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Posterior Interosseous Nerve Palsy Caused by a Myxoma
Hiroshige Sakai,
Hiroyuki Fujioka and
Takeshi Makino
Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe 650 0017, Japan, E-mail: hfujioka{at}med.kobe-u.ac.jp
Dear Sir,
A 67 year-old woman presented with inability to extend the metacarpophalangeal joints of all of the fingers of the right hand actively and a mass in the anterior aspect of her right elbow. She could extend her wrist actively and the full passive range of motion of the fingers was preserved. The elbow lesion was a soft tissue mass of approximately 3 cm in diameter which was well defined, firm and slightly tender. There was no sensory loss in the hand. Transverse T1-weighted MRI revealed a lesion with iso-signal intensity with normal muscle adjacent to the anterior surface of the radius and with an incomplete rim of fat (Fig 1A). Transverse T2-weighted MRI demonstrated a lesion with homogeneous high signal intensity, in which there were low signal striae (Fig 1B). Electrodiagnostic studies showed denervation of the extensor digitorum communis, identifying a posterior interosseous nerve palsy secondary to tumour. At surgery, the radial nerve was identified at the elbow and traced distally through an anterior approach. The posterior interosseous nerve was entrapped and compressed between the arcade of Frohse and the tumour, which was located deep to the nerve (Fig 1C). The posterior interosseous nerve was dissected off the mass under direct vision. The tumour, which was enclosed by a white capsule and attached to the neck of the radius and the supinator muscle, was then excised. Histological examination reported a myxoma. Two years after surgery, the patient was asymptomatic and there was no recurrence of the lesion.
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Fig 1 MRI findings (A) and (B) arrows indicate the tumour and (C) intraoperative finding. (A) Transverse T1-weighted MRI showing a lesion with an iso-signal intensity and normal muscle attached to the anterior surface of the radius. (B) Transverse T2-weighted MRI demonstrating the lesion as a homogeneous high signal intensity area in which there are low signal striae. (C) The posterior interosseous nerve is entrapped and compressed between the arcade of Frohse and the tumour, which is located deep to the nerve.
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Non-traumatic posterior interosseous nerve palsy can be caused by various space occupying lesions around the arcade of Frohse, including ganglion, lipoma, and bicipital bursa (Hashizume et al., 1996). Myxoma has been reported as a rare cause (Valer et al., 1993). The MRI findings of myxoma are similar to those of a cystic lesion, such as a ganglion or bursa, except that T2-weighted MRI demonstrates a lesion with homogeneous high signal intensity with low signal striae, suggesting septa in a tumour (Murphey et al., 2002).
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References
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- Hashizume H, Nishida K, Nanba Y et al Non-traumatic paralysis of the posterior interosseous nerve Journal of Bone and Joint Surgery B 1996 78 771 776.
- Murphey MD, McRae GA, Fanburg-Smith JC et al Imaging of soft-tissue myxoma with emphasis on CT and MR and comparison of radiologic and pathologic findings Radiology 2002 225 215 224.[Abstract/Free Full Text]
- Valer A, Carrera L, Ramirez G Myxoma causing paralysis of the posterior interosseous nerve Acta Orthopaedica Belgica 1993 59 423 425.[Medline]
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Journal of Hand Surgery (European Volume), Vol. 33, No. 1,
84-85 (2008)
DOI: 10.1177/1753193407087120
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