pophalangeal joints in flexion
Nonsurgical management of posterior interosseous syndrome includes rest, splinting, and activity modifications. Oral antiinflammatory agents may be helpful, primarily for pain relief. Corticosteroid injections generally have minimal benefit because the neuropathology is compression, not active synovitis.
Job or avocation changes may be of some benefit. Appropriate splintage should be provided if muscle paralysis is present. It is extremely important to emphasize full passive range-of-motion exercises to the involved joints in cases of muscle paralysis to prevent contracture. Patients with acute motor weakness without evidence of a mass may demonstrate spontaneous recovery.
Indications for surgical management include clinical or electrophysiologic denerva-tion without change or improvement over 60 to 90 days. Patients with a confirmed mass compressing the radial tunnel should be considered primarily for surgical management. A symptomatic radial tunnel that progresses to extensor motor paralysis is an indication for operative decompression.
The radial tunnel may be decompressed through one of three approaches— brachioradialis-splitting, anterior, and dorsal—which have all been described to release the radial tunnel. The brachioradialis-splitting approach provides excellent exposure to the entire radial tunnel and is easy to perform. The dorsal approach may be utilized particularly when a mass is present involving primarily the supinator muscle.
A 6-cm curved or straight incision is made over the mobile wad starting at the level of the cubital fossa and extending distally. Dissection is bluntly taken down to the fascia to protect the cutaneous nerves. The brachioradialis is then bluntly split, aiming toward the radial head. Blunt dissection and retraction with a blunt retractor reveal the radial nerve within a fibrofatty layer. Dissection proximally demonstrates the radial nerve as it divides into the posterior interosseous and the sensory nerve branches. The fibrous bands are released over the radial nerve. Bipolar electrocautery is necessary to release the leash of recurrent radial vessels. The posterior interosseous nerve is then traced as it passes under the proximal edge of the extensor carpi radialis brevis. Occasionally, the nerve gives off motor branches to the muscle at this location, and these need to be protected. The proximal edge of the supinator (Arcade of Frohse) is then identified. Care must be taken to identify the proximal edge of both the extensor carpi radialis brevis and the supinator. It is easy to release only the extensor carpi radialis brevis, thinking this was the supinator. The supinator should be released throughout its entire length in posterior interosseous syndrome. Meticulous hemostasis is mandatory before closure.
The posterior approach is useful when a mass is present in the supinator causing muscle paralysis, as more distal decompression of the nerve is easier from this
Figure 17—3. Photograph of the lipoma following excision.
approach. A 6-cm incision is made over the dorsal proximal forearm parallel with an imaginary line extending from the lateral epicondyle to Lister's tubercle. The interval between the extensor carpi radialis brevis and extensor digitorum communis is developed. This interval is easier to develop distally than proximally. The posterior interosseous nerve is identified as it exits distally through the supinator and is traced proximally (Figs. 17-2 and 17-3).
The anterior approach leaves a large unsightly scar. Although identification of the radial nerve is easy proximally through this approach, it becomes more difficult to fully release the posterior interosseous nerve distally. Care must be taken not to injure the lateral antebrachial cutaneous nerve. This approach is rarely used for radial tunnel decompression.
Postoperatively, the wrist and elbow are supported in a sugar-tong-type splint for 1 week. The patient is then placed in a wrist support splint and range-of-motion exercises are initiated. Resistive exercises are started at 6 weeks and are progressed.
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Fardin P, Negrin P, Sparta S, et al. Posterior interosseous nerve neuropathy—clinical and electromyographical aspects. Electromyogr Clin Neurophysiol 1992;32:229-234.
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