Radial Nerve Mononeuropathy

Disease/Disorder

Definition

The radial nerve (RN) is an upper extremity peripheral nerve and the main nerve to the extensor compartments of the upper extremity. It can be injured at multiple locations and by different mechanisms along its course. This article will review injuries to the radial nerve proper and to its main branches, the posterior interosseous nerve (PIN) and the superficial radial sensory nerve (RSN). Depending on the location, RN injury can cause extensive deficits in elbow, wrist and finger extension and forearm supination, often manifesting in wrist drop and grip weakness. Its sensory deficits extend along the posterior and lateral arm, the posterior forearm, and the dorsum of the first, second and third digits of the hand. 

Etiology

Radial nerve injury can occur from various medical conditions, or other etiologies including trauma, compression, and entrapment.

Trauma is the most common cause of RN injury, most commonly from mid-shaft fracture of the humerus. Prevalence of RN palsies after a humeral shaft fracture as determined by a systematic review of 21 studies is 11.8%,¹ with certain locations of humeral shaft fractures more likely to result in RN injury, and with incidence of RN palsy between 7-17%.² Another systematic review that included 23 studies and over 7200 humeral fractures described 41.5% of RN palsies to be associated with fractures in the middle third of the humerus and 56.9% to be associated with distal third fractures.³ Traumatic injuries at other points along the RN are less common, and cause specific dysfunctions depending on the location of the lesion.

External compression of the nerve has been described from

• Use of axillary crutches causing proximal RN lesions in the axilla
• Direct pressure on the RN in the upper arm, such as in “Saturday night palsy” or “Honeymoon palsy”
• Compression of the superficial radial sensory nerve at the wrist⁴  also variably termed “Handcuff palsy” or Wartenberg Syndrome

Entrapment neuropathies can occur along the course of the nerve but are most common in the forearm, predominately affecting the posterior interosseous nerve (PIN).

• Most commonly the PIN can be entrapped at the arcade of Frohse at the supinator muscle, termed “Supinator Syndrome”
• The PIN can be entrapped at the lateral intermuscular septum of the arm, termed “Radial tunnel Syndrome”
• Other focal entrapments, such as along the lateral head of the triceps brachii during intense muscle contraction⁵ or along an anomalous brachioradialis muscle,⁶ are less common

Various medical conditions can result in radial nerve injury

• Lead intoxication historically caused radial palsies, termed “Saturnine palsy”⁷
• Infections, vasculitides, autoimmune diseases, and more can cause a nerve condition called Mononeuropathy multiplex, which can affect the radial nerve
• Tumors can invade at any point along the nerve

Epidemiology including risk factors and primary prevention

Though RN neuropathy is common among mononeuropathies, the exact prevalence of RN injuries is unknown.⁸ Humeral fractures remain the most common etiology.⁵ Other common etiologies of injury include falls, overuse and work-related injuries and motor vehicle accidents.⁸ No racial or gender predilection has been shown. Newborn radial neuropathy is very rare, occurring with a frequency of 0.4-2.5 per 1,000 births.⁹

Patho-anatomy/physiology

Radial Nerve Anatomy

The radial nerve is derived from nerve roots C5-T1 and originates from the posterior cord of the brachial plexus.¹⁰ Within the axilla the RN is located posterior to the axillary artery. It then descends into the upper arm where it innervates the triceps and anconeus and branches into multiple sensory branches innervating the posterior arm and forearm. The RN has potential for injury as it courses down the posterior upper arm and around the posterior humerus, particularly at the midshaft. The RN then courses over the spiral groove of the humerus before it supplies the brachioradialis and extensor carpi radialis (ECR) longus. It then divides into the PIN and the superficial radial sensory nerve (RSN). In 30-50% of the population there is a fibrous band at the arcade of Frohse at the proximal head of the of the supinator muscle.¹¹ The PIN emerges from the supinator and can become entrapped at the opening of the supinator muscle as it abuts the arcade or within the supinator itself.

The RSN branches off the main radial nerve around the lateral humeral epicondyle, deep to the brachioradialis, and progresses distally along the anterolateral forearm, becoming more superficial and radial. It branches proximal to the radial styloid; to provide sensory input to the dorsal radial aspect of the hand and dorsum of the radial 3.5 digits¹² as it crosses over the anatomical snuff box.

There are some variations. The ECR brevis may be supplied by the RN proximal to the PIN, and the brachialis may be supplied by both the radial and musculocutaneous nerves.¹⁰

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Saturday Night Palsy/Honeymooner’s Palsy

Saturday Night Palsy is neuropathy caused by prolonged compression of the RN in the axilla against a firm object, classically described as an intoxicated person falling asleep with their arm hanging over the back of a chair or another firm edge (park bench or table, for example).¹⁰This situation commonly results in a neurapraxic type lesion with conduction block that usually resolves in up to 6 months’ time. A similar syndrome can be seen with Honeymooner’s palsy, in which another person is the source of the compression, typically on the lateral surface of the arm. RN lesions after prolonged non-invasive blood pressure monitoring with a cuff at the upper arm have also been described.⁵The clinical presentation of these injuries depends on the level at which the radial nerve is compromised. If compression occurs in the axilla, triceps function can be affected. However, if compression occurs around the spiral groove, the patient may be more likely to present with variable weakness in elbow flexion, wrist extension, and supination, and sensory changes in the dorsolateral hand and forearm.

Axilla

Radial neuropathy can result from direct pressure in the axillary region from a variety of reasons, including bullet wounds, lacerations, or direct blunt trauma. Use of crutches in the axilla can also cause direct compression, especially if the crutch is too long. To differentiate it from a distal RN lesion, triceps weakness should be evident.

Humeral Shaft Fractures

According to a systemic review of 23 studies, rates of primary nerve palsy were statistically higher in open humeral fractures compared to closed humeral fractures. Overall, 88.6% of patients with total RN palsy recovered function.³ Iatrogenic nerve injury can also occur during surgical repair of humeral diaphysis fracture,¹³ considered secondary nerve palsy. Clinical findings will vary depending on the location of the fracture along the humeral shaft, and mechanism of injury.

Spiral Groove Syndrome

Compression can occur after callus formation, or orthopedic hardware placement. Clinical signs include wrist drop, supination and elbow flexion weakness, and sensory changes in superficial RSN distribution. Elbow extension will be preserved.

Supinator Syndrome

The PIN can become entrapped at the level of the supinator muscle at the arcade of Frohse. This can be related to excessive supination or pronation, and is more common in tennis players, violinists, and swimmers. It presents with painless wrist and finger drop with wrist extension weakness, but radial wrist extension and sensation is spared.

With rheumatoid arthritis (RA), elbow synovitis can compress the PIN. The main differential diagnosis with RA is extensor tendon rupture. Elbow joint steroid injection has a 43% success rate. Early surgical nerve decompression, with or without synovectomy, results in good recovery, even in cases of failed joint injection.¹⁴

Radial Tunnel Syndrome

This controversial entrapment neuropathy can occur when the radial nerve or PIN pierces the septum between the brachialis and brachioradialis muscle. Patients can present with forearm aching, similar to chronic lateral epicondylitis, however there is no muscle weakness.¹⁰ Maximal tenderness may be distal to what occurs in lateral epicondylitis. Pain can be elicited with certain provocative maneuvers like resisted supination, passive pronation, and resisted long finger extension. Typically, there is limited objective data to support diagnosis (EMG can be inconclusive) and diagnosis can be made either clinically or through diagnostic injection. Most patients respond to steroid injection, but if non-operative management fails, surgical release may be considered.¹⁵

Handcuff Neuropathy (Cheiralgia paresthetica)/ Wartenberg Syndrome

The superficial radial nerve can be injured from a number of causes due to its superficial location in the forearm; in the distal forearm or wrist it can be compressed by tight handcuffs, fractures, lacerations, peripheral IV placements, or wrist watch bands.

In “handcuff neuropathy” tightened handcuffs can cause superficial radial neuropathies but also can affect the median and ulnar nerves due to circumferential pressure. If the RSN is affected, only sensory symptoms such as numbness and paresthesias in the dorsolateral hand will be produced. Physical findings of hand edema, wrist abrasions, and bruising are common. Symptoms can typically be reproduced with forearm pronation and ulnar wrist flexion.

The differential for RSN entrapment or damage can include De Quervain’s tenosynovitis. Physical findings can mimic De Quervain’s tenosynovitis and of note, Finkelstein sign is frequently positive in patients with Wartenberg Syndrome.¹⁶ Contrastingly, however, patients with pure tendinitis should have normal sensation over the hand’s dorsum. It is possible for a patient to present with both RSN neuropathy and De Quervain’s tendonitis; proper diagnosis of RSN neuropathy is recommended however due to risk of symptoms progressing to CRPS/RSD.¹⁷

Newborn Radial Nerve Palsy

This can be seen with intrauterine compression, iatrogenic injections, blood pressure monitoring, humerus fracture, septic shoulder, congenital constriction bands, as well as no identifiable etiology. Rapid recovery is expected except with constriction bands.⁹

Specific secondary or associated conditions and complications

There can be apparent weakness of ulnar-innervated muscles with radial neuropathy in the absence of ulnar nerve injury. The apparent weakness occurs primarily in the interossei and the abductor digiti minimi. These muscles insert on the extensor expansions, and with radial neuropathy there is unopposed traction on these extensor expansions.¹³

Essentials of Assessment

Physical examination

Symptoms depend upon site of RN injury/compression

Motor/ Sensory

• Axilla
  • Muscles affected: all radial innervated muscles, including the triceps brachii, superficial posterior forearm muscles which include the brachioradialis, extensor carpi radialis longus and brevis, extensor digitorum communis, extensor digiti minimi, extensor carpi ulnaris, and anconeus, deep posterior forearm muscles which include the supinator, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis
  • Motor deficit: weakness in elbow extension, wrist extension, elbow flexion, forearm pronation and supination (depending on forearm position), wrist extension, wrist abduction and adduction, thumb extension and adduction, and finger extension
  • Sensory deficit: decreased sensation over the posterior arm, posterior forearm, and dorsum of the lateral three and a half digits.
• Spiral groove
  • Muscles affected: all muscles involved in axillary compression, however the triceps is spared
  • Motor deficits: wrist extension, elbow flexion, forearm pronation and supination (depending on forearm position), wrist extension, wrist abduction and adduction, thumb extension and adduction, and finger extension
  • Sensory deficits: posterior forearm and dorsum of the lateral three and a half digits
• PIN
  • Muscles affected: abductor pollicis longus, extensor carpi ulnaris, extensor digiti minimi, extensor digitorum, extensor indicis, extensor pollicis longus and brevis
  • Motor deficit: wrist extension, wrist adduction, finger extension, and thumb abduction
  • Sensory deficit: none
• Wrist
  • Muscles affected: no motor innervation
  • Motor deficit: none
  • Sensory deficit: decreased sensation over the dorsum of the lateral three and a half digits

Functional assessment

Functional impairment to the hand can be significant with radial neuropathy. Inability to extend and stabilize the wrist causes inability to use long flexors adequately in a reciprocal tenodesis action¹⁸ with resulting loss of grip strength, despite normal ulnar and median nerve function. There are many tools to assess hand function, particularly the Disabilities of the Shoulder, Arm, or Hand Questionnaire (DASH),¹⁹ its shorter version, QuickDASH,²⁰ and the Jebsen Hand Function Test.²¹

Imaging

X-rays of the humerus and elbow may show osseous causes of potential RN compression. Imaging may show callus formation from a fracture, tumors, or osteophytes. MRI studies may show RA of the elbow with effusions and synovitis, as well as tumors or lipomas. Ultrasound may show dynamic causes of compression.²² Ultrasound can show abnormal nerve characteristics, such as increased nerve cross sectional area, and diminished echogenicity and fascicular structure.²² Ultrasound may be able to diagnose PIN lesions in some cases where electrodiagnostic studies are normal.²²

Regarding other upper extremity neuropathies, ultrasound is shown to accurately diagnose carpel tunnel syndrome and increase diagnostic sensitivity in the evaluation of ulnar neuropathies when combined with electrodiagnostic testing.²² Beyond some case studies and series demonstrating its diagnostic utility for RN neuropathies, larger studies are needed to further elucidate its diagnostic potential for diagnosis of radial mononeuropathy.

Supplemental assessment tools

Electrodiagnostic testing can help localize the lesion and help with prognosis as well as differentiate a radial neuropathy from other diagnostic possibilities. Common differential diagnoses include: C7 radiculopathy, posterior cord/plexus lesion, or central causes.

Potential EMG and NCS findings

• Spiral groove
  •  Conduction block across the spiral groove if demyelinating lesion, decreased extensor indicis proprius (EIP) CMAP if axonal loss.
  •  Reduced superficial radial nerve SNAP amplitude.
  • Abnormal spontaneous activity and neurogenic findings in the RN distribution excluding the triceps and anconeus.
• PIN syndrome
  • Conduction block across the elbow if demyelinating lesion, decreased EIP CMAP if axonal loss
  • Normal superficial radial nerve SNAP amplitude.
  • Abnormal spontaneous activity and neurogenic findings in the PIN distribution.
• Wrist
  • Normal CMAP
  • Decreased/ abnormal superficial radial SNAP
  • Normal EMG findings

Of note, one of the most important nerve conduction studies mentioned above is the radial motor study, which can be obtained by recording over the EIP and stimulating the radial nerve in the forearm, at the elbow, and below the spiral groove.²³ However, it should be mentioned that radial motor studies can be technically difficult due to difficulty isolating a CMAP from the EIP as there will likely be volume conduction from nearby radial innervated muscles. There may also be difficulty with accurate distance measurements due to circuitous radial nerve course in the forearm. Thus, the value in performing radial motor studies lies in looking for focal conduction block between proximal and distal recording sites or examining relative CMAP amplitude to assess for axonal loss, rather than measuring conduction velocities.

Management and Treatment

Available or current treatment guidelines

Treatment is dependent on the site and cause of the lesion.

In general, prognosis is excellent for spontaneous recovery in the setting of acute trauma or compression without the nerve being severed. Nearly all patients with acute compressive neuropathies have spontaneous resolution with time.²⁴ In the setting of radial palsy as a result of humeral shaft fractures, prognosis differs whether fracture is managed operatively or non-operatively. Spontaneous resolution occurs in approximately 95% of radial palsies in conservatively managed fractures, and 75% in fractures managed operatively.²⁵

• With external compression at the spiral groove, conservative management is indicated.
  • If no recovery, then surgical exploration is considered.²⁶
  • If there is neuroma in continuity, then neurolysis or graft is considered.
  • Occupational therapy and wrist splinting help in re-establishing functional use of the hand.

• With humeral fracture, conservative management or surgery is considered.^3,25
  • Closed fracture– conservative treatment for 6-12 weeks
  • Open fracture– early nerve exploration
    • nerve gap – graft or end-to-end repair
  • If no recovery is noted within several months, then exploration for the site of compression or transection with possible surgical re-anastomosis may be indicated. In a systemic review of 23 studies, a total of 166 RN palsies were treated with late surgical exploration (8 or more weeks post-injury) after failed expectant management and of these, 113 (68.1%) went on to recover.³
• With PIN Syndrome, treatment can be conservative or operative
  • Rest, activity modification, stretching, splinting, NSAID’s
  • Lidocaine/steroid injections if compressive mass ruled out
  • Repetitive supination of the forearm should be avoided.
  • Conservative treatment for 6-12 weeks, then surgical decompression can be considered if no improvement, and/or if a compressive mass identified
• In distal RSN lesions, management is typically conservative.
  • Thumb spica splinting trial
  • Rest, activity modification, stretching, splinting, NSAID’s
• In radial tunnel syndrome, prolonged conservative treatment is indicated. If pain does not resolve after 12 weeks, surgery may be considered.²⁴
• Ballistic related injuries tend to have poor spontaneous improvement due to the additional injury caused by thermal energy, microvascular trauma, and the presence of shrapnel, with less than 25% of upper extremity injuries showing resolution within 12 months.²⁷

Splinting for radial nerve palsy

Many types of splints have been described for patients with radial nerve palsy:

Splinting can be static, dynamic, or a combination of both. The goal is to maintain range of motion, prevent contracture of all joints of the wrist and hand (especially thumb-index web, all digits at the metacarpal phalangeal/MCP joint), and assist with function as nerve recovery occurs.²⁸

Static splinting

• Can be volar, dorsal, or circumferential
• Volar cock up wrist splint
  • Stabilizes the wrist. Consider for higher radial nerve injuries that require more wrist support
  • Improves wrist extension to enhance hand function
  • Prevents:
    • Overstretching of denervated muscles
    • Overpowering of wrist extensors by flexors
  • Limitations
    • Limits flexion of fingers
    • Prevents use of palmar sensation

Dynamic splinting with outriggers

• Dynamic outriggers extend the fingers and thumb with energy storing materials such as elastic, springs, or spring wire, while still allowing for active flexion
• Simultaneous dynamic thumb and finger extension
• Limitations
  • Ineffective in maintaining wrist extension during finger flexion
  • Can be cumbersome
  • Some studies suggest users do not fully re-establish the grasp/release pattern¹⁸

Surgical management and treatment

 Nerve repair and grafting

• Indications for early surgical exploration vary, but typically include open fractures, penetrating trauma, iatrogenic injury, vascular injury, or progressive deficits
• Late surgical exploration is a common strategy for persistent palsies and studies have shown good outcomes with repair, neurolysis, or grafting as far as 3 months after injury
• Repair should be performed tension-free
• Nerve grafting can also be used for residual gap management if distance is too great to overcome by direct epineural repair without tension.

Tendon transfers

• Consider for RN injury if no recovery
• May allow for restoration of wrist, finger, and thumb extension if performed successfully
• Ideal prerequisites for successful tendon transfers can include (elucidated by Jones, Brand Boyes, Steindler, Bunnell, and others²⁹)
  • Supple joints with full range of motion
  • Adequate donor tendon strength and excursion
  • Intact donor muscle innervation
• Typical transfers are:
  • Pronator teres transfer is favored to improve wrist extension
    • Can transfer to ECR longus or brevis
  • Debate over which transfers provide the best finger and thumb extension
    • Flexor Carpi Ulnaris vs Flexor Carpi Radialis vs Flexor Digitorum Superficialis
      • Can transfer to extensor digitorum communis to improve finger extension
    • Palmaris Longus vs Flexor carpi radialis vs Flexor Digitorum Superficialis
      • Can transfer to extensor pollicis longus or extensor indicis proprius to improve thumb and index finger extension

Patient & family education

Discussing prognosis of nerve lesions may help manage patient expectations and improve patient satisfaction. This conversation can help patients and their families create strategies for daily living while preventing further comorbidities. These recommendations can include activity modifications, like avoiding repetitive supination or pronation of the forearm, for PIN lesions.

Emerging/unique interventions

Ultrasonography is emerging as a cost-effective, portable, and non-invasive diagnostic aide for neuropathies. Regarding RN neuropathy, there is ongoing research to further describe and define diagnostic criteria and techniques, an example of which is identifying nerve cross-sectional area (CSA) values that correlate to nerve pathology.³⁰

Cutting Edge/Emerging and Unique Concepts and Practice

N/A

Gaps in the Evidence-Based Knowledge

N/A

References

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Original Version of the Topic

Stephen Kishner, MD, Otono R Silva MD. Radial nerve mononeuropathy. 8/30/2013

Previous Revision(s) of the Topic

Stephen Kishner, MD. Radial nerve mononeuropathy. 3/27/2017

Gabrielle Nguyen, MD. Radial Nerve Mononeuropathy. 7/20/2021

Author Disclosure

Dwayne Gentle, MD
Nothing to Disclose

Marcel Souffrant, MD
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Ziva Petrin, MD
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