What is the best course of treatment for a patient with a history of radial nerve injury near the antecubital fossa, presenting with subcutaneous tissue damage, most severely affected in the middle area?

Management of Radial Nerve Injury with Subcutaneous Tissue Damage Near the Antecubital Fossa

Immediate immobilization and urgent orthopedic/hand surgery referral within 24-48 hours is essential, as persistent nerve dysfunction after initial assessment requires specialized evaluation and potential surgical exploration, particularly when subcutaneous tissue damage suggests significant trauma to the neurovascular structures.

Initial Emergency Management

Immobilize the affected extremity immediately to prevent further injury to the compromised radial nerve and surrounding damaged subcutaneous tissues 1. The radial nerve is particularly vulnerable in the antecubital region where it courses through soft tissues before dividing into its terminal branches 2.

Critical Assessment Points

• Evaluate vascular status urgently: Look for a blue, purple, or pale hand indicating compromised circulation requiring emergency intervention 1
• Document baseline motor function: Test wrist extension, finger extension (metacarpophalangeal joints), and thumb extension specifically 3, 4
• Assess sensory function: Check the first dorsal web space for radial sensory nerve function 3
• Avoid overtight compression: Inappropriate padding or wrapping that is too tight can worsen nerve injury 2, 1

Timing of Surgical Intervention

Early surgical exploration within 5 months of injury yields significantly better outcomes for radial nerve recovery 4. The decision pathway depends on:

Indications for Urgent Surgical Exploration (Within Days)

• Progressive neurological deficit after initial assessment 5
• Complete nerve palsy with severe subcutaneous tissue disruption suggesting nerve transection 3, 6
• Associated vascular injury requiring repair 6
• Open wounds with visible nerve damage 3

Indications for Early Elective Surgery (2-5 Months)

• Persistent complete radial nerve palsy without recovery signs by 2-3 months 5
• Incomplete recovery with electromyographic evidence of severe axonal injury 5
• Nerve entrapment in healing subcutaneous scar tissue 7

Surgical Management Options

The specific surgical approach depends on intraoperative findings using nerve action potential recording 3:

• Primary end-to-end repair: For clean lacerations or short nerve gaps, achieving 91% recovery to Grade 3 or better motor function 3
• Nerve grafting: For longer defects or injuries in the antecubital region, achieving 80% satisfactory motor recovery 3, 4
• Neurolysis (external or internal): For nerves in continuity with conduction block, achieving 98% recovery to Grade 3 or better 3
• Soft tissue coverage: Pedicled latissimus dorsi muscle flap for extensive subcutaneous tissue loss with exposed neurovascular structures, allowing excellent nerve recovery in most cases 6

Expected Recovery Patterns

Level III injuries (lateral arm to antecubital fossa) have variable outcomes, with wrist extension recovering in at least 80% of patients regardless of injury level, but finger and thumb extension showing more variable recovery 4. Recovery is significantly better when reconstruction occurs within 5 months of injury 4.

Diagnostic Workup

• Electromyography and nerve conduction studies: Obtain at 3-4 weeks post-injury to confirm axonal injury and guide surgical timing 5
• MRI of the antecubital region: Superior to CT or ultrasound for visualizing nerve and soft tissue damage 5
• Duplex ultrasound: If a pulsatile mass is present, to exclude vascular aneurysm compressing the nerve 8

Critical Pitfalls to Avoid

• Delayed referral beyond 5 months: Results in significantly worse functional outcomes 4
• Assuming spontaneous recovery: While mild injuries may resolve, severe subcutaneous tissue damage suggests significant nerve trauma requiring intervention 3, 5
• Inadequate immobilization: Allows continued traction and compression injury to the damaged nerve 1
• Missing compartment syndrome: Monitor for progressive pain and swelling that could further compromise nerve function 1