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Diagnosis of radial nerve palsy caused by ganglion with use of different imaging techniques
Diagnosis of radial nerve palsy caused by ganglion with use of different imaging techniques Clinical features of six cases of radial nerve compression syndrome as a result of ganglion at the elbow are reported. The usefulness of different imaging techniques for detecting the location of ganglion is compared. The posterior interosseous nerve was Involved in two patients, the radial sensory nerve in one pat ient, and both nerves in three patients. Ultrasonography, computed tomography, and magnetic resonance imaging revealed the location of the ganglion in every patient. Ultrasonography was most convenient for screening examination when it was difficult to clearly define a ganglion by palpation. In all patients, a ganglion arose from the anterior capsule of the elbow joint. Dynamic factors in addition to compression of the nerve by ganglion' may influence occurrence of the nerve palsy. (J HAriD SURG 1991j16A:230-S.)
Toshihiko Ogino, MD, Akio Minami, MD, and Hiroyuki Kato, MD, Sapporo, Japan
Many causes of nontraumatic posterior interosseous nerve palsy have been reported. Compression of the nerve by a tumor or a tumor-like condition, fibrous bands at the arcade of Frohse, an unreduced radial head, rheumatoid arthritis, bursitis, neuritis, and neuralgic amyotrophy have all been cited. (·5 Other studies have reported posterior interosseous nerve or radial nerve compression caused by a ganglion arising from the elbow.6-20 These previous reports have included three different types of palsy, posterior interosseous nerve palsy, neuropathy of the sensory branch of the radial nerve, and neuropathy of both nerves. In this report, the 'clinical features of our own six cases of radial nerve compression syndrome due to a ganglion at the elbow are reported and the usefulness of diagnostic imaging methods for detecting ganglia is discussed .
From the Department of Orthopedic Surgery, School of Medicine. Hokkaido University, Sapporo, Japan. Received for publication Jan , 24, 1990; accepted in revised form June 5 ,1990, No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Toshihiko Ogino, MD, Department of Physical Therapy, School of Allied Health Professions , Sapporo Medical College. Minami-B, Nishi-I? Chuuouku , Sapporo, 060 Japan . 3/1123395
230
TilE JOURNAL OF HAND SURGERY
Materials and methods Six cases of radial nerve palsy caused by a ganglion arising from the anterior aspect of the elbow joint were treated in our department during the last 5 years. The patients' sex, the affected side, the age at the first visit to the clinic, the provoking cause of the palsy, the signs and symptoms, and the extent and degree of nerve palsy were analyzed . We also reviewed operative findings and the findings of ultrasonography, computerized tomography (CT) , and magnetic resonance imaging (MRI). Results Clinical features (Table I). Among six patients, one patient was a man and five were women. Ages at the first visit ranged from 27 to 56 years with an average of 40.7 years. The right side was affected in three patients and the left in three patients. Provoking causes of the palsy in four of the six patients included long use of a screwdriver in one patient, long use of scissors in one patient, and repeated lifting of heavy objects in two patients. In four patients the nerve palsy was improved by rest and was worsened by hard manual work. The type of palsy was a posterior interosseous nerve palsy in two patients, neuropathy of the radial sensory nerve in one patient, and neuropathy of both nerves in three patients . The degree of muscle weakness in each patient is shown in Table II. The triceps brachii, brachioradialis, and extensor carpi radialis were normal in all patients .
Vol. 16A, No.2
March 1991
Diagnosis of radial nerve palsy caused by ganglion
231
•
Fig. 1. A-B, Ultrasonography. A, Transverse section. B, Longitudinal section. A ganglion arose from the anterior aspect of the radial head. R. Radius; G, ganglion; C. capitulum.
Fig. 2. Computed tomography revealed a cystic shadow at the anterior aspect of the radial head.
The muscle weakness of other muscles innervated by the radial nerve differed in each patient. Other signs and symptoms included dullness around the elbow in six patients, pain of the elbow in one patient, tenderness of the radial humeral epicondyle in one patient, and a positive Tinel's sign in two patients. Palpation clearly detected a ganglion in two patients. In three patients palpation was equivocal while in one patient there was no suggestion of fullness or ganglion. Findings of the diagnostic imaging methods. Ultrasonography was used in five patients, CT in four patients, MRI in two patients. Ultrasonography revealed
an abnormal hypoechogenic area anterior to the radial head in each patient (Fig. 1). Because of the homogeneousnature of the echogenicity and the difference from the surrounding tissue, a ganglion was strongly suspected. Computerized tomography revealed a low density homogeneous abnormal shadow with sharp border anterior to the radial head in all cases (Fig. 2). The CT number of this shadow was 30 to 40. Magnetic resonance imaging also revealed an abnormality in the same area. In Tj-weighted MRI scans, the mass was of low signal and in T 2-weighted MRI scans it was of high signal (Fig. 3). Operative findings. Surgical excision of the ganglion was done in all patients. In each instance, a ganglion arose from the anterior capsule and extended over the radial head and pushed up the deep and superficial sensory branches of the radial nerve compressing them against the brachioradialis (Fig. 4). The ganglion and its attachment to the superficial layer of the capsule was removed. The length of follow-up ranged from 10 to 20 months (the average being 15 months). Every patient recovered completely from the nerve palsy. There was no incidence of recurrent ganglia or no late symptoms. Case report A 43-year-old. right-handed woman complained of weakness of the digital extensors of the right hand. She had first noticedthis 4 weeksearlier whenshe had lifteda heavyobject. She complained of pain on the lateral aspect of the elbow but did not notice a swelling or tumor in this area. On physical examination, a mass could not be definitely detected by palpation. The patient had slightly decreased sensitivity in the distribution of the sensory branch of the radial nerve. She
232
Ogino, Minami, and Kato
The Journal of HAND SURGERY
Fig. 3. A-B, Ty-weighted magnetic resonance imaging scan. A, Transverse section. B, Longitudinal' section. T 2-weighted MRI revealed a low signal mass at the anterior aspect of the radial head.
Fig-. 4. Operative findings: A ganglion arose from the anterior capsule of the elbow joint and compressed the deep and sensory branch of the radial nerve. Deep branch (white arrow); sensory branch (black arrow).
Fig. 5. A-B, Magnetic resonance imaging scan. A, T,-weightcd MRI. B, Ts-wcightcd MRI. R, Radius. The ganglion was of low signal in T,-weighted MRI and of high signal in Ty-wcighted MRI.
Vol. 16A, No.2 March 1991
Diagnosis of radial nerve pals)' caused by ganglion
233
Table I. Clinical features of radial nerve palsy due to ganglion arising from anterior aspect of the elbow joint
Patient
Sex
Age
Side
M
56
R
2
F
39
R
3
F
43
L
4 5
F F
27 36
L L
6
F
43
R
Provocative cause
Improvement or aggravation
Use of screwdriver Use of scissors Lift heavy object
Type of nerve pals)'
Dullness of the elbow
Pain
+
+
PIN
+ SRN
+
+
PIN
+ SRN
+
+
PIN
+
PIN PIN
Lift heavy object
Tinet's sign
Detection of ganglion
++
+-
+
+-
+ SRN
+ +
+ +
SRN
+
+
M. Male; F, female; R. right; L. left; PIN. posterior interosseous nerve; SRN. superficial radial nerve.
Table II. Muscle weakness in each case of radial nerve palsy caused by ganglion Patient
1 2 3 4 5 6
I
ECR
5 5 5 5 5 5
I
EDC
4 I
2 4 1 5
I
EDM
4 1 2 4 I
5
was unable to activate the extensor digitorum communis, extensor carpi ulnaris, extensor digiti minimi, extensor pollicis longus and brevis, and extensor indicis proprius muscles. X-ray films of the elbow and forearm were normal. Electrodiagnostic studies including an electromyogram and n~rve conduction study were consistent with the diagnosis of a right posterior interosseous nerve palsy. Ultrasonography, CT, and MRI each demonstrated a wel1 defined mass just anterior to the radial head (Fig. 5). Before surgery, she limited her activity while she was treated for diabetes mellitus. During this period of relative inactivity, she experienced slight improvement of finger extension. Surgical exposure of the anterior elbow defined a ganglion cyst in the axilla of the division of the radial nerve into its superficial sensory and posterior interosseous components. The ganglion was excised with its base. Muscle weakness and sensory change had completely recovered I. month after surgery.
Discussion Our review of the medical literature revealed 38 cases of radial nerve compression secondary to a ganglion. Only 6 of these cases were reported in the Englishlanguage literature." 17. 19.20 In 24 cases the details of the clinical features were described":" (Table III). Among 30 cases (these 24 cases and our 6 cases), 20 patients had posterior interosseous nerve palsy, 2 patients had neuropathy of the radial sensory nerve, and 8 patients had neuropathy of both nerves. When a gan-
I
ECU
4 1 2 4 2 5
I
EPL
EPB
EIP
4 I 2 4 1 5
4
4 1 2 4
I
2 4 1 5
t 5
glion arising from the anterior aspect of the elbow compresses the radial nerve, posterior interosseous nerve palsy occurs most often. Our operative findings in each case revealed that a ganglion arising from the anterior capsule of the elbow pushed up the deep and superficial sensory branches of the radial nerve compressing them against the brachioradialis. These facts suggest that there is a possibility that palsy of both the posterior interosseous nerve and the radial sensory nerve occur whenever a ganglion arises from the anterior capsule of the elbow. Among cases of radial nerve palsy secondary to a ganglion anterior to the radial head, compression of the nerve by ganglion was considered to be the principal cause of nerve palsy. However, in 9 of the 30 cases surveyed radial nerve palsy occurred after overuse of the arm. In 11 cases, the nerve palsy either improved with rest or worsened with heavy manual work. These observations suggest that dynamic factors in addition to compression of the nerve by ganglion may influence occurrence of the nerve palsy as reported by Spinner and Spencer.' When a ganglion is not detectable by palpation in cases with posterior interosseous nerve palsy, differential diagnosis of the cause of the palsy may be difficult. As reported by Derkash and Niebauer, I determining the location of the entrapment either at the arcade of Frohse or at the distal supinator muscle is
234
The Journal of HAND SURGERY
Ogino, Minami, and Kato
Table III. Reported cases of radial nerve palsy due to ganglion at the elbow Provoking calise
Author
Takano' Miyagi" Azuma" Bowen' Yamahiro'" Yamahiro Matsuzaki" Nagamine" Inoue"
Inoue" Inoue" Inoue"
Machida" Machida" Matsuishi"
Suka" Suka" Mass" Morimoto'S Morimoto's Hennansdorfer" McCollamlO McCollams McCollams Ogino Ogino Ogino
agino Ogino Ogino
1958 1959 1965 1966 1966 1966 1971 1973 1975 1975 1975 1975 1978 1978 1979 1981 1981 1982 1982 1982 1986 1988 1988 1988 1990 1990 1990 1990 1990 1990
F F F
M F F F F M
t-.I M F F F M F M F F M F M F F M F F F F F
24 35 23 57 21 43 46 38 40 28 45 41 30 32 31 27 50 41 28 67 30 16 40 52 56 39 43 27 36 43
L L L L R
Improvement or aggravation
Type of nerve palsy
+
PIN PIN PIN PIN PIN + SRN PIN + SRN PIN PIN PIN PIN PIN PIN PIN + SRN PIN PIN PIN PIN + SRN PIN PIN PIN SRN PIN PIN PIN + SRN PIN + SRN PIN + SRN PIN PIN + SRN PIN SRN
+ +
R R L R
NR
+
R
+
R L
+
R
R L R R L L L L
R L L R R L L L R
+
+
+ +
+ + + + +
+ + + +
+
M, Male; F, female; R, right; L, left; NR, not recorded; PIN, posterior interosseous nerve; SRN, superficial branch of the radial nerve.
important because the operative approachs to the two sites are different. Ultrasonography has not been previously reported as a means of determining the location of the ganglion in posterior interosseous nerve palsy. We used ultrasonography in five cases. In all, ultrasonography revealeda hypoechogenic area in front of the radial head and we could detect the location of the ganglion, MacCollom and Corley" reported on the usefulness of CT in detecting a ganglia in posterior interosseous nerve palsy. In cases, CT and MRI scan also revealed the gangla. These two methods are therefore also useful for detecting ganglia, but ultrasonography is noninvasive and inexpensive and is the easiest method of screening for ganglia in cases of posterior interosseous nerve palsy.
our
The authors thank Professor Kiyoshi Kaneda, MD, Department of Orthopaedic Surgery, Hokkaido University, School of Medicine, Sapporo. Japan, and Professor Terry Light, MD, Department of Orthopaedics and Rehabilitation, Loyola University Medical Center, Maywood. Illinois.
REFERENCES 1. Derkash RS, Niebauer JJ. Entrapment of the posterior interosseous nerve by a fibrous band in the dorsal edge of the supinator muscle and erosion of a groove in the proximal radius. J HAND SURG 1981;6:524-6. 2. Spinner A, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and experimental review. Clin Orthop 1974;104:46-7, 3. El-Hadidi S, Burke FD. Posterior interosseous nerve syndrome caused by a bursa in the vicinity of the elbow. J HAND SURG 1987;12B:23-4. 4. Holst-Nielsen F, Jensen V. Tardy posterior interosseous nerve palsy as a result of an unreduced radial head dislocation in Monteggia fractures: a report of two cases. J HAND SURG 1984;9A:572-5. 5. White SH, Goodfellow JW. Posterior interosseous nerve palsy in rheumatoid arthritis. J Bone Joint Surg 1988; 70B:468-71. 6. Takano A. A case of radial nerve palsy due to ganglion. J Jpn Orthop Assoc 1958;52:100-3. 7. Miyagi T, Miyagi D. Simple ganglion at the elbow joint causing radial palsy. Report of a case. Kurume Med J 1959;22:1665-7.
Vol. 16A, No.2 March 1991
8. Azuma T. A case of radial nerve palsy due to joint ganglion . Geka 1965;27:102-4. 9. Bowen TL, Stone KH. Posterior interosseous nerve paralysis caused by a ganglion at the elbow. J Bone Joint Surg 1966;48B:774-6. 10. Yamahiro K. Two cases of incomplete radial nerve palsy due to ganglion at the elbow. Seikeigeka 1966;17: 743-9. II. Matsuzaki A, Mitsuyasu M. Six cases of posterior interosseous nerve palsy. Seikeigeka to Saigaigeka 1971; 20:34-6. 12. Nagamine T. Imabayashi M. Morinaga H, Baba N. A case of paralysis of radial nerve caused by elbow jointganglion. Seikeigeka to Saigaig eka 1973;22:102-4. 13. Inoue K, Furukawa K. Honnda K.• et al. Paralysis of the deep branch of the radial nerve due to ganglion at the elbow. Seikeigeka 1975;26:43-8. 14. Machida M. Shibata K, Hasue K, Satou M. Mineshima T. Two cases of radial nerve palsy due to ganglion at the elbow . Rinsho Seikei Geka 1978;13:870-2.
Diagnosis of radial nerve palsy caused by ganglion
235
15. Matsuishi Y. Miura T. Hiramatsu K. Masuda K. Shima R. Iscki R. Four cases of paralys is of ramus profundus ofN. radialis. Seikeigeka to Saigaigeka 1979;28:238-41. 16. Suka T. Namiki T, Takatsuki S, Satoh Y, Ooi Y. Paralysis of deep branch of radial nerve due to ganglion at the elbow. Seikeigeka 1981;32:263-9. 17. Mass DP, Tortosa R. Newmeyer W, Kilgore ES. Compression of posterior interosseous nerve by a ganglion-case report. J HAND SURG 1982;7:92-4. 18. Morimoto K. Furuse K. Maeyama I. Yamane M. Two cases of paralysis of deep branch of radial nerve due to ganglion at the elbow. Seikeigeka to Saigaigeka 1982; 31:96-8. 19. Hermansdorfer JD, Greider JL, Dell PC. A case report of a compressive neuropathy of the radial sensory nerve caused by a ganglion cyst at the elbow. Orthopedics 1986;9: 1005-6. 20. McCollam SM, Corley FG, Green DP. Posterior interosseous nerve palsy caused by ganglion of the proximal radioulnar joint. J HAND SURG 1988;13A:725-7.
Toshihiko Ogino, MD, Akio Minami, MD, and Hiroyuki Kato, MD, Sapporo, Japan
Many causes of nontraumatic posterior interosseous nerve palsy have been reported. Compression of the nerve by a tumor or a tumor-like condition, fibrous bands at the arcade of Frohse, an unreduced radial head, rheumatoid arthritis, bursitis, neuritis, and neuralgic amyotrophy have all been cited. (·5 Other studies have reported posterior interosseous nerve or radial nerve compression caused by a ganglion arising from the elbow.6-20 These previous reports have included three different types of palsy, posterior interosseous nerve palsy, neuropathy of the sensory branch of the radial nerve, and neuropathy of both nerves. In this report, the 'clinical features of our own six cases of radial nerve compression syndrome due to a ganglion at the elbow are reported and the usefulness of diagnostic imaging methods for detecting ganglia is discussed .
From the Department of Orthopedic Surgery, School of Medicine. Hokkaido University, Sapporo, Japan. Received for publication Jan , 24, 1990; accepted in revised form June 5 ,1990, No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Toshihiko Ogino, MD, Department of Physical Therapy, School of Allied Health Professions , Sapporo Medical College. Minami-B, Nishi-I? Chuuouku , Sapporo, 060 Japan . 3/1123395
230
TilE JOURNAL OF HAND SURGERY
Materials and methods Six cases of radial nerve palsy caused by a ganglion arising from the anterior aspect of the elbow joint were treated in our department during the last 5 years. The patients' sex, the affected side, the age at the first visit to the clinic, the provoking cause of the palsy, the signs and symptoms, and the extent and degree of nerve palsy were analyzed . We also reviewed operative findings and the findings of ultrasonography, computerized tomography (CT) , and magnetic resonance imaging (MRI). Results Clinical features (Table I). Among six patients, one patient was a man and five were women. Ages at the first visit ranged from 27 to 56 years with an average of 40.7 years. The right side was affected in three patients and the left in three patients. Provoking causes of the palsy in four of the six patients included long use of a screwdriver in one patient, long use of scissors in one patient, and repeated lifting of heavy objects in two patients. In four patients the nerve palsy was improved by rest and was worsened by hard manual work. The type of palsy was a posterior interosseous nerve palsy in two patients, neuropathy of the radial sensory nerve in one patient, and neuropathy of both nerves in three patients . The degree of muscle weakness in each patient is shown in Table II. The triceps brachii, brachioradialis, and extensor carpi radialis were normal in all patients .
Vol. 16A, No.2
March 1991
Diagnosis of radial nerve palsy caused by ganglion
231
•
Fig. 1. A-B, Ultrasonography. A, Transverse section. B, Longitudinal section. A ganglion arose from the anterior aspect of the radial head. R. Radius; G, ganglion; C. capitulum.
Fig. 2. Computed tomography revealed a cystic shadow at the anterior aspect of the radial head.
The muscle weakness of other muscles innervated by the radial nerve differed in each patient. Other signs and symptoms included dullness around the elbow in six patients, pain of the elbow in one patient, tenderness of the radial humeral epicondyle in one patient, and a positive Tinel's sign in two patients. Palpation clearly detected a ganglion in two patients. In three patients palpation was equivocal while in one patient there was no suggestion of fullness or ganglion. Findings of the diagnostic imaging methods. Ultrasonography was used in five patients, CT in four patients, MRI in two patients. Ultrasonography revealed
an abnormal hypoechogenic area anterior to the radial head in each patient (Fig. 1). Because of the homogeneousnature of the echogenicity and the difference from the surrounding tissue, a ganglion was strongly suspected. Computerized tomography revealed a low density homogeneous abnormal shadow with sharp border anterior to the radial head in all cases (Fig. 2). The CT number of this shadow was 30 to 40. Magnetic resonance imaging also revealed an abnormality in the same area. In Tj-weighted MRI scans, the mass was of low signal and in T 2-weighted MRI scans it was of high signal (Fig. 3). Operative findings. Surgical excision of the ganglion was done in all patients. In each instance, a ganglion arose from the anterior capsule and extended over the radial head and pushed up the deep and superficial sensory branches of the radial nerve compressing them against the brachioradialis (Fig. 4). The ganglion and its attachment to the superficial layer of the capsule was removed. The length of follow-up ranged from 10 to 20 months (the average being 15 months). Every patient recovered completely from the nerve palsy. There was no incidence of recurrent ganglia or no late symptoms. Case report A 43-year-old. right-handed woman complained of weakness of the digital extensors of the right hand. She had first noticedthis 4 weeksearlier whenshe had lifteda heavyobject. She complained of pain on the lateral aspect of the elbow but did not notice a swelling or tumor in this area. On physical examination, a mass could not be definitely detected by palpation. The patient had slightly decreased sensitivity in the distribution of the sensory branch of the radial nerve. She
232
Ogino, Minami, and Kato
The Journal of HAND SURGERY
Fig. 3. A-B, Ty-weighted magnetic resonance imaging scan. A, Transverse section. B, Longitudinal' section. T 2-weighted MRI revealed a low signal mass at the anterior aspect of the radial head.
Fig-. 4. Operative findings: A ganglion arose from the anterior capsule of the elbow joint and compressed the deep and sensory branch of the radial nerve. Deep branch (white arrow); sensory branch (black arrow).
Fig. 5. A-B, Magnetic resonance imaging scan. A, T,-weightcd MRI. B, Ts-wcightcd MRI. R, Radius. The ganglion was of low signal in T,-weighted MRI and of high signal in Ty-wcighted MRI.
Vol. 16A, No.2 March 1991
Diagnosis of radial nerve pals)' caused by ganglion
233
Table I. Clinical features of radial nerve palsy due to ganglion arising from anterior aspect of the elbow joint
Patient
Sex
Age
Side
M
56
R
2
F
39
R
3
F
43
L
4 5
F F
27 36
L L
6
F
43
R
Provocative cause
Improvement or aggravation
Use of screwdriver Use of scissors Lift heavy object
Type of nerve pals)'
Dullness of the elbow
Pain
+
+
PIN
+ SRN
+
+
PIN
+ SRN
+
+
PIN
+
PIN PIN
Lift heavy object
Tinet's sign
Detection of ganglion
++
+-
+
+-
+ SRN
+ +
+ +
SRN
+
+
M. Male; F, female; R. right; L. left; PIN. posterior interosseous nerve; SRN. superficial radial nerve.
Table II. Muscle weakness in each case of radial nerve palsy caused by ganglion Patient
1 2 3 4 5 6
I
ECR
5 5 5 5 5 5
I
EDC
4 I
2 4 1 5
I
EDM
4 1 2 4 I
5
was unable to activate the extensor digitorum communis, extensor carpi ulnaris, extensor digiti minimi, extensor pollicis longus and brevis, and extensor indicis proprius muscles. X-ray films of the elbow and forearm were normal. Electrodiagnostic studies including an electromyogram and n~rve conduction study were consistent with the diagnosis of a right posterior interosseous nerve palsy. Ultrasonography, CT, and MRI each demonstrated a wel1 defined mass just anterior to the radial head (Fig. 5). Before surgery, she limited her activity while she was treated for diabetes mellitus. During this period of relative inactivity, she experienced slight improvement of finger extension. Surgical exposure of the anterior elbow defined a ganglion cyst in the axilla of the division of the radial nerve into its superficial sensory and posterior interosseous components. The ganglion was excised with its base. Muscle weakness and sensory change had completely recovered I. month after surgery.
Discussion Our review of the medical literature revealed 38 cases of radial nerve compression secondary to a ganglion. Only 6 of these cases were reported in the Englishlanguage literature." 17. 19.20 In 24 cases the details of the clinical features were described":" (Table III). Among 30 cases (these 24 cases and our 6 cases), 20 patients had posterior interosseous nerve palsy, 2 patients had neuropathy of the radial sensory nerve, and 8 patients had neuropathy of both nerves. When a gan-
I
ECU
4 1 2 4 2 5
I
EPL
EPB
EIP
4 I 2 4 1 5
4
4 1 2 4
I
2 4 1 5
t 5
glion arising from the anterior aspect of the elbow compresses the radial nerve, posterior interosseous nerve palsy occurs most often. Our operative findings in each case revealed that a ganglion arising from the anterior capsule of the elbow pushed up the deep and superficial sensory branches of the radial nerve compressing them against the brachioradialis. These facts suggest that there is a possibility that palsy of both the posterior interosseous nerve and the radial sensory nerve occur whenever a ganglion arises from the anterior capsule of the elbow. Among cases of radial nerve palsy secondary to a ganglion anterior to the radial head, compression of the nerve by ganglion was considered to be the principal cause of nerve palsy. However, in 9 of the 30 cases surveyed radial nerve palsy occurred after overuse of the arm. In 11 cases, the nerve palsy either improved with rest or worsened with heavy manual work. These observations suggest that dynamic factors in addition to compression of the nerve by ganglion may influence occurrence of the nerve palsy as reported by Spinner and Spencer.' When a ganglion is not detectable by palpation in cases with posterior interosseous nerve palsy, differential diagnosis of the cause of the palsy may be difficult. As reported by Derkash and Niebauer, I determining the location of the entrapment either at the arcade of Frohse or at the distal supinator muscle is
234
The Journal of HAND SURGERY
Ogino, Minami, and Kato
Table III. Reported cases of radial nerve palsy due to ganglion at the elbow Provoking calise
Author
Takano' Miyagi" Azuma" Bowen' Yamahiro'" Yamahiro Matsuzaki" Nagamine" Inoue"
Inoue" Inoue" Inoue"
Machida" Machida" Matsuishi"
Suka" Suka" Mass" Morimoto'S Morimoto's Hennansdorfer" McCollamlO McCollams McCollams Ogino Ogino Ogino
agino Ogino Ogino
1958 1959 1965 1966 1966 1966 1971 1973 1975 1975 1975 1975 1978 1978 1979 1981 1981 1982 1982 1982 1986 1988 1988 1988 1990 1990 1990 1990 1990 1990
F F F
M F F F F M
t-.I M F F F M F M F F M F M F F M F F F F F
24 35 23 57 21 43 46 38 40 28 45 41 30 32 31 27 50 41 28 67 30 16 40 52 56 39 43 27 36 43
L L L L R
Improvement or aggravation
Type of nerve palsy
+
PIN PIN PIN PIN PIN + SRN PIN + SRN PIN PIN PIN PIN PIN PIN PIN + SRN PIN PIN PIN PIN + SRN PIN PIN PIN SRN PIN PIN PIN + SRN PIN + SRN PIN + SRN PIN PIN + SRN PIN SRN
+ +
R R L R
NR
+
R
+
R L
+
R
R L R R L L L L
R L L R R L L L R
+
+
+ +
+ + + + +
+ + + +
+
M, Male; F, female; R, right; L, left; NR, not recorded; PIN, posterior interosseous nerve; SRN, superficial branch of the radial nerve.
important because the operative approachs to the two sites are different. Ultrasonography has not been previously reported as a means of determining the location of the ganglion in posterior interosseous nerve palsy. We used ultrasonography in five cases. In all, ultrasonography revealeda hypoechogenic area in front of the radial head and we could detect the location of the ganglion, MacCollom and Corley" reported on the usefulness of CT in detecting a ganglia in posterior interosseous nerve palsy. In cases, CT and MRI scan also revealed the gangla. These two methods are therefore also useful for detecting ganglia, but ultrasonography is noninvasive and inexpensive and is the easiest method of screening for ganglia in cases of posterior interosseous nerve palsy.
our
The authors thank Professor Kiyoshi Kaneda, MD, Department of Orthopaedic Surgery, Hokkaido University, School of Medicine, Sapporo. Japan, and Professor Terry Light, MD, Department of Orthopaedics and Rehabilitation, Loyola University Medical Center, Maywood. Illinois.
REFERENCES 1. Derkash RS, Niebauer JJ. Entrapment of the posterior interosseous nerve by a fibrous band in the dorsal edge of the supinator muscle and erosion of a groove in the proximal radius. J HAND SURG 1981;6:524-6. 2. Spinner A, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and experimental review. Clin Orthop 1974;104:46-7, 3. El-Hadidi S, Burke FD. Posterior interosseous nerve syndrome caused by a bursa in the vicinity of the elbow. J HAND SURG 1987;12B:23-4. 4. Holst-Nielsen F, Jensen V. Tardy posterior interosseous nerve palsy as a result of an unreduced radial head dislocation in Monteggia fractures: a report of two cases. J HAND SURG 1984;9A:572-5. 5. White SH, Goodfellow JW. Posterior interosseous nerve palsy in rheumatoid arthritis. J Bone Joint Surg 1988; 70B:468-71. 6. Takano A. A case of radial nerve palsy due to ganglion. J Jpn Orthop Assoc 1958;52:100-3. 7. Miyagi T, Miyagi D. Simple ganglion at the elbow joint causing radial palsy. Report of a case. Kurume Med J 1959;22:1665-7.
Vol. 16A, No.2 March 1991
8. Azuma T. A case of radial nerve palsy due to joint ganglion . Geka 1965;27:102-4. 9. Bowen TL, Stone KH. Posterior interosseous nerve paralysis caused by a ganglion at the elbow. J Bone Joint Surg 1966;48B:774-6. 10. Yamahiro K. Two cases of incomplete radial nerve palsy due to ganglion at the elbow. Seikeigeka 1966;17: 743-9. II. Matsuzaki A, Mitsuyasu M. Six cases of posterior interosseous nerve palsy. Seikeigeka to Saigaigeka 1971; 20:34-6. 12. Nagamine T. Imabayashi M. Morinaga H, Baba N. A case of paralysis of radial nerve caused by elbow jointganglion. Seikeigeka to Saigaig eka 1973;22:102-4. 13. Inoue K, Furukawa K. Honnda K.• et al. Paralysis of the deep branch of the radial nerve due to ganglion at the elbow. Seikeigeka 1975;26:43-8. 14. Machida M. Shibata K, Hasue K, Satou M. Mineshima T. Two cases of radial nerve palsy due to ganglion at the elbow . Rinsho Seikei Geka 1978;13:870-2.
Diagnosis of radial nerve palsy caused by ganglion
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