Download posterior interosseous nerve paralysis caused by a ganglion at the

POSTERIOR
INTEROSSEOUS
CAUSED
BY
T. LLEWELLYN
From
the
Compression
of
A GANGLION
and
BOWEN
Barnet
Royal
General
National
NERVE
K.
and
the
ENGLAND
of Orthopaedics,
London
simple
ELBOW
LONDON,
Institute
Hospital,
by
nerves
THE
H. STONE,
Hospital
Orthopaedic
peripheral
AT
PARALYSIS
and
ganglia
Stanmore
is well
recognised.
In a review
of
thirteen
cases Brooks
(1952) described
compression
of the ulnar
nerve at the elbow
and wrist,
the median
nerve at the wrist, and the lateral
popliteal
and tibial nerves.
Other
cases have been
reported
by Seddon
(1952),
Mar#{243}ttoli and Didier
(1953)
and by Mallett
and Zilkha
(1955).
Hustead,
Mulder
and MacCarty(1958)
reviewed
sixteen cases ofnon-traumatic,
progressive
paralysis
of the posterior
interosseous
nerve
and added
two more.
Exploration
was carried
out
in seven
two and
described
cases
; the
an anomalous
compression
lesion
was
found
course
ofthe
of peripheral
to be a benign
nerve in one.
Barber,
nerves
by soft-tissue
tumour
in four,
Bianco,
tumours.
Soule and MacCarty
They listed
nine
diseased
bursae
in
(1962)
cases of
radial
nerve
palsy (though
not mentioning
the posterior
interosseous
nerve)
but none of these
was caused
by a ganglion.
Posterior
interosseous
palsy may also be caused
by compression
of
the nerve
at the neck of the radius
by a parosteal
lipoma
(Richmond
1953, Campbell
and
Wulf
1954,
Moon
and
the
nerve and Goldsztajn
In our case a cystic
the
posterior
interosseous
Marmor
1964).
Whiteley
and
(1960)
found
no abnormality
lesion in the substance
ofthe
nerve.
This
appearances
of a simple
ganglion,
case has been found
in the literature.
may
lesion,
have
of the left elbow
showing
with
CASE
A man of fifty-seven
of his left hand.
He had
774
complained
first noticed
had
from
described
a neuroma
of
one case he explored.
muscle
was found,
compressing
the
macroscopic
an osteoarthritic
and
elbow.
microscopic
No
similar
1
an old ununited
degenerative
(1959)
in the
supinator
which
arisen
FIG.
Radiographs
Alpers
change
intercondylar
in the
fracture
of the humerus
joint.
REPORT
of weakness
this twelve
of grip and inability
to extend
the fingers
days before
when he had been cutting
tiles.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
T. L.
Two
days
of old
before
injury
coming
to the
to hospital
left
elbow
when
BOWEN
AND
K.
he had
fallen,
he was
eight
H.
775
STONE
injuring
years
the
left
wrist.
On examination
there
were 30 degrees
of valgus
of the elbow.
extension
was limited
by 45 degrees;
pronation
was full but supination
was bruising
and oedema
over the dorsum
of the wrist.
Sensation
was
muscles
of the
weak,
but there
fingers
were completely
was no other
weakness.
central
system
nervous
showed
humerus
and
an old ununited
with marked
Radiographs
of
the weakness
and localised
interosseous
wrist
Operation-The
posterior
a vertical
was
absent.
The
full
but
There
extensor
was
negative.
Radiographs
of the elbow
fracture
of the
change
(Fig.
1).
showed
a
small
flake
interosseous
incision
nerve
was
in the upper
half
forearm.
Through
the interval
between
the
digitorum
communis
and
extensor
digiti
muscles
the nerve
was found
at the lower
.
.
cystic
metres)
.
swelling
one
and
in length.
This
deep
parts
of
a half inches
(375
cent!lay between
the superficial
the
muscle,
as far
as the
bicipital
(Fig.
2).
The nerve
was
muscles
Progress-The
the
Flexion
was
normal.
the radial
extensors
of the wrist were
felt.
There
was no abnormality
of the
border
ofthe
supinator
muscle
and its branches
were
identified.
The superficial
part of the supinator
was
.
.
.
.
.
Inclsed
in the line of its fibres.
The nerve was found
to be flattened
and splayed
out over a well defined
and
a history
during
the next two weeks
was found
over the posterior
explored
of the
extensor
minimi
and
was
reaction
was
of the lower
end of the radius.
weakness
was ascribed
to local
tendons
at the wrist.
However,
increased
tenderness
nerve.
through
the Wassermann
intercondylar
degenerative
the
fracture
of the back
At first the extensor
trauma
to the extensor
paralysed
No lump
There
old.
next
six months
now regards
his left
Histo/ogy-Histological
of flattened
cells
extending
tuberosity
dissected
supplied
.
and
reached
muscle,
hand
as normal.
examination
the
was
then
elbow
The
Research
Council
lesion
appearances
with
were
posterior
over
interosseous
it.
excised.
nerve
a cystic
These
2
nerve stretched
interosseous
4 (Medical
showed
type.
with
.
medially
posterior
power
FIG.
ofposterioraspect
ofleft
the findings
at operation.
superficial
part of the supinator
muscle
was divided and turned back. The swellingwas
seen lying on the deep part of the
.
of the radius
off the cyst, which
by the
of endothelial
.
Diagram
showing
recovered
slowly
during
The
patient
Grading).
a fibrous
considered
wall
and
a lining
to represent
a simple
ganglion.
DISCUSSION
The
was
origin
simple
arisen
detail
ganglion.
from
it.
nerve
that
evidence
he
quoted
VOL.
the
lesion appeared
patients
with
refused
the
could
noted
compressing
operation
postero-lateral
48 B,
NO.
(1952).
The elbow
Weinberger
and
This
two
is still
by Brooks
interosseous
In
of ganglia
discussed
disputed
and
In the
case
be compressed
nerve
a case
close
of Agnew
nerve
his opinion
4, NOVEMBER
here
by bursae
passed
anteriorly
was
of the
1966
to
(1863)
and
to communicate
with
posterior
interosseous
aspect
context
was the seat of degenerative
(1939)
reviewed
the literature
the
median
in the
recorded
arthritis
and
the
elbow.
He
compression
appeared
to be a
ganglion
may have
that the posterior
discussed
and
a bursal
posterior
nerve
lesion
and the
suggested
interosseous
in which
the
cystic
anatomy
bicipito-radial
tumour
interosseous
was
in
bursae.
found
nerve
to be
posteriorly.
the bicipito-radial
bursa.
Weinberger
also described
palsy
and tenderness
over the bursae,
but as both
unconfirmed.
radial
near
the
of peripheral
the
neck
In our
well
away
patient
from
the cystic
the
usual
site
lesion
was
of bursae.
found
on
776
HARRY
Nerve
nerves.
compression
by simple
Compression
1963).
The
neck
is
course
of the
radius
It is therefore
is most
common
a nerve
passes
interosseous
resembles
of the
reasonable
VOLUME
where
of the posterior
that
BIRTHDAY
ganglia
likely
most
PLATT
to expect
nerve
lateral
a similar
in the
ulnar
through
through
popliteal
lateral
round
of the
popliteal
space
the supinator
nerve
compression
and
a confined
muscle
the
neck
posterior
(Brooks
round
of the
interosseous
the
fibula.
nerve.
The frequent
movements
of pronation
and supination
may compress
or irritate
the nerve
further.
Valgus
or varus
at the elbow
could
increase
distortion
of the nerve.
In our patient
nerve compression
was caused
by a cystic
lesion.
This may have been a
simple
ganglion,
a ganglion
arising
from
an osteoarthritic
joint,
or an enlarged
bursa.
The
appearances
at operation
and
the
histological
evidence
suggest
a simple
ganglion.
SUMMARY
1 . A case of posterior
interosseous
nerve
palsy
from
what appeared
to be a simple
ganglion
is described.
2.
Surgical
3.
4.
The course
of the nerve
Rotation
of the forearm,
decompression
led to an effective
the
compresssion.
through
especially
Director
of Pathology,
We are indebted
Barnet
General
compression.
deformity
Mr H. Jackson
For histological
Hospital,
to Mr R. J. Whitley
and the staff
for help with the photography.
of Orthopaedics
in the
supinator
muscle
by
cure.
this muscle
invites
with super-added
We are grateful
to Professor
Sir Herbert
Seddon,
interest and advice in the preparation
of this paper.
Welch,
compression
and
Dr
of the
Burrows
examination
P. D.
of the Medical
Byers
limb,
may
increase
and Mr Donal
we are grateful
Brooks
for their
to Dr Ronald
F.
of the
of
Photographic
Institute
Department
Orthopaedics.
of the
Institute
REFERENCES
D. H. (1863)
AGNEW,
Society
: Bursal
ofPhiladelphia,
K. W., Jun.,
Soft-Tissue
Tumors
Producing
Journal
Loss
of the
A. J., Jun., SOULE,
of the Extremities
Causing
BIANCO,
BARBER,
44-A,
Tumour
America,z
of Power
Medical
of the Forearm.
46, 404.
Transactions
ofthe
C. S. (1962):
Benign
Pathological
Sciences,
E. H., and
Compression
MACCARTY,
of Nerves.
Journal
ofBone
Extraneural
andJoint
Surgery,
98.
D. M. (1952):
Nerve Compression
by Simple Ganglia.
A Review of Thirteen
Collected
Cases.
Journal
34-B, 391.
BROOKS,
D. M. (1963):
Nerve Compression
Syndromes.
Journal
ofBone
and Joint
Surgery,
45-B, 445.
CAMPBELL,
C. S., and WULF, R. F. (1954): Lipoma
Producing
a Lesion of the Deep Branch
of the Radial Nerve.
Journal
of Neurosurgery,
I I , 310.
BROOKS,
ofBone
GOLDSZTAJN,
and
Deep
MALLEn’,
Surgery,
M. (1960) : Nieurazowe
uszkodzenie
Polska,
10, 397.
A. P., MULDER,
D. W., and MACCARTY,
chirurgia
HUSTEAD,
Joint
nerwu
promieniowego
glebokiego.
Neurologia,
Neuro-
i Psychiatria
Radial
(Posterior
B. L., and ZILKHA,
Interosseous)
K. J. (1955):
C. S. (1958) : Nontraumatic,
Progressive
Paralysis
Nerve.
Archives
of Neurology
and Psychiatry,
79, 269.
Compression
ofthe
Ulnar Nerve at the Wrist by a Ganglion.
of the
Lancet,
i, 890.
MAR#{243}rrou, 0. R., and DIDIER,
A. (1953) : Lesiones
nerviosas
en los quistes sinoviales.
Anales
de Cfrugia,
18, 49.
(1942) : War Memorandum
No. 7 ; Aids to the Investigation
of Peripheral
Nerve
Injuries.
London
: His Majesty’s
Stationery
Office.
MOON,
N., and MARMOR,
L. (1964) : Parosteal
Lipoma
of the Proximal
Part of the Radius.
Journal
of Bone
andJoint
Surgery, 46-A,
608.
RICHMOND,
D. A. (1953) : Lipoma
Causing
a Posterior
Interosseous
Nerve Lesion.
Journal
of Bone
and Joint
Surgery,
35-B, 83.
SEDDON,
H. J. (1952): Carpal Ganglion
as a Cause of Paralysis
of the Deep Branch
of the Ulnar Nerve.
Journal
ofBone
andJoint
Surgery, 34-B,
386.
WEINBERGER,
L. M. (1939) : Non-Traumatic
Paralysis
of the Dorsal
Interosseous
Nerve.
Surgery,
Gynecology
and Obstetrics,
69, 358.
WHITELEY,
W. Ft., and ALPERS,
B. J. (1959):
Posterior
Interosseous
Palsy with Spontaneous
Neuroma
Formation.
Archives
of Neurology,
I, 226.
MEDICAL
RESEARCH
COUNCIL
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY