Download RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.
Name of the Candidate
and Address
(in block letters)
2.
Name of the Institution
Dr. RAGHAVENDRA.D.R.
OM SRI ANUGRAHA,NEAR SRI
ANJANEYA TEMPLE,CHIKKANAHALLI
NEW EXTENSION,NITTUVALLI,
DAVANGERE – 577 004.
KARNATAKA.
J.J.M. MEDICAL COLLEGE,
DAVANGERE - 577 004.
3.
Course of study and subject
POST GRADUATE DEGREE
M.D. – ANATOMY
4.
Date of Admission to course
30-05-2012
5.
Title of the Topic
“STUDY OF RADIAL NERVE; ITS
COURSE AND BRANCHING PATTERN
IN THE AXILLA AND POSTERIOR
COMPARTMENT OF THE ARM”
6.
Brief Resume of the intended work :
6.1 Need for the study :
The radial nerve is the largest branch of the brachial plexus. It arises from
the posterior cord(ventral primary rami of C5,C6,C7,C8 and T1) and it is the
larger terminal branch of the posterior cord. It extends from the axilla to the
hand. It descends behind the third part of the axillary artery and the proximal
part of the brachial artery. It soon leaves the front of the arm in the interval
between the long and the medial heads of the triceps and enters a shallow
groove on the back of the humerus. In that groove it passes round the back of
the humerus, under cover of the lateral head of the triceps; and, on the lateral
side of the limb, it pierces the lateral intermuscular septum and passes in to the
anterior compartment of the arm.
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The radial nerve is particularly vulnerable to injury by compression at the
proximal arm due to its course along the proximal humerus.
Lesions of the radial nerve in the axilla may be caused by pressure from a
long crutch (crutch palsy).
A midhumeral fracture may injure the radial nerve in the radial groove in
the humeral shaft.
Exploring the course of the radial nerve in the arm and identifying
practical anatomic landmarks can be used to avoid iatrogenic injury during
humerus fracture fixation.
Hence the study of the radial nerve is undertaken, the results of this study
may be useful in evaluating the radial nerve injuries and their management for
Surgeons, Orthopedicians,Neurophysicians and Physiotherapists.
6.2 Review of literature :
Lesions of the radial nerve at its origin from the posterior cord in the
axilla may be caused by pressure from a long crutch (Crutch palsy). Triceps is
only involved when lesions occur at this level and is usually spared in the more
common lesions of the radial nerve in the arm as it lies alongside the spiral
groove,where the nerve is commonly affected by fractures of the humerus.
Compression of the nerve against the humerus occurs if the arm is rested on a
sharp edge such as the back of a chair (Saturday night palsy).1
The radial nerve is at risk during the posterior plating of the humerus.A
cadaver study was conducted approaching the humerus by a posterior midline
incision. The extent of dissection of the radial nerve necessary for plate fixation
of the humerus fracture was measured Plating required a dissection of the radial
nerve 1.78cm proximal and 2.13cm distal to the spiral groove. Transfracture
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anterior transposition of the radial nerve required an average dissection of 2.24
cm proximal and 2.68cm distal to the spiral groove. The lateral intermuscular
septum had to be released for 2.21cm on the distal fragment to maintain laxity
of the transposed nerve. Transfracture anterior transposition of the radial nerve
before plating is feasible.2
The study was conducted on 27 adult cadaveric specimens,there it was
observed that the radial nerve is at risk of injury with fractures of the humerus
and with subsequent operative fixation in 2 areas.
The first is along the
posterior midshaft region for a distance of 6.3cm ± 1.7 centered at the distal
aspect of the deltoid tuberosity. The second is along the lateral aspect of the
humerus in its distal third from 10.9cm ± 1.5 proximal to the lateral epicondyle
to the level of the proximal aspect of the metaphyseal flare.
The deltoid
tuberosity is a consistent and practical anatomic landmark that can be used to
determine the level of the radial nerve along the posterior aspect of the humerus
during operative fixation from an anterior approach.3
A cadaver dissection observed an abnormal origin of radial nerve as two
roots from the posterior cord. One root was passing posterior to the subscapular
artery and other root anterior and the artery was situated between the two roots
of the radial nerve. Further down both the roots united to form the trunk of the
radial nerve. This might have caused compression the subscapular artery.4
Radial nerve palsy affecting premature infants after long term application
of an arm cuff for the measurement of blood pressure has also been reported.
Placing the blood pressure cuff more superiorly on the arm, away from the
elbow joint to avoid the most superficial portion of the radial nerve may prevent
this type of compression injury. 5
There was a report of two cases of intraoperative radial nerve injury
during coronary artery surgery.
Although very uncommon, external
compression due to the use of a self retractor during coronary artery surgery can
3
affect-especially in obese subjects-the radial nerve within the spiral groove
leading to paresis and should therefore be included in the list of possible
mechanisms of radial nerve injury. 6
A case was reported of high radial nerve palsy in an elite bodybuilder
caused by an extrinsic mass effect of muscular hypertrophy. Surgical
decompression resulted in complete clinical resolution.7
A patient with a radial nerve palsy which persisted nine months after a
diaphyseal
fracture of the humerus was referred to our department.
Radiographs and ultrasound examination showed that the radial nerve was
transected and partially entrapped in the fracture callus. This double injury was
confirmed and was repaired during subsequent surgical treatment. We report
this rare case of combined primary and secondary nerve lesion.8
The radial nerve may accompany the axillary nerve through the
quadrilateral space. The radial nerve may communicate with the ulnar nerve in
the arm.9
6.3 Objectives of the study :
 To study the course of the radial nerve in the axilla and posterior
compartment of the arm.
 To study the branches of the radial nerve in the axilla and posterior
compartment of the arm.
7.
Material and Methods :
7.1 Source of data :
Specimens for the study are obtained from embalmed cadavers of either
sex from the Department of Anatomy, J.J.M.Medical College, Davangere and
embalmed fetuses from the Chigateri District Hospital and Women and
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Children Hospital ,Davangere.
Sample size : 50
7.2. Method of collection of data (including sampling procedure if any):
Methodology :
As per Cunnigham’s Manual of Practical Anatomy, the radial nerve is
dissected in the axilla and posterior compartment of the arm. The course and
branching pattern are observed and recorded. The specimens are numbered and
photographed.
7.3 Does the study require any investigations or interventions to be
conducted on patients or other humans or animals? If so, please describe
briefly.
No
7.4. Has ethical clearance been obtained from your institution in case
of 7.3?
Yes
5
8.
References :
1.
Standring
S.
Gray’s Anatomy. The Anatomical Basis of Clinical
Practice. 40th Ed., London: Churchill Livingstone; 2008. p. 829.
2.
Yakkanti MR,
RobertsCS, Murphy JBS, Acland RD.
Anterior
transposition of the radial nerve-Acadeveric study. Journal of Orthopedic
Trauma 2008; 22( 10) : 705-708.
3.
Carlan D, Pratt J, Patterson JMM, Weiland AJ, Boyer MI, Gelberman
RH. The radial nerve in the brachium: An anatomic study in human
cadevers. The Journal of Hand Surgery 2007; 32(8): 1177-1182.
4.
Kuwar RB, Bilodi AKS. Clasping of subscapular artery by radial nerve.
Katmandu University Medical Journal 2007; 5-2(18): 253-255.
5.
Tollner U, Bechinger D, Pohlandt F. Radial nerve palsy in a premature
infant fallowing long term measurement of blood pressure. J Pediatr
1980; 96: 921-922.
6.
Papadopoulou M, Spengos K, Papapostolou A, Tsivgoulis G,
Karandreas N. Intraoperative radial nerve injury during coronary artery
surgery-Report of two cases. J Brachial Plex Peripher Nerve Inj 2006; 1:
7. doi:10.1186/1749-7221-1-7.
7.
Ng ABY, Berhan J, Ashton HR, Misra AN, Redfern DRM. Radial nerve
palsy in an elite bodybuilder. Br J Sports Med 2003; 37: 185-186.
8.
Hugon S, Daubresse F, Depierreux L. Radial nerve entrapment in a
humeral fracture callus. Acta Orthop. Belg., 2008; 74: 118-121.
9.
Bergman RA, Thompson SA, Afifi AK, Saadeh FA. Compendium Of
Human
Anatomic
Variation.
Schwarzenberg; 1988 .p. 142.
6
Baltimore-Munich:
Urban
and
9.
Signature of candidate
10. Remarks of the guide
11. Name & Designation of
(in block letters)
11.1 Guide
This study may be helpful for Orthopedicians,
Neurophysicians and Surgeons.
Dr. H.V.RAJASEKHAR M.S.,
PROFESSOR,
DEPARTMENT OF ANATOMY,
J.J.M. MEDICAL COLLEGE,
DAVANGERE - 577 004.
11.2 Signature
11.3 Co-Guide (if any)
--
11.4 Signature
11.5 Head of the
Department
Dr. C.M. RAMESH M.S.,
PROFESSOR AND H.O.D.,
DEPARTMENT OF ANATOMY,
J.J.M. MEDICAL COLLEGE,
DAVANGERE - 577 004.
11.6 Signature
12. Remarks of the
Chairman & Principal
12.2. Signature.
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