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Hand Surgery, Vol. 19, No. 3 (2014) 405–408 © World Scientific Publishing Company DOI: 10.1142/S0218810414720253

CASE REPORTS TARDY POSTERIOR INTEROSSEOUS NERVE PALSY FOLLOWING TOTAL ELBOW ARTHROPLASTY: REPORT OF A CASE, LITERATURE REVIEW AND A CLASSIFICATION SYSTEM Numaera Sabir, Mahvash Zaman, Tariq A. Kwaees and Charalambos P. Charalambous Department of Trauma and Orthopaedics Blackpool Victoria Hospital, Blackpool, UK Institute of Inflammation and Repair The University of Manchester, Manchester, UK Received 29 October 2013; Revised 21 February 2014; Accepted 25 February 2014; Published 1 October 2014 ABSTRACT We present an unusual case of tardy posterior interosseous nerve palsy in a female patient following total elbow arthroplasty for rheumatoid arthritis. The patient was neurologically intact immediately following surgery but developed loss of active finger and thumb extension within 12 hours following surgery. Expectant management was adapted. The palsy recovered fully without the need of surgical intervention. A literature review is presented and a classification system proposed. Keywords: Tardy Posterior Interosseous Nerve Palsy; Posterior Interosseous Nerve; Elbow Arthroplasty.

INTRODUCTION

was examined by the surgical team and was found to be neurologically intact, with intact finger and wrist extension and intact sensation. On examination the following morning, attempted wrist extension was weak but produced radial deviation. The patient had also developed loss of finger extension at the metacarpophalangeal joint and thumb extension. Sensation was intact. The plaster was removed. The postero-lateral aspect of the elbow was found to be swollen and tender. There was no evidence of compartment syndrome (no pain out of proportion, no pain on stretching the forearm muscles). Plain radiographs showed the implants to be in a satisfactory position (Fig. 1). The neurological deficit found was consistent with TPINP. The TPINP was considered to be secondary to neuropraxia as a

Tardy posterior interosseous nerve palsy (TPINP) is a rare event. We present a case of TPINP presenting soon after total elbow arthroplasty (TEA). A literature review of this condition is presented and a classification system proposed.

CASE A 45-year-old female underwent a left cemented TEA (Biomet, Bridgend, UK) for sero-positive rheumatoid arthritis. The procedure was uneventful. A posterior triceps reflecting approach was utilised and the radial head was excised. A deep drain was used, and the arm was placed in a light plaster backslab (dorsal half plaster). Immediately following surgery the patient

Correspondence to: Dr. Charalambos Charalambous, Department of Trauma and Orthopaedics, Blackpool Victoria Hospital, Whinney Heys Road, Blackpool, Lancashire, FY3 8NR, UK. E-mail: [email protected] 405

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Fig. 1 Plain radiographs of a left total elbow arthroplasty, with satisfactory implant positioning.

result of bleeding and oedema around the supinator area. A light plaster backslab (dorsal half plaster) was applied for two weeks and passive elbow extension was commenced. A watch and wait policy was adapted, and the patient recovered fully without surgical intervention after six weeks.

DISCUSSION The posterior interosseous nerve (PIN) arises from spinal segments C7, C8 and is predominantly a motor branch of the radial nerve. It enters the arcade of Frohse formed from the superficial head of the supinator.1 At the distal portion of supinator, the PIN divides into a recurrent branch (innervating extensor digitorum communis, extensor digiti minimi, and extensor carpi ulnaris) and a descending branch (innervating abductor policis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis proprius).2 PIN palsy is seen in chronic conditions such as chronic rheumatoid arthritis, where nerve compression is often due to an anterior synovial bulge that traps the PIN between this synovium and the arcade of Frohse.3–6 TPINP describes posterior interosseous nerve palsy occurring following a lag after an initiating cause. Such delayed nerve dysfunction may be due to; compression of the nerve by soft tissue edema, hematoma, scar tissue or ganglion formation, or may be due to repetitive nerve friction, or nerve stretching. PIN palsy occurring as a result of further insult such as further displacement of a fracture, implant displacement or loosening, or foreign body migration cannot be described as true TPINP.7,8 PIN palsy due

to compartment syndrome is also a separate entity, but one to be considered in dealing with such cases. PIN palsy may occur in TEA as a result of traction or compression by retractors placed around the radial head, as a result of laceration of the nerve by sharp dissection or due to nerve compression by post-operative soft tissue edema or hematoma. The first two causes would elicit PIN palsy immediately following surgery whereas the latter may cause TPINP. To the best of our knowledge, this is the first case reporting TPINP following TEA. Our patient was fully neurologically intact after surgery with functioning PIN, hence iatrogenic injury was not the case in this patient. PIN palsy occurred within a day of surgery and hence it was likely to be due to a haematoma or soft tissue oedema. The absence of disproportionate pain, pain on stretching the forearm muscles and any other neurological deficit made it unlikely that compartment syndrome was present. It is recommended that if tardy sciatic nerve palsy develops after total hip arthroplasty, urgent exploration and decompression of the nerve should be performed to avoid permanent damage.9 We feel that such an approach may not be essential for the PIN, as unlike the case of the sciatic nerve, a large dead space is not available for massive haematoma formation. In addition the motor units innervated by the PIN are closer to the site of potential nerve compromise as compared to those innervated by the sciatic nerve, which may also facilitate recovery in the former. If there is however a suspicion of compartment syndrome then acute decompression should be performed. Baseline electromyogram (EMG) and nerve conduction studies may be performed at two to four weeks following the insult and then again at three months. However, these tests were not deemed necessary in this case as recovery was seen within six weeks. A review of the literature identifies several causes of TPINP, occurring from within a few hours to several years following the initiating event.10–19 These are summarized in Table 1. Based on the published literature a classification system has been developed by the senior author for TPINP (Charalambous CP Classification; Table 2) taking into account the potential causes of tardy PIN palsy in relation to the timing at which it occurs. This classifies TPINP according to the timing of occurrence: type 1 occurring within 72 hours of the initiating event, and usually attributed to acute inflammation, edema, or hematoma formation; and type 2 occurring at > 72 hours and attributed to compression by chronic fibrosis, ganglia cysts,

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Tardy Posterior Interosseous Nerve Palsy Following Total Elbow Arthroplasty

Table 1

Published Reports of Tardy Posterior Interosseous Nerve Palsy.

Age/Sex at Presentation

Author Lal et al.13

40/M

Daurka et al.10

55/M

Cho et al.11

46/F

Gill et al.19

Cause Fracture of radius and ulna shaft, treated by plating Mason type III radial head fracture

TPINP Onset

Management and Outcome

19 years

Removal of plate and tendon transfer to regain power Supinator release and neurolysis, recovery to normal at six weeks Radial head excision, complete functional recovery at eight months Release of arcade of Froshe, excision of heterotopic ossification, significant improvement at three months Supinator release, complete functional recovery at four months Nerve released from scar tissue, full recovery at one year Radial head excision and release of arcade of Froshe, complete functional recovery Radial head excision, extensor pollicis longus and wrist dorsiflexors grade 4 and finger extensors grade 3 at 9 months Radial head excision, almost complete recovery at 74 days Radial and PIN mobilized to lie more medially. Recovery at one year but slight weakness of thumb extension and abduction Radial head excision, complete functional recovery at one year

36 hours

57/M

Anterior dislocation of the radial head in a Monteggia fracture Repair of distal biceps tendon rupture

7 months

Spinner et al.14

28/F

Childhood osteomyelitis of proximal radius

24 years

Katzman et al.18

51/M

Repair of distal biceps tendon rupture

4 months

Hashizume et al.12

44/F

39 years

Austin et al.16

73/M

Anterior dislocation of the radial head in a Monteggia fracture Monteggia fracture with radial head dislocation

65 years

Lichter et al.15

46/M

Monteggia fracture with radial head dislocation

39 years

Sharrard WJ20

39/M

Supracondylar humeral fracture united in 30  varus

32 years

Adams et al.17

50/M

Elbow fracture with radial head subluxation and hypertrophy

47 years

Table 2 Charalambous CP’s Classification of Tardy Posterior Interosseous Nerve Palsy.

Type 1 2

Symptom Onset Relative to Insult < 72 hours > 72 hours

407

Potential Cause Soft tissue edema, hematoma Compression (chronic fibrosis, ganglia), repetitive nerve friction, nerve traction

repetitive nerve friction, or nerve stretching. Our case suggests that type 1 lesions may be managed expectantly, while a review of the literature suggests that type 2 lesions require surgery to decompress the PIN. It is of interest that Daurka et al.10 reported a case of tardy PIN palsy occurring at 36 hours post a Mason type III radial head fracture, which was treated with supinator release and neurolysis, recovering to normal by six weeks. However the time given for potential spontaneous recovery was less in that case as compared to ours, hence it is

40 years

difficult to postulate whether their outcome would have been different had more time been allowed. The cut point of 72 hours used in the proposed Charalambous classification is based on the usual duration of the inflammatory response seen following a soft tissue insult and the fact that most soft tissue oedema and swelling may occur within such a time frame.21

References 1. Sinnatamby CS, Lasts Anatomy, 12th ed., Churchill Livingstone/Elsevier Publishing, pp. 58–96, 2011. 2. Spinner M, The radial nerve, In Spinner M (ed.) Injuries to the Major Branches of the Peripheral Nerves of the Forearm, WB Saunders, Philadelphia, pp. 80–157, 1978. 3. Ogawa H, Akaike A, Ishimaru D, Yamada K, Shimizu T, Koyama Y, Hori H, Posterior interosseous nerve palsy related to rheumatoid synovitis of the elbow, Mod Rheumatol 17(4):327–329, 2007. 4. Fernandez AM, Tiku ML, Posterior interosseous nerve entrapment in rheumatoid arthritis, Semin Arthritis Rheum 24:57–60, 1994.

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5. 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 24:727–731, 1999. 6. Chan JKK, Kennett R, Smith G, Posterior interosseous nerve palsy in rheumatoid arthritis: case report and literature review, Plast Reconstr Aesthet Surg 62(12):556–560, 2009. 7. Butler MA, Holt GE, Crosby SN, Weikert DR, Late posterior interosseous nerve palsy associated with loosening of radial head implant, J Shoulder Elbow Surg 18(6):e17–e21, 2009. 8. Sharma R, Dimri RK, Dias J, Delayed posterior interosseous nerve palsy. An unusual presentation of a forgotten glass injury, J Hand Surg 23 (3):418–419, 1998. 9. Butt AJ, McCarthy T, Kelly IP, Glynn T, McCoy G, Sciatic nerve palsy secondary to postoperative haematoma in primary total hip replacement, J Bone Joint Surg Br 87(11):1465–1467, 2005. 10. Daurka J, Chen A, Akhtar K, Kamineni S, Tardy posterior interosseous nerve palsy associated with radial head fracture: a case report, Cases J 2 (1):22, 2009. 11. Cho CH, Lee KJ, Min BW, Tardy posterior interosseous nerve palsy resulting from residual dislocation of the radial head in a Monteggia fracture: a case report, J Med Case Reports 3:930, 2009. 12. Hashizume H, Nishida K, Yamamoto K, Hirooka T, Inoue H, Delayed posterior interosseous nerve palsy, J Hand Surg Br 20(5):655–657, 1995.

13. Lal H, Pankaj B, Khare R, Mittal D, Tardy palsy of descending branch of posterior interosseous nerve: sequela to plate osteosynthesis of forearm bones, J Hand Surg 35(2):274–276, 2010. 14. Spinner RJ, Spinner M, Tardy posterior interosseous nerve palsy due to childhood osteomyelitis: a case report, J Hand Surg 22(6):1049–1051, 1997. 15. Lichter RL, Jacobsen T, Tardy palsy of the posterior interosseous nerve with a Monteggia fracture, J Hand Surg 57(1):124–125, 1975. 16. Austin, R, Tardy palsy of the radial nerve from a Monteggia fracture, Injury 7(3):202–204, 1976. 17. Adams JR, Rizzoli HV, Tardy radial and ulnar nerve palsy, J Neurosurg 16:342, 1959. 18. Katzman BM, Caligiuri DA, Klein DM, Gorup JM, Delayed onset of posterior interosseous nerve palsy after distal biceps tendon repair, J Shoulder Elbow Surg 6(4):393–395, 1997. 19. Gill IR, Pearce SJ, Iossifidis A, A rare case of progressive and late onset posterior interosseous nerve palsy following distal biceps tendon repair, Injury Extra 37:244–246, 2006. 20. Sharrard WJ, Posterior interosseous neuritis, J Bone Joint Surg 48B:777–780, 1966. 21. Garrett WE, Jr Muscle strain injuries: clinical and basic aspects, Med Sci Sports Exerc 22:436–443, 1990.

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Tardy posterior interosseous nerve palsy following total elbow arthroplasty: report of a case, literature review and a classification system.

We present an unusual case of tardy posterior interosseous nerve palsy in a female patient following total elbow arthroplasty for rheumatoid arthritis...
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