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Background: Brachioradial pruritus (BRP) is a localized pruritus of the dorsolateral aspect of the arm. BRP is an enigmatic condition with a controversial cause; some authors consider BRP to be a photodermatosis whereas other authors attribute BRP to compression of cervical nerve roots., Objective: We sought to investigate the presence of neuropathy in patients with BRP., Methods: We performed electrophysiologic studies of the median, ulnar, and radial nerves in consecutive patients with BRP, including measurement of sensory and motor distal latency, conduction velocity and F responses of the median and ulnar nerves, and sensory distal latency of the radial nerves in both upper limbs., Results: Included in the study were 7 patients, 5 men and 2 women, with an average age of 58.3 years (range: 42-72 years). Of the patients, 4 (57%) had abnormal F responses that were diagnostic for cervical radiculopathy, and 3 of these patients had prolonged distal latencies of the nerves tested, which may be interpreted as sensory motor neuropathy secondary to chronic radiculopathy. The fourth patient had polyneuropathy secondary to diabetes mellitus., Conclusion: BRP may be attributed to a neuropathy, such as chronic cervical radiculopathy. The possibility of an underlying neuropathy should be considered in the evaluation and treatment of all patients with BRP.

A case is reported of high radial nerve palsy in an elite bodybuilder caused by an extrinsic mass effect of muscular hypertrophy. Surgical decompression resulted in complete clinical resolution.

Nerve injuries complicating elbow dislocation reported in literature involve ulnar and median nerve. A case of radial nerve paralysis after lateral dislocation of the elbow is reported.

Study Design: A B design with subjects acting as their own control when the device is turned off., Objective: Evaluation of the efficacy of the NeuroControl Freehand System., Setting: A supra regional spinal unit in the UK., Methods: The Freehand system is an implanted Functional Electrical Stimulation (FES) device for restoration of lateral and palmar grasps following C5 or C6 tetraplegia. Its use was assessed using the Grasp Relies Test (GRT), Activities of Daily Living (ADL), Grip strength and two-point discrimination., Results: Seven out of nine subjects are currently daily users of the device. There were statistically significant increases in the number of types of task achieved and the number of repetitions of those tasks in the Grasp Release Test. The system produced a functionally strong grasp where no grip strength at all was possible prior to implantation. Three of the four subjects who had sensory ability prior to implant showed improvements in two-point discrimination. Most of the selected tasks were achieved in the ADL assessment indicating a significant improvement in independence., Conclusion: The Freehand system can significantly improve the functional ability of C5 and C6 lesion tetraplegics., Sponsorship: This study was funded by the charity INSPIRE.

Purpose of the Study: Radial palsy is a serious complication of humeral shaft fractures. The risk results from the anatomic position of the radial nerve which turns around the distal portion of the humeral shaft, in contact with the bone. As a rule, radial palsy regresses spontaneously, but in a few cases surgery may be required to achieve neurological recovery. We conducted a retrospective study of thirty cases of radial palsy after humeral fracture treated surgically. Our objective was to define causes of non-recovery and assess therapeutic efficacy, searching for the characteristic features of the fractures involved., Material and Methods: We limited our analysis to post-humeral fracture radial palsies, which were operated due to the absence of neurological recovery. We recorded the type of fracture, treatment used to achieve bone healing, surgical approach, and type of radial nerve surgery. The series included 30 patients, predominantly male, mean age 38.4 years. The fractures were situated in the middle or lower third of the humeral shaft. Most were spiral fractures. Plate fixation (30%) or nailing (33%) were generally used for fixation. There were six cases of iatrogenic palsy, all after plate fixation. A revision procedure was required in one-third of the cases due to nonunion. Exploration of the radial nerve demonstrated compression at the intermuscular septum in one-third of the cases and a direct conflict with the fixation plate in one-fifth of the cases. Neurolysis was required in 23 cases, nerve grafts in five and first-intention tendon transfer in two., Results: Results of nerve surgery were assessed with the Alnot classification at a mean follow-up of 6.3 years. Outcome was rated good or very good in 22 patients, fair in one and poor (failure) in three. First-intention tendon transfers were performed in two patients and two patients were lost to follow-up. Mean delay to recovery was seven months after neurolysis and fifteen months after nerve grafts., Discussion: Our experience and data in the literature suggest that several factors could be involved in persistent radial palsy after humeral shaft fracture. The greatest risk of radial nerve injury or absence of recovery after the primary lesion is encountered after fracture of the lower third of the humerus, spiral fracture, and plate fixation. Particular features observed in our series were nonunion and compression in the intermuscular septum.

The experience of locked nailing of spiral humeral fractures and the perioperative conditions of the radial nerve are reported. The nerve is at risk of entrapment after such a fracture, and severe injury may occur during closed nailing. Among 162 humeral fractures treated by locked nailing, there were 21 spiral fractures: 18 acute fractures, and three delayed unions. The distribution of the fractures was two at the middle and 19 at the distal (1/3). Twelve patients had preoperative radial nerve palsy. All fractures excluding one middle fracture were retrograde nailed, and all patients had radial nerve exploration. Thirteen fractures were locked statically, seven were locked distally and had cerclage wiring, and one was locked distally only. Fisher's exact tests showed that the risk of radial nerve entrapment significantly increased in fractures with varus angulation or resulting from high-energy trauma. All the patients achieved fracture union and regained satisfactory joint functions. The author suggests that in external rotational spiral humeral fractures, radial nerve exploration should be done if nerve entrapment is highly suspected, irrespective of the fracture location or nerve palsy. Locked nailing with transfixing screws or cerclage wire could be a reliable treatment method for these fractures.

Learning Objectives: After studying this article, the participant should be able to: 1. Identify all potential points of radial nerve compression and other likely causes of radial nerve injury. 2. Accurately diagnose both surgical and nonsurgical causes of radial nerve paralysis. 3. Define a safe and effective approach to the surgical release and reconstruction of the radial nerve. Radial nerve paralysis, which can result from a complex humerus fracture, direct nerve trauma, compressive neuropathies, neuritis, or (rarely) from malignant tumor formation, has been reported throughout the literature, with some controversy regarding its diagnosis and management. The appropriate management of any radial nerve palsy depends primarily on an accurate determination of its cause, severity, duration, and level of involvement. The radial nerve can be injured as proximally as the brachial plexus or as distally as the posterior interosseous or radial sensory nerve. This article reviews the etiology, prognosis, and various treatments available for radial nerve paralysis. It also provides a new classification system and treatment algorithm to assist in the management of patients with radial nerve palsies, and it offers a simple, five-step approach to radial nerve release in the forearm.

Concomittant lesions of neural structures represent a rare type of complications in Monteggia's fractures. In acute fractures spontaneous neurological remission usually occurs after reduction of the dislocated radial head. In the presented case a 33-year old man experienced a trady palsy of the posterior interosseus nerve 27 years after a Monteggia's fracture with the radial head left dislocated. Following a minimal trauma in badminton a neurological deficiency probably caused by distraction occurred and resulted in impairment of wrist extension and extension of the fingers. Initiated conservative treatment including intensive physiotherapy and electrotherapy for 4 months was unsuccessful. Consecutively the radial nerve was surgically exposed and released from an entrapping and thickened arcade of Frohse. The radial head was left dislocated. Full neurological recovery was obtained 9 months after surgery.

Purpose of the Study: Fractures of the proximal humerus are increasingly frequent. Conservative treatment is most often proposed, but surgery must be performed when the displacement is significant and/or when the fracture is unstable. Osteoporosois and comminution are two essential elements for deciding on the surgical technique., Material and Methods: This retrospective study included 31 patients who underwent pinning from the deltoid V according to the Kapandji procedure. There were 19 females and 12 males. Mean age was 61 years. There was a fracture of one of the tuberosities in 12 cases and significant metaphyseal comminution in 8., Results: Mean follow-up was 26 months. Outcome was excellent or good in 22 cases (70.9%), fair in 4 (12.9%), and poor in 5 (16.2%). Fifteen complications were noted (48.4%): material displacement 8 cases, reflex sympathic dystrophy 3 cases, radial nerve palsy 2 cases, head osteonecrosis 1 case, and humeral fracture at the site of insertion of the K wires 1 case., Discussion: At the present time, there is no consensus for the surgical management of fractures of the proximal humerus, including proximal metaphyseal fracture with or without fracture of one of the tuberosities. Closed reduction and pinning is not really an invasive procedure, and does not injure the rotator cuff. Surgical approach at the level of the deltoid V according to the Kapandji technique avoids elbow pain and stiffness. The procedure requires a fluoroscan and experience to obtain satisfactory divergence of the K wires in the humeral head, an essential technical point. This procedure cannot be recommended for elderly patients whose bone quality is too poor to obtain good fixation of the K wires.

Radial nerve palsy is a rather frequent complication caused by an accident as well as by surgery of the humerus. As a primary, i.e., accidental lesion, its incidence as stated in the literature is up to 30%, primarily fractures in the distal diaphyseal half. Secondary, i.e., surgically induced, nerve lesions surprisingly are reported with a similar frequency, though recently the incidence only approaches some 3%. Experts continue to argue over the timing for operative revision. Many authors rely on spontaneous recovery of the nerve as maintained by L. Boehler in the early 1960s, but this theory was rendered obsolete by the technical achievements of microsurgery and the patients' economic constraints. Other authors are afraid of accidentally damaging the nerve by revision surgery. The stand we take in this controversy is instant revision surgery both for accidental lesions as well as uncompromisingly for those incurred during surgery when the surgeon had not explored the nerve far enough to preserve it during the operation. Three exemplary cases are reported, one of them submitted for an expert's opinion because of an alleged mistake on the part of the doctor. Forensic responsibility has to match actual indication principles and the specific technique applied.

The development of interlocking humeral nail systems has greatly broadened the indications for nailing of humeral shaft fracture. Rotational control is better than with earlier nail systems, and most nails have an oblong distal hole that allows axial loading of the fracture site with muscle contraction. When nailing is done with closed technique, loss of the fracture hematoma and periosteal stripping are avoided. Even when open reduction is required, periosteal stripping can be kept to a minimum. Surgical wounds are smaller, even when open reduction is necessary, and when closed nailing is done, bone grafting is unnecessary. Intramedullary nails are ideal for segmental fractures, pathologic fractures, and fractures in osteopenic bone. Because the arm usually is not a weight-bearing extremity, hardware failure is rare and union rates are equivalent to those of compression plate and screw fixation. Compression plates and external fixation certainly have their place for some fracture patterns and for severe wounds that are unsuitable for intramedullary nailing. The surgeon should be well versed in all three techniques and should be able to rapidly choose among these, depending upon the fracture pattern, skin wound, associated injuries, and overall condition of the patient.

Displaced subcapital fractures of the humerus represent a therapeutic challenge for the surgeon, all the more so because of their high incidence among osteoporotic patients. Open surgical repair involves increased risk of avascular necrosis of the humeral head, while percutaneous reduction and fixation often fails as a result of loosening pins. As a possible solution, a minimally invasive technique was developed in which a dynamic titanium wire helix is inserted into the medullary space of the diaphysis of the humerus and then rotated proximally into the head fragment. This new approach for osteosynthesis was performed in 84 patients, most of whom had suffered two- or three-part fractures. Results were evaluated by the Constant Functional Score, indicating an average 87% rehabilitation. An associated anatomical study of 53 human cadavers investigated the position of the main branches of the axillary nerve relative to the surgical placement of the wire helix. In all cases, the distance between the most vulnerable anterior branch of the axillary nerve (ABAN) and the operative site was sufficient, as long as insertion occurs in the distal third of the distance between the head of the humerus and the deltoid tuberosity. Utilization of the titanium helix results in prompt healing of subcapital fractures while offering minimal risk for the elderly osteoporotic patient and does not endanger branches of the axillary nerve., (Copyright 2001 Wiley-Liss, Inc.)

Penetrating injuries to the gravid uterus are rare. This report documents a fetus that sustained a complete radial nerve palsy (a hemopneumothorax) after a knife wound (complete nerve transection is suspected). Surgical exploration of the nerve was delayed because of respiratory distress. Six weeks later, when exploration was scheduled to be undertaken, some recovery was noted, and exploration was thus deferred. The injury recovered completely in the absence of formal repair.

Twenty humeral lengthenings were done on 10 achondroplastic dwarfs using the Ilizarov circular fixator. There were five female and five male patients from 6 years 11 months to 17 years 8 months of age (mean, 12 years 10 months) at the time of the operation. Mean length obtained was 7.8 cm (range, 3.5 cm-10 cm). External fixation time ranged from 105 days to 368 days (mean, 221 days). Healing index averaged 30 days/cm (27 days/cm when two patients with radial nerve palsy were excluded). Two half pins in one patient required replacement. Two humeral fractures occurred, one while in the fixator and the other after removal of the apparatus. Transient radial nerve palsy developed during lengthening in two patients, and lengthening was discontinued. Symptoms of radial nerve palsy resolved completely in both patients, but one patient required an additional surgery to explore the radial nerve for persistent paresthesia of the forearm. Although preexisting loose shoulders deteriorate during lengthening and sometimes cause pain and discomfort, they always resolve spontaneously as lengthening proceeds. Bilateral humeral lengthening was very effective for improving function and overall proportion in patients with achondroplasia.

Keloid scarring of the distal upper extremity is very rare. We report a Caucasian woman who presented with aggressive keloids of the hand and wrist causing De Quervain's syndrome, superficial radial-nerve entrapment and ulnar-nerve compression at the wrist. Multiple operations were required to alleviate her symptoms. A number of management conundrums arose, requiring defensive planning to pre-empt the possible complications of recurrent keloid scarring as a result of the surgical procedures., (Copyright 2001 The British Association of Plastic Surgeons.)

This study examines which of three splint designs most effectively improved hand function in a patient with radial nerve palsy, and demonstrates the application of a single-subject experimental design. The static volar wrist cock-up splint (splint 1), dynamic tenodesis suspension splint (splint 2), and dorsal wrist cock-up with dynamic finger extension splint (splint 3) were evaluated. Each splint was worn for 3 weeks, and hand function was assessed by means of standardized measures of function and disability. Statistical significance was calculated using the minimal level of detectable change (MDC) at the 95% confidence level. Only with splints 2 and 3 did a true change in function occur, compared with baseline scores (no splint). In addition, the patient completed all tasks while using splints 2 and 3 but did not complete three tasks while using splint 1. The hand therapists' goal is to fabricate a splint that improves function and that the patient will wear. Only splint 3 met these criteria. This experiment highlights the need to evaluate both the statistical and the clinical significance of treatment interventions.

We reported a 24-year-old man with right radial nerve palsy. He had suffered from a right humeral shaft fracture approximately three years before. The fracture was treated with intramedullary nailing. Our radiograph of the right upper limb showed callus around the fracture site. A nerve conduction study revealed conduction block of the radial nerve at the lateral side of the callus. Tinel's sign was present in the median nerve at the medial side of the callus. Surgical exploration revealed that the radial nerve trunk was compressed at the callus site. The median nerve trunk was close to the callus. We decompressed radial nerve trunk, and the patient's neurological symptoms improved gradually after the operation. Delayed radial nerve palsy has been reported only rarely, whereas acute compression of the nerve sometimes occurs after humeral shaft fractures. Morever, the median nerve also was vulnerable to compression at the site of callus. These findings underscore the importance of taking into account the possibility of delayed compression neuropathy after humeral shaft fracture.

Purpose: To determine the feasibility of using ultrasonography (US) for evaluation of a radial nerve injury associated with humeral shaft fracture., Materials and Methods: In a prospective study, 11 consecutive patients with sensorimotor radial deficiency after distal humeral fracture were evaluated with conventional radiography, US, electroneurography, and electromyography. Surgical repair of the fracture and nerve inspection were performed in five patients. The remaining six patients were successfully treated conservatively. The US appearance of the radial nerve was studied in 10 healthy volunteers and in the noninjured arm of the 11 patients for comparison., Results: In five patients, US findings of a severely damaged radial nerve were confirmed at surgical nerve inspection. In one patient, the nerve was entrapped between fragments. One patient had a complete nerve dissection, one had a lacerated nerve from a loose compression plate, and one had a nerve riding on the edge of a bone fragment. In the fifth patient who underwent surgical inspection, the nerve was buried in the callus. In the six patients treated conservatively, US showed continuity of the nerve., Conclusion: US may be useful for accurate evaluation of the radial nerve in patients with nerve palsy associated with humeral shaft fracture.

We report two patients who developed progressive, severe, painless radial neuropathies (bilateral in one, unilateral in the other) as a delayed complication of chronic intramuscular analgesic injection. In each instance, exploration of the radial nerve revealed multifocal entrapment within a densely fibrotic triceps muscle at sites between the spiral groove and distal course of the radial nerve near the elbow. Release of the nerve from constriction within the fibrotic triceps muscle produced improvement in all three affected nerves., (Copyright 2001 John Wiley & Sons, Inc.)

Radial nerve palsy is a common complication of simple fracture of the humerus. The aim of this retrospective study was to assess the degree of spontaneous recovery and the need for exploration and repair of the nerve. The study included 26 patients with radial nerve palsy after simple fracture of the humerus. The male:female ratio was 3:1 and the median age was 21 years (range 9-79). Three patients had early exploration of the radial nerve in connection with osteosynthesis, and no appreciable damage to the nerve was found. Two other patients were explored later because they failed to recover. This exploration showed damage to the nerve which required further operation. Twenty-one patients were treated conservatively and all recovered well. None needed later operation. Because of the low incidence of nerve lesions we recommend an expectant policy initially.

Background: The purpose of this study is to present the results of closed fixation of humeral shaft fractures with multiple intramedullary Kirschner wires., Methods: Twenty-nine humeral shaft fractures in patients 14 to 60 years old were treated by closed fixation with multiple intramedullary Kirschner wires. Each patient was placed supine on the table and was administered general anesthesia. The fractured arm was held vertically up by a transolecranon traction, while the C-arm was kept parallel to the ground and opposite to the affected arm. A cortical window was created approximately 1.5 cm proximal to the olecranon fossa, after splitting the triceps. Under fluoroscopic control, multiple Kirschner wires were introduced retrograde therein, into the medullary cavity, to reach the humeral head. The wire tips were kept splayed to stabilize the fracture. Postoperatively, the limb was supported by an arm sling., Results: Twenty-five fractures (86.4%) healed with excellent clinical and functional results, in an average of 11 weeks. Union was delayed in two patients, and one fracture had a nonunion after repeated trauma. Movements at the shoulder and the elbow were excellent to good in 27 patients (93%), whereas 2 patients (6.8%) had significant limitation of extension at the elbow., Conclusion: This technique has been found simple and effective in providing a stable fixation of transverse and short oblique fractures of the humeral diaphysis. Further study is required to evaluate this procedure in more extensive fracture patterns, as well as to compare the results with other methods of internal fixation.

Purpose of the Study: Evaluate outcome of different techniques used for radial nerve repair after humeral shaft fractures. Identify situations where nerve exploration is required or inversely unneeded. Evaluate the risk of more systematic nerve exploration in case of radial nerve palsy., Material and Methods: Over a 10 year period, we cared for 62 patients with humeral fractures associated with radial nerve palsy who were addressed directly to our unit or referred after prior care. There were 54 men (mean age 30 years, 17 - 66) and 8 women (mean age 40 years, 19 - 80). There were 40 fractures of the mid-third and 22 fractures of the distal third of the humerus. Anatomic severity varied although most fractures were displaced or subsequent to high-energy trauma. Orthopedic treatment was used alone in 14 cases. There were 6 plate fixations and 42 intramedullary nailings. Twenty-four of the 62 cases of radial nerve palsy resulted from nerve tears but a continuous nerve was found in 38 cases. Tears were treated by primary suture (n =4), secondary graft (n =17, 5 with 2 torons and 12 with 3 or 4 torons), or primary muscle transfer (n =3). Neurolysis was used in 6 of the 38 cases with continuous nerve. Motor outcome was assessed using composite criteria taking into account the physiological role of each muscle group., Results: All primary sutures gave excellent results. Excellent or good outcome was achieved in 12 of the 17 secondary grafts although a complementary transfer was required in 2 cases. Conversely, outcome was average in 2 cases and a failure in 3. Outcome depended on the length of the graft and the number of torons used. The importance of a proximal resection in healthy tissue sometimes required a complementary medial access and a graft between the biceps and the brachialis. Recovery was achieved in 37 of the 38 lesions with continuous nerve including 31 cases which did not require a second procedure., Discussion: In case of nerve rupture, the outcome of primary suture appears to be better than that of secondary grafts. The success of the graft depends on the length of the tissue loss after sectioning in healthy tissue and on the number of torons used. This difference in prognosis points out the usefulness of systematic exploration in order to use primary or early direct suture in cases of high-energy displaced fractures. Minimally displaced fractures often are accompanied by a simple contusion with spontaneous recovery. However, in intermediary cases, the decision to make a systematic nerve exploration during the osteosynthesis procedure (aimed at early mobilization) is based on the fact that recovery was achieved in 23 cases in which initial exploration of a continuous nerve has been performed. Indirectly, the favorable outcome of postoperative paralyses reported by several authors, also supports this policy.

We present two cases of hypoaesthesia over the dorsal radial aspect of the hand with an associated painful mass in the wrist. At operation a dorsal wrist ganglion was compressing the superficial branch of the radial nerve at the anatomical snuff-box. After removal of the ganglion the hypoaesthesia was relieved.

Radial neuropathy can have one of several clinical presentations, depending on the level of compression: high radial nerve palsy, PIN palsy, radial tunnel syndrome, and Wartenberg's syndrome. Elucidating the history and progression of symptoms with a physical examination directed at testing individual muscles will determine the approximate anatomic level of radial injury. Identification of a Tinel's sign will often locate the site of compression. Electrodiagnostic studies can confirm the diagnosis in a radial motor neuropathy, but are unreliable in radial tunnel syndrome and sensory radial nerve compression. A trial of nonsurgical treatment is warranted in all cases except those with progressive motor weakness or palsy. Patients who do not respond or continue to progress despite conservative treatment are candidates for surgical decompression.

Both radial tunnel syndrome and posterior interosseous nerve compression syndrome are caused by compression of the posterior interosseous nerve. Posterior interosseous nerve (PIN) compression syndrome is a rare condition--less than 10 percent of our cases of PIN-compression showed signs of palsy--and must be differentiated from tendinous lesions. From 1992 to 1997, we decompressed the PIN using an anterior approach in nine cases because of palsy without a history of trauma. Only one patient was lost to follow-up. Our study indicates that the results of operative decompression of the PIN depend on the time interval between first symptoms of palsy and operation. On the other hand, some cases of posterior interosseous nerve compression syndrome show spontaneous recovery. We recommend operative decompression of the PIN if incomplete palsy worsens or if complete palsy persists for more than 12 weeks.

We report a case of left radial neuropathy from a venipuncture, in a 59-year-old woman. She had a history of amputation of the four last fingers of the right hand, when she was 27-year-old. One year before, she had a difficult venipuncture of the left radial vein, for a preanaesthetic assessment for cataract surgery. The puncture elicited an excruciating pain, associated with hypoaesthesia in the area of the radial nerve, at forearm and the wrist. Conventional therapeutic means had only a minor efficiency. The concept of nervous system sensitizing is discussed. Prevention is essential.

We report a patient with multiple constrictions within the main trunk of the radial nerve that was found after epineurectomy and speculate that the etiology is an inflammatory response. (J Hand Surg 2000; 25A:134-137., (Copyright 2000 by the American Society for Surgery of the Hand.).)

A 41-year-old man developed multifocal mononeuropathies manifesting right and left foot drop successively, following the left radial nerve palsy as an initial symptom. Based on the neurological findings and the results of the genetic study of peripheral myelin protein (PMP) 22 gene and the histological study of the sural nerve on biopsy, the diagnosis of hereditary neuropathy with liability to pressure palsies (HNPP) was made. Two asymptomatic carriers were found among his family members based on the genetic study. The diagnosis of HNPP can be definitely established by the genetic study and this disease is relatively rare. In this report it is important to note that there are a few patients who show radial nerve palsy as an initial symptom, that we should carefully study the family members to obtain the prevalence of HNPP because asymptomatic carriers may be present, and that the carriers should be advised to avoid strenuous exercises and works which may produce excessive extension or compression of nerve trunks with the subsequent development of clinical symptoms.