Posterior interosseous nerve syndrome

Definition/Description

Posterior interosseous nerve syndrome is a neuropathic compression of the posterior interosseous nerve where it passes through the radial tunnel.[1] This may result in paresis or paralysis of the digital and thumb extensor muscles, resulting in an inability to extend the thumb and fingers at their metacarpophalangeal joints. The only movement patients may be able to do is the dorsoradial direction.[2]

Radial nerve.jpg

Clinically relevant anatomy

The posterior interosseous nerve is located close to shaft of the humerus and the elbow. This nerve is the deep motor branch of the radial nerve. Proximal to the supinator arch, the radial nerve is divided into a superficial branch and posterior interosseous branch.The radial nerve supplies the majority of the forearm and hand extensors. Damage to this branch of the radial nerve results in posterior interosseous nerve syndrome.


The radial tunnel is a space that extends 5cm from the radial head to the distal margin of the supinator. This tunnel is attached laterally to the brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevis and medially to the biceps tendon and brachialis. The floor is formed by the deep head of the supinator and the capsule of the radiocapitellar joint, while the roof is formed by the superficial head of the supinator and the radial recurrent vessels.[3]


At the level of the lateral epicondyle, between the brachioradialis and brachialis muscles, the radial nerve, which has its origin in the brachial plexus, divides into its 2 terminal branches: the superficial radial nerve and the posterior interosseous nerve.[4] The superficial radial nerve ends proximal to the radial tunnel. The posterior interosseous nerve is much longer and enters the radial tunnel underneath a musculotendinous arch, the arcade of Frohse. The arcade of Frohse, which is the most common point of compression, is a connection between the deep and superficial heads of the supinator and is fibrotendinous in 30% of the population. The posterior interosseous nerve continues in the radial tunnel through the supinator, as it goes from the anterior to the posterior surface of the forearm.

The posterior interosseous nerve is a motor nerve and sequentially innervates supinator, extensor carpi radialis brevis, extensor digitorum communis, extensor digiti minimi, extensor carpi ulnaris, abductor pollicis, extensor pollicis brevis, extensor pollicis longus, and extensor indicis.[3][5]

Epidemiology/Etiology

Epidemiology

Posterior interosseous nerve syndrome is more common in males, manual laborours and bodybuilders, with an incidence of 3 per 100 000.[6] With a humeral shaft fracture, there is a 12% chance of associated with radial nerve paralysis.[7]

Etiology

Posterior interosseous nerve syndrome can be caused by a traumatic injury, tumors, inflammation and an anatomic injury. With repeated pronation and supination a dynamic compression of the nerve in the proximal part of the forearm can be created.[8]

Posterior interosseous nerve syndrome usually develops spontaneously[1] and is caused by compression injuries to the upper extremity, mostly in the arcade of Frohse[9]. It is the area where the nerve enters the supinator muscle[10] and is the most common place for a compression of the nerve. However, it can also occur following trauma, such as a blow to the proximal dorsal region of the forearm. Impingement of the radial nerve results in posterior interosseous nerve syndrome.[7] Compression of the posterior interosseous nerve is associated with repetitive activities that involve wrist supination and pronation, with a component of wrist extension.[11]

Posterior interosseous nerve syndrome can be iatrogenic following reduction of radial fracture, transposition of the ulnar nerve or release of the extensor origin for lateral epicondylitis.[1] The causes of posterior interosseous nerve syndrome include intrinsic nerve abnormalities and extrinsic compression.[2]

Characteristics/Clinical presentation

Most nerve entrapments occurs due to an osseoligamentous tunnel narrowing. In the case of a posterior interosseous nerve entrapment, the compression occurs within the musculo-tendinous radial tunnel. In 69.4%, the nerve is compressed by the fibrous arcade of Frohse.[12]


There is a very slow development of the symptoms. The duration of symptoms averaged 2-3 years before a definitive diagnosis could be made.[8] Symptoms of nerve entrapment syndromes are generally involving pain, sensory and motor changes, sensations of popping, paresthesias, and paresis.


Posterior interosseous nerve syndrome is characterized by motor deficits in the distribution of the posterior interosseous nerve.[12] While the posterior interosseous nerve does have afferent fibres that transmit pain signals from the wrist, it does not carry any cutaneous sensory information that can help distinguish a posterior interosseous nerve palsy from cervical radiculopathy.The clinical presentation of posterior interosseous nerve syndrome is characterized by the loss of function due to variable degrees of weakness involving ulnar deviation.

Differential diagnosis

Posterior interosseous nerve syndrome is one of the pathologies that can cause lateral elbow pain. The other pathologies that are associated with lateral elbow pain are:

  • Pigmented villonodular synovitis[1]
  • Lateral epicondylitis[4]
  • Radial nerve injury/palsy[4]
  • Cervical radiculopathy[4]
  • Extensor carpi radialis brevis tendinosis[5]
  • Cervical spine C5-C7[5]
  • Extensor tendon rupture[13]
  • Trigger finger
  • Sagittal band ruptures
  • Inflammatory involvement of the metacarpalphalangeal joints
  • Anconeus muscle tendonitis[14]
  • Supinator syndrome[14]
  • Brachialis neuritis[14]
  • Artirits/artrose of the radiohumeral joint
  • Meniscus of the radiohumeral joint
  • Olecranon bursitis
  • Neuralgic amyotrophy
  • Rupture of the intermetacarpal space[13]

Diagnostic procedures

Careful clinical and electrophysiological examination is important and essential for a reliable diagnosis.[10]

Physical examination

  • History
  • Functional limitations or deficits
  • Palpation: Abnormal tenderness is expected over the arcade of Frohse and eventually over the lateral epicondyle
  • Neural tension test
  • Muscle testing (with resistance):[3][15] There a partial or complete paralysis of the wrist extensors:
    • The patient is unable to extend the thumb and other fingers of the affected side at the metacarpophalangeal joints
    • Wrist extension is possible, but only with a dorso-radial direction, due to the weakened extensor carpi ulnaris
    • Resisted supination and pronation of the forearm can produce pain, as well as resisted extension of the middle finger
    • The brachioradialis, extensor carpi radialis longus and extensor capri radialis brevis are innervated by more proximal branches of the radial nerve, so may be spared

Special investigations

The following special investigations are used to assist in making the diagnosis.[1] It further aids to establish the topography of the lesion and the severity of the muscular denervation.[10]

  • Electromyography: Identify level of compression
  • Nerve conduction velocity
  • MRI: Not commonly used:
    • To determine specific area of compression
    • Assist in surgical planning

Outcome measures

Medical management

There are several medical ways to treat the posterior interosseous nerve syndrome.

Conservative management

  • Reduction of local inflammation and swelling around the nerve:[16]
    • Wrist and/or elbow splints
      • The arm can be put in an above-elbow cast for ten days with the elbow flexed at 90°, the forearm supinated and the wrist in neutral position[17]
    • NSAID’s
    • Activity modification to reduce local inflammation and swelling around the nerve
  • Corticosteroid injections[17]
  • Therapeutic ultrasound[17]
  • Physiotherapy[17]
  • Reduction of synovitis:[18]
    • Heat
    • Rest
    • Mild range of motion

Surgery

  • Indication:
    • No improvement with conservative management
    • Pain present after 12 weeks
  • Aim: To obtain full recovery
  • Surgery: Depends on how and where impingement is present[18][19]
    • Arcade of Frohse release
    • Resection of lesions
    • Posterior interosseous nerve release

Physiotherapy management

Conservative management

3-6 months of physiotherapy with regular re-assessment of signs and symptoms is recommended. If there is no response to therapy, evidence of denervation, or persistent paralysis, surgical decompression should be considered.[12]

Physiotherapy should include a multimodal approach. The following can be considered based on the patient presentation:

Post-surgical rehabilitation

  • Commence active range of motion from day 3-5
    • Incorporate stretching of extensors
  • Commence strengthening from week 3-4

Patients can return to light duty work between week 2 and 3 post-operatively, while return to baseline function can take between 6 and 12 weeks.

[21]

Clinical bottom line

The posterior interosseous nerve is the deep branch stemming off the radial nerve. Compression can be caused by trauma, repetitive strain and inflammation. This is then known as posterior interosseous nerve syndrome, which may result in paresis or paralysis of the digital and thumb extensor muscles, resulting in an inability to extend the thumb and fingers at their metacarpophalangeal joints. Conservative management includes splinting, NSAID's and physiotherapy, and symptoms normally resolve within 3-6 months. Failed conservative management is an indication for surgery, where nerve releases are the most common surgical intervention. Physiotherapy also plays a big part in the post-operative management, and rehabilitation generally lasts between 6 and 12 weeks.

References

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  2. 2.0 2.1 Chien AJ, Jamadar DA, Jacobson JA, Hayes CW, Louis DS. Sonography and MR imaging of posterior interosseous nerve syndrome with surgical correlation. American Journal of Roentgenology 2003;181(1):219-21.
  3. 3.0 3.1 3.2 Cha J, York B, Tawfik J. Posterior interosseous nerve compression. Eplasty 2014;14.
  4. 4.0 4.1 4.2 4.3 Bevelaqua AC, Hayter CL, Feinberg JH, Rodeo SA. Posterior interosseous neuropathy: electrodiagnostic evaluation. HSS Journal 2012;8(2):184-9.
  5. 5.0 5.1 5.2 Ekstrom RA, Holden K. Examination of and intervention for a patient with chronic lateral elbow pain with signs of nerve entrapment. Physical therapy 2002;82(11):1077-86.
  6. Ortho Bullets. PIN Compression Syndrome. Available from: https://www.orthobullets.com/hand/6023/pin-compression-syndrome (accessed 30/01/2019).
  7. 7.0 7.1 7.2 Quignon R, Marteau E, Penaud A, Corcia P, Laulan J. Posterior interosseous nerve palsy. A series of 18 cases and literature review. Chirurgie de la Main 2012;31(1):18-23.
  8. 8.0 8.1 Molina AP, Bour C, Oberlin C, Nzeusseu A, Vanwijck R. The posterior interosseous nerve and the radial tunnel syndrome: an anatomical study. International orthopaedics 1998;22(2):102-6.
  9. Andreisek G, Crook DW, Burg D, Marincek B, Weishaupt D. Peripheral neuropathies of the median, radial, and ulnar nerves: MR imaging features. Radiographics 2006;26(5):1267-87.
  10. 10.0 10.1 10.2 Huisstede BM, Miedema HS, Van Opstal T, De Ronde MT, Kuiper JI, Verhaar JA, Koes BW. Interventions for treating the posterior interosseus nerve syndrome: a systematic review of observational studies. Journal of the Peripheral Nervous System 2006;11(2):101-10.
  11. Rosenbaum R. Disputed radial tunnel syndrome. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine 1999;22(7):960-7.
  12. 12.0 12.1 12.2 12.3 Saratsiotis J, Myriokefalitakis E. Diagnosis and treatment of posterior interosseous nerve syndrome using soft tissue manipulation therapy: A case study. Journal of bodywork and movement therapies 2010;14(4):397-402.
  13. 13.0 13.1 Millender LH, Nalebuff EA, Holdsworth DE. Posterior interosseous-nerve syndrome secondary to rheumatoid synovitis. JBJS 1973;55(4):753-7.
  14. 14.0 14.1 14.2 Kaswan S, Deigni O, Tadisina KK, Totten M, Kraemer BA. Radial tunnel syndrome complicated by lateral epicondylitis in a middle-aged female. Eplasty 2014;14.
  15. Singh VA, Michael RE, Dinh DB, Bloom S, Cooper M. Posterior interosseous nerve syndrome from thermal injury. Case reports in surgery 2014;2014.
  16. Mansuripur PK, Deren ME, Kamal RO. Nerve compression syndromes of the upper extremity: diagnosis, treatment, and rehabilitation. Rhode Island Medical Journal 2013;96(5):37-9.
  17. 17.0 17.1 17.2 17.3 Maffulli N, Maffulli F. Transient entrapment neuropathy of the posterior interosseous nerve in violin players. Journal of Neurology, Neurosurgery & Psychiatry 1991;54(1):65-7.
  18. 18.0 18.1 Chang LW, Gowans JD, Granger CV, Millender LH. Entrapment neuropathy of the posterior interosseous nerve. A complication of rheumatoid arthritis. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology 1972;15(4):350-2.
  19. Hashizume H, Nishida K, Nanba Y, Shigeyama Y, Inoue H, Morito Y. Non-traumatic paralysis of the posterior interosseous nerve. The Journal of bone and joint surgery. British volume 1996;78(5):771-6.
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