RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

| |NAME OF THE CANDIDATE AND |DR. KAPIL DEV. M, |

|1. |ADDRESS: |14/7, THIYAGIGAL STREET, |

| | |MALLASAMUDRAM (PO), |

| | |NAMAKKAL (DT), |

| | |TAMIL NADU. |

| | |PIN - 637503. |

|2. |NAME OF THE |M.S. RAMAIAH MEDICAL |

| |INSTITUTION |COLLEGE. |

| | |BANGALORE - 560054. |

|3. |COURSE OF THE STUDY | |

| |AND SUBJECT |M.D ANATOMY. |

|4. |DATE OF ADMISSION TO | |

| |THE COURSE |31.05.2011. |

|5. |TITLE OF THE TOPIC |A CADAVERIC STUDY OF THE COURSE OF POSTERIOR |

| | |INTEROSSEOUS NERVE BY FOLLOWING THE RULE OF NINE TEST FOR RADIAL |

| | |TUNNEL SYNDROME. |

6. Brief resume of intended work.

6.1. Introduction and need for the study:

Posterior interosseous nerve is the deep terminal branch of radial nerve. It arises at the level of lateral epicondyle of the humerus. The nerve descends between the elbow joint and brachioradialis, and reaches the back of the forearm round the lateral aspect of radius and between the two planes of the fibres of supinator. Before entering the supinator it gives branches to extensor carpi radialis brevis and supinator. As it travels the supinator muscle, it also gives additional branches to the same muscle.1

After emerging from the supinator, it gives off three short branches which supply the extensor digitorum, extensor digiti minimi and extensor carpi ulnaris, and two long branches, a medial to extensor pollicis longus, extensor indicis, and a lateral to abductor pollicis longus and ends by supplying extensor pollicis brevis.1

Course of the posterior interosseous nerve:

The nerve arises from the radial nerve at the level of the lateral epicondyle of the humerus, 1 cm lateral to biceps tendon. Then it reaches the back of the forearm round the lateral aspect of radius and between the two planes of the fibres of supinator. At first the nerve is between the superficial and deep extensor muscles. At the level of distal border of extensor pollicis brevis it passes deep to extensor pollicis longus to accompany the terminal part of the anterior interosseous artery on the posterior surface of the interosseous member. It ends on the back of the wrist joint by sending branches to that joint and the inter-carpal joints.1

Radial tunnel syndrome:

This is the entrapment neuropathy of the posterior interosseous nerve within the forearm extensor muscles. This radial tunnel has specific anatomical boundaries. The tunnel is a 5 cm long furrow bounded by brachialis and the biceps tendon medially and the mobile extensor muscles anterolaterally, beginning just proximal to the radiocapitular joint and ending at the distal edge of the supinator. The capsule of the radiocapitular joint forms the floor of the tunnel.2

The syndrome manifests as pain over the lateral aspect of the forearm and the weakness of the muscles supplied by the posterior interosseous nerve. There is no sensory impairment as the superficial radial nerve arises above the level of lateral epicondyle. Extensor carpi ulnaris is usually affected so that attempted wrist extension causes marked radial deviation. Radial wrist extension and brachioradialis muscles are normal.1

6.2. Review of literature:

Compression of posterior interosseous nerve within the radial tunnel leads to pain in the lateral aspect of elbow and forearm without motor or sensory deficits. So it will be difficult to differentiate the condition from lateral epicondylitis which also presents with pain in the lateral aspect of forearm. So Loh YC, Lam WL, Stanley JK conducted a study to propose the rule of nine test to differentiate the condition from lateral epicondylitis. In their study they observed that the posterior interosseous nerve traveled consistently across the lateral column of the constructed square in front of forearm in all the specimens.2

In another study conducted by Portilla Molina AE, Bour C, Oberlin C et al, observed posterior interosseous nerve distal to supinator muscle may be compressed by various structures like distal border of supinator muscle, the ramification of anterior and posterior interosseous vessels and the septum between extensor carpi ulnaris, extensor digiti minimi. This suggest that the posterior interosseous nerve distal to supinator muscle should be explored in radial tunnel compression syndromes.3

The clinical diagnosis of radial tunnel syndrome must be distinguished from that of lateral epicondylitis by the location of tenderness on physical examination. In lateral epicondylitis the focal point of tenderness is on the lateral epicondyle, in contrast, the characteristic pain of radial tunnel syndrome is located 3-4 cm distal to the lateral epicondyle in the area of mobile wad and radial tunnel.4 So the knowledge of the course of posterior interosseous nerve will help to diagnose the radial tunnel syndrome clinically.

6.3. Objective of the study:

1. To know the origin and course of posterior interosseous nerve.

2. To help the clinician to diagnose the radial tunnel syndrome clinically.

7. Materials and methods:

7.1 Source of data: Materials for this study will be randomly selected 50 upper limbs of formalin embalmed cadavers from the dept of anatomy.

Study design: Cross sectional study.

Study area: M.S. Ramaiah medical college, Bangalore.

Study subject:

The study will be performed on 50 upper limbs of formalin embalmed cadavers from department of anatomy, M S Ramaiah medical college.

Sample size:

Non probabilistic purposive sampling shall be adapted from the previous study A NEW CLINICAL TEST FOR RADIAL TUNNEL SYNDROME – THE RULE OF NINE TEST: A CADAVERIC STUDY, it has been observed that the course of posterior interosseous nerve in 19 upper limbs sample studied was consistently in the lateral columns. Assuming 5% variants it is proposed to consider 50 upper limbs.

7.2. Method of collection of data:

Method of collection of data is by standard dissection method of posterior compartment of forearm in 50 formalin embalmed cadavers.

The rule of nine test consist of drawing up a large squared box over the anterior aspect of the proximal part of the forearm with a fully extended elbow and fully supinated forearm. The sides of the square are determined by the width of the elbow crease. This large square will be further divided into 3 columns and 3 rows forming 9 smaller squares of equal measurements2. The position of the 9 smaller squares will be mapped on to transparency acetate which will then be placed over the dissected specimen to note the relation of the posterior interosseous nerve to the smaller squares. The frequency of the smaller square being crossed by the posterior interosseous nerve will be recorded.

Method of dissection:

Using a standard medial skin incision at the front and back of the forearm, subcutaneous tissue will be removed. Deep fascia will be removed and then separate the superficial muscles from each other, and then completely separate the three anterolateral muscles (brachioradialis and the radial extensors of the carpus) from the extensor digitorum and expose the supinator muscle lying deep to them. Expose the posterior interosseous nerve emerging from supinator near its distal border. Pull brachioradialis and the radial extensor of the carpus laterally to expose the radial nerve at the elbow. Pull gently on the deep branch to establish its continuity with the posterior interosseous nerve by noting the movement of that nerve.6

Inclusion criteria:

Formalin embalmed upper limb specimens irrespective of age, sex or race.

Exclusion criteria:

Upper limb showing gross asymmetry, any injury to forearm that damaged the posterior interosseous nerve or any surgical procedure that disturbed the course of the PIN.

Statistical analysis:

Descriptive statistics comprising of mean (+/- SD) and percentage and proportions shall be used to represent the continuous data and ordinal data respectively.

The descriptive study statistics of relation of posterior interosseous nerve with the constructed square will be analysed and expressed in percentage.

Chi square test (Fisher exact test) of proposal shall be employed appropriately to access the statistical significance of the difference in proportions observed.

7.3. Does the study require any investigations or interventions to be conducted on patients or other humans or animals?

No.

7.4. Has ethical clearance been obtained from your institution?

Yes.

8. List of references:

1. Bannister LH, Berry MM, Collins P, et al. Gray’s Anatomy. The Anatomical basis of medicine and surgery. 38th Ed., New york, Churchill and livingstone 1995; 1273-1274.

2. Loh YC, Lam WL, Stanley JK, et.al. A new clinical test for radial tunnel syndrome – The rule of nine test : A cadaveric study. Journal of orthopedic surgery 2004; 12(1):83-86.

3. Portilla Molina AE, Bour C, Oberlin C et al, The posterior interosseous nerve and the radial tunnel syndrome: an anatomical study. International Orthopaedics, International Society of Orthopedic Surgery and Traumatology 1998; 22:102-106.

4. Dang AC, Rodner CM, Unusual compression neuropathies of the forearm, Past I : Radial nerve. J Hand Surg 2009; 34A:1906-1914.

5.Witt JD, Kaminani S. The posterior inter-osseous nerve and the posterolateral approach to the proximal radius. J Bone joint surg 1998; 80-B: 240-2.

6. Romanes GJ. Cunningham s Manual of Practical Anatomy. Vol. 1, 15th Ed., New york, Oxford medical publication press Inc 2011: 74-75, 93-94.

|9 |SIGNATURE OF THE | |

| |CANDIDATE | |

|10 |REMARKS OF THE GUIDE |The posterior interosseous nerve may be compressed in the proximal |

| | |forearm in the area of supinator muscle or distal to |

| | |supinator. The compression of the nerve in the Radial tunnel causes pain |

| | |on the lateral aspect of the forearm referred as Radial tunnel |

| | |syndrome. The objective of the study is to test the assumption that the |

| | |rule of nine test is a reliable method of diagnosing radial tunnel |

| | |syndrome. |

|11 |NAME AND | |

| |DESIGNTION OF | |

|11.1 |GUIDE |DR. SEEMA. S.R. M.D |

| | |ASSOCIATE PROFESSOR, |

| | |DEPARTMENT OF ANATOMY, |

| | |M.S. RAMAIAH MEDICAL |

| | |COLLEGE, |

| | |BANGALORE. 560054 |

|11.2 |SIGNATURE | |

| | | |

|11.3 |CO GUIDE |- |

|11.4 |SIGNATURE |- |

|11.5 |HEAD OF THE |DR. SHESHGIRI.C. M.S. |

| |DEPARTMENT |SENIOR PROFESSOR AND HEAD, |

| | |DEPARTMENT OF ANATOMY, |

| | |M.S. RAMAIAH MEDICAL |

| | |COLLEGE, |

| | |BANGALORE - 560054. |

|11.6 |SIGNATURE | |

| | | |

| | | |

|12 | | |

|12.1 |REMARKS OF DEAN AND PRINCIPAL |DR. SARASWATHI G RAO, MD, |

| | |PRINCIPAL AND DEAN, |

| | |M.S.RAMAIAH MEDICAL |

| | |COLLEGE, |

| | |TEACHING AND MEMORIAL |

| | |HOSPITALS, BANGALORE. |

|12.2 |SIGNATURE | |

| | | |

| | | |

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