Anatomy

Arises from posterior cord

All three trunks contribute

posterior divisions to the
posterior cord

Lies on the posterior wall of

axilla

Leaves axilla passing through

lower triangular space
Accompanied by the profunda brachii artery, the
nerve enters the spiral groove

 Between the medial and lateral heads of the triceps

Crosses the humerus posteriorly from proximal

medial to distal lateral

Branches to the lateral and medial heads of the

triceps and to the lower lateral brachial cutaneous
nerve
Passes anterior by
piercing lateral
intermuscular septum

Enters the interval

between the brachialis
and brachioradialis
muscles

Proximal to the lateral

epicondyle - BR and ECRL
Near the level of the lateral epicondyle - bifurcates
into the superficial and deep branches

Superficial branch – continues beneath the BR

Between the tendons of the BR and the ECRL, approx

9 cm proximal to the radial styloid

Sensory innervation to the dorsoradial aspect of the

hand, thumb, index finger and variably, the long and
ring fingers
Distal to elbow PIN, passes beneath recurrent vessels
from the radial artery

Approx 5 cm distal to the lateral epicondyle - enters

the supinator muscle underneath the arcade of Frohse

Multiple branches innervate the supinator

As the PIN exits the supinator, supplies the EDC,

EDM and ECU
Remaining trunk of PIN continues distally in the
interval between EPL and APL

It supplies the EPL , EPB , EIP and APL

Articular branches – radio carpal, DRUJ,

intercarpal and CMC joints

Proximal-to-distal muscle innervation order is

important when observing for radial nerve recovery
1. Brachioradialis
2. ECRL
3. ECRB
4. Supinator
5. EDC
6. ECU
7. EDM
8. APL
9. EPL
10. EPB
11. EIP
Closed and open injuries

Primary injury and secondary injuries

Crush, Avulsion, Laceration, Stretching,

Compression and combination
 Pathophysiology

Rarely occurs proximal to the innervation of the triceps

Functional deficits after radial nerve injury involve the

wrist, finger and thumb extensors

Traditionally, radial nerve palsy has been categorized

into high and low types
High palsy: Injury proximal to the elbow and that
results in deficits in wrist and digital extension

Low palsy: Refers to denervation of muscles that are

innervated by the PIN, thus sparing wrist extension,
with deficits in thumb and finger extension

ECU is denervated in a low palsy, wrist extension

occurs in a dorsoradial direction.
High radial nerve palsy associated with humeral shaft
fractures can be secondary to

Nerve contusion or entrapment

 Evaluation
Careful history and physical examination that focus
on nerve function are indicated

When evaluating motor function, the muscle that is

being tested should be palpated to appreciate its
activation

Testing a relatively distally innervated muscle, such

as the EPL, serves as a good motor screening test
Dont misinterpret thumb IP joint extension,
necessarily, as an indication that the EPL is functional

Thumb IP joint extension can occur via the EPL or by

median and ulnar - innervated thumb intrinsic
muscles that affect terminal joint extension via the
extensor hood
A detailed motor and sensory examination should
follow, especially if the initial screening examination
indicates a deficit

When evaluating a patient with a chronic radial nerve

palsy, evaluation must include potential donor
muscles
Management of Radial nerve palsy
caused by Special injuries
 Penetrating Trauma
Glass or knife lacerations, usually result in nerve
transection

After management of emergent associated injuries,

nerve exploration and repair should proceed as early
as possible
 Fractures and Dislocations
Considerable controversy - humeral shaft fractures

The superiority of early versus delayed exploration is

contingent on

1. whether there is a significant incidence of remediable

lesions (nerve laceration or entrapment)
2. whether the prognosis for correcting the problem early
is better than addressing it later
Omer observed spontaneous recovery in 83% of nerve
injuries associated with upper extremity fractures

72% recovering in the first 4 months.

No appreciable recovery was noted after 7 months.

Radial nerve exploration - only if recovery is delayed.

If initial recovery is delayed beyond 4 to 5 months

beyond the predicted recovery duration, exploration
is indicated.

Incidence of radial nerve laceration or fracture site

entrapment appears to be quite significant with open
humeral fractures - prefered to explore the nerve
when treating open fractures and vascular injury

Exploration of a dysfunctional radial nerve that was

fully functional before fracture manipulation
An irreducible radial head or a secondary palsy are
indications for early exploration

Otherwise, late exploration is undertaken only if

recovery is delayed beyond what would be anticipated
 Non Operative Treatment
Most appropriate for those patients who await
spontaneous nerve recovery or after radial nerve
repair

Wrist splints [cock-up] can enhance hand function

Unless contraindications, nonsurgical reconstruction

is not the treatment of choice for radial nerve palsy in
the setting of an irreparable nerve
Maintaining a supple hand is of paramount
importance, whether nerve recovery is expected or
tendon transfers are anticipated

If a wrist drop is neglected, a wrist flexion contracture

ensues

Patients should be taught ROM and stretching

exercises that focus on wrist extension and MCP joint
flexion.
A simple wrist extension
splint may assist

Grip strength may be

increased three to five
times by simply stabilizing
the wrist

Patients find frequently

that a splint that stabilizes
the wrist in slight
extension improves grasp
Surgical Management
 Nerve - Repair
Repaired using epineurial or epi-perineurial sutures

Axilla – mobilize nerve and posterior cord of brachial

plexus , 6 -7 cm gap

Middle third of arm – can be mobilized by about 10 to 12

cms
 Early Transfers (Internal Splint)
To provide a temporary “internal splint” and not as
definitive treatment

Burkhalter - greatest functional loss in the patient

with radial nerve injury is weakness of power grip

Early PT to ECRB transfer to eliminate the need for

an external splint and at the same time, to restore a
significant amount of power grip to the patient's
hand.
The uses of the transfer

1. As a substitute during regeneration of the nerve to

eliminate the need for splintage
2. As a helper after reinnervation by adding the power of
a normal muscle to the reinnervated muscles
3. As a substitute in cases in which the results of nerve
repair are statistically poor
The important principles are

1. not significantly decrease the remaining

function in the hand

2. not create a deformity if significant return

occurs following nerve repair

3. be a phasic transfer or one capable of phase

conversion.
Nerve repair/grafting Vs Tendon transfers
Whether to attempt late repair of the nerve or to
restore lost function with tendon transfers

If the prognosis for return after nerve repair is poor, it

would appear prudent to forego an attempt at repair
and proceed directly to tendon transfer

If the nerve repair should fail, that costs the patient
an additional 4 to 6 months of waiting for function to
return before resorting to tendon transfers
Principles of Tendon Transfers
1) Straight line of pull
2) Expendable donor
3) Adequate strength
4) Correction of contracture
5) One Tendon – One Function
6) Amplitude of motion
7) Synergism
8) Tissue equilibrium
Carefully Planned Incisions
Tendons Should Not Lie Beneath Scars

Careful Mobilization Of Muscles

Prevent Neurovascular Pedicle Damage

Subcutaneous Tunneling Of Transfers

No Small Fascial Windows
Functional Deficits

Wrist Extension
Finger Extension
Extension and Radial abduction of the
thumb
 Critical limit of Delay of repair

Radial nerve – No function beyond 15

months

PIN – No function beyond 9 months

Evolved During The Two World Wars
Classic Jones Transfer

1916
PT to ECRL and ECRB
FCU to EDC III-V
FCR to EIP, EDC II and EPL

1921
PT to ECRL and ECRB
FCU to EDC III-V
FCR to EIP, EDC II, EPL, EPB and APL
FCU Transfer
Incision 1:
FCU and PL transected
FCU freed up proximally

Incision 2:
Deep fascia overlying FCU incised and muscle
freed proximally
Limit – neurovascular pedicle

Incision 3:
Insertion of PT freed with strip of periosteum
EPL tendon identified
 Setting the Proper Tension
PT  ECRB
Wrist45° extension
Tendon sutured with maximal tension

FCU  EDC
Wrist and MP joints in neutral
Adjust EDC tension individually
PL  EPL
Wrist in neutral
Maximal tension on EPL and PL

Test Passive ROM

 Wrist In Extension
Passively Flex Fingers Into Palm

Wrist in flexion
MP joints in full extension
Should not hyperextend
Postoperative Management
Splint For 4 Weeks
Wrist 15-30° Pronation
Forearm 45° Extension

MP joints slight flexion (10-15°)

Thumb – Maximal extension and abduction

PIP joints – left free

4 To 6 Weeks
Removable Splint
Planned exercise program – with therapist
FCR Transfer
FCR  EDC

PT  ECRB, when required

performed as before

PL  EPL
Performed as before
If absent
EPL joined with EDC to FCR transfer
Superficialis Transfer
(Boyes)
PT  ECRB

FDS III  EIP & EPL

FDS IV  EDC III,IV,V

FCR  APL & EPB

 summary
Transfer Advantage Disadvantage
Standard PT  ECRB Requires little retraining Unable to extend
FCU  EDC Predictable fingers & wrist
Pl  rerouted EPL simultaneously
Dominance of radial
forces across the
wrist
FCR PT  ECRB Maintains FCU as an ulnar Unable to extend
transfer FCR  EDC wrist flexor – important in fingers & wrist
heavy laborer simultaneously
Pl  rerouted EPL

Modified PT  ECRB Able to extend fingers & wrist Potential F/ E def of

Boyes FDS IV EDC simultaneously; independent donor finger PIPJs
transfer FDS III EIP & EPL control of index & thumb from Transfer not
others for pinch synergistic with
FCR  APL & EPB
potential for difficult
rehabilitation
Potential for
adhesions at IOM
“There is usually only one chance to obtain good
restoration of function in a paralyzed hand”
Riordan

THANK YOU
 Nerve transfers
• Lore(1948) described the use of nerve
transfers for severe brachial plexus injuries

•Limited application for certain types of high radial

nerve palsies or in cases of radial neuritis
 Pre requisites
1. Require an expendable, distal, normal motor nerve - in
close proximity to muscle

2. Donor motor nerve also must have a large enough number

of motor fibers to allow for recovery of function and be
“pure" enough to prevent reinnervation with unwanted
sensory axons

3. Synergistic nerve function will improve the clinical result

by decreasing the requirement of motor re education and
training.

4. Nerve transfers require a tension free repair - other wise

use nerve graft
 Sources
 Median nerve – limited anatomic variations in the forearm-
provides several dependable sources
several redundant nerve br. to FDS groups that can be
transferred
nerve branch to PL can also be sacrificed

 Redundant branch of the ulnar nerve

(A) the nerve br. to the PL and sublimis transferred into PIN and ECRB
respectively.

(B) the nerve br. to PL and sublimis transferred into the PIN and another
sublimis br. transferred to the ECRB
 Advantages of Nerve transfer
• The recovery of motor function is potentially greater
because the muscle biomechanics are not altered

• Nerve transfer permits the recovery of target muscle

function with significantly less muscle dissection

• The target muscle is often undisturbed in its anatomic bed,

with very little scarring or adhesion formation that may limit
target muscle excursion.
 Results of radial nerve repair
89% - regain function of proximal muscles

63% regain function of all muscles supplied

by radial nerve

36% - regain fine control of extensors

JONES TRANSFERS

The only current controversy regarding the pronator

transfer centers around the optimal insertion of the
PT.