Radial Mononeuropathy

Introduction

Background
Radial neuropathies result from injury due to penetrating wounds or fractures of the arm,
compression, or ischemia. Most commonly, they present with a wrist drop. The pattern of clinical
involvement is dependent on the level of injury.

Radial neuropathies can occur from surgical procedures such as humeral nailing performed to
stabilize an acute humeral fracture.1

The terms Saturday night palsy and honeymooner's palsy refer to the concept of placing one's
arm over another chair, with the resultant pressure causing injury to the radial nerve.

Pathophysiology
An introduction to radial nerve anatomy is essential for understanding the common mechanisms
and location of its injury. The radial nerve branches from the posterior cord of the brachial
plexus. It receives root innervation from C5-T1 spinal roots. In the upper arm, the radial nerve
gives off a branch to the triceps muscle before it wraps around the humerus at the spiral groove.
Three sensory branches, which supply the skin over the triceps and posterior forearm, also are
given off at this level. Here, its proximity to the humerus makes it susceptible to compression
and/or trauma.

After exiting the spiral groove, the radial nerve supplies the brachioradialis muscle before
dividing into the posterior interosseous branch and a sensory branch. The posterior
interosseous branch is a pure motor nerve that supplies the supinator. It then dives into the
supinator through the fascia to supply the muscles of the wrist and finger extension. This fascia
is another common site for nerve damage to occur. The sensory branch that arises
approximately at the elbow travels down the forearm, becoming superficial at the wrist before it
supplies the lateral aspect of the dorsum of the hand.
Radial Mononeuropathy

Introduction

Background
Radial neuropathies result from injury due to penetrating wounds or fractures of the arm,
compression, or ischemia. Most commonly, they present with a wrist drop. The pattern of clinical
involvement is dependent on the level of injury.

Radial neuropathies can occur from surgical procedures such as humeral nailing performed to
stabilize an acute humeral fracture.1

The terms Saturday night palsy and honeymooner's palsy refer to the concept of placing one's
arm over another chair, with the resultant pressure causing injury to the radial nerve.

Pathophysiology
An introduction to radial nerve anatomy is essential for understanding the common mechanisms
and location of its injury. The radial nerve branches from the posterior cord of the brachial
plexus. It receives root innervation from C5-T1 spinal roots. In the upper arm, the radial nerve
gives off a branch to the triceps muscle before it wraps around the humerus at the spiral groove.
Three sensory branches, which supply the skin over the triceps and posterior forearm, also are
given off at this level. Here, its proximity to the humerus makes it susceptible to compression
and/or trauma.

After exiting the spiral groove, the radial nerve supplies the brachioradialis muscle before
dividing into the posterior interosseous branch and a sensory branch. The posterior
interosseous branch is a pure motor nerve that supplies the supinator. It then dives into the
supinator through the fascia to supply the muscles of the wrist and finger extension. This fascia
is another common site for nerve damage to occur. The sensory branch that arises
approximately at the elbow travels down the forearm, becoming superficial at the wrist before it
supplies the lateral aspect of the dorsum of the hand.
Radial Mononeuropathy
Radial Mononeuropathy

The Radial Nerve from Gray's Anatomy (published 1918, public domain, copyright
expired).
Radial Mononeuropathy
Radial Mononeuropathy

The Radial Nerve from Gray's Anatomy (published 1918, public domain, copyright
expired).

Frequency
United States

Radial neuropathy is the fourth most common mononeuropathy.

Race
No racial preponderance is known.

Sex
No gender predilection has been observed.

Age
Radial neuropathy is reported in all age groups.

Clinical

History
Symptoms are dependent on the site of the lesion.

• The most common reported symptom is wrist drop.

• If the lesion is high above the elbow, then numbness of the forearm and hand may
be an additional symptom.
• If the lesion is in the forearm, sensation typically is spared despite the wrist drop.
o Pain in the forearm resembling tennis elbow may be prominent.
o This presentation is initially acute for several days to weeks.
• If the lesion is at the wrist, patients report isolated sensory changes and
paresthesias over the back of the hand without motor weakness.

Physical
Radial neuropathy typically presents with weakness of wrist dorsiflexion (ie, wrist drop) and
finger extension.

• If the lesion is in the axilla, all radial-innervated muscles are involved.

o The triceps and brachioradialis reflexes are decreased.
Radial Mononeuropathy

o Sensation is decreased occur over the triceps, the posterior part of the
forearm, and dorsum of the hand.
• Acute compression of the radial nerve commonly occurs at the spiral groove. If
the lesion is at this level, all radial-innervated muscles distal to the triceps are
weak.
o Triceps reflex is preserved, but brachioradialis is decreased.
o Sensory loss is over the radial dorsal part of the hand and the posterior
part of the forearm.
o Numbness over the triceps area is variable.
• In isolated posterior interosseous lesions, sensation is spared and motor
involvement occurs in radial muscles distal to the supinator.
o Brachioradialis reflex is intact.
o The extensor carpi radialis sometimes is also spared, resulting in radial
deviation with wrist extension.
o Pain may occur with palpation at the proximal forearm and with forceful
supination.
• In distal radial sensory lesions at the wrist, no motor weakness occurs. Numbness
of the dorsal hand is noted, sparing the fifth digit.

Causes

• Penetrating trauma can cause injury anywhere along the nerve.

• Compressive lesions high in the axilla can occur from improper use of crutches.
• Compression injuries at the humeral spiral groove occur in patients with
sustained compression of this area over a period of several hours.
o This is reported in patients who fall asleep in a drunken or drug-induced
stupor with the arm over a chair. It also can occur in honeymooners.
o Fracture of the humerus is a common cause of radial neuropathy due to
compression or secondary laceration of the nerve as it wraps around the
humerus near the spiral groove.
o Radial neuropathy has also been reported in wheelchair users, when the
spiral groove of the humerus is compressed on a hard wheelchair surface.2
• Subluxation of the radius can produce radial nerve injury in the proximal forearm.
• The posterior interosseous syndrome typically occurs from compression of this
division of the radial nerve as penetrates the supinator muscle within the proximal
forearm.3
o It is associated with repetitive supination of the forearm and hypertrophy of
the supinator muscle.
o It also can occur secondary to elbow synovitis, ganglion cysts4 , enlarged
bursa from the elbow, or tumors (especially lipomas at the entry of the
radial nerve into the supinator muscle).
Radial Mononeuropathy

• Isolated distal sensory radial neuropathy is associated with compression from

handcuffs and tight bracelets.
• Bilateral radial palsies suggest lead intoxication. Lead exposure may be
occupational.

The Radial Nerve from Gray's Anatomy (published 1918, public domain, copyright
expired).

Frequency
United States

Radial neuropathy is the fourth most common mononeuropathy.

Race
No racial preponderance is known.

Sex
No gender predilection has been observed.

Age
Radial neuropathy is reported in all age groups.

Clinical

History
Symptoms are dependent on the site of the lesion.

• The most common reported symptom is wrist drop.

• If the lesion is high above the elbow, then numbness of the forearm and hand may
be an additional symptom.
• If the lesion is in the forearm, sensation typically is spared despite the wrist drop.
o Pain in the forearm resembling tennis elbow may be prominent.
o This presentation is initially acute for several days to weeks.
• If the lesion is at the wrist, patients report isolated sensory changes and
paresthesias over the back of the hand without motor weakness.
Radial Mononeuropathy

Physical
Radial neuropathy typically presents with weakness of wrist dorsiflexion (ie, wrist drop) and
finger extension.

• If the lesion is in the axilla, all radial-innervated muscles are involved.

o The triceps and brachioradialis reflexes are decreased.
o Sensation is decreased occur over the triceps, the posterior part of the
forearm, and dorsum of the hand.
• Acute compression of the radial nerve commonly occurs at the spiral groove. If
the lesion is at this level, all radial-innervated muscles distal to the triceps are
weak.
o Triceps reflex is preserved, but brachioradialis is decreased.
o Sensory loss is over the radial dorsal part of the hand and the posterior
part of the forearm.
o Numbness over the triceps area is variable.
• In isolated posterior interosseous lesions, sensation is spared and motor
involvement occurs in radial muscles distal to the supinator.
o Brachioradialis reflex is intact.
o The extensor carpi radialis sometimes is also spared, resulting in radial
deviation with wrist extension.
o Pain may occur with palpation at the proximal forearm and with forceful
supination.
• In distal radial sensory lesions at the wrist, no motor weakness occurs. Numbness
of the dorsal hand is noted, sparing the fifth digit.

Causes

• Penetrating trauma can cause injury anywhere along the nerve.

• Compressive lesions high in the axilla can occur from improper use of crutches.
• Compression injuries at the humeral spiral groove occur in patients with
sustained compression of this area over a period of several hours.
o This is reported in patients who fall asleep in a drunken or drug-induced
stupor with the arm over a chair. It also can occur in honeymooners.
o Fracture of the humerus is a common cause of radial neuropathy due to
compression or secondary laceration of the nerve as it wraps around the
humerus near the spiral groove.
o Radial neuropathy has also been reported in wheelchair users, when the
spiral groove of the humerus is compressed on a hard wheelchair surface.2
• Subluxation of the radius can produce radial nerve injury in the proximal forearm.
Radial Mononeuropathy

• The posterior interosseous syndrome typically occurs from compression of this

division of the radial nerve as penetrates the supinator muscle within the proximal
forearm.3
o It is associated with repetitive supination of the forearm and hypertrophy of
the supinator muscle.
o It also can occur secondary to elbow synovitis, ganglion cysts4 , enlarged
bursa from the elbow, or tumors (especially lipomas at the entry of the
radial nerve into the supinator muscle).
• Isolated distal sensory radial neuropathy is associated with compression from
handcuffs and tight bracelets.
• Bilateral radial palsies suggest lead intoxication. Lead exposure may be
occupational.

Lead
Median Neuropathy
Multifocal Motor Neuropathy With Conduction Blocks
Ulnar Neuropathy

Other Problems to Be Considered

Lesion of the posterior cord of the brachial plexus
Cervical disk syndromes

Workup

Imaging Studies

• A recent study showed that ultrasound examination can localize radial neuropathy
more rapidly than standard electrophysiological testing.6,7 Visualization of the
superficial radial nerve with high-resolution sonography has recently been
reported.8,9
• Occasionally, imaging of the elbow region or the humeral area is indicated to
determine if any mass or bony lesions are compressing the nerve. Plain
radiographs may show bony causes of compression, such as fractures,
dislocations, callus formations, or osteophytes. MRI is particularly helpful for soft
tissue evaluation and more direct imaging of the nerve.3

Other Tests
Nerve conduction studies and needle electromyography (EMG) are essential for specific
localization and to rule out a more generalized process.
Radial Mononeuropathy

Treatment

Medical Care
Therapy is dependent on the site and cause of the lesion.

• When the lesion is due to external compression at the spiral groove, removing the
source of the compression and conservative management is indicated.
• Physical therapy and wrist splinting helps in reestablishing functional use of the
hand.
• If the lesion is due to a humeral fracture, the fracture must be carefully reduced
and set to avoid further injury. This may require external fixation.
• 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.10
• With posterior interosseous neuropathies, repetitive supination of the forearm
should be avoided.
• In distal radial sensory nerve lesions, management is typically conservative.

Surgical Care
Surgical exploration may be considered for a chronic compressive lesion or transection.

• Surgical exploration frequently is indicated for release of the nerve from tethered
points in the forearm.
• Localizing the lesion prior to surgery via EMG is important to assist the surgeon
in identifying which section of the nerve is most likely involved.
• When transection is suspected as the mechanism of injury, conservative
management for several months is indicated to assure that no nerve regrowth has
occurred either clinically or by electrodiagnostic measures.
• If no regeneration or inadequate regeneration is confirmed, surgical exploration
with possible re-anastomosis may be indicated.
• Selective tendon transfer may allow for finger extension and thumb extension in
cases of long-standing, irreparable radial nerve lesions.11
• Consensus has not been reached regarding the need for and timing of surgical
therapy to treat radial nerve palsy with accompanying humeral fracture.12,13,14

Consultations
Electrodiagnostic consultation is important in radial mononeuropathy in order to:

• Localize the lesion

• Provide useful prognostic information in traumatic radial neuropathy
Radial Mononeuropathy

Medication

Although no medications are specifically designed for radial mononeuropathy, in cases of

neuropathic pain related to the neuropathy, various agents that may help reduce neuropathic
pain should be considered.

Keywords

radial mononeuropathy, Saturday night palsy, honeymooner's palsy, wrist drop, radial
neuropathy, radial nerve palsy