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Judy c. Colditz, O.T.R./L. ~BSTRACT: The radial nerve is the most frequently injured ma-
From the Raleigh Hand Rehabilitation Jor nerve of the upper extremity. Splinting to maintain joint mo-
tion and functional use of the hand is usually required until nerve
Center, Inc., Raleigh, North Carolina.
rec~)Very occu~s or tendon transfer procedures are performed. A
review of the literature reveals numerous splint designs for radial
palsy. The biomechanics of "harnessing" the hand with radial nerve
palsy are reviewed and splint designs are analyzed to determine
appropriate use. A design is recommended that reestablishes the
normal tenodesis pattern of the hand.
ETIOLOGY OF RADIAL PALSY seous palsy, radial wrist extension is spared, since the
extensor carpi radialis longus and brevis muscles are
T he radial nerve is the most frequently injured
of the three major peripheral nerves in the
upper extremity.u is most vulnerable to injury at
It
innervated more proximally and the brachioradialis
~unction will always be present.!,3The clinical picture
IS one of radially directed wrist extension, but absent
the mid-humeral level, since it lies superficially and finger and thumb extension.
wraps around the spiral groove of the humerus. The
most common causes of radial palsy are fractures of
the humerus, elbow dislocations, and Monteggia frac- DEFORMITY jlOSS OF FUNCTION
ture-dislocations. Barton states that one in every ten
humeral shaft fractures is complicated by radial nerve The deformity in radial palsy is classic: inability
palsy.! Neuropathy of the radial nerve is also fre- to extend the wrist, loss of finger extension at the
quently seen as a result of direct pressure from an metacarpophalangeal joints, and inability to extend
external source, such as pressure in the axilla from a and abduct the thumb (Fig. 2). This is commonly re-
crutch or pressure over the nerve at the mid-humeral ferred to as the wrist-drop deformity.
level (often referred to as Saturday night or drunk- With radial palsy functional impairment to the
ard's palsy). Although direct trauma is the most com- hand is significant (Fig. 3). The inability to extend
mon cause of radial palsy, other etiological factors and stabilize the wrist causes the patient to be unable
may cause the loss of radial nerve function, e.g., sys- to use his long flexors adequately in making a fist.
temic disease such as diabetes mellitus, polyarteritis Since palmar extrinsic muscles and all intrinsic mus-
nodosa, alcoholism, and serum sickness; or the loss cles are intact in isolated radial palsy, there is the
of function may result from a general neurological problem of the absent antagonistic muscles being un-
disorder. Dysfunction may also result from internal a.ble to position the normal muscles so they can func-
anatomical compression aSSOciated. with spontaneous tIon. The sensibility of the palmar surface of the hand
compression syndromes or the-presence of a tumor. is uninvolved; therefore, the loss of active extension
robs the otherwise normal palmar surface of its use-
fulness: For this reason appropriate splinting during
ANATOMY the penod of recovery has the potential of establish-
Injury commonly occurs as the radial nerve ing almost normal functional use of the hand. This
courses around the spiral groove of the humerus (Fig. is in sharp contrast to median or ulnar palsy, both of
1). Injury at this level is described as high radial palsy. which rob the hand simultaneously of portions of
Innervation of the triceps muscle is spared, leaving palmar sensibility and intrinsic function.
elbow function intact. Loss of innervation of the bra- Splinting to preserve movement and prevent
chioradialis and supinator muscles (which'results in overs.tretching of the denervated muscles is particu-
little functional loss since both provide accessory mo- larly Important when the recovery is prolonged. With
tions), all wrist extensors, all extrinsic finger exten- complete lesions recovery of radial nerve function
sors and all extrinsic thumb abductors characterize either spontaneously or following neurorrhaphy, ma~
this lesion. Before the nerve plunges below the su- be quite lengthy. Barton states that onset of recovery
pinator muscle, it bifurcates, dividing into the su- occurs at an average of five weeks, but it may be seen
perficial sensory branch, which innervates the dor- as late as the eighth month.' Green reports that one
soradial aspect of the hand, and a motor branch, the can expect to wait five or six months following neu-
posterior interosseous nerve. In posterior interos- rorrhaphy before one begins to see return in proximal
musculature. 4 Bevin's series showed an average of 7.5
months until full functional recovery.s Packer, et al.
Presented at the .Seventh Annual Meeting of the American Society
observed that complete recovery may take from 1 to
of Hand Therapists, Atlanta, Georgia, February 1984. 24 months. 6
Reprint requests to Ms. Colditz, Raleigh Hand Rehabilitation Cen- The loss of power in the wrist and finger exten-
ter, Inc., P.O. Box 3062, Raleigh, NC 27622. sors destroys the reciprocal tenodesis action that is
~
:1 ~="~
brachioradialis innervation
superficial
sensory
branch
ext. carpi
radialis longus
and brevis
innervation
FIGURE 1. Anatomy of the radial nerve showing the levels of muscle innervation.
essential to the grasp-release pattern of normal hand the denervated muscles. Most authors advocate some
function. The ideal splint would recreate this har- type of splinting. With the potential for normal use
mony of tenodesis action: finger extension with wrist of the flexor surface, there is a specific challenge to
flexion and wrist extension with finger flexion. provide a splint that will effectively substitute for the
Although tendon transfers for radial nerve palsy absent extensor power.
are predictable and dependable, and some authors Many authors suggest that the priority is stabi-
advocate early tendon transfer to eliminate the need lization of the wrist with a static splint. 1,7,1l,13,14 Al-
for external splinting, most surgeons attempt a period though stabilization of the wrist does allow trans-
of conservative treatment or nerve suture prior to mission of force to the flexors for power grip,
tendon transfers. 5,7Barton states that radial nerve pal- immobilization of the wrist only accentuates the in-
sy usually recovers spontaneously, and therefore the ability of the fingers and thumb to open out of the
therapist may need to provide effective splinting for palm. With the metacarpophalangeal joints resting in
months in anticipation of such an outcome. 1 flexion, the use of intrinsic control is limited by the
tension on the collateral ligaments of the metacar-
pophalangeal joints; in order to spread the fingers the
SPLINTING SOLUTIONS metacarpophalangeal joints must first be lifted man-
Although many authors hJI,1r.e clarified the im- ually into extension. Static wrist splinting does not
portance of wrist stability ina position of extension replace the fine manipulative ability of the hand, a
to facilitate the power of finger flexion, there still function needed more frequently in our daily tasks
exists a wide variety of splinting solutions for the than that of the power grip. The exaggerated teno-
problem of radial nerve palsy.4,8-12 There is little con- desis seen in radial nerve palsy-of wrist flexion to
troversy over the need to prevent overstretching of obtain metacarpophalangeal extension-is lost when
October-December 1987 19
. ~-
radial
palsy
October-December 1987 21
FIGURE 8. The dorsal low pro-
file outrigger provides minimal
bulk to the splint
be used effectively by the patient in his daily routine, transfer is impossible since wrist and finger flexion
since the bulk lies on the dorsum of the hand and cannot be achieved simultaneously.
the palmar surface is unencumbered (Fig. 7). Posterior interosseous palsy with radial wrist ex-
Splint Construction. A dorsal piece of ther- tension present creates a significant splinting chal-
moplastic material is molded over the distal half of lenge, and the inability to extend the fingers makes
the forearm, with particular attention to preventing grasp and release difficult. Even with radial wrist ex-
pressure over the ulnar styloid. Careful molding be- tension present, the splint remains the recommended
yond the midline of the forearm and a flattening over choice, since it does not preclude use of active wrist
the interosseous membrane area will assist in pre- extension and does assist with finger extension when
venting the base from shifting excessively during the wrist flexes slightly.
normal forearm motion.
An outrigger made of heavy wire (VB" brass weld-
ing rod is recommended) is formed to fit the descend- CONCLUSION
ing configuration of the proximal phalangeal area and Splinting is necessary following the commonly
is curved to allow space for the metacarpals to move encountered injury to the radial nerve. From the var-
dorsally during fisting. The outrigger must be at- ious splint designs reviewed, one is recommended
tached securely to the distal aspect of the forearm that maintains the normal tenodesis pattern of the
base, since the weight of the hand generates signif- hand while awaiting return of function. The splint
icant force here. Once applied, the outrigger should is also recommended for use following tendon trans-
be bent up (into extension) at the point where it leaves fers for radial palsy or with posterior interosseous
the splint base. A piece of low temperature thermo- palsy.
plastic splinting material is draped over the outrigger
and trimmed. When cool, holes are punched above
each proximal phalanx. Leatheunger loops, with a REFERENCES
long string (nylon string is recommended) attached
to each side, are fed through the holes and tied to a 1. Barton NJ: Radial nerve lesions. Hand 5(3),1973.
2. Sunderland S: Nerves and Nerve Injuries, London, E.&S. Liv-
hook on the dorsum of the splint. When adjusting ingstone, Ltd., 1968, P 827.
tension for the loops, it is helpful to hold all the 3. Spinner M: Injuries to the Major Branches of the Peripheral
strings, allowing the patient to open and close the Nerves of the Forearm. Philadelphia, W.B. Saunders, 1978, p
hand a number of times to assure the balance is correct 102.
before securing them to the hook. The patient should 4. Green DP: Radial nerve palsy. In Green DP (ed): Operative
Hand Surgery. New York, Churchill Livingstone, 1982, p 1016.
be able to achieve full extension of the fingers when 5. Bevin AG: Early tendon transfer for radial nerve transection.
the wrist approaches neutral. The outrigger .may be Hand 8(2),1976.
bent up further at the point where it leaves the splint 6. Packer JW, Foster RR, Garcia A, Grantham SA: The humeral
in order to give the best balance of motion. fracture with radial nerve palsy: Is exploration warranted? Clin
Orthop 88:38-43, 1972.
Use of Splin t Following Tendon Transfer or with 7. Burkhalter WE: Early tendon transfer in upper extremity pe-
Posterior Interosseous Palsy. The previously de- ripheral nerve injury. Clin Orthop 104:68-79, 1974.
scribed splint design is also very suitable for use fol- 8. Fess EE, Phillips CA: Hand Splinting: Principles and Methods,
lowing tendon transfers for irreparable radial nerve 2nd ed. St. Louis, C.V. Mosby Co., 1987, P 346.
palsy, allowing early protected motion. Following the 9. Goldner J1: Function of the hand following peripherial nerve
injuries. In American Academy of Orthopaedic Surgeons: In-
removal of the postsurgical immobilization at ap- structional Course Lectures, Vol. X. St. Louis, C.V. Mosby Co.,
prOXimately three weeks, the goal is to allow motion 1953.
of the hand but to prevent overstretching of the trans- 10. Penner DA: Dorsal splint for radial palsy. Am J Occup Ther
fer. The splint allows the patient to gain full finger 26:46-47,1972.
11. Bowden R, Napier EM Jr: The assessment of hand function
flexion with wrist extension but maintains the range after peripheral nerve injury. J Bone Joint Surg 43B:481, 1961.
of motion within the limited tenodesis pattern, the 12. Thomas FB: An improved splint for radial (musculospiral) nerve
ultimate goal of the transfer. Overstretching of the paralysis. J Bone Joint Surg 33B:727-728, 1951.
SURGERY AND
REHABILITATION OF THE HAND - 88
VON'T MISS WASHINGTON, V.C. AT
Symposium and Workshop CHERRY BLOSSOM TIME
Sponsored by
Hand Rehabilitation Foundation and
Thomas Jefferson University The FoUftteenth Annual
WIUlh.i.n.g.ton Hand and WILW.t SympO.6.i.wn
Honored Senior Professor (Upp~ E~emi.ty)
Daniel C. Riordan, M.D. A~ 14-16, 1988
New Orleans, Louisiana
Pcvr.k. Hya.t.t Ho.tel. (LuxwUoUA)
MARCH 13-16, 1988 Fa.c.u1..ty .inci.u.du EYII!.OUmen.t
Philadelphia, Pennsylvania
1n:te/Ll'lation.all.y k.nown ex.peJr;tA Send cheek pa.ya.ble .to:
Course Chairmen: .in Upp~ E~emliy Swrg ~y WIUlh.i.n.g.ton Hand SympO.6.i.wn
James M. Hunter, M.D. Lawrence H. Schneider, M.D. and Hand Th~py Phy.6~~ $425: Allied
Evelyn J. Mackin, L.P. T. He.a.Uh PJt.O 6U.6M na.to $300
SympO.6.i.wn Foromat GloJUa. ChJU.6tia.n
Wyndham Franklin Plaza Hotel Lec;twr.u P.O. Box 32073
Vine Street between 16th & 17th Streets, amade1phia, PA 19103 Panel. V~c.u..6.6~On.6 WIUlh.i.ng.ton, V.C. 20007
Th~py Wo~hop.6 (202)342-1779
Anatomy of the upper 11mb demonstrated In J-dlmenslonal projection
Noroman J. Cowen, M.V.
Live Surgery using c1osed-clrcult television demonstrations M~y K. SO~en.6on, R.P.T.
SympO.6.i.wn Co-Chairomen
A symposium and workshop designed to present to the surgeon,
resident, physiatrist, physical and occupational therapist, and Inci.u.du one-ha£.6 da.y Rev~ew COUMe 6M BOMd Exam
registered nurse, a unique opportunity to correlate the concepts,
C~erli:t.4 19 HOUM CME CategMY I
indications, surgical techniques, and pre- and post-operative care
of the injured and disabled upper extremity. "Hands-on" workshops Spon.6Med By
and panel discussions will complement the didactic sessiol1s.
The Na.:t.£onai. Hand Ru~ch and Reha.b..i..U.ta.t.Wn Fund, Inc..
a.nd
Information: Evelyn J. Mackin, L.P. T. The C0n.60~ Me~c.ctI'. Educ.a.;Uon
Hand Rehabilitation Foundation
901 Walnut Street, Philadelphia, PA 19107
(215) 925-4579
October-December 1987 23