Median to radial nerve transfer for treatment of radial nerve palsy

Case report

Restricted access

✓The purpose of this study is to report a surgical technique of nerve transfer to restore radial nerve function after a complete palsy due to a proximal injury to the radial nerve. The authors report the case of a patient who underwent direct nerve transfer of redundant or expendable motor branches of the median nerve in the proximal forearm to the extensor carpi radialis brevis and the posterior interosseous branches of the radial nerve. Assessment included degree of recovery of wrist and finger extension, and median nerve function including pinch and grip strength.

Clinical evidence of reinnervation was noted at 6 months postoperatively. The follow-up period was 18 months. Recovery of finger and wrist extension was almost complete with Grade 4/5 strength. Pinch and grip strength were improved postoperatively. No motor or sensory deficits related to the median nerve were noted, and the patient is very satisfied with her degree of functional restoration.

Transfer of redundant synergistic motor branches of the median nerve can successfully reinnervate the finger and wrist extensor muscles to restore radial nerve function. This median to radial nerve transfer offers an alternative to nerve repair, graft, or tendon transfer for the treatment of radial nerve palsy.

Abbreviations used in this paper:AIN = anterior interosseous nerve; ECRB = extensor carpi radialis brevis; ECRL = extensor carpi radialis longus; FCR = flexor carpi radialis; FDS = flexor digitorum sublimis; PIN = posterior interosseous nerve; PL = palmaris longus.

Article Information

Address reprint requests to: Susan E. Mackinnon, M.D., Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Suite 5401, 660 South Euclid Avenue, St. Louis, Missouri 63110. email: mackinnons@wustl.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Illustration of transfer of redundant FDS and FCR/PL branches of the median nerve in the proximal forearm to the ECRB and posterior interosseous branches of the radial nerve through a single proximal volar forearm incision.

  • View in gallery

    Radiograph of the patient's right upper extremity following placement of an intramuscular rod for the humeral fracture.

  • View in gallery

    Intraoperative photographs. Upper: Dissection of motor branches of the right median nerve through the proximal volar forearm incision (elbow to the right, and hand to the left). A indicates the FCR/PL branch; B, the median nerve (proximal to the AIN branch); C, the FDS branch; and D, the pronator teres branch. Lower: The FDS and FCR/PL branches (black arrow) of the median nerve are divided distally and transposed laterally toward the ECRB, and posterior interosseous branches of the radial nerve (white arrow) are divided proximally prior to direct end-to-end co-aptation.

  • View in gallery

    Photographs taken at 1-year follow-up demonstrating restoration of finger and wrist extension of the right hand.

  • View in gallery

    Illustrations. The tenodesis effect refers to the length–tension relationship between wrist position and the extrinsic flexors of the fingers. Wrist extension increases the passive tension of the flexor tendons and thereby passively causes finger flexion and increases flexion strength, whereas wrist flexion has the opposite effect and allows the digits to passively extend.

References

1

Barber KWBianco AJSoule EHMacCarty CS: Benign extra-neural soft-tissue tumors of the extremities causing compression of nerves. J Bone Joint Surg Am 44:981962

2

Barton NJ: Radial nerve lesions. Hand 5:2002081973

3

Bateman JE: Trauma to Nerves in Limbs PhiladelphiaSaunders1962

4

Belkas JSShoichet MSMidha R: Peripheral nerve regeneration through guidance tubes. Neurol Res 26:1511602004

5

Bevin AG: Early tendon transfer for radial nerve transection. Hand 8:1341361976

6

Burkhalter WE: Early tendon transfer in upper extremity peripheral nerve injury. Clin Orthop Relat Res 104:68791974

7

Calder JSGreen CJ: Nerve-muscle sandwich grafts: the importance of Schwann cells in peripheral nerve regeneration through muscle basal lamina conduits. J Hand Surg [Br] 20:4234281995

8

Cederna PSYoussef MKAsato HUrbanchek MGKuzon WM Jr: Skeletal muscle reinnervation by reduced axonal numbers results in whole muscle force deficits. Plast Reconstr Surg 105:200320112000

9

Dellon AL: The moving two-point discrimination test: clinical evaluation of the quickly adapting fiber/receptor system. J Hand Surg [Am] 3:4744811978

10

Fu SYGordon T: Contributing factors to poor functional recovery after delayed nerve repair: prolonged axotomy. J Neurosci 15:387638851995

11

Gawande A: Complications: A Surgeon's Notes on an Imperfect Science New YorkPicador2002

12

Gawande A: Desperate measures. The New Yorker May 5 2003

13

Guelinckx PJCarlson BMFaulkner JA: Morphologic characteristics of muscles grafted in rabbits with neurovascular repair. J Reconstr Microsurg 8:4814891992

14

Guelinckx PJFaulkner JA: Parallel-fibered muscles transplanted with neurovascular repair into bipennate muscle site in rabbits. Plast Reconstr Surg 89:2902981992

15

Guelinckx PJFaulkner JAEssig DA: Neurovascular-anastomosed muscle grafts in rabbits: functional deficits result from tendon repair. Muscle Nerve 11:7457511988

16

Hazari AWiberg MJohansson-Ruden GGreen CTerenghi G: A resorbable nerve conduit as an alternative to nerve autograft in nerve gap repair. Br J Plast Surg 52:6536571999

17

Holstein ALewis GM: Fractures of the humerus with radial-nerve paralysis. J Bone Joint Surg Am 45:138213881963

18

Kettelkamp DBAlexander H: Clinical review of radial nerve injury. J Trauma 7:4244321967

19

Kim JDellon AL: Reconstruction of a painful post-traumatic medial plantar neuroma with a bioabsorbable nerve conduit: a case report. J Foot Ankle Surg 40:3183232001

20

Kitahara AKNishimura YShimizu KEndo K: Facial nerve repair accomplished by the interposition of a collagen nerve guide. J Neurosurg 93:1131202000

21

Kobayashi JMackinnon SEWatanabe OBall DJGu XMHunter DA: The effect of duration of muscle denervation on functional recovery in the rat model. Muscle Nerve 20:8588661997

22

Kruft Svon Heimburg DReill P: Treatment of irreversible lesion of the radial nerve by tendon transfer: indication and long-term results of the Merle d'Aubigne procedure. Plast Reconstr Surg 100:6106181997

23

Leechavengvongs SWitoonchart KUerpairojkit CThuvasethakul PKetmalasiri W: Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases. J Hand Surg [Am] 23:7117161998

24

Lowe JB IIISen SKMackinnon SE: Current approach to radial nerve paralysis. Plast Reconstr Surg 110:109911132002

25

Lowe JB IIITung TRMackinnon SE: New surgical option for radial nerve paralysis. Plast Reconstr Surg 110:8368432002

26

Mackinnon SEDellon AL: Surgery of the Peripheral Nerve New YorkThieme1988

27

Mackinnon SENovak CB: Nerve transfers. New options for reconstruction following nerve injury. Hand Clin 15:6436661999

28

Mailander PBerger ASchaller ERuhe K: Results of primary nerve repair in the upper extremity. Microsurgery 10:1471501989

29

Manske PR: Compression of the radial nerve by the triceps muscle: a case report. J Bone Joint Surg Am 59:8358361977

30

Marmor LLawrence JFDubois EL: Posterior interosseous nerve palsy due to rheumatoid arthritis. J Bone Joint Surg Am 49:3813831967

31

Mast JWSpiegel PGHarvey JP JrHarrison C: Fractures of the humeral shaft: a retrospective study of 240 adult fractures. Clin Orthop Relat Res 112:2542621975

32

Midha R: Epidemiology of brachial plexus injuries in a multi-trauma population. Neurosurgery 40:118211891997

33

Millesi H: Progress in peripheral nerve reconstruction. World J Surg 14:7337471990

34

Millesi HMeissl GBerger A: Further experience with inter-fascicular grafting of the median, ulnar, and radial nerves. J Bone Joint Surg Am 58:2092181976

35

Moberg E: Criticism and study of methods of examining sensibility of the hand. Neurology 12:8191962

36

Moon NMarmor L: Parostal lipoma of the proximal part of the radius. A clinical entity with frequent radial-nerve injury. J Bone Joint Surg Am 46:6086141964

37

Morris AH: Irreducible Monteggia lesion with radial-nerve entrapment. A case report. J Bone Joint Surg Am 56:174417461974

38

Nath RKMackinnon SE: Nerve transfers in the upper extremity. Hand Clin 16:1311392000

39

Nath RKMackinnon SEShenaq SM: New nerve transfers following peripheral nerve injuries. Oper Techn Plast Reconstr Surg 4:2111997

40

Nichols CMBrenner MJFox IKTung THHunter DARickman SR: Effect of motor versus sensory nerve grafts on peripheral nerve regeneration. Exp Neurol 190:3473552004

41

Nielsen HO: Posterior interosseous nerve paralysis caused by fibrous band compression at the supinator muscle. A report of four cases. Acta Orthop Scand 47:3043071976

42

Novak CBMackinnon SETung TH: Patient outcome following a thoracodorsal to musculocutaneous nerve transfer for reconstruction of elbow flexion. Br J Plast Surg 55:4164192002

43

Omer GE JrThe prognosis for untreated traumatic injuries. Omer GE JrSpinner M Van Beek AL: Management of Peripheral Nerve Problems PhiladelphiaWB Saunders1998. 365370

44

Popelka SVainio K: Entrapment of the posterior interosseous branch of the radial nerve in rheumatoid arthritis. Acta Orthop Scand 45:3703721974

45

Samardzic MGrujicic DMilinkovic ZB: Radial nerve lesions associated with fractures of the humeral shaft. Injury 21:2202221990

46

Sharrard WJ: Posterior interosseous neuritis. J Bone Joint Surg Br 48:7777801966

47

Spinner M: The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. J Bone Joint Surg Br 50:8098121968

48

Spinner M: Injuries to the Major Branches of Peripheral Nerves of the Forearm PhiladelphiaWB Saunders1972

49

Sulaiman OARMidha RMunro CAMatsuyama TAl-Majed AGordon T: Chronic Schwann cell denervation and the presence of a sensory nerve reduce motor axonal regeneration. Exp Neurol 176:3423542002

50

Sunderland S: Nerve and Nerve Injuries EdinburghChurchill Livingstone1968

51

Sunderland S: Traumatic injuries of the peripheral nerves: I. Simple compression of the radial nerve. Brain 68:561945

52

Sungpet ASuphachatwong CKawinwonggowit V: One-fascicle median nerve transfer to biceps muscle in C5 and C6 root avulsions of brachial plexus injury. Microsurgery 23:10132003

53

Teboul FKakkar RAmeur NBeaulieu JYOberlin C: Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy. J Bone Joint Surg Am 86:148514902004

54

Terzis JKPapakonstantinou KC: The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 106:109711242000

55

Tung THMackinnon SE: Flexor digitorum superficialis nerve transfer to restore pronation: two case reports and anatomic study. J Hand Surg [Am] 26:106510722001

56

Tung THNovak CBMackinnon SE: Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg 98:3133182003

57

Tung THWeber RVMackinnon SE: Nerve transfers for the upper and lower extremities. Oper Tech Orthop 14:2132222004

58

Vernadakis AJHumphreys DBMackinnon SE: Distal anterior interosseous nerve in the recurrent motor branch graft for reconstruction of a median nerve neuromain-continuity. J Reconstr Microsurg 20:7112004

59

Wang YZhu S: Transfer of a branch of the anterior interosseous nerve to the motor branch of the median nerve and ulnar nerve. Chin Med J 110:2162191997

60

Weber RVMackinnon SE: Nerve transfers in the upper extremity. J Am Soc Surg Hand 4:2002132004

61

Weinberger LM: Non-traumatic paralysis of the dorsal interosseous nerve. Surg Gynecol Obstet 69:3581939

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 80 80 36
Full Text Views 275 275 22
PDF Downloads 137 137 9
EPUB Downloads 0 0 0

PubMed

Google Scholar