Deep Branch of the Radial Nerve

Entrapment 35
Richard E. Seroussi, Virtaj Singh, and Helen W. Karl

Introduction
Entrapment of the deep branch of the radial nerve (DBRN)
results in two distinct clinical syndromes. Posterior interosse-
ous nerve syndrome (PINS) is a well-defined but rare nerve
palsy involving some of the wrist extensors and all of the fin-
ger extensors [1, 2]. By contrast, radial tunnel syndrome
(RTS) is a controversial, painful repetitive stress type of injury
without “hard” neurologic symptoms [3–7].
Of note, there is a fair amount of ambiguity in the literature
as to what constitutes the radial tunnel, as well as the defini-
tions of the DBRN and the posterior interosseous nerve (PIN).
Further confusion stems from RTS coexisting with other diag-
noses such as lateral epicondylitis (“tennis elbow”), milder
forms of carpal tunnel or cubital tunnel syndrome [8], proxi-
mal radial nerve entrapment [9], or tendinitis in the forearm or
wrist. Other names for DBRN entrapment include supinator
syndrome [10, 11] and treatment-resistant tennis elbow [3].
Also, of note, some authors and clinicians merge RTS and
PINS, using the terms interchangeably. For the purposes of
this review, RTS is considered distinct from PINS—involving
Electronic supplementary material The online version of this chapter
(doi:10.1007/978-3-319-27482-9_35) contains supplementary material,
which is available to authorized users.
more pain than palsy and implying a more proximal entrap-
ment. PINS involves much more palsy than pain and should
be considered as a distinct nerve disorder, often caused by
abrupt trauma or space-occupying lesions such as lipomas or
ganglion cysts.
Most of the focus of this chapter will be on RTS—a more
commonly diagnosed disorder in an outpatient musculoskele-
tal practice than PINS. To put into perspective the controversy
behind RTS, the authors offer the following quote from one
recent neurology review of radial nerve disorders: “The radial
tunnel and its associated syndrome seem to be orthopedic con-
cepts that engender much skepticism from neurologists” [12].
Clinical Presentation (Table 35.1)
Numerous authors have reviewed the causes for DBRN
entrapment, often without distinguishing between RTS and
PINS. The most common causes are listed in Table 35.1.
In the absence of discrete trauma, patients with PINS usu-
ally have a gradual onset of weakness in PIN-innervated
muscles, with finger extension more affected than wrist
extension [12]. They may have pain, but motor symptoms are
more prominent [2, 15]. Patients with PINS presenting with

R.E. Seroussi, MD, MSc (*) Table 35.1 Occupation/exercise/trauma history relevant to DBRN
Seattle Spine and Sports Medicine, entrapment
3213 Eastlake Ave East, Seattle, WA 98102, USA Cause Comments
Department of Rehabilitation Medicine, Courtesy Clinical Faculty, Benign tumors, cysts Lipomas are most common [1]
University of Washington, Seattle, WA, USA Repetitive stress injuries, Manual labor [4, 13]
e-mail: rseroussi@comcast.net involving repeated Writer’s cramp [13]
V. Singh, MD forearm supination-
Violin player or music director [14, 15]
Clinical Faculty, Department of Rehabilitation Medicine, pronation with elbow
extended Athletic activities [14], especially
University of Washington, Seattle Spine and Sports Medicine,
throwing sports [9], swimming
Seattle, WA, USA
activities [15], and tennis [16]
e-mail: vsingh@seattlespine.com
Trauma Proximal radial fracture or dislocation
H.W. Karl, MD [12, 17]
Department of Anesthesiology and Pain Medicine, University of Ulnar fracture [12]
Washington, Seattle Children’s Hospital, Seattle, WA, USA
e-mail: helen.karl@seattlechildrens.org Inflammatory conditions Rheumatoid arthritis [12]

© Springer International Publishing Switzerland 2016 349

A.M. Trescot (ed.), Peripheral Nerve Entrapments: Clinical Diagnosis and Management, DOI 10.1007/978-3-319-27482-9_35
350
weakness have compression to the point where large myelin-
ated motor fiber function is compromised [1].
Patients with RTS present with a deep ache in the proxi-
mal lateral forearm extensor muscles, just distal to the lateral
epicondyle (Fig. 35.1) [4]. Initial symptoms are usually
fatigue and skill decrement, rather than pain. Note that for
patients with repetitive stress injuries and neurologic symp-
toms, compressions of the ulnar (see Chap. 38) and median
nerve (see Chap. 37) are much more common than radial
nerve involvement [7, 12, 15].
Pain onset is usually insidious [18]. It is often in the domi-
nant arm, may extend proximally or distally [13], and is
often troublesome at night [9]. It generally worsens with
increased use of the lateral extensor muscles of the arm, such
as with keyboarding, other fine motor activities, or lifting.
Tasks involving handgrip combined with elbow pronation
and wrist extension, such as picking up a luggage, may be
particularly painful. Generally, there are no significant pares-
thesias or numbness unless there is concomitant carpal tun-
nel syndrome, which is not unusual in the setting of treating
Fig. 35.1 Patient identification of elbow pain, consistent with radial
tunnel entrapment (Image courtesy of Andrea Trescot, MD)
R.E. Seroussi et al.
injured workers. Patients with RTS may also have weakness,
but this is often due to pain with use of the forearm, rather
than a primary neurologic deficit [4].
Anatomy (Table 35.2)
The radial nerve arises from the posterior cord of the brachial
plexus, with contributions from C5 to T1, wrapping around the
humerus and then traveling across the radial-humeral (RH) joint
near the lateral epicondyle to descend into the forearm.
Figure 35.2 illustrates the major cutaneous nerves of the upper
extremity. Note that patients with RTS do not have involvement
of the superficial radial nerve. The main trunk of the radial nerve
then divides into the superficial sensory branch (SRN) and the
DBRN (Fig. 35.3). Most authors define the proximal edge of the
radial tunnel as the point at which the DBRN crosses the RH
joint, just distal to the bifurcation, although some characterize
the radial tunnel as beginning proximal to the RH joint and
including the SRN [13].
The distal terminus of the radial tunnel has a more variable
definition. Some authors include the proximal portion of the
supinator muscle, known as the arcade of Frohse (AF), but
not the entire length of the supinator muscle [4, 12, 24].
Others add the entire span of the supinator muscle, including
the muscle’s distal edge [23, 25, 29]. The supinator muscle
itself has a complicated anatomy, arising from the humerus,
lateral collateral ligament of the elbow, and the ulna and then
attaching to the radius in both a deep and superficial layer.
Further complicating nomenclature is the variable
labeling of the DBRN. Most authors consider that the PIN
begins at the bifurcation of the main trunk of the radial nerve
(synonymous with the DBRN) [1, 11, 15, 22, 24], while
some state that the PIN does not strictly begin until the nerve
emerges from the distal edge of the supinator [25]. These
anatomic distinctions likely do not have much clinical
importance, but they certainly add to the confusion in the
literature on radial nerve entrapment near the elbow.
The cadaveric study by Hazani [25] and others mapped
out the proximal and distal borders of the supinator muscle,
using the radial head as a reference point. The DBRN dives
under the AF, at an average of 3.5 cm distal to the radial
head, and emerges as the PIN 7.5 cm distal to the radial head.
These are fairly straightforward landmarks, helpful when
planning a diagnostic injection for a patient with RTS.
Similarly, Berton et al. [28] dissected 28 embalmed upper
limbs and traced the radial nerve from the bicipital groove to
the distal edge of the supinator. They found superficial and
deep layers of the supinator in all the specimens, and the motor
innervation of the supinator was from the DBRN in each case;
20 specimens had a clear arcade of Frohse, and all the DBRNs
were slightly flattened at proximal and distal radial tunnel.
Thirty limbs dissected by Clavert et al. [23] showed that
the AF was not the only compression site. These authors
35 Deep Branch of the Radial Nerve Entrapment 351

Table 35.2 Radial (deep) nerve anatomy

Origin A direct continuation of the posterior cord of the brachial plexus, C5–T1
General route Spirals around the posterior humerus, gives off branches to the triceps and anconeus muscles, then through the
lateral intermuscular septum into the anterior compartment ~ 10 cm proximal to the elbow [19]
Gives off a branch to the extensor carpi radialis longus (ECRL), then divides near the lateral epicondyle into the
deep and superficial branches [16]
Deep branch of the radial nerve (DBRN) passes through the radial tunnel underneath the proximal edge of the
supinator muscle and then between the superficial and deep layers of the supinator
Sensory distribution Wrist joint [15, 16, 20, 21]
Occasionally elbow joint [4, 16]
Motor innervation All the wrist and finger extensors with variable numbers of branches to each [22]
RN: triceps, brachioradialis (BR), brachialis (shared innervation with musculocutaneous nerve), ECRL
PIN: extensor carpi radialis brevis (ECRB), supinator, finger extensors, extensor pollicis longus (EPL), extensor
pollicis brevis (EPB), abductor pollicis longus (APL), extensor carpi ulnaris (ECU)
Anatomic variability Site of radial nerve bifurcation into deep and superficial branches. This may occur distal to the radiohumeral
(RH) joint [4, 22, 23]
Order of muscle innervation by a web of deep radial nerve branches [22]
Structure of the proximal edge of the supinator muscle, more commonly known as the arcade of Frohse (AF)
[23–25]. The degree of fibrosis seems to be use related, since this structure is entirely muscular in full-term
fetuses [26]
Structure of the distal edge of the supinator muscle [25]
Number and position of recurrent branches of the radial artery [24]
Position of the PIN changes with forearm pronation and supination [15, 23] though not with elbow flexion [27]
Other relevant structures Supinator muscle [28]
“Mobile wad”: the proximal forearm compartment containing BR, ECRL, ECRB

believe that repeated supination and pronation promote grad-
ual DBRN compression in adults.
One may wonder how a nerve often described as having
“pure motor function” can cause a painful condition. This was
nicely reviewed in a paper by Naam and Nemani [6]. They
note that the DBRN includes unmyelinated group IV afferent
nerve fibers—also called C fibers—which carry nociceptive
inputs to the spinal cord from structures in the forearm [4, 15].
Entrapment
“Radial tunnel syndrome,” caused by compression of the
DBRN, actually has several potential etiologies. The
most common site of compression is the proximal edge of
the superficial portion of the supinator muscle (the
arcade of Frohse), especially when the forearm is pro-
nated [4, 14, 15, 28, 30]. The DBRN is seen adjacent to
the supinator muscle in a proximal forearm MRI cross-
section in Fig. 35.4. Changes in position increase the
pressure in the radial tunnel, believed to occur when the
supinator edge is fibrous. According to one study, passive
pronation increases the pressure to 46 ± 21 mmHg, while
tetanic contraction of the supinator dramatically esca-
lates it to 195 ± 65mmHg [31]. Proposed mechanisms of
compression include the stress of the activity itself—for
example, throwing—or secondary anatomic changes such
as muscular hypertrophy or injury and repetitive traction
stresses [9].
Multiple other potential sites of compression have been
described, including, from proximal to distal:
• Above the elbow, the radial nerve (RN) is compressible
by a fibrous arcade within the lateral or long head of the
triceps [9, 13].
• Fibrous bands from the annular ligament and radial head
[25].
• Recurrent branches of the radial vessels (“leash of
Henry”) may compress the PIN at the radial neck [14, 25,
30].
• The edge of the ECRB [4, 14].
• Distal edge of the supinator muscle [4, 14, 28].
Rarely, compression and entrapment can be caused by a
ganglion or lipoma, which would likely cause the well-
defined, but rare, PINS, with clear weakness and electrodiag-
nostic abnormalities [4, 6].
Physical Exam
Radial Tunnel Syndrome
The history and physical examination for RTS are fairly
nonspecific, although its hallmark is pain and tenderness
approximately 3–6 cm or three fingerbreadths distal to the
radial head (Fig. 35.5). One may attempt to palpate the prox-
imal radius in this area. However, in practice, it is easiest for
352 R.E. Seroussi et al.

Biceps tendon

Brachioradialis

ECRL

ECRB
Fibrous
edge of Radial nerve:
ECRB
Superficial
branch
Arcade of
Frohse
Deep
branch
EDC
Supinator
Distal edge
of Supinator PIN

ECU

Fig. 35.3 Relevant anatomy for radial tunnel syndrome. Illustration of

the radial tunnel content through a dorsal approach demonstrating the
bifurcation of the radial nerve into superficial and deep branches. The deep
branch becomes the posterior interosseous nerve as it exits the distal edge
of the supinator. Points of compression are marked in red. ECRB extensor
carpi radialis brevis, ECRL extensor carpi radialis longus, ECU extensor
carpi ulnaris, EDC extensor digitorum communis, PIN posterior interosse-
Fig. 35.2 Distribution of arm nerves: A axillary nerve, B radial nerve ous nerve (Reproduced with permission from Hazani et al. [25])
(1 posterior cutaneous nerve of the arm, 2 inferior lateral cutaneous
nerve, 3 posterior cutaneous nerve of the forearm, 4 superficial radial
nerve), C intercostal brachial nerve, D medial cutaneous nerve of the
forearm, E median nerve, F lateral cutaneous nerve of the forearm
(Image courtesy of Terri Dallas-Prunskis, MD)
35 Deep Branch of the Radial Nerve Entrapment
Fig. 35.4 MRI axial image of the proximal forearm. A anconeus mus-
cle, B biceps tendon, C flexor digitorum profundus muscle, D flexor
carpi ulnaris muscle, E flexor digitorum superficialis muscle, F pal-
maris longus muscle, G flexor carpi radialis muscle, H pronator teres
muscle (humeral head), I pronator teres muscle (ulnar head), J supina-
tor muscle, K extensor digiti minimi muscle, L extensor digitorum
Fig. 35.5 Physical exam of radial nerve entrapment, showing point of
maximum tenderness. (Image courtesy of Richard Seroussi, MD)
the examiner to press the patient’s pronated forearm at a
junction between the dorsal proximal ulna and the extensor
mass of muscles—often termed the “mobile” wad—which
includes the brachioradialis and the wrist extensors (Video
35.1). This area can be mildly tender in asymptomatic per-
sons, so the examiner should compare tenderness between
353
muscle, M extensor carpi radialis brevis muscle, N extensor carpi radia-
lis longus muscle, O brachioradialis muscle, P brachialis muscle; a
ulnar artery, b radial artery, c radial recurrent artery, d recurrent interos-
seus artery, 1 median nerve, 2 lateral cutaneous nerve of the forearm, 3
superficial branch radial nerve, 4 deep branch radial nerve, 5 ulnar
nerve (Image courtesy of Andrea Trescot, MD)
Fig. 35.6 Point of maximum tenderness for lateral epicondylitis, prox-
imal to RTS tenderness. (Image courtesy of Richard Seroussi, MD)
the affected and unaffected sides to gauge the clinical rele-
vance of this finding.
Also, the patient may have lateral epicondylitis (tennis
elbow) (Fig. 35.6) as a competing or additional diagnosis,
and comparison of palpation findings between the lateral
epicondyle and the radial tunnel should be made. Indeed,
RTS has been called “treatment-resistant tennis elbow,”
given ambiguity between the two disorders on history and
physical exam.
Positions that increase traction on the radial nerve (fore-
arm pronation with elbow extended and wrist flexed)
354
Fig. 35.7 Provocation of radial nerve tension by pronation of the fore-
arm with the elbow extended and wrist flexed (Image courtesy of Virtaj
Singh, MD)
(Fig. 35.7) can be used as provocative tests to enhance
symptoms [1]. However, this position will also aggravate
lateral epicondylitis symptoms.
Resisted wrist extension in patients with RTS is gener-
ally only mildly painful, in contrast to the usual sharp pain
elicited in those with lateral epicondylitis. Some authors
describe the “middle finger test,” where resisted middle
finger extension reproduces concordant pain for the RTS
patient, but in these authors’ experience, this is also a
fairly nonspecific finding [32].
RTS may be part of a “double crush” situation with an
associated more proximal injury [9]. We recommend
screening evaluation of the neck and shoulders and a myo-
tomal screen of upper extremity strength, even in the
absence of symptoms in these regions, to rule out compet-
ing or additional diagnoses. Neck examination includes
passive or active assisted range of motion of the neck with
paraspinal palpation and the use of What is this?. Shoulder
examination should include passive overhead forward
flexion and crossed adduction of the shoulder, as well as
forward shoulder flexion with internal rotation (Hawkins
test) (Fig. 35.8) [33].
Posterior Interosseous Nerve Syndrome
The wrist extensor weakness of patients with PINS is more
subtle than the wrist drop of patients with proximal RN pal-
sies, since the extensor carpi radialis longus muscle
(ECRL) remains intact. Careful neurologic exam is there-
fore essential for clinical detection of PINS. The classic
findings are decreased finger extension—especially fourth
and fifth fingers—and drift of the hand in a radial direction
when wrist extension is attempted due to extensor carpi
ulnaris (ECU) weakness [15]. Again, careful neurologic
exam reveals well-defined and painless finger extensor
weakness for PINS.
R.E. Seroussi et al.
Fig. 35.8 Hawkins test—passive overhead forward flexion and cross
adduction (Image courtesy Virtaj Singh, MD)
A more proximal radial nerve lesion can be excluded with
the following manual muscle tests during neurologic exam:
(1) intact strength of triceps: the examiner’s ability to detect
weakness is maximized if the patient attempts elbow exten-
sion from an initially flexed position; (2) sparing of brachio-
radialis, tested with the patient attempting elbow flexion
while simulating holding a glass of water to maximize the
muscle action of brachioradialis and minimize contribution
from biceps; and (3) detection of partial wrist extensor
strength, confirming sparing of ECRL.
Differential Diagnosis (Table 35.3)
There are several causes of forearm and elbow pain
(Table 35.3). The most closely related disorder is lateral epi-
condylitis, and patients may present with a combination of
both disorders [9, 32]. Additional conditions such as cervical
radiculopathy, shoulder impingement syndrome, thoracic
outlet syndrome, and CTS should be addressed by history.
For example, if pain extends proximally toward the shoulder
and neck and is worse with overhead activities or movement
of the neck, consider cervical and/or shoulder problems in
the differential diagnosis. If the patient wakes at night “flick-
ing” their wrist because it has “fallen asleep,” this is highly
suggestive of CTS (see Chap. 37). If the patient has increased
symptoms with flexion of the elbow such as with holding a
telephone, cubital tunnel syndrome (see Chap. 38) should be
considered as well.
35 Deep Branch of the Radial Nerve Entrapment 355

Table 35.3 Differential diagnosis of forearm and elbow pain Table 35.4 Diagnostic tests for deep radial nerve (PIN) entrapment
Diagnosis Potential distinguishing features Potential distinguishing features
Lateral epicondylitis (tennis Lateral elbow pain accompanied by Physical exam Tenderness over the “mobile wad,”
elbow) [4, 9, 32] tenderness at the lateral epicondyle 3–6 cm distal to the radial head
at the ECRB insertion (Fig. 35.4), Provocative test(s) Proximal wrist pain with resisted wrist
decreased grip strength with the extension [1, 3]
elbow extended. Notable pain with
Extend elbow and pronate arm—
isometric wrist extension against
resisted supination will lead to RTS
resistance
symptoms [1, 4, 13]
May coexist with RTS
Resisted middle finger extension
Extensor tendinitis [4] Pain with isometric muscle compresses the PIN against the edge of
activation or passive stretch of the ECRB, causing pain [1, 4, 13]
affected tendon, without radial
Diagnostic injection Radial tunnel injection results in pain
tunnel tenderness
relief [4]—this is particularly useful
Joint pathology [4] Pain and crepitance over the elbow because there are few objective tests
joint, including with passive range for RTS
of motion
Ultrasound May be useful in clarifying the anatomic
More proximal radial nerve, Weakness of more proximally cause of neuropathy [34, 35] in PINS,
brachial plexus, or cervical innervated muscles, decreased but generally not useful for RTS
spine problem [4, 12] reflexes, pain worse with overhead
MRI MRI microscopy can demonstrate PIN
activities
swelling and its cause (e.g., mass
Other peripheral nerve Carpal tunnel syndrome followed by lesion) [34, 35]
entrapments [8] cubital tunnel syndrome (ulnar
Routine MRI shows early and late
neuropathy at the elbow) are much
signs of muscle denervation [18]
more common peripheral nerve
entrapments and present with Only 4/25 of patients with RTS (no
specific sensorimotor abnormalities weakness) had normal MRI in one
on neurologic exam retrospective study, but MRI
abnormalities were nonspecific [18]
X-ray To rule out other bony pathologies
[4, 13]
There are few reliable objective data for the diagnosis Electrodiagnostic studies RTS: usually normal [1, 9]
of RTS, which has a primarily clinical basis (Table 35.4) Electrodiagnosis is viewed on the
[4–6, 36, 37]. spectrum from “very helpful” [14] to
“necessary to confirm the diagnosis” of
PINS [12, 28]
Identification and Treatment of Contributing
Factors Myofascial release techniques, muscle energy techniques,
eccentric strengthening, and gradual lengthening of the
Repeated pronation-supination of the forearm while lifting, extensor muscles can all be considered as part of a noninvasive
especially when combined with elbow extension, appears to treatment program. Treatment of associated conditions such
be an occupational risk factor for RTS [7, 38]. RTS is also as poor posture with weakness of the scapular muscles and
frequent among office workers with repetitive wrist exten- anterior head carriage may also provide some relief. In these
sion and pronation activities [13]. authors’ experience, a proximal forearm band often is help-
Relative rest from activities that aggravate upper extrem- ful for lateral epicondylitis, but not generally for RTS.
ity symptoms; ergonomic intervention including, increas- If the patient is not responding to the above regimen, it is
ingly, the use of wireless headsets and voice recognition advised to move forward with an injection to the area of
technology; medications including some of the newer topical maximal tenderness within the radial tunnel, partly to
gels that provide analgesia locally; sleep restoration if appli- establish the diagnosis and partly to provide pain relief, if
cable, and physical or occupational therapy, including hand needed.
therapy [4, 9], may help alleviate symptoms. Splinting with
the wrist extended and forearm pronated [4, 9] and anti-
inflammatory medication may also be useful [4, 9]. Workers Injection Technique
with jobs that require sustained reaching and lifting, espe-
cially with repetitive forearm rotation, should be evaluated Landmark-Guided Technique
for any possible remedies from these work site tasks.
Unfortunately, a number of patients, especially those in the The patient is positioned either supine or sitting supported, with
building trades, do not have much in the way of “light duty” the forearm pronated. In these authors’ experience, it is most
or ergonomic hope for modifying occupational tasks. comfortable to have the patient on a raised exam table in the
356
supine position with the elbow extended and the forearm pro-
nated. The proximal and distal borders of the supinator muscle
are mapped, using the radial head as a reference point. The point
of maximal tenderness is palpated as described above (Video
35.2). After sterile skin preparation, a 27-gauge, 1.5-in. needle is
directed anteromedially in a transverse plane without image
guidance toward the point of maximal tenderness (Fig. 35.9). It
is counterproductive to anesthetize the skin first, as this may
obscure the patient’s response to reaching the point of maximal
tenderness, and involves a second needle procedure. A reason-
able injectate composition is 1 cc of 1 % or 2 % lidocaine mixed
with 1 cc of a corticosteroid, such as triamcinolone.
The role of an injection is mostly diagnostic, although
some patients can have benefit from an injection for up to
Fig. 35.9 Landmark-guided injection of deep branch of radial nerve at
the radial tunnel (Image courtesy of Richard Seroussi, MD)
Fig. 35.10 Ultrasound-guided injection of deep branch of radial nerve at the radial tunnel (Image courtesy of Richard Seroussi, MD)
R.E. Seroussi et al.
months at a time. For better diagnostic information, provide
a post-procedure symptom diary for patients to return on
follow-up. Patients are advised to use their forearm, includ-
ing aggravating activities, but not to push themselves too
hard while the anesthetic is still in effect. RTS patients usu-
ally have at least 50 % acute improvement in symptoms,
including activities that would normally aggravate their con-
dition. Patients usually experience acute palsy of the finger
extensors with this procedure and should be informed before
the block that this is an expected outcome that implies injec-
tion accuracy. Depending on the duration of nerve palsy,
patients are advised against driving and may need a driver to
accompany them for the procedure. If the physician does not
use a large volume of concentrated local anesthetic, most
patients can be discharged independently 10–40 min after
the procedure.
Fluoroscopic-Guided Technique
There is no role for fluoroscopic guidance for this procedure.
Ultrasound (US)-Guided Technique
Ultrasound-guided DBRN injections can be quite helpful.
Martinoli and others highlight the US anatomy of the trans-
verse and the longitudinal anatomy of the proximal radial tun-
nel under ultrasound; the DBRN is sandwiched between the
superficial and deep bellies of supinator muscle [10, 11]. The
transducer is held in a transverse plane over the brachioradia-
lis muscle at the area of maximal tenderness (Fig. 35.10) for
a long axis view of the injecting needle. Injection just adja-
cent to the nerve is generally fairly straightforward; however,
it can be difficult to discern in cross section, so shifting the
35 Deep Branch of the Radial Nerve Entrapment
probe proximally and distally to track the nerve as it courses
radially toward the wrist can be helpful.
Surgical Treatment
There is a body of surgical literature regarding PINS and
RTS, mostly outside the scope of this discussion. To date,
there are no reports of controlled trials of operative or nonop-
erative interventions to treat either syndrome. Systematic
reviews of observational case series revealed only a few
reports of sufficient quality for analysis: all involved surgical
treatment of RTS (n = 6) [5] or PINS (n = 2) [2]. The authors
concluded that “surgical decompression of the radial tunnel
might be effective in patients with RTS” [5] and “there is a
tendency for the effectiveness of surgical decompression of
the PIN in patients with PINS” [2].
If the patient has a fairly good response to diagnostic
injection, referral to a surgical specialist for radial tunnel sur-
gery is likely indicated [4]. Since PINs may lead to perma-
nent nerve injury, patients should have surgical release if not
improved by 3 months [9]. Delay is usually not a problem in
patients with RTS, because of the pain [4]. It is most
important to have the correct diagnosis (especially with
respect to possible lateral epicondylitis) [4] and to release all
sites of compression [4, 13].
When referring a patient for possible surgery, the provider
should have confidence that the surgical consultant has
extensive experience in radial tunnel release, since it is not a
common procedure.
Complications
Complications of the injection technique are similar to those of
most peripheral nerve injections, including the chance of exces-
sive bleeding, nerve injury, and/or infection. Inducing increased
pain is possible; acute nerve palsy is an expected outcome, as
discussed above. Generally, however, the procedure is fairly
well tolerated without significant long-term morbidity.
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