July 16th 2019

RADIAL NERVE PALSY :

HISTORY
PHYSICAL EXAMINATION
CLASSIFICATION
TEAM VII
VC-AB-NO-MZ

Moderator: SI
Supervisor: dr M. Ruksal Saleh, Ph. D, Sp. OT (K)
Case
45-year-old right handed patient with pain and swelling
immediately following blunt trauma. His past medical history
revealed that he had been injured in a combat and strucked on
his left arm three months ago. He went to the emergency
department the following day because a weakness developed on
his left wrist.
• On examination, his upper arm was swollen, tender, and
ecchymotic. Unable of active finger and wrist extension with
anesthesia over the first web space dorsally were observed.
 Anatomy
Origin: posterior cord of the brachial plexus (C5-T1)

AAOS Comprehensive Orthopaedic Review 2

INNERVATES
– Radial nerve
• Triceps, brachioradialis, ECRL, anconeus
• Radial half of the brachialis

– PIN
• supinator, ECRB, EDC, APL, EIP, EPL, EPB

AAOS Comprehensive Orthopaedic Review 2

Mechanism Injury
• TRAUMA
• NON-TRAUMA
• ENTRAPMENT

Classification
• VERY HIGH LESION
• HIGH LESION
• LOW LESION
Compression in the arm
• Fibrous band at the origin of the lateral head of the triceps
• Lateral intermuscular septum

Compression in the elbow

• Fibrous tissue anterior to the radiocapitellar joint
• Radial recurrent vessels (Leash of Henry)
• Extensor carpi radialis brevis edge
• Arcade of Frohse : the most common entrapment site
• Supinator muscle edgeAAOS Comprehensive Orthopaedic Review 2
Compression in the wrist
• Compression between the brachioradialis and ECRL tendons in
the distal forearm

AAOS Comprehensive Orthopaedic Review 2

ENTRAPMENT BELOW ELBOW
• PIN syndrome
• Radial tunnel syndrome
• Cheiralgia paresthetica (Wartenberg syndrome)
Physical Examination

McRae, Clinical Orthopaedic Examination 6th ed ,2010

Physical Examination

McRae, Clinical Orthopaedic Examination 6th ed ,2010

Physical Examination

McRae, Clinical Orthopaedic Examination 6th ed ,2010

VERY HIGH LESION

• Causes: Chronic compression of the axilla

– “Saturday night palsy”
– “crutch palsy”

• Manifestation: Total palsy

– Triceps paralysis
– Weakness extension of wrist and hand
HIGH LESION
• Causes:
– Fracture of the humerus (holstein – lewis fracture)
– Prolonged tourniquet pressure

• Manifestation:
– Elbow extension spared
– Weakness wrist and finger extension
– Anatomical snuffbox sensory loss
LOW LESION
– Below elbow

• Causes:
– Fracture radial head
– Radial recurrent artery (leash of henry)
– Elbow fracture
– Dislocation elbow
– Entrapment “FREAS”

• Manifestation:
– Finger drop
– Elbow and wrist extension spared with radial deviation
– Weakness of thumb extension & abduction
• Lesions:
– Very high (above radial groove): Total palsy
– High (radial groove): Elbow extension spared
– Low (below elbow): Elbow and wrist extension spared
Treatment
• Recovery is usually spontaneous
• No recovery by 3 to 4 months  neurolysis, nerve grafting,
tendon transfers can be considered

AAOS Comprehensive Orthopaedic Review 2

 PIN Compression Syndrome
Pathoanatomy :
1. Fibrous tissue anterior to the
radiocapitellar joint
2. Radial recurrent vessels (Leash
of Henry)
3. Extensor carpi radialis brevis
edge
4. Arcade of Frohse
5. Supinator muscle edge

Orthobullets, Volume one Trauma, 2017

Physical exam
– Weakness of finger extension
– Radial deviation with active wrist extension

• Provocative tests 
– Resisted supination
• will increase pain

Orthobullets, Volume one Trauma, 2017

Treatment
• Non-surgical
– Splinting
– Avoidance of provocative behavior
– NSAID and lidocaine/corticosteroid injection

• Surgical decompression
– Indicated if non-surgical management for 3 months is unsuccessful
– Release of Arcade of Frohse and the fibrous edge of the ECRB
– Release of the fibrous bands superficial to the radiocapitellar joint
– Ligation of the leash of Henry
Orthobullets, Volume one Trauma, 2017
AAOS Comprehensive Orthopaedic Review 2
Radial Tunnel Syndrome

• A compressive neuropathy of the posterior interosseous nerve

(PIN) with pain only 
– no motor dysfunction

• Pathophysiology
– involves same sites of compression as PIN syndrome

Orthobullets, Volume one Trauma, 2017

Presentation
• Symptoms
– Deep aching pain in dorsoradial proximal forearm 
• from lateral elbow to wrist
• increases during forearm rotation and lifting
activities

Orthobullets, Volume one Trauma, 2017

• Physical exam
– Tenderness below lateral elbow
– Provocative tests
• resisted supination test (with elbow and wrist in extension)
• passive pronation with wrist flexion
• radial tunnel injection test
– diagnostic if injection leads to a PIN palsy and relieves pain
– Sensory
• may have paresthesias in the first dorsal web space
– Motor
• no motor manifestations

Orthobullets, Volume one Trauma, 2017

Treatment

• Nonoperative
– activity modification, temporary splinting, NSAIDS
– corticosteroid injection

• Operative
– radial tunnel release    

Orthobullets, Volume one Trauma, 2017

Wartenberg's Syndrome

• Also called "cheiralgia paresthetica"

• compressive neuropathy of the superficial sensory radial
nerve (SRN)
• Compression between the brachioradialis and ECRL tendons in
the distal forearm
• sensory manifestation only 
• no motor deficits

Orthobullets, Volume one Trauma, 2017

Presentation
• Symptoms
– Pain over dorsoradial hand 
– Paresthesias over dorsoradial hand
– Symptom aggravation by motions involving repetitive wrist
flexion and ulnar deviation
– no motor weakness

Orthobullets, Volume one Trauma, 2017

• Physical exam
– Provocative tests
• Tinel's sign over the superficial sensory radial nerve
• Wrist flexion, ulnar deviation and pronation for one minute  
• Finkelstein test increases symptoms in 96% of patients

Orthobullets, Volume one Trauma, 2017

Treatment
• Non-surgical
– Wrist splint
– Avoidance of offending activities
• Surgical
– Considered after 6 months of nonsurgical management
– Neurolysis
– Release of fascia between the brachioradialis and the ECRL

AAOS Comprehensive Orthopaedic Review 2

• Radial nerve palsy (5%-10%)
• When to observe:
– The vast majority (up to 92%) resolve with observation for 3 to 4
months.
– Brachioradialis and ECRL are the first to return
– EIP are last to return

Miller's Review of Orthopaedics, 6th ed

Q&A
 Spontaneous entrapment of the posterior interosseous nerve
most commonly occurs in which of the following locations?

1- Lateral intermuscular septum

2- Extensor carpi radialis brevis
3- Arcade of Frohse
4- Midsubstance of the supinator
5- Leash of Henry
 Spontaneous entrapment of the posterior interosseous nerve
most commonly occurs in which of the following locations?

1- Lateral intermuscular septum

2- Extensor carpi radialis brevis
3- Arcade of Frohse
4- Midsubstance of the supinator
5- Leash of Henry
PREFERRED RESPONSE: 3

DISCUSSION:
The extensor carpi radialis brevis, supinator muscle, arcade of Frohse,
and leash of Henry are potential sites of compression for the posterior
interosseous nerve.
The most common location of spontaneous entrapment is the arcade of
Frohse. The lateral intermuscular septum is a site of compression for the
radial nerve.
REFERENCE: Spinner RJ, Spinner M: Nerve entrapment syndromes, in
Morrey BF: The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB
Saunders, 2000, pp 839-862.
 A 22-year-old man reports a 2-week history of a burning pain along the dorsoradial aspect of the
distal forearm. The pain radiates to the dorsum of the thumb. Examination reveals tenderness and
reproduction of symptoms with percussion 8 cm proximal to the radial styloid. Reproduction of
symptoms also occurs with forearm pronation and ulnar deviation of the wrist. No discrease
sensory deficit is noted and electrodiagnostic studies are normal. Nonsurgical management
consisting of rest, splinting, and antiinflammatory medications for 6 weeks has failed to provide
relief. Treatment should now consist of decompression of the

1. lateral antebrachial cutaneous nerve in the interval between the abductor pollicis longus and the
extensor pollicis brevis in the forearm.
2. lateral antebrachial cutaneous nerve in the interval between the brachioradialis and the extensor carpi
radialis longus in the distal forearm.
3. radial sensory nerve in the interval between the extensor carpi radialis longus and the extensor carpi
radialis brevis in the distal forearm.
4. radial sensory nerve in (the interval between the brachioradialis and the extensor carpi radialis longus
in the distal forearm.
5 . radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis brevis in
the distal forearm.
 A 22-year-old man reports a 2-week history of a burning pain along the dorsoradial aspect of the
distal forearm. The pain radiates to the dorsum of the thumb. Examination reveals tenderness and
reproduction of symptoms with percussion 8 cm proximal to the radial styloid. Reproduction of
symptoms also occurs with forearm pronation and ulnar deviation of the wrist. No discrease
sensory deficit is noted and electrodiagnostic studies are normal. Nonsurgical management
consisting of rest, splinting, and antiinflammatory medications for 6 weeks has failed to provide
relief. Treatment should now consist of decompression of the

1. lateral antebrachial cutaneous nerve in the interval between the abductor pollicis longus and the
extensor pollicis brevis in the forearm.
2. lateral antebrachial cutaneous nerve in the interval between the brachioradialis and the extensor carpi
radialis longus in the distal forearm.
3. radial sensory nerve in the interval between the extensor carpi radialis longus and the extensor carpi
radialis brevis in the distal forearm.
4. radial sensory nerve in (the interval between the brachioradialis and the extensor carpi radialis
longus in the distal forearm.
5 . radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis brevis in
the distal forearm.
PREFERRED RESPONSE: 4

DISCUSSION: Wartenberg's syndrome, or compression of the sensory branch of the radial

nerve, occurs in the interval between the brachiorad ialis and the extensor carpi radialis
longus approxJrnatcly 8 cm proximal to the radial styloid. There may be history of
repetitive wristlforeann circumduction activity (ie, knitting) or of wearing a tight
wristwatch or jewelry. It can occur in patients who have been handcuffed. Typical clinical
findings are pain. paresthesia, andlor hypesthesia in the dorsoradial aspect of the wrist
and hand in the distribution of the rad ial sensory nerve. There is often a positive Tinel's
sign over the compression site. Hypesthesia may be present in the distribution of the
radial sensory nerve which is typically on the dorsal aspect of the first dorsal web space
and dorSlml of the thumb; however, with overlap in the distribution of the superficial
radial nerve and the lateral cutaneous nerve of the foreaml this may not always be
present. Surgical management consists of release of the nerve as it exits the interval
between the brachioradialis and the extensor carpi radialis longus in the distal forearm.
Compressive injury to the posterior interosseous nerve will lead to
EMG fibrillations in which of the following muscles?
1. Extensor Carpi Radialis Longus/Extensor Carpi Radialis
Brevis/Brachoradialis
2. Extensor Carpi Radialis Longus/Supinator/Abductor Pollicis Longus
3. Extensor Pollicis Longus/Supinator/Abductor Pollicis Longus
4. Brachoradialis/Supinator/Extensor Pollicis Longus
5. Extensor Pollicis Longus/Supinator/Abductor Pollicis Brevis
Compressive injury to the posterior interosseous nerve will lead to
EMG fibrillations in which of the following muscles?
1. Extensor Carpi Radialis Longus/Extensor Carpi Radialis
Brevis/Brachoradialis
2. Extensor Carpi Radialis Longus/Supinator/Abductor Pollicis Longus
3. Extensor Pollicis Longus/Supinator/Abductor Pollicis Longus
4. Brachoradialis/Supinator/Extensor Pollicis Longus
5. Extensor Pollicis Longus/Supinator/Abductor Pollicis Brevis
PREFERRED RESPONSE 3
Based on the choices above, fibrillations will be seen in the extensor pollicis longus, supinator and
abductor pollicis longus muscles.

The radial nerve splits into the superficial radial branch and the posterior interosseous nerve (PIN) at the
anterior aspect of the radiocapitellar joint, just proximal to the supinator muscle. The PIN innervates the
EDC, EDM, ECU, EPB, EPL, EIP, APL and sometimes the ECRB. Compressive neuropathy of the PIN leads
to motor dysfunction, namely weakness with wrist and finger extension.
Lubhan et al. review uncommon compression neuropathies affecting the upper extremity. They indicate
that PIN syndrome may be caused by rheumatoid arthritis and compressive ganglion cysts. Depending
on which nerve branch is affected, partial lesions may develop. They recommend use of conservative
measures (rest, activity modification and splinting) first. Decompressive procedures may be indicated in
symptoms lasting greater than 3 months.
The course of posterior interosseous nerve from proximal to distal along the course of the supinator.
This proximal edge of the supinator (Arcade of Froshe), the fibrous edge of the ECRB and the leash of
Henry are three main points of compression of the PIN. 
Incorrect Answers
Answer 1, 2, 4: The radial nerve proper innervates the ECRL, ECRB and Brachoradialis 
Answer 5: The recurrent motor branch of the median nerve innervates the APB
A 22-year-old man reports a 2-week history of a burning pain along the dorsoradial
aspect of the distal forearm. The pain radiates to the dorsum of the thumb.
Examination reveals tenderness and reproduction of symptoms with percussion 8 cm
proximal to the radial styloid. Reproduction of symptoms also occurs with forearm
pronation and ulnar deviation of the wrist. No discrete sensory deficit is noted and
electrodiagnostic studies are normal. Nonsurgical management consisting of rest,
splinting, and anti-inflammatory medications for 6 weeks has failed to provide relief.
Treatment should now consist of decompression of the
1. lateral antebrachial cutaneous nerve in the interval between the abductor pollicis longus and the
extensor pollicis brevis in the forearm.
2. lateral antebrachial cutaneous nerve in the interval between the brachioradialis and the extensor
carpi radialis longus in the distal forearm.
3. radial sensory nerve in the interval between the extensor carpi radialis longus and the extensor
carpi radialis brevis in the distal forearm.
4. radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis
longus in the distal forearm.
5. radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis
brevis in the distal forearm.
A 22-year-old man reports a 2-week history of a burning pain along the dorsoradial
aspect of the distal forearm. The pain radiates to the dorsum of the thumb.
Examination reveals tenderness and reproduction of symptoms with percussion 8 cm
proximal to the radial styloid. Reproduction of symptoms also occurs with forearm
pronation and ulnar deviation of the wrist. No discrete sensory deficit is noted and
electrodiagnostic studies are normal. Nonsurgical management consisting of rest,
splinting, and anti-inflammatory medications for 6 weeks has failed to provide relief.
Treatment should now consist of decompression of the
1. lateral antebrachial cutaneous nerve in the interval between the abductor pollicis longus and the
extensor pollicis brevis in the forearm.
2. lateral antebrachial cutaneous nerve in the interval between the brachioradialis and the extensor
carpi radialis longus in the distal forearm.
3. radial sensory nerve in the interval between the extensor carpi radialis longus and the extensor
carpi radialis brevis in the distal forearm.
4. radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis
longus in the distal forearm.
5. radial sensory nerve in the interval between the brachioradialis and the extensor carpi radialis
brevis in the distal forearm.
• PREFERRED RESPONSE 4 
Wartenberg's syndrome, or compression of the sensory branch of the radial nerve,
occurs in the interval between the brachioradialis and the extensor carpi radialis
longus approximately 8 cm proximal to the radial styloid. There may be history of
repetitive wrist/forearm circumduction activity (ie, knitting) or of wearing a tight
wristwatch or jewelry. It can occur in patients who have been handcuffed. Typical
clinical findings are pain, paresthesia, and/or hypesthesia in the dorsoradial aspect of
the wrist and hand in the distribution of the radial sensory nerve. There is often a
positive Tinel's sign over the compression site. Hypesthesia may be present in the
distribution of the radial sensory nerve which is typically on the dorsal aspect of the
first dorsal web space and dorsum of the thumb; however, with overlap in the
distribution of the superficial radial nerve and the lateral cutaneous nerve of the
forearm this may not always be present. Surgical management consists of release of
the nerve as it exits the interval between the brachioradialis and the extensor carpi
radialis longus in the distal forearm.
THANK YOU