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