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Congenital Radial Nerve Palsy

Published:October 22, 2014DOI:https://doi.org/10.1016/j.jhsa.2014.08.040
      Although advancement in obstetrical care has been made, shoulder dystocia and brachial plexus birth palsy (BPBP) continue to have a relatively stable incidence.
      • Abzug J.M.
      • Kozin S.H.
      Evaluation and management of brachial plexus birth palsy.
      • Foad S.L.
      • Mehlman C.T.
      • Foad M.B.
      • Lippert W.C.
      Prognosis following neonatal brachial plexus palsy: an evidence-based review.
      Isolated congenital radial nerve palsy is much more rare, and may represent only 1% to 2% of cases referred for evaluation of a brachial plexus injury.
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.
      Whereas brachial plexus injury can have high variability in recovery, isolated congenital radial nerve palsy has almost uniformly resulted in complete nerve recovery regardless of how severe the initial presentation was.
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.
      • Siqueira M.G.
      • Scaramuzzi V.
      • Heise C.O.
      • Martins R.S.
      • Sterman H.
      Bilateral radial nerve compression neuropathy in the newborn.
      • Bohringer E.
      • Weber P.
      Isolated radial nerve palsy in newborns—case report of a bilateral manifestation and literature review.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      • Hayman M.
      • Roland E.H.
      • Hill A.
      Newborn radial nerve palsy: report of four cases and review of published reports.
      Due to the low incidence and typical spontaneous recovery, the true incidence of congenital radial nerve palsy remains unknown.
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.
      • Siqueira M.G.
      • Scaramuzzi V.
      • Heise C.O.
      • Martins R.S.
      • Sterman H.
      Bilateral radial nerve compression neuropathy in the newborn.
      • Bohringer E.
      • Weber P.
      Isolated radial nerve palsy in newborns—case report of a bilateral manifestation and literature review.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      • Hayman M.
      • Roland E.H.
      • Hill A.
      Newborn radial nerve palsy: report of four cases and review of published reports.

      Evaluation

      The assessment should begin by obtaining a thorough birth history including the weight of the baby, mode of delivery, utilization of assistive devices, and immediate function in the affected extremity. Subsequently, the physical examination should focus on determining which nerve roots and/or peripheral nerves are not functioning (Fig. 1). It is also important to ensure that there are no fractures present—these may result in a “pseudopalsy.” Separating a BPBP from a congenital radial nerve palsy can be difficult, therefore assessment may lie in eliciting flexor functions of the upper extremity. A lack of grasp reflex, or weak hand grip, can be seen in BPBP but not in congenital radial nerve palsy.
      • Bohringer E.
      • Weber P.
      Isolated radial nerve palsy in newborns—case report of a bilateral manifestation and literature review.
      • Hayman M.
      • Roland E.H.
      • Hill A.
      Newborn radial nerve palsy: report of four cases and review of published reports.
      Additionally, shoulder and elbow motion are normal in congenital radial nerve palsies (Video 1, available on the Journal’s Web site at www.jhandsurg.org) but may not be in BPBP patients.
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      BPBP can also be distinguished from congenital radial nerve palsies by assessing for the Moro and asymmetric tonic neck reflexes, as well as symptoms of Horner’s syndrome.
      • Abzug J.M.
      • Kozin S.H.
      Evaluation and management of brachial plexus birth palsy.
      The Moro reflex will elicit shoulder abduction and elbow extension, which should be present in congenital radial nerve palsies but may be impaired in BPBP. The asymmetric tonic neck reflex induces flexion of the upper and lower extremities on one side with extension of the arm and leg on the contralateral side, which again should be a normal reflex in an isolated peripheral radial nerve injury.
      • Abzug J.M.
      • Kozin S.H.
      Evaluation and management of brachial plexus birth palsy.
      Figure thumbnail gr1
      Figure 1Left-sided congenital radial nerve palsy in an infant as demonstrated by the left-sided wrist drop.
      (Image courtesy of Joshua M. Abzug, MD.)
      An additional clue in establishing the diagnosis of a congenital radial nerve palsy can be characteristic skin findings (Fig. 2). Of the 55 cases of congenital radial nerve palsies in the literature, 44 of 55 cases (80%) had specifically documented some form of discoloration or skin change at the mid humeral level of the affected limb.
      • Bohringer E.
      • Weber P.
      Isolated radial nerve palsy in newborns—case report of a bilateral manifestation and literature review.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      • Lenn N.J.
      • Hamill J.S.
      Congenital radial nerve pressure palsy.
      • Coppotelli B.A.
      • Lonsdale Jr., J.D.
      • Kass E.
      Sclerema neonatorum complicated by radial nerve palsy following nontraumatic delivery.
      • Morgan L.
      Radial nerve paralysis in the newborn.
      • Lightwood R.
      Radial nerve palsy associated with localized subcutaneous fat necrosis in the newborn.
      • Feldman G.V.
      Radial nerve palsies in the newborn.
      • Craig W.S.
      • Clark J.M.
      Radial palsy simulating Volkmann's contracture in a newly-born baby.
      • Lundy C.T.
      • Goyal S.
      • Lee S.
      • Hedderly T.
      Bilateral radial nerve palsy in a newborn.
      • Ghinescu C.E.
      • Kamalanathan A.N.
      • Morgan C.
      Unilateral radial nerve palsy in a newborn.

      Haider S. Images in paediatrics: subcutaneous fat necrosis causing radial nerve palsy. BMJ Case Rep. Available at: http://casereports.bmj.com/content/2012/bcr.10.2011.4904.full. Published January 10, 2012. Accessed October 1, 2014. http://dx.doi.org/10.1136/bcr.10.2011.4904.

      • Ross D.
      • Jones Jr., R.
      • Fisher J.
      • Konkol R.J.
      Isolated radial nerve lesion in the newborn.
      Alsubhi et al,
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.
      with the largest series (25 patients), found that 17 of 25 (68%) of their cases included the presence of a subcutaneous nodule. Biopsy of subcutaneous nodules has confirmed definitively that fat necrosis is present, suggesting that compression in an isolated location is the underlying etiology of a congenital radial nerve palsy.
      • Lightwood R.
      Radial nerve palsy associated with localized subcutaneous fat necrosis in the newborn.
      • Lundy C.T.
      • Goyal S.
      • Lee S.
      • Hedderly T.
      Bilateral radial nerve palsy in a newborn.
      Figure thumbnail gr2
      Figure 2Skin dimpling and ecchymosis present at the left lateral mid humerus level in an infant with a congenital radial nerve palsy. A Lateral view. B Frontal view.
      (Images courtesy of Joshua M. Abzug, MD.)

      Treatment

      Congenital radial nerve palsy is managed with observation and physical therapy including passive range of motion exercises.
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.
      • Siqueira M.G.
      • Scaramuzzi V.
      • Heise C.O.
      • Martins R.S.
      • Sterman H.
      Bilateral radial nerve compression neuropathy in the newborn.
      • Bohringer E.
      • Weber P.
      Isolated radial nerve palsy in newborns—case report of a bilateral manifestation and literature review.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      • Lenn N.J.
      • Hamill J.S.
      Congenital radial nerve pressure palsy.
      • Coppotelli B.A.
      • Lonsdale Jr., J.D.
      • Kass E.
      Sclerema neonatorum complicated by radial nerve palsy following nontraumatic delivery.
      The use of nighttime wrist splinting may also be helpful.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      • Lenn N.J.
      • Hamill J.S.
      Congenital radial nerve pressure palsy.
      • Coppotelli B.A.
      • Lonsdale Jr., J.D.
      • Kass E.
      Sclerema neonatorum complicated by radial nerve palsy following nontraumatic delivery.
      Additional treatments may include stretching exercises
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      or stimulation of active movements.
      • Siqueira M.G.
      • Scaramuzzi V.
      • Heise C.O.
      • Martins R.S.
      • Sterman H.
      Bilateral radial nerve compression neuropathy in the newborn.
      However, there is clear evidence of spontaneous resolution with complete recovery and no sequelae in cases without any intervention.
      • Siqueira M.G.
      • Scaramuzzi V.
      • Heise C.O.
      • Martins R.S.
      • Sterman H.
      Bilateral radial nerve compression neuropathy in the newborn.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.

      Outcomes

      Of the 55 reported cases in the literature to date, all had some form of recovery reported.
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.
      • Siqueira M.G.
      • Scaramuzzi V.
      • Heise C.O.
      • Martins R.S.
      • Sterman H.
      Bilateral radial nerve compression neuropathy in the newborn.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      • Hayman M.
      • Roland E.H.
      • Hill A.
      Newborn radial nerve palsy: report of four cases and review of published reports.
      • Coppotelli B.A.
      • Lonsdale Jr., J.D.
      • Kass E.
      Sclerema neonatorum complicated by radial nerve palsy following nontraumatic delivery.
      • Morgan L.
      Radial nerve paralysis in the newborn.
      • Lightwood R.
      Radial nerve palsy associated with localized subcutaneous fat necrosis in the newborn.
      • Feldman G.V.
      Radial nerve palsies in the newborn.
      • Craig W.S.
      • Clark J.M.
      Radial palsy simulating Volkmann's contracture in a newly-born baby.
      • Lundy C.T.
      • Goyal S.
      • Lee S.
      • Hedderly T.
      Bilateral radial nerve palsy in a newborn.
      • Ghinescu C.E.
      • Kamalanathan A.N.
      • Morgan C.
      Unilateral radial nerve palsy in a newborn.

      Haider S. Images in paediatrics: subcutaneous fat necrosis causing radial nerve palsy. BMJ Case Rep. Available at: http://casereports.bmj.com/content/2012/bcr.10.2011.4904.full. Published January 10, 2012. Accessed October 1, 2014. http://dx.doi.org/10.1136/bcr.10.2011.4904.

      The average recovery occurred at 9 weeks (range, 1–40 wk).
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.
      • Siqueira M.G.
      • Scaramuzzi V.
      • Heise C.O.
      • Martins R.S.
      • Sterman H.
      Bilateral radial nerve compression neuropathy in the newborn.
      • Bohringer E.
      • Weber P.
      Isolated radial nerve palsy in newborns—case report of a bilateral manifestation and literature review.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      • Hayman M.
      • Roland E.H.
      • Hill A.
      Newborn radial nerve palsy: report of four cases and review of published reports.
      • Lenn N.J.
      • Hamill J.S.
      Congenital radial nerve pressure palsy.
      • Coppotelli B.A.
      • Lonsdale Jr., J.D.
      • Kass E.
      Sclerema neonatorum complicated by radial nerve palsy following nontraumatic delivery.
      • Morgan L.
      Radial nerve paralysis in the newborn.
      • Lightwood R.
      Radial nerve palsy associated with localized subcutaneous fat necrosis in the newborn.
      • Feldman G.V.
      Radial nerve palsies in the newborn.
      • Craig W.S.
      • Clark J.M.
      Radial palsy simulating Volkmann's contracture in a newly-born baby.
      • Lundy C.T.
      • Goyal S.
      • Lee S.
      • Hedderly T.
      Bilateral radial nerve palsy in a newborn.
      • Ghinescu C.E.
      • Kamalanathan A.N.
      • Morgan C.
      Unilateral radial nerve palsy in a newborn.

      Haider S. Images in paediatrics: subcutaneous fat necrosis causing radial nerve palsy. BMJ Case Rep. Available at: http://casereports.bmj.com/content/2012/bcr.10.2011.4904.full. Published January 10, 2012. Accessed October 1, 2014. http://dx.doi.org/10.1136/bcr.10.2011.4904.

      • Ross D.
      • Jones Jr., R.
      • Fisher J.
      • Konkol R.J.
      Isolated radial nerve lesion in the newborn.
      • Deshmukh N.V.
      • Phillips G.E.
      Isolated radial nerve palsy in a newborn: report of two cases.
      All but three patients had full recovery documented.
      • Hayman M.
      • Roland E.H.
      • Hill A.
      Newborn radial nerve palsy: report of four cases and review of published reports.
      • Coppotelli B.A.
      • Lonsdale Jr., J.D.
      • Kass E.
      Sclerema neonatorum complicated by radial nerve palsy following nontraumatic delivery.
      • Lundy C.T.
      • Goyal S.
      • Lee S.
      • Hedderly T.
      Bilateral radial nerve palsy in a newborn.
      In these three patients, full recovery likely occurred but complete outcome details were undocumented. One patient had rapid clinical improvement by 12 days of age and only showed mild weakness of left wrist extension. Needle electromyography (EMG) showed polyphasic units in the left radial forearm muscles and a decreased interference pattern, findings consistent with resolving axonal abnormality.
      • Hayman M.
      • Roland E.H.
      • Hill A.
      Newborn radial nerve palsy: report of four cases and review of published reports.
      Another patient had marked improvement of bilateral wrist drop at 2 weeks with EMG showing no acute denervation of the radial nerve.
      • Lundy C.T.
      • Goyal S.
      • Lee S.
      • Hedderly T.
      Bilateral radial nerve palsy in a newborn.
      The third patient initially presented with right wrist drop with dimpling and bluish discoloration of the skin. Day 4 and 8 EMGs showed persistent absence of motor units in the forearm extensor muscles. Improvement was noticed on the 22nd day of life with the EMG showing a few motor units in the forearm extensor group muscles. By 3 weeks of age, there was no longer any dimpling of the skin and the right wrist drop had improved. The child was lost to follow-up thereafter.
      • Coppotelli B.A.
      • Lonsdale Jr., J.D.
      • Kass E.
      Sclerema neonatorum complicated by radial nerve palsy following nontraumatic delivery.
      In the series reported by Alsubhi et al, 72% of patients had full recovery at 8 weeks with all but one patient having recovery by 3 months.
      • Alsubhi F.S.
      • Althunyan A.M.
      • Curtis C.G.
      • Clarke H.M.
      Radial nerve palsy in the newborn: a case series.

      Summary

      Neonatal upper extremity “paralysis” can present due to numerous etiologies including clavicle and humerus fractures (pseudopalsy), BPBP, congenital radial nerve palsy, neonatal compartment syndrome, arthrogryposis, perinatal cerebral ischemia, and congenital constriction band.
      • Monica J.T.
      • Waters P.M.
      • Bae D.S.
      Radial nerve palsy in the newborn: a report of four cases and literature review.
      The most important distinction is to differentiate between a BPBP and congenital radial nerve palsy; an accurate diagnosis is imperative because the counseling of the patients' families is different depending upon the diagnosis. All cases of congenital radial nerve palsies in the literature thus far have been noted to have spontaneous resolution. Although some authors may include constriction band syndrome within the spectrum of congenital radial nerve palsies that have much poorer outcomes,
      • Siqueira M.G.
      • Scaramuzzi V.
      • Heise C.O.
      • Martins R.S.
      • Sterman H.
      Bilateral radial nerve compression neuropathy in the newborn.
      • Bohringer E.
      • Weber P.
      Isolated radial nerve palsy in newborns—case report of a bilateral manifestation and literature review.

      Weeks PM. Radial, median, and ulnar nerve dysfunction associated with a congenital constricting band of the arm. Plast Reconstr Surg. 982;69(2):333–336.

      • Weinzweig N.
      • Barr A.
      Radial, ulnar, and median nerve palsies caused by a congenital constriction band of the arm: single-stage correction.
      we feel these have distinctly different etiologies. Typically, patients with a congenital radial nerve palsy achieve full spontaneous recovery by 3 months of age whether formal therapy and/or splinting was utilized or not.

      Pearls

      • Assess for skin changes such as ecchymosis, skin dimpling, a subcutaneous nodule, erythema, or induration at or around the mid lateral humeral region.
      • Fat necrosis seen on histologic biopsy of subcutaneous nodules is consistent with isolated compression being the underlying etiology of a congenital radial nerve palsy.
      • Differentiate between BPBP and congenital radial nerve palsies utilizing a thorough physical examination.
      • Recall that the vast majority of congenital radial nerve palsies have spontaneous resolution.

      Supplementary Data

      References

        • Abzug J.M.
        • Kozin S.H.
        Evaluation and management of brachial plexus birth palsy.
        Orthop Clin North Am. 2014; 45: 225-232
        • Foad S.L.
        • Mehlman C.T.
        • Foad M.B.
        • Lippert W.C.
        Prognosis following neonatal brachial plexus palsy: an evidence-based review.
        J Child Orthop. 2009; 3: 459-463
        • Alsubhi F.S.
        • Althunyan A.M.
        • Curtis C.G.
        • Clarke H.M.
        Radial nerve palsy in the newborn: a case series.
        CMAJ. 2011; 183: 1367-1370
        • Siqueira M.G.
        • Scaramuzzi V.
        • Heise C.O.
        • Martins R.S.
        • Sterman H.
        Bilateral radial nerve compression neuropathy in the newborn.
        Childs Nerv Syst. 2014; 30: 1435-1439
        • Bohringer E.
        • Weber P.
        Isolated radial nerve palsy in newborns—case report of a bilateral manifestation and literature review.
        Eur J Pediatr. 2014; 173: 537-539
        • Monica J.T.
        • Waters P.M.
        • Bae D.S.
        Radial nerve palsy in the newborn: a report of four cases and literature review.
        J Pediatr Orthop. 2008; 28: 460-462
        • Hayman M.
        • Roland E.H.
        • Hill A.
        Newborn radial nerve palsy: report of four cases and review of published reports.
        Pediatr Neurol. 1999; 21: 648-651
        • Lenn N.J.
        • Hamill J.S.
        Congenital radial nerve pressure palsy.
        Clin Pediatr (Phila). 1983; 22: 388-389
        • Coppotelli B.A.
        • Lonsdale Jr., J.D.
        • Kass E.
        Sclerema neonatorum complicated by radial nerve palsy following nontraumatic delivery.
        Mt Sinai J Med. 1979; 46: 143-144
        • Morgan L.
        Radial nerve paralysis in the newborn.
        Arch Dis Child. 1948; 23: 137-139
        • Lightwood R.
        Radial nerve palsy associated with localized subcutaneous fat necrosis in the newborn.
        Arch Dis Child. 1951; 26: 436-437
        • Feldman G.V.
        Radial nerve palsies in the newborn.
        Arch Dis Child. 1957; 32: 469-471
        • Craig W.S.
        • Clark J.M.
        Radial palsy simulating Volkmann's contracture in a newly-born baby.
        J Obstet Gynaecol Br Commonw. 1961; 68: 130-131
        • Lundy C.T.
        • Goyal S.
        • Lee S.
        • Hedderly T.
        Bilateral radial nerve palsy in a newborn.
        Neurology. 2009; 72: 576
        • Ghinescu C.E.
        • Kamalanathan A.N.
        • Morgan C.
        Unilateral radial nerve palsy in a newborn.
        Arch Dis Child Fetal Neonatal Ed. 2012; 97: F153
      1. Haider S. Images in paediatrics: subcutaneous fat necrosis causing radial nerve palsy. BMJ Case Rep. Available at: http://casereports.bmj.com/content/2012/bcr.10.2011.4904.full. Published January 10, 2012. Accessed October 1, 2014. http://dx.doi.org/10.1136/bcr.10.2011.4904.

        • Ross D.
        • Jones Jr., R.
        • Fisher J.
        • Konkol R.J.
        Isolated radial nerve lesion in the newborn.
        Neurology. 1983; 33: 1354-1356
        • Deshmukh N.V.
        • Phillips G.E.
        Isolated radial nerve palsy in a newborn: report of two cases.
        Hand Surg. 2002; 7: 293-294
      2. Weeks PM. Radial, median, and ulnar nerve dysfunction associated with a congenital constricting band of the arm. Plast Reconstr Surg. 982;69(2):333–336.

        • Weinzweig N.
        • Barr A.
        Radial, ulnar, and median nerve palsies caused by a congenital constriction band of the arm: single-stage correction.
        Plast Reconstr Surg. 1994; 94: 872-876