WRIST DROP SECONDARY TO HIGH RADIAL NERVE PALSY:

Wrist drop that develops in the aftermath of radial nerve injury, results in severely compromised function of the hand and wrist. There is loss of extension of the wrist, fingers and the thumb. To top them all, the most remarkable disability is weakness of the grip.

We label it as high radial nerve injury when the level of nerve injury is somewhere proximal to the division of the nerve into its terminal sensory and motor branches at the elbow.

How is this injury sustained? Most often a humeral shaft fracture is the culprit. The palsy is termed primary if it develops with the fracture itself. It is called secondary or iatrogenic when it develops following some orthopedic intervention.

Also not surprisingly we still continue to receive a small percentage of patients with iatrogenic radial nerve injury secondary to injections in the deltoid region.

The iatrogenic injuries of radial nerve are largely preventable. A proactive approach is prudent in this regard. At the time of orthopedic interventions, routine identification and isolation of the nerve helps to avoid serious iatrogenic injuries. Also avoid unnecessary injections by quacks.

Among judiciously selected late presenting patients, tendon transfers provide the most robust means of restoring hand function. In the FCR set of triple tendon transfers, the following tendons are transferred:
1- Palmaris longus (PL) to the re-routed extensor pollicis longus (EPL).
2- Pronator teres (PT) to the extensor carpi radialis brevis (ECRB)
3- Flexor carpi radialis (FCR) to the extensor digitorum communis (EDC).

The ideal candidates for tendon transfers are those cases of high radial nerve injury which have neither showed signs of spontaneous recovery over 4-6 months nor where other treatments such as the nerve repair, nerve reconstruction or nerve transfers have not worked or not tried earlier. The tendon transfer ensures restoration of the critically important functions of hand opening, wrist extension and improvement in grip power.

Here is a male aged 19 years, who had encountered a road traffic accident nine months ago. He had sustained a fracture of the humerus which was managed elsewhere. He presented with high radial nerve injury and enjoyed a remarkable recovery of the lost functions of hand and wrist following triple tendon transfer.

Pulvertaft weaving is imperative for ensuring durable outcome in the long term. The author prefers at least three weaves for each transfer. Also tension setting at the transfer is crucial. PL to EPL transfer is the first in order where tension is set with the wrist in neutral position and maximal tension on both PL and EPL. The FCR to EDC transfer is the second to be weaved and tensioned. Here again the wrist is in neutral position whereas the MCPJs are put in full extension. The last one is PT to ECRB transfer which is weaved and tensioned with the wrist joint in full extension.

An above elbow volar slab is fashioned and applied to the operated limb while on table and continued for 6-weeks post-operatively. The wrist is kept in 20-30° extension and the thumb in extension and radial abduction. The MCPJs are kept slightly flexed. Beware of hyper-extension of the MCPJs and subsequent formidable disability.

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Dr Saaiq Plastic & Esthetic Surgeon, Islamabad.

Dr Saaiq’s Qualifications:
FCPS (Plastic Surgery), FCPS (Surgery), MHPE (Medical Education), MBBS (Khyber). Plastic & Esthetic Surgeon, Islamabad.

Dr Saaiq’s Specialty: Esthetic surgery; Plastic surgery, Hand surgery and Burns Management.

Dr Saaiq’s Brief Intro:

His special proficiency areas include wound-management with flaps & skin grafts, Management of skin cancers, Breast cancer, Gynecomastia, Keloids, unsightly Scars, Abdominoplasty, Abdominal hernias, Liposuction, Fat grafting, Body contouring after massive weight loss, Blepharoplasty, Rhinoplasty (Nose job), Circumcision, Hypospadias, Cleft lip, Carpal tunnel syndrome, De Quervains disease, Injuries to Hand, Tendon & Nerves etc.

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