Hand Surgery Source

RADIAL NERVE LACERATION

Introduction

Radial nerve lacerations and other injuries are most often seen with supracondylar humerus fractures, while penetrating trauma to the arm, forearm or wrist may also be responsible. These injuries are less common than those of the medial and ulnar nerves, but the complete transection of the radial nerve still remains a challenging problem for hand surgeons and their patients. Despite advances in microsurgical nerve repair, these procedures can leave patients with functional deficits, especially in adults.1-5

Pathophysiology

  • When a nerve is transected, the distal segment of the nerve undergoes Wallerian degeneration.
    • Distal axons degenerate secondary to calcium-activated calpain enzymes;6,7 degenerating myelin is phagocytized by Schwann cells and macrophages.
      • In the proximal stump, degeneration also occurs in a proximal direction for a distance of ≥1 nodes of Ranvier.
      • In the distal segment, Schwann cells proliferate forming the bands of Bunger after nerve transection.
    • In the proximal segment, the axon cone develops and grows distally at a rate of 1-2mm/day (1 inch/mo) after the cut ends of the nerve have been approximated and realigned by microsurgical repair.
      • Radial nerve lacerations are usually classified as complete or partial.
    • Partial: some intact nerve tissue connections between the nerve endings
    • Complete: no physical connection between the nerve endings (neurotomesis)
      • Axonotomesis: nerve is subjected to severe crush, stretch, or blast injury; axon can be severed with distal degeneration, while the Schwann cell basil lamina remains intact
      • Neuropraxia: nerve is stretched and stops conducting impulses while the neural. anatomy remains intact; there is no Wallerian degeneration after this type of stretch injury, and they usually recover without surgical intervention.7
  • The radial nerve,more than any other major nerve, can be injured during orthopaedic surgical treatments like K-wire pin placement or during fracture fixation (ORIF).8
  • The radial nerve can also be injuried by knife wounds, glass cuts, bullet wounds etc.

Related Anatomy

  • The radial nerve, which is composed of nerve fibers and axons covered by connective tissue called epineurium.  The radial nerve travels in the posterior compartment of the arm, deep to the long head and enveloped in the medial and lateral heads of the triceps muscle. It traverses the spiral groove of the humerus, and passes anteriorly through the lateral intermuscular septum in the supracondylar region of the humerus.4
  • The axon has a cell membrane (axolemma) surrounding a tube of neural cytoplasm (axoplasm).7 Axons are encased by the endoneurium.
  • Axons are grouped in fascicles that are surrounded by the perineurium.9  Perineurium provides a diffusion and conduction barrier between the fascicles.7
  • In the radial nerve, groups of fascicles are arranged in fascicular groups, defined by the connective tissue called the internal epineurium.
  • In the distal part of the nerve, there are few connections between the fascicular groups; thus, the internal epineurium provides a surgical plane that can be dissected with microsurgical techniques.9
  • These fascicular groups together compose the radial nerve; external surface of the radial nerve is the external epineurium.
  • When the radial nerve is cut sharply, e.g. by broken glass, the nerve ends separate producing a functional gap due to fascicular group inherent elasticity.
  • In sharp cuts there is no loss of nerve tissue, i.e., no true defect; therefore, these ends can be repaired without excessive tension even if a few millimeters of neuroma are resected.9
  • If there is a long delay between laceration and nerve repair, the functional elastic gap may become more of a true defect because of scarring.
  • Most surgeons recommend mobilizing the nerve and gentle flexion of adjacent joints and end-to-end repair; if the true defect is 3-4 cm, nerve grafting would be indicated.10,11

Incidence

  • Peripheral nerve injury remains a common injury in civilian life and usually presents as a wrist drop with loss of thumb and finger extension. 19
  • In one report, an estimated 20 million Americans suffer peripheral nerve injuries annually.12
  • In 2006, there were 3,300 admissions for radial nerve lacerations; 70.8% of these patients were male, and 58.7% were in the 18-44 age group.13
  • Another report showed that 9% of wartime nerve injuries were lacerations of the radial nerve.14
  • Approximately 11.8% to 22% of humeral shaft fractures are associated with blunt injury to the radial nerve.15  These injuries are usually a neuropraxia and will recover without surgical intervention.19

Differential Diagnosis

  • Complete nerve laceration
  • Partial nerve laceration
  • Neuropraxia (stretch or crush injury)
  • Neuroma-in-continuity
ICD-10 Codes

RADIAL NERVE LACERATION

Diagnostic Guide Name

RADIAL NERVE LACERATION

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
RADIAL NERVE LACERATION (UPPER ARM LEVEL)   S44.22X_ S44.21X_  
RADIAL NERVE LACERATION (FOREARM LEVEL)   S54.22X_ S54.21X_  
RADIAL NERVE LACERATION (WRIST/HAND LEVEL)   S64.22X_ S64.21X_  

Instructions (ICD 10 CM 2020, U.S. Version)

THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S55 AND S65
A - Initial Encounter
D - Subsequent Routine Healing
S - Sequela

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Radial Nerve Laceration
  • Classic wrist drop after untreated recent radial nerve laceration. Note lack of thumb and finger extension as well.
    Classic wrist drop after untreated recent radial nerve laceration. Note lack of thumb and finger extension as well.
Basic Science Photos and Related Diagrams
Nerve Micro-anatomy
  • Radial Nerve with axons enclosed in endoneurium (1); Fascicle enclosed in perineurium (2); Fascicular groups enclosed in connective tissue called internal epineurium (3); Internal epineurium (4); External epineurium (5); Epineural blood vessels (6)
    Radial Nerve with axons enclosed in endoneurium (1); Fascicle enclosed in perineurium (2); Fascicular groups enclosed in connective tissue called internal epineurium (3); Internal epineurium (4); External epineurium (5); Epineural blood vessels (6)
Pathoanatomy Photos and Related Diagrams
Radial Nerve Anatomy
  • Distribution of Radial Nerve Motor Branches
    Distribution of Radial Nerve Motor Branches
  • Anterior (palmar or volar ) Sensation by Nerve: 1 = median nerve; 2 = dorsal radial sensory nerve; 3 = ulnar nerve; 4 = lateral antebrachial cutaneous nerve; 5 = medial antebrachial cutaneous nerve; 6 = radial dorsal antebrachial cutaneous nerve; 7 = medial brachial cutaneous nerve; 8 = intercostobrachial nerve; 9 = axillary nerve (superior lateral brachial cutaneous nerve.
    Anterior (palmar or volar ) Sensation by Nerve: 1 = median nerve; 2 = dorsal radial sensory nerve; 3 = ulnar nerve; 4 = lateral antebrachial cutaneous nerve; 5 = medial antebrachial cutaneous nerve; 6 = radial dorsal antebrachial cutaneous nerve; 7 = medial brachial cutaneous nerve; 8 = intercostobrachial nerve; 9 = axillary nerve (superior lateral brachial cutaneous nerve.
  • Posterior (Dorsal) Sensation by Nerve: 1 = median nerve; 2 = dorsal radial sensory nerve; 3 = ulnar nerve (dorsal ulnar sensory nerve); 4 = lateral antebrachial cutaneous nerve; 5 = medial antebrachial cutaneous nerve; 6 = posterior brachial cutaneous nerve, inferior lateral cutaneous nerve, posterior antebrachial cutaneous nerve; 7 = medial brachial cutaneous nerve; 8 = intercostobrachial nerve; 9 = axillary
    Posterior (Dorsal) Sensation by Nerve: 1 = median nerve; 2 = dorsal radial sensory nerve; 3 = ulnar nerve (dorsal ulnar sensory nerve); 4 = lateral antebrachial cutaneous nerve; 5 = medial antebrachial cutaneous nerve; 6 = posterior brachial cutaneous nerve, inferior lateral cutaneous nerve, posterior antebrachial cutaneous nerve; 7 = medial brachial cutaneous nerve; 8 = intercostobrachial nerve; 9 = axillary
Symptoms
History of trauma with a laceration in the area of the radial nerve or a distal third humerus fracture
Loss of normal motor function i.e. loss of wrist, finger, and thumb extension
Wound pain and paresthesias
Sensory loss to dorsal radial aspect of the hand
Loss of elbow extension is rare
Impaired grasp
Typical History

A 29-year-old male was running towards an open door.  An individual running in front of him did see the man running towards the glass door and let it go just as the man approached.  The man blocked the door with this elbow.  The glass door shattered and a large shard of glass pierced the man’s arm just proximal to the elbow on the lateral anterior surface. Without thinking, the man immediately pulled the glass shard out of his arm. The laceration caused significant bleeding initially, which the man stopped with a towel before having his wife take him to the emergency room. Once there, the examination revealed a relatively clean cut and a loss of sensation and motor function in the radial nerve distribution of his right limb distal to the cut. The wound was anesthetized with 1% local, and the wound was irrigated, debrided, the skin sutured.  A dressing and splint were applied. The patient saw a hand surgeon three days later who did a microsurgical radial nerve repair in the local ambulatory surgery center the following week.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Identify the presence of a complete radial nerve laceration, a partial radial nerve laceration, or a radial nerve neuropraxia.
  • Repair the complete or partial nerve laceration.
  • Carefully follow the patient with a radial nerve stretch injury (neuropraxia); a few patients with neuropraxia will require neurolysis but most will have spontaneous recovery in 3-6 months.
  • Improve function of injured upper extremity with a radial nerve laceration.
Conservative
  • Nonoperative treatment of radial nerve complete or partial lacerations is appropriate when the patient’s associated injuries or medical comorbidities prevent anesthesia and a lengthy microsurgical repair under anesthesia. 4,8  Isolated radial nerve complete and partial lacerations should be repaired early, but repair is not an emergency.
  • Irrigation, debridement, and closure of the skin laceration with a scheduled operative nerve repair 1-3 few weeks is reasonable.
  • Radial nerve injuries associated with a humerus fracture or the manipulation of a humerus fracture should be followed carefully without surgical intervention because these radial nerve injuries are usually a neuropraxia and will recover spontaneously.
  • Neuropraxia of the radial nerve secondary to a stretch injury is fairly common after a distal humerus fracture. These stretch injuries could be watched for signs of spontaneous recovery.
  • If the humerus fracture has been treated with ORIF and before treatment the radial nerve function was normal and after surgery the radial nerve function is completely absent, then the possibility of an iatrogenic injury must be considered.
Operative

Complete Nerve Laceration

  • Complete radial nerve lacerations in civilian practice are usually seen acutely and are usually caused by sharp lacerations from broken glass, knives, saws, or vehicular accidents.
  • Complete nerve lacerations should be repaired with microsurgical procedures.
  • Choices for microsurgical repair include:
    1. Epineural repair
    2. Group fascicular repair
    3. Nerve repair with nerve grafts
    4. Nerve repair with nerve conduit
    5. Nerve transfers (rare)

Partial Nerve Laceration

  • Partial nerve lacerations can be repaired by dissecting the internal epineurium and isolating the transected fascicular groups, gently looping the intact fascicular groups and then repairing the cut fascicular groups by suturing the internal epineurial sheaths or by using nerve grafts for the cut fascicular groups is more likely to be needed.
  • If there is a significant true defect, for example after a bullet wound, then repairing the cut fascicular groups with nerve grafts between the cut fascicular groups is indicated.
  • Neurolysis of the radial nerve for a neuropraxia is uncommon.1,7

Nerve Grafting

  • Nerve grafting is an accepted treatment modality for larger radial nerve defects, but it is less efficacious for adults.  These are very reliable tendon transfers which will allow these patients to regain thumb, finger and wrist extension.5
  • The Martin Singer treatment algorithm for radial nerve lacerations, which is based on patient age and whether the injury can be repaired, recommends the following:
    • Patients <18 years: end-to-end suture repair when the laceration is repairable, and nerve graft when it is not
    • Patients >18 years: end-to-end suture repair when the laceration is repairable and has presented within 6 months, and tendon transfer when these criteria have not been met5

Nerve Transfers21

  • Nerve transfer for brachial plexus reconstruction are well defined in the literature; however, their usefulness for reconstructing median nerve lacerations is still evolving.1 However, nerve transfer(s) have been gaining in popularity as an alternative to tendon transfers/nerve grafting for patients with severe proximal nerve injuries, but the field is still evolving with new techniques being described as microsurgical techniques improve and more patients experience good outcomes.
  • Proposed Advantages of Nerve Transfer

-       Able to also restore sensory function

-       Multiple muscle groups can be reinnervated with a single nerve transfer

-       Muscle origin/insertions are not disrupted

  • Principles of Nerve Transfer

-       Ideally pick a donor nerve near the motor endplates of the target muscle to minimize time to innervation.  A shorter distance means shorter time  for reinnervation

-       Use expendable or redundant nerve fibers

-       Use donors that have a large number of axons

-       Use donors that already innervate synergistic muscles with the target muscle (helps facilitate re-education)

-       Using donors that match the target is ideal, i.e. motor donors for motor targets, sensory donors for sensory targets

-       Re-innervation after 12-18 months may be impossible, as prolonged denervation will cause muscle cell death and fibrosis.

  • Nerve transfers for Radial Nerve Palsy

-       Goals: Restore wrist extension, finger extension, radial sensation

-       Often augmented with pronator teres to ECRB tendon transfer (allows for wrist extension while nerve recovers)

-       Fascicles of Median nerve to FCR, PL or FDS are transferred to the PIN and the branch of the radial nerve innervating ECRB.  The strongest donor should be used to restore ECRB function

-       Radial sensory branch may be coapted end to side to the median nerve in an attempt to restore sensation

Treatment Photos and Diagrams
Radial Nerve Laceration Repair
  • Most radial nerve repairs will be done with an operative microscope.
    Most radial nerve repairs will be done with an operative microscope.
  • Micro-surgical radial nerve repairs will require micro-surgical instruments.
    Micro-surgical radial nerve repairs will require micro-surgical instruments.
  • Micro-surgical radial nerve repairs will require micro-sutures: 8-O supplemented with 9-O; and 10-O sutures
    Micro-surgical radial nerve repairs will require micro-sutures: 8-O supplemented with 9-O; and 10-O sutures
  • Most surgeons will do a micro-surgical radial nerve repair with an epieneural repair technique.
    Most surgeons will do a micro-surgical radial nerve repair with an epieneural repair technique.
  • Radial dorsal sensory branch of the radial nerve undergoing a micro-surgical repair with an epieneural repair technique.
    Radial dorsal sensory branch of the radial nerve undergoing a micro-surgical repair with an epieneural repair technique.
  • Micro-Surgical repair of the radial nerve with a group fascicular repair technique.
    Micro-Surgical repair of the radial nerve with a group fascicular repair technique.
  • Radial nerve laceration with a true loss of nerve tissue repaired with a micro-surgical nerve grafting procedure using a sural nerve graft (see insert).
    Radial nerve laceration with a true loss of nerve tissue repaired with a micro-surgical nerve grafting procedure using a sural nerve graft (see insert).
  • Radial nerve neuroma-in-continuity being evaluated by intra-operative electrophysiological testing.
    Radial nerve neuroma-in-continuity being evaluated by intra-operative electrophysiological testing.
  • Micro-Surgical epineural repair of small partial nerve laceration.
    Micro-Surgical epineural repair of small partial nerve laceration.
  • Radial nerve 60% partial laceration repaired by separating the intact fascicular groups from the sharply cut groups followed by fascicular group repair of the cut portion of the nerve. Tension temporarily controlled by a epieneural suture in the intact fascicular groups (arrow).
    Radial nerve 60% partial laceration repaired by separating the intact fascicular groups from the sharply cut groups followed by fascicular group repair of the cut portion of the nerve. Tension temporarily controlled by a epieneural suture in the intact fascicular groups (arrow).
  • Larger radial nerve partial laceration with significant nerve loss. Nerve graft repair done by separating (yellow line) the intact fascicular groups from the groups with nerve loss. The damage portion of the nerve (red box) removed and graft trimmed and sutured into the gap.
    Larger radial nerve partial laceration with significant nerve loss. Nerve graft repair done by separating (yellow line) the intact fascicular groups from the groups with nerve loss. The damage portion of the nerve (red box) removed and graft trimmed and sutured into the gap.
Radial Nerve Laceration Secondary to Humerus Fracture
  • Open segmental humerus fracture (arrows) with radial nerve laceration in a patient with multiple injuries.
    Open segmental humerus fracture (arrows) with radial nerve laceration in a patient with multiple injuries.
  • Radial nerve ends (arrows) at secondary nerve grafting procedure, Original injury cut the radial nerve and damaged a significant length of the radial nerve creating a true nerve gap.
    Radial nerve ends (arrows) at secondary nerve grafting procedure, Original injury cut the radial nerve and damaged a significant length of the radial nerve creating a true nerve gap.
  • Sural nerve grafts (arrows) taken from the opposite leg.
    Sural nerve grafts (arrows) taken from the opposite leg.
  • Sural nerve grafting of radial laceration with large true nerve gap. Plate on humerus for fracture ORIF(1); Humerus distal end (2).; Sural nerve grafts (3); Proximal radial nerve (4); Distal radial nerve (5).
    Sural nerve grafting of radial laceration with large true nerve gap. Plate on humerus for fracture ORIF(1); Humerus distal end (2).; Sural nerve grafts (3); Proximal radial nerve (4); Distal radial nerve (5).
Radial Nerve Laceration Secondary Mangled Left Upper Extremity
  • Severe injuries to the left upper extremity secondary to a MVA. Insert bottom left shows open metacarpal base fracture and lacerated thumb extensors (arrows). Insert top right shows massive injury to lateral elbow with loss radial nerve segment, loss of proximal extensor muscles, and los of lateral epicondyle and half of the capitellum.
    Severe injuries to the left upper extremity secondary to a MVA. Insert bottom left shows open metacarpal base fracture and lacerated thumb extensors (arrows). Insert top right shows massive injury to lateral elbow with loss radial nerve segment, loss of proximal extensor muscles, and los of lateral epicondyle and half of the capitellum.
  • Lateral elbow after debridement with damaged distal and proximal radial nerve ends in the forceps. Unsalvageable radial nerve extended proximally and distally.; Capitellum (arrow).
    Lateral elbow after debridement with damaged distal and proximal radial nerve ends in the forceps. Unsalvageable radial nerve extended proximally and distally.; Capitellum (arrow).
  • Left upper extremity after months rehabilitation and reconstructive surgeries including care for thumb fracture and extensors, skin grafting, and Jones style tendon transfers ( PT to ECRB, FCR to finger extensors, FDS IV to EPL). See functional outcome in video below.
    Left upper extremity after months rehabilitation and reconstructive surgeries including care for thumb fracture and extensors, skin grafting, and Jones style tendon transfers ( PT to ECRB, FCR to finger extensors, FDS IV to EPL). See functional outcome in video below.
CPT Codes for Treatment Options

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Common Procedure Name
Tendon transfer
CPT Description
Tendon transplant or transfer flexor/extensor single each tendon
CPT Code Number
25310
Common Procedure Name
Extensor tendon transfer
CPT Description
Tendon transfer or transplant, CM area or dorsum of hand single w/o free graft
CPT Code Number
26480
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

 CPT QuickRef App.  For Apple devices: App Store. For Android devices: Google Play

 CPT 2021 Professional Edition: Spiralbound

Complications
  • Loss of sensory and/or motor function
  • Persistent pain and/or paresthesias
  • Neuroma-in-continuity
  • Infection
  • Complex regional pain syndrome
Outcomes
  • Permanent deficits after nerve repair remain a problem, especially for adults.1
  • Since World War II, the results of nerve repair also have been classified using a grading system designed by the British Medical Research Council.7,16,17

THE MEDICAL RESEARCH COUNCIL SYSTEM7,16,17

Motor Recovery
M0 No contraction
M1 Return of perceptible contraction in the proximal muscles
M2 Return of perceptible contraction in both the proximal muscles and distal muscles
M3 Return of perceptible contraction in both the proximal muscles and distal muscles of such a degree that all important muscles are sufficiently powerful to act against resistance
M4 Return of function as in stage 3 with the addition that all synergic and independent movements are possible
M5 Complete recovery
 
Sensory Recovery
S0 Absence of sensibility in the autonomous area
S1 Recovery of deep cutaneous pain sensibility within the autonomous area of the nerve
S2 Return of some degree of cutaneous pain and tactile sensibility within the autonomous area
S3 Return of some degree of superficial cutaneous pain and tactile sensibility within the autonomous area with disappearance of any previous overreaction within the autonomous area
S3+ Return of some sensibility as in stage 3 with the addition that there some recovery of two point discrimination within the autonomous area
S4 Complete recovery
  • Other factors that affect the outcome of radial nerve repair include the age of patient (young patients do better); the level of the laceration (distal lacerations do better); the type of nerve (pure motor or pure sensory nerves do better); the delay between injury and repair (earlier repairs do better); and the cause of the radial nerve laceration (sharp clean cuts do better).1,7
    • Proximal radial nerve lacerations are associated with lower recovery rates of finger and thumb extension because of the increased distance of innervation of the target muscles.5
  • When the laceration is caused by a sharp transection, then primary end-to-end surgical nerve repair achieves better favorable functional outcomes than delayed repair.18
  • In one series, 9 patients with radial nerve lacerations were treated surgically: 3 with primary end-to-end suture repair, 2 with secondary suture repair, 2 with secondary graft repairs, and 2 with a partial split-graft repair.  Overall, 8 of 9 patients achieved Grade 3 (moderate) or better functional recovery (89%), and both patients with sharp lacerations who underwent primary end-to-end repair achieved an excellent recovery.18
Video
Left upper extremity after months rehabilitation and reconstructive surgeries including care for thumb fracture and extensors, skin grafting, and Jones style tendon transfers ( PT to ECRB, FCR to finger extensors, FDS IV to EPL). See functional outcome i
Key Educational Points
  • The radial nerve is one of the terminal branches of the posterior cord. 19
  • Before crossing the elbow, the radial nerve innervates part of the brachialis muscle; the brachioradialis; the anconeus and the extensor carpi radialis longus.19
  • The Holstein-Lewis spiral or transverse fracture in the distal third of the humerus are supposed to put the radial nerve at risk but other investigations have shown that the nerve is at risk over a much wider area. The area of susceptibility extends from the posterior humerus where the radial nerve lies against the bone to the lateral metaphyseal area of the humerus. Therefore, it is believed that the classic Holstein-Lewis fracture patterns are not the only humeral fractures associated with the radial nerve injury.19,20
  • Radial nerve palsies that are associated with closed humerus fractures recovered spontaneously in 60 to 90% of the cases. Therefore, observation for 4-6 months is warranted before exploring the radial nerve surgically. However, other experts argued that 20-42% of late radial nerve explorations revealed a nerve laceration and therefore recommend early nerve exploration in all cases.19
  • EMGs/NCV at 2-3 months post radial injury can show signs of early radial nerve recovery and provide support for observation alone.
  •  In open radial nerve injuries with significant nerve gaps, nerve grafting can be used as an appropriate treatment. If the injury has caused a large true nerve tissue loss then tendon transfers can restore function without nerve grafting.
  • Anterior transposition of the radial nerve when caring for an open humerus fracture and nerve injury can increase her functional level of the radial nerve significantly and allow end-to-end repair in cases that might otherwise need grafting.19
  • Pre-operative EMG/NCV electrodiagnostic testing can help define the level of the nerve injury and the completeness of the nerve injury (i.e., neuropraxia vs axonotomesis).1,7Electrodiagnostic testing may also show signs of recovery before recovery can be identified by physical examination.  Early EMG/NCV may be less helpful than studies done after a few weeks from the time of injury.
  • MRI can help identify and define nerve tumors, some nerve stretch,injuries and neuromas-in-continuity.1
  • Several experts recommend that direct end-to-end suture repair should always be attempted or at least considered in all radial nerve lacerations.5
References

New and Cited Articles

  1. Pederson, WC. Median nerve injury and repair.J Hand Surg Am 2014;39(6):1216-22. PMID: 24862118
  2. Galanakos, SP, Zoubos, AB, Ignatiadis, I, et al. Repair of complete nerve lacerations at the forearm: an outcome study using Rosen-Lundborg protocol. Microsurgery 2011;31(4):253-62.PMID: 21557303
  3. Chemnitz, A, Bjorkman, A, Dahlin, LB, et al. Functional outcome thirty years after median and ulnar nerve repair in childhood and adolescence. J Bone Joint Surg Am 2013;95(4):329-37. PMID: 23426767
  4. Martin, DF, Tolo, VT, Sellers, DS, et al. Radial nerve laceration and retraction associated with a supracondylar fracture of the humerus. J Hand Surg Am 1989;14(3):542-5.PMID: 2544642
  5. Laubscher, M, Held, M, Maree, M, et al. Radial nerve lacerations--the outcome of end-to-end repairs in penetrating trauma. Hand Surg 2015;20(1):67-72. PMID: 25609277
  6. Fernandez, L, Komatsu, DE, Gurevich, M, et al. Emerging Strategies on Adjuvant Therapies for Nerve Recovery. J Hand Surg Am 2018;43(4):368-373. PMID: 29618417
  7. Birch R. Nerve Repair. In: Green’s Operative Hand Surgery, Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds), Philadelphia, Elsevier Churchill Livingstone, 2011, pp. 1035-1092
  8. Fatemi, MJ, Habibi, M, Pooli, AH, et al. Delayed radial nerve laceration by the sharp blade of a medially inserted Kirschner-wire pin: a rare complication of supracondylar humerus fracture. Am J Orthop (Belle Mead NJ) 2009;38(2):E38-40.PMID: 19340386
  9. Hurst, LC, Dowd, A, Sampson, SP, et al. Partial lacerations of median and ulnar nerves. J Hand Surg Am 1991;16(2):207-10. PMID: 2022827
  10. Millesi, H. The nerve gap. Theory and clinical practice. Hand Clin 1986;2(4):651-63.PMID: 3539948
  11. Terzis, J, Faibisoff, B and Williams, B. The nerve gap: suture under tension vs. graft. Plast Reconstr Surg 1975;56(2):166-70. PMID: 1096197
  12. Taylor, CA, Braza, D, Rice, JB, et al. The incidence of peripheral nerve injury in extremity trauma. Am J Phys Med Rehabil 2008;87(5):381-5. PMID: 18334923
  13. Lad, SP, Nathan, JK, Schubert, RD, et al. Trends in median, ulnar, radial, and brachioplexus nerve injuries in the United States. Neurosurgery 2010;66(5):953-60.PMID: 20414978
  14. Birch, R, Misra, P, Stewart, MP, et al. Nerve injuries sustained during warfare: part II: Outcomes. J Bone Joint Surg Br 2012;94(4):529-35. PMID: 22434471
  15. Shao, YC, Harwood, P, Grotz, MR, et al. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br 2005;87(12):1647-52.PMID: 16326879
  16. Seddon HJ. Surgical Disorders of the Peripheral Nerves, ed 7. Edinburgh, Churchill-Livingstone, 1975, pp. 276-280.17.
  17. Seddon HJ (ed): Peripheral Nerve Injuries, Medical Research Council Special Report Series No. 282, London, Her Majesty’s Stationery Office, 1954.
  18. Kim, DH, Kam, AC, Chandika, P, et al. Surgical management and outcome in patients with radial nerve lesions. J Neurosurg 2001;95(4):573-83. PMID: 11596951
  19. Ljungquist KL, Martineau P, Allan C. Radial Nerve Injuries. J Hand Surg Am. 2015; 40(1): 166-172.
  20. Carlan D, Pratt J, Patterso MM, Weiland AJ, Boyer MI, Gelberman RH. The radial nerve in the brachium: an anatomical study in human cadavers. J Hand Surg Am. 2007; 32(8): 1177-1182.
  21. Weber RV, Mackinnon SE. Nerve transfers in the upper extremity. J Hand Surg Am. 2004; 4(3): 200-213.
  1. Classic
  1. Carroll RE, Match RM. Common errors in the management of wrist lacerations. J Trauma1974;14(7):553-62. PMID: 4601963