❖ CASE 2 A 32-year-old man is involved in a motor vehicle accident. He used three-point restraints and was driving a sedan. The driver of a pick-up truck ran a stop sign while going at approximately 45 mph and “T-boned” the patient’s vehicle on the driver’s side. The patient has multiple injuries including a displaced fracture of the left humerus. He complains of an inability to open his left hand and loss of sensation to a portion of his left hand. ◆ What is the most likely diagnosis? ◆ What is the likely mechanism of the injury? ◆ What portion of the left hand is likely to have sensory deficit? ANSWERS TO CASE 2: RADIAL NERVE INJURY Summary: A 32-year-old man is involved in a motor vehicle accident that causes a displaced fracture of the left humerus. He has motor and sensory losses to his left hand. ◆ Most likely diagnosis: Injury to the radial nerve as it spirals around the humerus, resulting in an inability to extend the wrist or fingers and loss of sensation of the hand ◆ Likely mechanism: Stretch or crush injury to the radial nerve as it spirals around the midshaft of the humerus ◆ Likely location of sensory deficit: Radial (lateral) side of the dorsum of the hand and dorsum of the thumb and index and middle digits CLINICAL CORRELATION The radial nerve is at particular risk of injury in its course in the radial groove as it spirals around the midshaft of the humerus. Humeral fractures involving the midshaft region are of particular concern. There is loss of innervation of the posterior extensor muscles in the forearm, resulting in wrist drop and an inability to extend the digits at the metacarpophalangeal joints. The sensory loss on the dorsum of the hand and digits reflects the distal cutaneous distribution of the radial nerve. The triceps muscle (extensor of the elbow) is typically spared; however, the patient usually will not attempt to move the limb due to pain from the fracture. The deep brachial artery has the same path as the radial nerve in the radial groove and has a similar risk for injury. APPROACH TO THE RADIAL NERVE Objectives 1. Be able to describe the origin, course, muscles innervated, and distal cutaneous regions supplied by the radial nerve. 2. Be able to describe the arterial blood supply to the upper limb. 3. Be able to describe the origin, course, muscles innervated, and distal cutaneous regions supplied by the five major terminal branches of the brachial plexus (Cases 1, 2, and 4). Definitions Fracture: A break in the normal integrity of a bone or cartilage. Blunt trauma: Injury due to a crushing force as opposed to a sharp penetrating force. 18 CASE FILES: ANATOMY DISCUSSION The radial nerve is a continuation of the posterior cord of the brachial plexus, and it reaches the posterior compartment of the arm by coursing around the radial groove of the humerus with the deep brachial artery (Figure 2-1). It gives off multiple muscular branches to the triceps muscle in