm. 1 Bone Foint Surg [Br] 48:770-773, 1966, Chang L. Gowans ID. Granger CV. Millender. 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