Arch Hand Microsurg.  2021 Sep;26(3):199-208. 10.12790/ahm.21.0100.

Current Concepts of Anterior Interosseous Nerve Syndrome

• Chae S
• Kim J
• Park IJ

• KMID: 2519474
• DOI: http://doi.org/10.12790/ahm.21.0100

Abstract

The causes and treatment of anterior interosseous nerve syndrome have not been established yet. Two causes are known, as a result of compressive neuropathy and as a result of neuralgic amyotrophy. An hourglass-like constriction found in the main trunk of the median nerve suggests a new paradigm for the cause and treatment of anterior interosseous nerve syndrome. It is necessary to differentiate it from other diseases through a meticulous physical examination, and surgical treatment is recommended only when there are no other related neurological lesions and no improvement despite conservative treatment for more than 6 months.

Keyword

Anterior interosseous syndrome; Compressive neuropathy; Neuralgic amyotrophy; Median nerve

Figure

• 

  Fig. 1. Initial inflammation leads to intraneural edema and swelling of the nerve. This renders the fascicles less flexible, so that motion of a nearby joint induces kinking. After repetitive kinking, rotation of the nerve can lead to constriction and fascicular entwinement.

• 

  Fig. 2. Complete anterior interosseous nerve syndrome. The photographs showed the inability to form an ‘O’ with the thumb and the index finger in the right hand (A) and the left hand (B).

• 

  Fig. 3. Incomplete anterior interosseous nerve syndrome. (A) The photograph showed the flexion inability of the right index distal interphalangeal (DIP) joint. The interphalangeal (IP) joint flexion of the thumb was normal. (B) The photograph showed the flexion inability of the left thumb IP joint. The DIP joint flexion of the index was normal.

• 

  Fig. 4. (A) The examiner dorsiflexes the patient’s wrist fully by pressing the palm. Then he hyperextends the patient’s thumb at the carpometacarpal and metacarpophalangeal joints with his own fingers. If the flexor pollicis longus is in continuity (though paralyzed), the interphalangeal (IP) joint flexes spontaneously. (B) If the examiner applies firm pressure with his thumb at the musculotendinous junction of the flexor pollicis longus tendon and causes the patient’s thumb IP joint flexion, it is confirmed that the flexor pollicis longus musculotendinous unit is intact.

• 

  Fig. 5. The intraoperative clinical photograph showed decompression of the median and anterior interosseous nerve in the forearm. All potential compressive sites should be released.

• 

  Fig. 6. (A) External neurolysis of the median nerve was performed to remove the compression caused by fibrosis around the nerve. (B) After intrafascicular neurolysis, a constriction of the anterior interosseous nerve fascicle within the median nerve was observed. Provided by Professor Jong Woo Kang of Korea University.

Reference

1. Tinel J, Rothwell F, Joll CA, Schlesinger EB. Nerve wounds: symptomatology of peripheral nerve lesions caused by war wounds. London: Baillière, Tindall & Cox;1918.

2. Parsonage MJ, Turner JW. Neuralgic amyotrophy; the shoulder-girdle syndrome. Lancet. 1948; 1:973–8.

3. Kiloh LG, Nevin S. Isolated neuritis of the anterior interosseous nerve. Br Med J. 1952; 1:850–1.

4. Spinner M. The anterior interosseous-nerve syndrome, with special attention to its variations. J Bone Joint Surg Am. 1970; 52:84–94.

5. Saeed MA, Gatens PF. Anterior interosseous nerve syndrome: unusual etiologies. Arch Phys Med Rehabil. 1983; 64:182.

6. Pavesi G, Medici D, Mancia D. Anterior interosseous nerve syndrome secondary to forearm thrombo-phlebitis. Ital J Neurol Sci. 1989; 10:221.

7. Gainor BJ, Olson S. Combined entrapment of the median and anterior interosseous nerves in a pediatric both-bone forearm fracture. J Orthop Trauma. 1990; 4:197–9.

8. Geissler WB, Fernandez DL, Graca R. Anterior interosseous nerve palsy complicating a forearm fracture in a child. J Hand Surg Am. 1990; 15:44–7.

9. Proudman TW, Menz PJ. An anomaly of the median artery associated with the anterior interosseous nerve syndrome. J Hand Surg Br. 1992; 17:507–9.

10. Cramer KE, Green NE, Devito DP. Incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. J Pediatr Orthop. 1993; 13:502–5.

11. Huang K, Pun WK, Coleman S. Entrapment and transection of the median nerve associated with greenstick fractures of the forearm: case report and review of the literature. J Trauma. 1998; 44:1101–2.

12. Mackinnon SE, Novak CB. Compression neuropathies. In : Green DP, Wolfe SW, editors. Green’s operative hand surgery. Philadelphia, PA: Elsevier;2011. p. 977–1014.

13. Sneag DB, Arányi Z, Zusstone EM, et al. Fascicular constrictions above elbow typify anterior interosseous nerve syndrome. Muscle Nerve. 2020; 61:301–10.

14. Strohl AB, Zelouf DS. Ulnar tunnel syndrome, radial tunnel syndrome, anterior interosseous nerve syndrome, and pronator syndrome. J Am Acad Orthop Surg. 2017; 25:e1–10.

15. Fearn CB, Goodfellow JW. Anterior interosseous nerve palsy. J Bone Joint Surg Br. 1965; 47:91–3.

16. Hill NA, Howard FM, Huffer BR. The incomplete anterior interosseous nerve syndrome. J Hand Surg Am. 1985; 10:4–16.

17. Spinner M, Schreiber SN. Anterior interosseous-nerve paralysis as a complication of supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 1969; 51:1584–90.

18. van Alfen N, van Engelen BG. The clinical spectrum of neuralgic amyotrophy in 246 cases. Brain. 2006; 129(Pt 2):438–50.

19. Gstoettner C, Mayer JA, Rassam S, et al. Neuralgic amyotrophy: a paradigm shift in diagnosis and treatment. J Neurol Neurosurg Psychiatry. 2020; 91:879–88.

20. ArÁnyi Z, Csillik A, DéVay K, et al. Ultrasonography in neuralgic amyotrophy: sensitivity, spectrum of findings, and clinical correlations. Muscle Nerve. 2017; 56:1054–62.

21. Milner CS, Kannan K, Iyer VG, Thirkannad SM. Parsonage-Turner syndrome: clinical and epidemiological features from a hand surgeon's perspective. Hand (N Y). 2016; 11:227–31.

22. Werner CO. The anterior interosseous nerve syndrome. Int Orthop. 1989; 13:193–7.

23. Sood MK, Burke FD. Anterior interosseous nerve palsy. A review of 16 cases. J Hand Surg Br. 1997; 22:64–8.

24. Park IJ, Roh YT, Jeong C, Kim HM. Spontaneous anterior interosseous nerve syndrome: clinical analysis of eleven surgical cases. J Plast Surg Hand Surg. 2013; 47:519–23.

25. Na KT, Jang DH, Lee YM, Park IJ, Lee HW, Lee SU. Anterior interosseous nerve syndrome: is it a compressive neuropathy? Indian J Orthop. 2020; 54(Suppl 1):193–8.

26. Nagano A, Shibata K, Tokimura H, Yamamoto S, Tajiri Y. Spontaneous anterior interosseous nerve palsy with hourglass-like fascicular constriction within the main trunk of the median nerve. J Hand Surg Am. 1996; 21:266–70.

27. Nagano A. Spontaneous anterior interosseous nerve palsy. J Bone Joint Surg Br. 2003; 85:313–8.

28. Lundborg G. Commentary: hourglass-like fascicular nerve compressions. J Hand Surg Am. 2003; 28:212–4.

29. Arányi Z, Csillik A, Dévay K, et al. Ultrasonographic identification of nerve pathology in neuralgic amyotrophy: enlargement, constriction, fascicular entwinement, and torsion. Muscle Nerve. 2015; 52:503–11.

30. Chhabra A, Madhuranthakam AJ, Andreisek G. Magnetic resonance neurography: current perspectives and literature review. Eur Radiol. 2018; 28:698–707.

31. Madhuranthakam AJ, Lenkinski RE. Technical advancements in MR neurography. Semin Musculoskelet Radiol. 2015; 19:86–93.

32. Sneag DB, Saltzman EB, Meister DW, Feinberg JH, Lee SK, Wolfe SW. MRI bullseye sign: an indicator of peripheral nerve constriction in parsonage-turner syndrome. Muscle Nerve. 2017; 56:99–106.

33. Du R, Auguste KI, Chin CT, Engstrom JW, Weinstein PR. Magnetic resonance neurography for the evaluation of peripheral nerve, brachial plexus, and nerve root disorders. J Neurosurg. 2010; 112:362–71.

34. Krishnan KR, Sneag DB, Feinberg JH, Wolfe SW. Anterior interosseous nerve syndrome reconsidered: a critical analysis review. JBJS Rev. 2020; 8:e2000011.

35. Seror P. Anterior interosseous nerve lesions. Clinical and electrophysiological features. J Bone Joint Surg Br. 1996; 78:238–41.

36. Alderman AK, Chung KC. Incomplete anterior interosseous nerve syndrome: use of tendon transfer to expedite recovery. Ann Plast Surg. 2001; 47:682–3.

37. Mahring M, Semple C, Gray IC. Attritional flexor tendon rupture due to a scaphoid non union imitating an anterior interosseous nerve syndrome: a case report. J Hand Surg Br. 1985; 10:62–4.

38. Mody BS. A simple clinical test to differentiate rupture of flexor pollicis longus and incomplete anterior interosseous paralysis. J Hand Surg Br. 1992; 17:513–4.

39. Melton JT, Murray JR, Lowdon IM. A simple clinical test of flexor pollicis longus rupture. J Hand Surg Br. 2005; 30:624–5.

40. Wong L, Dellon AL. Brachial neuritis presenting as anterior interosseous nerve compression: implications for diagnosis and treatment: a case report. J Hand Surg Am. 1997; 22:536–9.

41. Futami T, Kobayashi A, Itoman M, Shimajiri I, Fujita T. Clinical investigation on the anterior interosseous nerve syndrome. J Jpn Soc Surg Hand. 1993; 10:338–41.

42. Goyal M, Goyal K, Narkeesh K, Samuel AJ, Sharma S, Chatterjee S. The strain: counter strain technique in the management of anterior interosseous nerve syndrome. A case report. J Taibah Univ Med Sci. 2016; 12:70–4.

43. Schantz K, Riegels-Nielsen P. The anterior interosseous nerve syndrome. J Hand Surg Br. 1992; 17:510–2.