Eur J Plast Surg (2002) 25:35–37

DOI 10.1007/s00238-001-0335-7

C A S E R E P O RT

E. Monteiro · A. Moura · F. Barros · P. Carvalho

A. Ferraro

Lipoma causing a posterior interosseous nerve syndrome

Received: 20 August 2001 / Accepted: 29 November 2001 / Published online: 15 February 2002
© Springer-Verlag 2002

Abstract Posterior interosseous nerve syndrome is an Case report

entrapment neuropathy of the deep terminal branch of
the radial nerve – the posterior interosseous nerve – at
the radial tunnel. Radial neuropathy without prior injury
or other obvious etiology occurs frequently. However,
sometimes previous trauma, surgery, or tumors over the
radial nerve contribute to chronic entrapment and can
produce the classic syndrome. In this report we describe
an unusual case of a 68-year-old-woman with a chronic
posterior interosseous nerve syndrome due to a lipoma.
The patient had poor recovery after surgery, despite
splinting and rehabilitation physiotherapy, mainly be-
cause of the long duration (2 years) and severity of the
compression neuropathy.
Keywords Posterior interosseous nerve syndrome ·
Lipoma · Chronic entrapment
Introduction
The posterior interosseous nerve syndrome (PINS) is
characterized by weakness of the muscles innervated by
the motor branch of the radial nerve: the supinator mus-
cle, the extensor muscles of the wrist (except the exten-
sor carpi radialis longus), the extensor muscles of the
fingers, and the abductor pollicis longus muscle. In the
vast majority of cases, PINS develops spontaneously,
combining anatomical anomalies and occupational fac-
tors. This paper describes an unusual case of severe
PINS caused by an undiagnosed lipoma, treated by im-
mediate surgical exploration.
A right-hand-dominant, 68-year-old-woman presented with inabil-
ity to extend the fingers of the right hand. She worked at home
and did not have a high degree of repetitive motion in her daily ac-
tivities. The patient noticed a gradually increasing inability to ex-
tend the fingers over the course of more than 2 years. She was un-
able to perform her domestic activities, especially by the end of
the day, because of weakness and paresis of the right hand. The
patient was hypertensive and had a history of contusion injury in
the right arm 1 year before the onset of the symptoms.
Physical examination revealed inability to extend the right
hand fingers, including the thumb, at the level of metacarpopha-
langeal joints; it also revealed that the thumb could not be abduct-
ed (Fig. 1). There was a slightly visible muscle atrophy of the ex-
tensor group, but there was no wrist drop. The hand deviated radi-
ally during wrist extension. Palpation of the proximal third of the
forearm over the arcade of Froshe, produced local tenderness, but
no mass was palpated in this area. The Tinel’s sign was negative,
and there were no sensory changes over the radial area in the fore-
arm. The electromyogram revealed signs of severe, chronic com-
pression of the posterior interosseous nerve (PIN), with involve-
ment of the branch of the extensor carpi radialis brevis.
After a group consultation, surgical exploration was recom-
mended. Axillary block anesthesia was administered and under
tourniquet control, a lazy-S incision was made over the elbow. The

E. Monteiro (✉)
R. Marta Mesquita da Câmara 149 Hab:31, 4150 Porto, Portugal
e-mail: eduardojmonteiro@clix.pt
E. Monteiro · A. Moura · F. Barros · P. Carvalho · A. Ferraro
Department of Plastic, Reconstructive and Aesthetic Surgery,
Hospital da Prelada, Rua de Sarmento Beires, 153, Fig. 1 Right hand with inability to extend the fingers, including
P.O. BOX 52857, 4251–901 Codex, Porto, Portugal the thumb. The thumb cannot be abducted
36

Fig. 2 A fatty mass in the dependency of the proximal edge of the Fig. 3 Removal of the tumor, which was revealed as being well-
supinator muscle, after dividing the arcade of Froshe demarcated and encapsulated, with a fatty consistency

radial nerve was identified in the intermuscular plane in the arm,

as well as the leading edge of the supinator muscle. Exploration
revealed a fatty encapsulated mass, compatible with lipoma, con-
stricting the PIN (Fig. 2, Fig. 3). The arcade of Froshe was divid-
ed, and the lipoma was excised en bloc. The superficial radial
nerve and PIN were preserved (Fig. 4), hemostasis was achieved,
and the incision was closed in layers. Pathologic examination re-
vealed a fatty mass, with 4×2.5 cm, consistent with lipoma
(Fig. 5). The outcome 6 months postoperatively was poor, with no
recovery of radial paralysis.

Discussion
PINS frequently occur without prior injury or other obvi-
ous etiology [1, 2, 3], combining anatomical anomalies
and occupational factors [4]. Previous trauma in 25% of
cases and following surgery in 15% are other causes of
PINS, which cannot be neglected.
The PIN can be compressed against the arcade of
Froshe by space-occupying lesions, causing a long-last-
ing and well-established PINS. Lipomas are benign tu-
mors composed of mature lipocytes and they represent
one of the most prevalent tumors of mesenchymal origin
[5, 6, 7]. Lipomas and other tumors over the radial nerve
are rare causes of chronic entrapment of the PIN, but
they can produce a classic picture of PINS. There are
some reports of compression neuropathies [8, 9] of the
Fig. 4 The posterior interosseous nerve was decompressed and
the superficial branch of the radial nerve was protected. Note the
presence of the lateral antebrachial cutaneous nerve, a sensory
branch of the musculocutaneous nerve
upper limb caused by this kind of tumor. Other causes of
PIN compression have been described: rheumatoid syno-
vial cysts [10], ganglion [11], myxoma [12], and pseudo-
gout [13], among others.
The diagnosis of PINS is based on clinical history and
physical examination, and is confirmed by electrophysi-

Fig. 5 Tumor dimensions (4×2.5 cm)
ological studies. Classically, this syndrome has neither
pain nor other sensory symptoms, but there are cases of
forearm pain and paralysis of the extensor muscles of the
forearm. The explanation for this can be that pain pre-
sumably arises from the compression of small myelinat-
ed afferent fibers or from supra-maximal stimulation of
large afferents from muscle spindles [14]. Another possi-
bility is that direct trauma to the proximal forearm, with
injury to the lateral cutaneous nerve, may cause sensory
changes in the radial part of the forearm. The electromy-
ogram can confirm the diagnosis of PIN palsy, as well as
the topography and severity of the lesion. If there is any
suspicion, based on clinical examination, of a mass as
the causative factor of PINS, MRI scan is the imaging
method of choice for evaluating their presence and ex-
tent. In this clinical case there was no palpable mass on
the forearm, perhaps because the lipoma was located in-
tramuscularly, protected by the arcade of Froshe.
The treatment of PINS is initially conservative, with
splinting to prevent overstretching of the weak muscles,
but the period of observation varies widely in the litera-
ture. Young et al. in a report of 51 patients with PINS
concluded that if there was no clinical or electrophysio-
logical recovery after 3 months, the patient should be op-
erated on, before the onset of muscle atrophy [15]. In
this report we performed surgical exploration without a
period of observation, because the patient already had a
full paralysis with end-organs atrophy. Jürgens und
Haupt, in a study of 20 patients with PIN paralysis, con-
cluded that the result of the operation depended on the
duration of the symptoms, so that long-lasting paralysis
37
made reinnervation less likely to occur [16]. According
to the study by De-song et al., early diagnosis and sur-
gery are very important in the treatment of PINS [17].
In patients such as the one presented, with a full pa-
ralysis of the muscles innervated by the deep terminal
branch of the radial nerve, the prognosis is poor and de-
pends on the severity, duration, site of entrapment neu-
ropathy, and the age of the patient.
References
1. Kaplan PE (1984) Posterior interosseous neuropathies: natural
history. Arch Phys Med Rehabil 65:399–400
2. Cravens G, Kline DG (1990) Posterior interosseous nerve pal-
sies. Neurosurgery 27:397
3. Spinner M (1968) The arcade of Froshe and its relationship to
posterior interosseous nerve paralysis. J Bone Joint Surg Br
50:809
4. Serra G, Aiello I, Cristofori MC, Rosati G, Tugnoli V, Traina
GC (1984) Posterior interosseous nerve palsy: report of three
unusual cases. Ital J Neurol Sci 5:85–87
5. Scherl MP, Biller HF, Shah K, Som PM (1986) Recurrent in-
filtrating lipoma of the head and neck: case report and litera-
ture review. Arch Otolaryngol Head Neck Surg 112:1210
6. Harrington AC, Adnot J, Chesser RS (1990) Infiltrating lipo-
mas of the upper extremities. J Dermatol Surg Oncol 16:834
7. Leffert RD (1972) Lipomas of the upper extremity. J Bone
Joint Surg [Am] 54:1262
8. Pidgeon KJ, Abadee P, Kanakamedala R, Uchizono M (1985)
Posterior interosseous nerve syndrome caused by an intermus-
cular lipoma. Arch Phys Med Rehabil 66:468–471
9. Kremchek TE, Kremchek E (1988) Carpal tunnel syndrome
caused by flexor tendon sheath lipoma. Orthop Rev 17:1083
10. Ishikawa H, Hirohata K (1990) Posterior interosseous nerve
syndrome associated with rheumatoid synovial cysts of the el-
bow joint. Clin Orthop 254:134–139
11. Ogino T, Minami A, Kato H (1991) Diagnosis of radial nerve
palsy caused by ganglion with use of different imaging tech-
niques. J Hand Surg [Am] 16:230–235
12. Valer A, Carrera L, Ramirez G (1993) Myxoma causing paral-
ysis of the posterior interosseous nerve. Acta Orthop Belg
59:423–425
13. Taniguchi Y, Yoshida M, Tamaki T (1999) Posterior interosse-
ous nerve syndrome due to pseudogout. J Hand Surg [Br]
24:125–127
14. Birch R, Bonney G, Wynn PCB (1998) Surgical disorders of
the peripheral nerves. 1st. edn, Churchill Livingstone, London.
283–284
15. Young C, Hudson A, Richards R (1990) Operative treatment
of palsy of the posterior interosseous nerve in the forearm. J
Bone Joint Surg [Am] 72:1215–1219
16. Jürgens R, Hampt WF (1987) The supinator syndrome: clini-
cal course in 20 patients and recommendations for treatment.
Nervenarzt 58:30–32
17. De-song C, Gao-meng Z, Yu-dong G (1994) Entrapment of
posterior interosseous nerve of forearms: report of 25 cases.
Chin Med J (Engl) 107:196–99