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Posterior Interosseous and Ulnar Nerve Motor Palsies After a Minimally Displaced Radial Neck Fracture
SCIENTIFIC ARTICLE
Posterior Interosseous and Ulnar Nerve Motor Palsies After a Minimally Displaced Radial Neck Fracture Matthew T. Stepanovich, MD, Christopher J. Hogan, MD Peripheral nerve injury is a serious potential complication following an upper extremity fracture. A rare case of acute posterior interosseous nerve and ulnar nerve palsy following a minimally displaced radial neck fracture is reported. With nonsurgical management, both nerves demonstrated excellent functional recovery. Although rare, nerve palsies can occur during a variety of upper extremity clinical situations, including minimally displaced fractures, and the importance of a detailed neurologic examination cannot be overstated. (J Hand Surg 2012;37A:1630 –1633. Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Fracture, nerve palsy, radial neck.
upper extremity fractures occur most commonly in association with substantial fracture displacement following high-energy injuries. In most cases, the initial fracture displacement imparts a traction injury to the nerve, and the deficit is appreciated soon after the trauma. In other settings, reduction of the fracture can entrap the nerve between fragments, leading to a direct compression injury. We present a case of a much less common clinical course, that of progressive posterior interosseous and ulnar nerve deficits that followed a minimally displaced radial neck fracture.
N
ERVE PALSIES FOLLOWING
From the Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA. Received for publication February 9, 2012; accepted in revised form May 17, 2012. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Theviewsexpressedinthisarticlearethoseoftheauthorsanddonotnecessarilyreflecttheofficial policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors are of the material are military service members. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not availableforanyworkoftheUnitedStatesGovernment.”Title17U.S.C.101definesaUnitedStates Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties. Correspondingauthor:LTMatthewStepanovich,MCUSN,DepartmentofOrthopaedicSurgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708; e-mail: [email protected]. 0363-5023/12/37A08-0016$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2012.05.028
1630 䉬 Published by Elsevier, Inc. on behalf of the ASSH
CASE REPORT A 38-year-old, right-handed man presented to the emergency department with a complaint of right lateral elbow pain after sustaining a fall onto his outstretched right hand from a standing height while playing basketball. The patient was otherwise healthy, did not use tobacco products, and had no noteworthy medical or surgical history. On physical examination, he was noted to have lateral elbow tenderness and full motion of his wrist and fingers. There were no neurologic deficits noticed in his forearm, wrist, or hand, and radiographs revealed a minimally displaced radial neck fracture (Fig. 1). His elbow was immobilized with a posterior splint, and he was given a sling for comfort. Later that evening, he noticed increased clumsiness and weakness of his right hand and wrist. By the following morning, this had progressed to a complete inability to cross his fingers, extend his fingers, or adduct his thumb. The following afternoon he was evaluated in our hand surgery clinic, at which time his physical examination was notable for mild tenderness and swelling over the radial head, with no accompanying medial elbow tenderness, ecchymosis, or instability. There was no evidence of extrinsic forearm compression from the splint, and all forearm and hand compartments were soft. The patient had no tenderness throughout his forearm, wrist, or hand. Percussion over the entire course of the posterior interosseous nerve (PIN) and ulnar nerve was normal, with absence of a Tinel sign. His sensation was intact to light touch throughout his forearm and
COMBINED PIN AND ULNAR NERVE PALSIES
1631
FIGURE 1: A Anteroposterior and B lateral injury radiographs showing a minimally displaced radial neck fracture. A Arrows indicate the fracture line.
FIGURE 2: A Lateral, oblique, and B anteroposterior radiographs of the patient’s right elbow, showing a healed, minimally displaced radial neck fracture.
hand with 4-mm 2-point discrimination in the ulnar and median nerve distributions. His motor examination showed active elbow motion from 40° to120° and 70° each of supination and pronation, limited by pain. His wrist and hand motor examination showed 0/5 strength for the extensor carpi radialis brevis, extensor digitorum communis, extensor digiti quinti, extensor pollicis longus, extensor indicis proprius, abductor pollicis longus, extensor pollicis brevis, flexor digitorum profundus to the ring and small fingers, ulnar lumbricals, and the hypothenar musculature. The brachioradialis and extensor carpi radialis longus were intact, and the patient could extend his wrist with radial deviation. Repeat radiographs demonstrated no changes in fracture alignment. An elbow aspiration recovered a minimal amount of thick, bloody fluid. The patient was instructed to min-
imize the use of a sling and was referred to occupational therapy for elbow range of motion exercises. The patient was offered radial nerve bracing for the fingers and wrist, but he declined. At 2 weeks after injury, he had regained full elbow motion without pain, but his neurologic deficits persisted. Given the low-energy mechanism and closed nature of his injury, we felt that there was little risk of nerve transection. As a result, nerve studies were not obtained. At 6 weeks, his fracture had healed (Fig. 2), and by 10 weeks, his ulnar nerve had nearly recovered, with only mild residual weakness of his first dorsal interosseous muscle. At that visit, he also demonstrated a partial recovery of his PIN, with full power of his extensor carpi radialis brevis, extensor digitorum communis, extensor carpi ulnaris, and extensor digiti quinti. He did not have any function of his
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extensor indicis proprius, extensor pollicis longus, extensor pollicis brevis, or abductor pollicis longus. Nerve conduction study and EMG evaluation were obtained 12 weeks after injury and showed mild ulnar nerve myelinopathy at the elbow and severe axonal compromise of the PIN. At 6 months after injury, the patient exhibited near-complete recovery, with 5/5 strength noted for all upper extremity musculature except a slight residual weakness in his extensor pollicis longus, which did not impact his activities of daily living. DISCUSSION Certain upper extremity fractures are associated with an elevated incidence of peripheral nerve injury, with contributing risk factors being the relative proximity between the individual nerves and the fracture, the energy of the injury, and the displacement of the bone fragments. The incidence is particularly high for displaced fractures of the distal humerus, with palsies to the radial or ulnar nerves reported in as many as 20% to 50% of individuals.1 Proximal radius fractures carry a much lower incidence of nerve injury, with most of these occurring with highly displaced fractures of the radial neck or in the setting of a complex elbow dislocation. Anatomically, the radial nerve passes between the brachialis and brachioradialis as it approaches the elbow, innervating the brachioradialis and extensor carpi radialis longus before bifurcating approximately 4 cm proximal to the leading edge of the supinator. The innervation of the extensor carpi radialis brevis is somewhat variable, as it can arise as a terminal branch from the PIN, branch more distally from the superficial radial nerve, or occur as a distinct branch at the level of the bifurcation.2 More distally, the deep branch of the radial nerve winds around the proximal radius and passes through the supinator, often coming into direct contact with the proximal radius.3 While this location places it at risk during surgical exposure, palsies of the PIN are relatively uncommon following minimally displaced proximal radius fractures.4 The subcutaneous course of the ulnar nerve and its anatomic confinement within the cubital tunnel make it susceptible to direct trauma with fractures around the elbow.5 In addition, valgus loading can impart a distraction load across the nerve, further increasing the degree of nerve injury. Patients with these injuries often demonstrate major fracture displacement or evidence of trauma to the ulnar collateral ligament of the elbow. Isolated palsies to either the PIN or the ulnar nerve have been reported following fractures, dislocations, penetrating injuries, and posttraumatic contusions.4 –13 Similarly, late dysfunction of single nerves has been
documented, identifying heterotopic ossification, malreduction, and malalignment as contributing factors.14 Our case of a combined ulnar and PIN palsy following a minimally displaced radial neck fracture is distinguished from those previous reports in that the earlier cases described dysfunction of a single nerve, involved high-energy mechanisms, and occurred in association with widely displaced fractures. Nontraumatic, isolated PIN palsies have also been reported, resulting from septic arthritis,15 benign soft tissue masses, or inflammatory arthropathies.15–18 Three cases of a combined PIN and ulnar nerve palsy have been described, one after prolonged immobilization in a compressive plaster of Paris splint for a wrist fracture19 and a second occurring after a spontaneous hemarthrosis in a patient with hemophilia.20 The third report identified a combined palsy in the setting of a distal humerus malunion with radial head subluxation following an injury that had occurred 47 years previously.21 All 3 of these patients had a complete recovery; the first following surgical lysis of adhesions, the second following surgical decompression of the joint hematoma and subcutaneous ulnar nerve transposition, and the third after subcutaneous ulnar nerve transposition and radial head resection.19 –21 For our patient, there was no evidence of any injury to the ulnar collateral ligament, making it unlikely that a major distraction force had been directly applied to the ulnar nerve. The absence of flexor digitorum profundus function to the ring and small fingers indicated that the nerve injury occurred proximal to the wrist, although it is difficult to reconcile this finding with the preservation of his ulnar sensation. One would suspect that the sensory fibers would be affected to a greater degree than the motor fibers, given their superficial location in the ulnar nerve at the cubital tunnel. We hypothesize that the small degree of bony trauma allowed the elbow capsule to remain intact. The resulting hematoma expanded the capsule and might have applied direct pressure to the PIN and ulnar nerve with their known proximal and distal tethers. The EMG study findings of mild ulnar nerve myelinopathy at 12 weeks suggests that the patient might have had a subclinical ulnar nerve compression before his injury, which expressed itself as a motor palsy following the fracture. With nonsurgical management, both of the patient’s nerves demonstrated excellent functional recovery. REFERENCES 1. Browner BD, Levine AM, Jupiter JB, Trafton PG, Krettek C, eds. Skeletal trauma: basic science, management, and reconstruction, 4th ed. Philadelphia, PA: WB Saunders; 2009.
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COMBINED PIN AND ULNAR NERVE PALSIES
2. Branovacki G, Hanson M, Cash R, Gonzalez M. The innervation pattern of the radial nerve at the elbow and in the forearm. J Hand Surg 1998;23B:167–169. 3. Abrams RA, Ziets RJ, Lieber RL, Botte MJ. Anatomy of the radial nerve motor branches in the forearm. J Hand Surg 1997;22A:232– 237. 4. Hirachi K, Kato H, Minami A, Kasashima T, Kaneda K. Clinical features and management of traumatic posterior interosseous nerve palsy. J Hand Surg 1998;23B:413– 417. 5. Khoo D, Carmichael SW, Spinner RJ. Ulnar nerve anatomy and compression. Orthop Clin North Am 1996;27:317–338. 6. Mohler LR, Hanel DP. Closed fractures complicated by peripheral nerve injury. J Am Acad Orthop Surg 2006;14:32–37. 7. Chang MC, Liu Y, Lo WH. Wraparound injury of posterior interosseous nerve on the unreduced radial head: a case report. M C Zhonghua Yi Xue Za Zhi (Taipei) 1996;58:459 – 463. 8. Sudhahar TA, Patel AD. A rare case of partial posterior interosseous nerve injury associated with radial head fracture. Injury 2004;35: 543–544. 9. Serra G, Aiello I, Rosati G, Tugnoli V, Traina GC, Cristofori MC. Posterior interosseous nerve palsy. Report of three unusual cases. Ital J Neurol Sci 1984;5:85– 87. 10. Serrano KD, Rebella GS, Sansone JM, Kim MK. A rare case of posterior interosseous nerve palsy associated with radial head fracture. J Emerg Med 2010 Jan 14. Epub ahead of print. Doi:10.1016/ j.jemermed.2009.10.017. 11. Daurka J, Chen A, Akhtar K, Kamineni S. Tardy posterior interosseous nerve palsy associated with radial head fracture: a case report. Cases J 2009;2:22. 12. Bekler H, Riansuwan K, Vroemen JC, McKean J, Wolfe VM, Rosenwasser MP. Innervation of the elbow joint and surgical per-
13.
14. 15.
16.
17.
18.
19.
20.
21.
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spectives of denervation: a cadaveric anatomic study. J Hand Surg. 2008;33A:740 –745. Erratum in: J Hand Surg 2008;33A:1445. Vroeman, Joy C [corrected to Vroemen, Joy C]. Calfee RP, Wilson JM, Wong AH. Variations in the anatomic relations of the posterior interosseous nerve associated with forearm trauma.J Bone Joint Surg 2011;93A:81–90. Adams JE, Steinmann SP. Nerve injuries about the elbow. J Hand Surg 2006;31A:303–313. Kato H, Iwasaki N, Minami A, Kamishima T. Acute posterior interosseous nerve palsy caused by septic arthritis of the elbow: a case report. J Hand Surg 2003;28A:44 – 47. Ogino T, Minami A, Kato H. Diagnosis of radial nerve palsy caused by ganglion with use of different imaging techniques. J Hand Surg 1991;16A:230 –235. Wu KT, Jordan FR, Eckert C. Lipoma, a cause of paralysis of deep radial (posterior interosseous) nerve: report of a case and review of the literature. Surgery 1974;75:790 –795. Westkaemper JG, Varitimidis SE, Sotereanos DG. Posterior interosseous nerve palsy in a patient with rheumatoid synovitis of the elbow: a case report and review of the literature. J Hand Surg 1999;24A:727–731. Benfenati A, Poppi M, Galassi E, Martinelli P. Combined tardy palsy of posterior interosseous nerve and ulnar nerve at the elbow. Neurochirurgia (Stuttg) 1982;25:143–144. Culver JE Jr. Combined posterior interosseous and ulnar nerve compression in a hemophiliac. Bull Hosp Joint Dis 1978;39:103– 106. Adams JP, Rizzoli Hv. Tardy radial and ulnar nerve palsy: case report. Tardy radial and ulnar nerve palsy: case report. J Neurosurg 1959;16:342–344.
JHS 䉬 Vol A, August
Posterior Interosseous and Ulnar Nerve Motor Palsies After a Minimally Displaced Radial Neck Fracture Matthew T. Stepanovich, MD, Christopher J. Hogan, MD Peripheral nerve injury is a serious potential complication following an upper extremity fracture. A rare case of acute posterior interosseous nerve and ulnar nerve palsy following a minimally displaced radial neck fracture is reported. With nonsurgical management, both nerves demonstrated excellent functional recovery. Although rare, nerve palsies can occur during a variety of upper extremity clinical situations, including minimally displaced fractures, and the importance of a detailed neurologic examination cannot be overstated. (J Hand Surg 2012;37A:1630 –1633. Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Fracture, nerve palsy, radial neck.
upper extremity fractures occur most commonly in association with substantial fracture displacement following high-energy injuries. In most cases, the initial fracture displacement imparts a traction injury to the nerve, and the deficit is appreciated soon after the trauma. In other settings, reduction of the fracture can entrap the nerve between fragments, leading to a direct compression injury. We present a case of a much less common clinical course, that of progressive posterior interosseous and ulnar nerve deficits that followed a minimally displaced radial neck fracture.
N
ERVE PALSIES FOLLOWING
From the Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA. Received for publication February 9, 2012; accepted in revised form May 17, 2012. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Theviewsexpressedinthisarticlearethoseoftheauthorsanddonotnecessarilyreflecttheofficial policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors are of the material are military service members. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not availableforanyworkoftheUnitedStatesGovernment.”Title17U.S.C.101definesaUnitedStates Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties. Correspondingauthor:LTMatthewStepanovich,MCUSN,DepartmentofOrthopaedicSurgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708; e-mail: [email protected]. 0363-5023/12/37A08-0016$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2012.05.028
1630 䉬 Published by Elsevier, Inc. on behalf of the ASSH
CASE REPORT A 38-year-old, right-handed man presented to the emergency department with a complaint of right lateral elbow pain after sustaining a fall onto his outstretched right hand from a standing height while playing basketball. The patient was otherwise healthy, did not use tobacco products, and had no noteworthy medical or surgical history. On physical examination, he was noted to have lateral elbow tenderness and full motion of his wrist and fingers. There were no neurologic deficits noticed in his forearm, wrist, or hand, and radiographs revealed a minimally displaced radial neck fracture (Fig. 1). His elbow was immobilized with a posterior splint, and he was given a sling for comfort. Later that evening, he noticed increased clumsiness and weakness of his right hand and wrist. By the following morning, this had progressed to a complete inability to cross his fingers, extend his fingers, or adduct his thumb. The following afternoon he was evaluated in our hand surgery clinic, at which time his physical examination was notable for mild tenderness and swelling over the radial head, with no accompanying medial elbow tenderness, ecchymosis, or instability. There was no evidence of extrinsic forearm compression from the splint, and all forearm and hand compartments were soft. The patient had no tenderness throughout his forearm, wrist, or hand. Percussion over the entire course of the posterior interosseous nerve (PIN) and ulnar nerve was normal, with absence of a Tinel sign. His sensation was intact to light touch throughout his forearm and
COMBINED PIN AND ULNAR NERVE PALSIES
1631
FIGURE 1: A Anteroposterior and B lateral injury radiographs showing a minimally displaced radial neck fracture. A Arrows indicate the fracture line.
FIGURE 2: A Lateral, oblique, and B anteroposterior radiographs of the patient’s right elbow, showing a healed, minimally displaced radial neck fracture.
hand with 4-mm 2-point discrimination in the ulnar and median nerve distributions. His motor examination showed active elbow motion from 40° to120° and 70° each of supination and pronation, limited by pain. His wrist and hand motor examination showed 0/5 strength for the extensor carpi radialis brevis, extensor digitorum communis, extensor digiti quinti, extensor pollicis longus, extensor indicis proprius, abductor pollicis longus, extensor pollicis brevis, flexor digitorum profundus to the ring and small fingers, ulnar lumbricals, and the hypothenar musculature. The brachioradialis and extensor carpi radialis longus were intact, and the patient could extend his wrist with radial deviation. Repeat radiographs demonstrated no changes in fracture alignment. An elbow aspiration recovered a minimal amount of thick, bloody fluid. The patient was instructed to min-
imize the use of a sling and was referred to occupational therapy for elbow range of motion exercises. The patient was offered radial nerve bracing for the fingers and wrist, but he declined. At 2 weeks after injury, he had regained full elbow motion without pain, but his neurologic deficits persisted. Given the low-energy mechanism and closed nature of his injury, we felt that there was little risk of nerve transection. As a result, nerve studies were not obtained. At 6 weeks, his fracture had healed (Fig. 2), and by 10 weeks, his ulnar nerve had nearly recovered, with only mild residual weakness of his first dorsal interosseous muscle. At that visit, he also demonstrated a partial recovery of his PIN, with full power of his extensor carpi radialis brevis, extensor digitorum communis, extensor carpi ulnaris, and extensor digiti quinti. He did not have any function of his
JHS 䉬 Vol A, August
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COMBINED PIN AND ULNAR NERVE PALSIES
extensor indicis proprius, extensor pollicis longus, extensor pollicis brevis, or abductor pollicis longus. Nerve conduction study and EMG evaluation were obtained 12 weeks after injury and showed mild ulnar nerve myelinopathy at the elbow and severe axonal compromise of the PIN. At 6 months after injury, the patient exhibited near-complete recovery, with 5/5 strength noted for all upper extremity musculature except a slight residual weakness in his extensor pollicis longus, which did not impact his activities of daily living. DISCUSSION Certain upper extremity fractures are associated with an elevated incidence of peripheral nerve injury, with contributing risk factors being the relative proximity between the individual nerves and the fracture, the energy of the injury, and the displacement of the bone fragments. The incidence is particularly high for displaced fractures of the distal humerus, with palsies to the radial or ulnar nerves reported in as many as 20% to 50% of individuals.1 Proximal radius fractures carry a much lower incidence of nerve injury, with most of these occurring with highly displaced fractures of the radial neck or in the setting of a complex elbow dislocation. Anatomically, the radial nerve passes between the brachialis and brachioradialis as it approaches the elbow, innervating the brachioradialis and extensor carpi radialis longus before bifurcating approximately 4 cm proximal to the leading edge of the supinator. The innervation of the extensor carpi radialis brevis is somewhat variable, as it can arise as a terminal branch from the PIN, branch more distally from the superficial radial nerve, or occur as a distinct branch at the level of the bifurcation.2 More distally, the deep branch of the radial nerve winds around the proximal radius and passes through the supinator, often coming into direct contact with the proximal radius.3 While this location places it at risk during surgical exposure, palsies of the PIN are relatively uncommon following minimally displaced proximal radius fractures.4 The subcutaneous course of the ulnar nerve and its anatomic confinement within the cubital tunnel make it susceptible to direct trauma with fractures around the elbow.5 In addition, valgus loading can impart a distraction load across the nerve, further increasing the degree of nerve injury. Patients with these injuries often demonstrate major fracture displacement or evidence of trauma to the ulnar collateral ligament of the elbow. Isolated palsies to either the PIN or the ulnar nerve have been reported following fractures, dislocations, penetrating injuries, and posttraumatic contusions.4 –13 Similarly, late dysfunction of single nerves has been
documented, identifying heterotopic ossification, malreduction, and malalignment as contributing factors.14 Our case of a combined ulnar and PIN palsy following a minimally displaced radial neck fracture is distinguished from those previous reports in that the earlier cases described dysfunction of a single nerve, involved high-energy mechanisms, and occurred in association with widely displaced fractures. Nontraumatic, isolated PIN palsies have also been reported, resulting from septic arthritis,15 benign soft tissue masses, or inflammatory arthropathies.15–18 Three cases of a combined PIN and ulnar nerve palsy have been described, one after prolonged immobilization in a compressive plaster of Paris splint for a wrist fracture19 and a second occurring after a spontaneous hemarthrosis in a patient with hemophilia.20 The third report identified a combined palsy in the setting of a distal humerus malunion with radial head subluxation following an injury that had occurred 47 years previously.21 All 3 of these patients had a complete recovery; the first following surgical lysis of adhesions, the second following surgical decompression of the joint hematoma and subcutaneous ulnar nerve transposition, and the third after subcutaneous ulnar nerve transposition and radial head resection.19 –21 For our patient, there was no evidence of any injury to the ulnar collateral ligament, making it unlikely that a major distraction force had been directly applied to the ulnar nerve. The absence of flexor digitorum profundus function to the ring and small fingers indicated that the nerve injury occurred proximal to the wrist, although it is difficult to reconcile this finding with the preservation of his ulnar sensation. One would suspect that the sensory fibers would be affected to a greater degree than the motor fibers, given their superficial location in the ulnar nerve at the cubital tunnel. We hypothesize that the small degree of bony trauma allowed the elbow capsule to remain intact. The resulting hematoma expanded the capsule and might have applied direct pressure to the PIN and ulnar nerve with their known proximal and distal tethers. The EMG study findings of mild ulnar nerve myelinopathy at 12 weeks suggests that the patient might have had a subclinical ulnar nerve compression before his injury, which expressed itself as a motor palsy following the fracture. With nonsurgical management, both of the patient’s nerves demonstrated excellent functional recovery. REFERENCES 1. Browner BD, Levine AM, Jupiter JB, Trafton PG, Krettek C, eds. Skeletal trauma: basic science, management, and reconstruction, 4th ed. Philadelphia, PA: WB Saunders; 2009.
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COMBINED PIN AND ULNAR NERVE PALSIES
2. Branovacki G, Hanson M, Cash R, Gonzalez M. The innervation pattern of the radial nerve at the elbow and in the forearm. J Hand Surg 1998;23B:167–169. 3. Abrams RA, Ziets RJ, Lieber RL, Botte MJ. Anatomy of the radial nerve motor branches in the forearm. J Hand Surg 1997;22A:232– 237. 4. Hirachi K, Kato H, Minami A, Kasashima T, Kaneda K. Clinical features and management of traumatic posterior interosseous nerve palsy. J Hand Surg 1998;23B:413– 417. 5. Khoo D, Carmichael SW, Spinner RJ. Ulnar nerve anatomy and compression. Orthop Clin North Am 1996;27:317–338. 6. Mohler LR, Hanel DP. Closed fractures complicated by peripheral nerve injury. J Am Acad Orthop Surg 2006;14:32–37. 7. Chang MC, Liu Y, Lo WH. Wraparound injury of posterior interosseous nerve on the unreduced radial head: a case report. M C Zhonghua Yi Xue Za Zhi (Taipei) 1996;58:459 – 463. 8. Sudhahar TA, Patel AD. A rare case of partial posterior interosseous nerve injury associated with radial head fracture. Injury 2004;35: 543–544. 9. Serra G, Aiello I, Rosati G, Tugnoli V, Traina GC, Cristofori MC. Posterior interosseous nerve palsy. Report of three unusual cases. Ital J Neurol Sci 1984;5:85– 87. 10. Serrano KD, Rebella GS, Sansone JM, Kim MK. A rare case of posterior interosseous nerve palsy associated with radial head fracture. J Emerg Med 2010 Jan 14. Epub ahead of print. Doi:10.1016/ j.jemermed.2009.10.017. 11. Daurka J, Chen A, Akhtar K, Kamineni S. Tardy posterior interosseous nerve palsy associated with radial head fracture: a case report. Cases J 2009;2:22. 12. Bekler H, Riansuwan K, Vroemen JC, McKean J, Wolfe VM, Rosenwasser MP. Innervation of the elbow joint and surgical per-
13.
14. 15.
16.
17.
18.
19.
20.
21.
1633
spectives of denervation: a cadaveric anatomic study. J Hand Surg. 2008;33A:740 –745. Erratum in: J Hand Surg 2008;33A:1445. Vroeman, Joy C [corrected to Vroemen, Joy C]. Calfee RP, Wilson JM, Wong AH. Variations in the anatomic relations of the posterior interosseous nerve associated with forearm trauma.J Bone Joint Surg 2011;93A:81–90. Adams JE, Steinmann SP. Nerve injuries about the elbow. J Hand Surg 2006;31A:303–313. Kato H, Iwasaki N, Minami A, Kamishima T. Acute posterior interosseous nerve palsy caused by septic arthritis of the elbow: a case report. J Hand Surg 2003;28A:44 – 47. Ogino T, Minami A, Kato H. Diagnosis of radial nerve palsy caused by ganglion with use of different imaging techniques. J Hand Surg 1991;16A:230 –235. Wu KT, Jordan FR, Eckert C. Lipoma, a cause of paralysis of deep radial (posterior interosseous) nerve: report of a case and review of the literature. Surgery 1974;75:790 –795. Westkaemper JG, Varitimidis SE, Sotereanos DG. Posterior interosseous nerve palsy in a patient with rheumatoid synovitis of the elbow: a case report and review of the literature. J Hand Surg 1999;24A:727–731. Benfenati A, Poppi M, Galassi E, Martinelli P. Combined tardy palsy of posterior interosseous nerve and ulnar nerve at the elbow. Neurochirurgia (Stuttg) 1982;25:143–144. Culver JE Jr. Combined posterior interosseous and ulnar nerve compression in a hemophiliac. Bull Hosp Joint Dis 1978;39:103– 106. Adams JP, Rizzoli Hv. Tardy radial and ulnar nerve palsy: case report. Tardy radial and ulnar nerve palsy: case report. J Neurosurg 1959;16:342–344.
JHS 䉬 Vol A, August