radial tunnel syndrome
TRANSCRIPT
Radial Tunnel SyndromeRadial Tunnel Syndrome
review of current experience with review of current experience with the Transbrachioradialis approachthe Transbrachioradialis approach
Dr S.L. CarterDr S.L. CarterMartin Singer Hand Unit Groote Martin Singer Hand Unit Groote SchuurSchuurAnd Vincent Pallotti Hospital.And Vincent Pallotti Hospital.
IntroductionIntroduction Recognized entity for over 20 yearsRecognized entity for over 20 years
First described Michele / Kreuger 1956 “ First described Michele / Kreuger 1956 “ Radial pronator syndrome”Radial pronator syndrome”
Roles & Maudsley JBJS Vol 54 B 1972 Radial Roles & Maudsley JBJS Vol 54 B 1972 Radial tunnel exploration for Resistant Tennis Elbowtunnel exploration for Resistant Tennis Elbow
Capener 10 cases 1966, Lister 1979Capener 10 cases 1966, Lister 1979
PathophysiologyPathophysiology Radial Tunnel Syndrome ( RTS ) is the most Radial Tunnel Syndrome ( RTS ) is the most
common entrapment neuropathy of the Radial common entrapment neuropathy of the Radial nervenerve
Radial Nerve is a combination of motor, sensory, Radial Nerve is a combination of motor, sensory, proprioreceptive and autonomic fibresproprioreceptive and autonomic fibres
Continuation of the Post Cord C 5,6,7,8Continuation of the Post Cord C 5,6,7,8
Intermittent or dynamic compression = Ischaemia Intermittent or dynamic compression = Ischaemia
AnatomyAnatomy Radial Tunnel extends from Radial Tunnel extends from
radial head to the inferior radial head to the inferior border of supinator, approx border of supinator, approx 5cm in length5cm in length
5 possible areas of 5 possible areas of compression compression
- - FFascial bands proximallyascial bands proximally - - RRadial recurrent vesselsadial recurrent vessels - - EECRB fibrous edgeCRB fibrous edge - - AArcade of Frohsercade of Frohse - - SSupinator fibres upinator fibres
Supinator ( Wang Journal of Supinator ( Wang Journal of Hand Surg (Br) 29B 2004 Hand Surg (Br) 29B 2004
ClinicalClinicalThree “ Pathagnomic signs”Three “ Pathagnomic signs”
1.1. Pain predominant featurePain predominant feature LocilizationLocilization Weakness not a featureWeakness not a feature
2.2. Middle finger extension Middle finger extension testtest
3.3. Resisted supination testResisted supination test
Special investigationsSpecial investigations Problem is there are no special investigations !Problem is there are no special investigations !
Nerve conduction studies most authors agree Nerve conduction studies most authors agree unhelpfulunhelpful
-Ritts (1987) only 9% had a positive study-Ritts (1987) only 9% had a positive study -Stanley (1995) 25 cases only 30% showed changes -Stanley (1995) 25 cases only 30% showed changes Provocative injections - Green Provocative injections - Green
Future - Role of MRI / USFuture - Role of MRI / US - Provocative supinator Emg testing - Provocative supinator Emg testing
TreatmentTreatment Conservative, rest, modification of activities, Conservative, rest, modification of activities,
splinting physiotherapysplinting physiotherapy
Cortisone injection – controversialCortisone injection – controversial
Mainstay remains surgicalMainstay remains surgical
Results satisfactoryResults satisfactory Ritts (1987) 51% Excellent/GoodRitts (1987) 51% Excellent/Good Stanley ( 1995) 70% Excellent/Good Stanley ( 1995) 70% Excellent/Good
Surgical OptionsSurgical Options1.1. Anterior approach Anterior approach
modified Henrymodified Henry
2.2. Brachioradialis / Brachioradialis / ECRB approachECRB approach
3.3. Posterior approach Posterior approach Thomsons Thomsons
ControversiesControversies Difficult diagnosisDifficult diagnosis
Radial tunnel syndrome vs tennis elbowRadial tunnel syndrome vs tennis elbow
Lack of objective clinical signsLack of objective clinical signs
No special investigationsNo special investigations
Difficult surgical exposuresDifficult surgical exposures
SolutionSolution Attempt to develop a provocative testAttempt to develop a provocative test
- “ Supinator fatigue test’ - “ Supinator fatigue test’
Simple surgical solution Simple surgical solution
- “ Transbrachioradialis approach”- “ Transbrachioradialis approach”
Supinator Fatigue TestSupinator Fatigue Test
Transbrachioradialis Transbrachioradialis ApproachApproach
Transbrachioradialis Transbrachioradialis ApproachApproach
Transbrachioradialis Transbrachioradialis ApproachApproach
PatientsPatientsAgAgee
SexSex OccupOccup HandeHandedd
RTRTSS
HxHx OPOP
4545 malemale BusinesBusinesss
RR LL 18/1218/12 Yes TBRYes TBR
4444 malemale LawyerLawyer RR R R 24/1224/12 Yes TBRYes TBR3939 femalfemal
eeUnempUnemp RR RR 12/1212/12 Yes TBRYes TBR
7070 femalfemalee
RetiredRetired LL RR 12/1212/12 NoNo
4444 malemale SurgeoSurgeonn
RR RR 2/122/12 NoNo
50 50 malemale BusinesBusinesss
RR RR 12/1212/12 Yes TBRYes TBR
4545 malemale TechTech RR RR 24/1224/12 YesTBR YesTBR 4040 femalfemal
eeUnempUnemp RR LL 24/1224/12 Yes TBRYes TBR
3838 femalfemalee
UnempUnemp RR RR 10/1210/12 Yes TBRYes TBR
36 36 malemale TechTech RR RR 18/1218/12 Yes TBRYes TBR
ResultsResults Average age = 45Average age = 45
6 males and 4 females6 males and 4 females
Average symptom history=17Average symptom history=17
Supinator fatigue test positive 70%Supinator fatigue test positive 70%
Excellent / Good results 75% Excellent / Good results 75%
ConclusionConclusion Supinator fatigue test, provocative test, helps Supinator fatigue test, provocative test, helps
in Dx. However remains subjectivein Dx. However remains subjective Transbrachioradialis approach, simple, quick, Transbrachioradialis approach, simple, quick,
reproducible. Allows full visualization radial reproducible. Allows full visualization radial tunneltunnel
Can be combined with tennis elbow release Can be combined with tennis elbow release by proximal extensionby proximal extension
Under diagnosed condition?Under diagnosed condition? Patient satisfaction is high Patient satisfaction is high