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Compression of the radial nerve caused by an occult ganglion
COMPRESSION
OF T H E R A D I A L N E R V E C A U S E D B Y A N OCCULT GANGLION Three case reports R. STEIGER and E. VOGELIN
From the Department of Hand Surgery, CantonalHospital Liestal, Switzerland We report on three patients with radial nerve compression in the region of the supinator muscle caused by an occult ganglion. After excision of the ganglion and decompression of the posterior interosseous nerve, the nerve palsy resolved completely in all cases. Journal of Hand Surgery (British and European Volume, 1998) 23B." 3:420-421 Compression can occur at several points along the anatomical course of the radial nerve in the arm but the cubital fossa and the proximal forearm are the most common sites. The posterior interosseous nerve and/or the sensory branch of the radial nerve are frequently involved in compression at this location. Compression may occur at the arcade of Frohse (the tendinous proximal part of the supinator muscle), which constitutes an anatomical constriction of the nerve, and can also be caused by benign tumours such as lipomas, fibromas or as a result of synovitis in osteoarthrosis or rheumatoid arthritis (Bowen and Stone, 1966; Capener, 1966; Sawin and Loftus, 1995). Focal constriction of the nerve without trauma or external compression has also been described (Hashizume and Inoue, 1993; Inoue and Shionoya, 1996). We describe three cases of radial nerve compression caused by an occult ganglion in the region of the supinatot muscle.
Fig 1
CASE REPORTS
Intraoperative exposure of a ganglion in the region of the supinator muscle which is causing a compression neuropathy of the posterior interosseous nerve (case 1).
obvious atrophy of the extensors on the forearm. Neurological investigations confirmed compression of the radial nerve at the level of the supinator tunnel. At operation, there was marked compression of the radial nerve at the entrance of the supinator and a prominence in the muscle. The cause was found to be a ganglion, about 4 x 5 cm in size, with a pedicle arising from the elbow joint. The postoperative course was uncomplicated and the radial nerve palsy resolved completely.
Case 1 A 31-year-old woman complained of acute pain in the region of the left elbow after heavy lifting. Various symptoms were associated with hand and finger extensor weakness. Nerve conduction studies of the radial nerve confirmed a prolonged distal motor latency period of 4.2 ms (upper limit of normal, 3.5 ms) proximal to the common extensor muscles. M R I confirmed a cystic lesion in the supinator muscle connected to the humeroradial joint. The radial nerve was located proximally via an anterior approach and followed distal to the arcade of Frohse. A ganglion in the region of the supinator muscle was found to be the cause of the nerve compression and removed (Fig 1). Postoperatively, she noticed an increase in wrist extension by 2 days. The final check 2 years later confirmed that elbow and wrist function were the same on both sides, and she no longer had any symptoms.
Case 3 A 64-year-old mechanic complained of pain in the left elbow after lifting. A partial biceps tendon rupture was the most prominent clinical feature. This was treated conservatively. The elbow pain persisted. A disturbance of impulse conduction could not be detected neurophysiologically. However, a feeling of weakness associated with marked pain on pressure over the radial nerve tunnel and a swelling over the brachioradialis muscle prompted reassessment. The radial nerve was exposed in its course between the brachioradialis and supinator muscles via a palmar-radial incision. A ganglion-like protruberance was found over the head of the radius.
Case 2 A 50-year-old warehouse supervisor complained of sudden weakness in the region of the right wrist. There was 420
421
R A D I A L NERVE COMPRESSION
After incision, an effusion discharged and a villous synovitis became visible under the partially ruptured biceps tendon. The entire bursa and synovitis were excised as well as the stumps of the ruptured biceps tendon. The postoperative course was normal. One year later, he developed a painful exostosis in the region of the radial tuberosity; this was excised. One year later, he was free of elbow symptoms and the strength was equal on both sides. DISCUSSION Ganglia in the region of the supinator muscle are rare causes of radial nerve compression. Bowen and Stone (1966) described one case of a ganglion in the region of the posterior interosseous nerve. Ganglia occur in association with tendon sheaths or joints. Nerve compression most often occurs in the region of anatomical constrictions. The posterior interosseous branch of the radial nerve runs close to the joint and there may be a constriction in the region of the arcade of Frohse which can often lead to neurological symptoms or pain without
other external compression. When the elbow is arthritic, external compression by degenerative synovitis or bui'sitis may also cause radial tunnel syndrome and should be borne in mind. References Bowen TL, Stone K H (1966). Posterior interosseous nerve paralysis caused by a ganglion at the elbow. Journal of Bone and Joint Surgery, 48B: 774-776 Capener N (t966). The vulnerability of the posterior interosseous nerve of the forearm: A case report and an anatomical study. Journal of Bone and Joint Surgery, 48B: 770 773. Hashizume H, Inoue H, Nagashima K, H a m a y a K (1993). Posterior interosseous nerve paralysis related to focal radial nerve constriction secondary to vasculitis. Journal of H a n d Surgery, 18B: 757-760. Inoue G, Shionoya K (1996). Constrictive paralysis of the posterior interosseous netwe without external compression. Journal of H a n d Surgery, 21B: 164-168. Sawin PD, Loftus CM (1995). Posterior interosseous nerve palsy after brachiocephalic arteriovenous fistula construction: report of two cases. Neurosurgery 37: 53%540.
Received: 1 October 1997 Accepted after revision: 1 December 1997 R. Steiger MD, Department of Hand Surgery,Orthopaedic Surgery Division, Cantonal Hospital Liestal, Switzerland. © 1998The British Society for Surgery of the Hand
OF T H E R A D I A L N E R V E C A U S E D B Y A N OCCULT GANGLION Three case reports R. STEIGER and E. VOGELIN
From the Department of Hand Surgery, CantonalHospital Liestal, Switzerland We report on three patients with radial nerve compression in the region of the supinator muscle caused by an occult ganglion. After excision of the ganglion and decompression of the posterior interosseous nerve, the nerve palsy resolved completely in all cases. Journal of Hand Surgery (British and European Volume, 1998) 23B." 3:420-421 Compression can occur at several points along the anatomical course of the radial nerve in the arm but the cubital fossa and the proximal forearm are the most common sites. The posterior interosseous nerve and/or the sensory branch of the radial nerve are frequently involved in compression at this location. Compression may occur at the arcade of Frohse (the tendinous proximal part of the supinator muscle), which constitutes an anatomical constriction of the nerve, and can also be caused by benign tumours such as lipomas, fibromas or as a result of synovitis in osteoarthrosis or rheumatoid arthritis (Bowen and Stone, 1966; Capener, 1966; Sawin and Loftus, 1995). Focal constriction of the nerve without trauma or external compression has also been described (Hashizume and Inoue, 1993; Inoue and Shionoya, 1996). We describe three cases of radial nerve compression caused by an occult ganglion in the region of the supinatot muscle.
Fig 1
CASE REPORTS
Intraoperative exposure of a ganglion in the region of the supinator muscle which is causing a compression neuropathy of the posterior interosseous nerve (case 1).
obvious atrophy of the extensors on the forearm. Neurological investigations confirmed compression of the radial nerve at the level of the supinator tunnel. At operation, there was marked compression of the radial nerve at the entrance of the supinator and a prominence in the muscle. The cause was found to be a ganglion, about 4 x 5 cm in size, with a pedicle arising from the elbow joint. The postoperative course was uncomplicated and the radial nerve palsy resolved completely.
Case 1 A 31-year-old woman complained of acute pain in the region of the left elbow after heavy lifting. Various symptoms were associated with hand and finger extensor weakness. Nerve conduction studies of the radial nerve confirmed a prolonged distal motor latency period of 4.2 ms (upper limit of normal, 3.5 ms) proximal to the common extensor muscles. M R I confirmed a cystic lesion in the supinator muscle connected to the humeroradial joint. The radial nerve was located proximally via an anterior approach and followed distal to the arcade of Frohse. A ganglion in the region of the supinator muscle was found to be the cause of the nerve compression and removed (Fig 1). Postoperatively, she noticed an increase in wrist extension by 2 days. The final check 2 years later confirmed that elbow and wrist function were the same on both sides, and she no longer had any symptoms.
Case 3 A 64-year-old mechanic complained of pain in the left elbow after lifting. A partial biceps tendon rupture was the most prominent clinical feature. This was treated conservatively. The elbow pain persisted. A disturbance of impulse conduction could not be detected neurophysiologically. However, a feeling of weakness associated with marked pain on pressure over the radial nerve tunnel and a swelling over the brachioradialis muscle prompted reassessment. The radial nerve was exposed in its course between the brachioradialis and supinator muscles via a palmar-radial incision. A ganglion-like protruberance was found over the head of the radius.
Case 2 A 50-year-old warehouse supervisor complained of sudden weakness in the region of the right wrist. There was 420
421
R A D I A L NERVE COMPRESSION
After incision, an effusion discharged and a villous synovitis became visible under the partially ruptured biceps tendon. The entire bursa and synovitis were excised as well as the stumps of the ruptured biceps tendon. The postoperative course was normal. One year later, he developed a painful exostosis in the region of the radial tuberosity; this was excised. One year later, he was free of elbow symptoms and the strength was equal on both sides. DISCUSSION Ganglia in the region of the supinator muscle are rare causes of radial nerve compression. Bowen and Stone (1966) described one case of a ganglion in the region of the posterior interosseous nerve. Ganglia occur in association with tendon sheaths or joints. Nerve compression most often occurs in the region of anatomical constrictions. The posterior interosseous branch of the radial nerve runs close to the joint and there may be a constriction in the region of the arcade of Frohse which can often lead to neurological symptoms or pain without
other external compression. When the elbow is arthritic, external compression by degenerative synovitis or bui'sitis may also cause radial tunnel syndrome and should be borne in mind. References Bowen TL, Stone K H (1966). Posterior interosseous nerve paralysis caused by a ganglion at the elbow. Journal of Bone and Joint Surgery, 48B: 774-776 Capener N (t966). The vulnerability of the posterior interosseous nerve of the forearm: A case report and an anatomical study. Journal of Bone and Joint Surgery, 48B: 770 773. Hashizume H, Inoue H, Nagashima K, H a m a y a K (1993). Posterior interosseous nerve paralysis related to focal radial nerve constriction secondary to vasculitis. Journal of H a n d Surgery, 18B: 757-760. Inoue G, Shionoya K (1996). Constrictive paralysis of the posterior interosseous netwe without external compression. Journal of H a n d Surgery, 21B: 164-168. Sawin PD, Loftus CM (1995). Posterior interosseous nerve palsy after brachiocephalic arteriovenous fistula construction: report of two cases. Neurosurgery 37: 53%540.
Received: 1 October 1997 Accepted after revision: 1 December 1997 R. Steiger MD, Department of Hand Surgery,Orthopaedic Surgery Division, Cantonal Hospital Liestal, Switzerland. © 1998The British Society for Surgery of the Hand