Radiol Oncol 2024; 58(4): 480-485. doi: 10.2478/raon-2024-0041
480
review 
Posterior interosseous nerve lesion due to 
lipoma. Review of the literature and rare case 
presentation
Bojan Rojc1,2, Peter Golob1
1 General Hospital Izola, Izola, Slovenia
2 Faculty of Mathematics, Natural Sciences and Information Technologies, University of Primorska, Koper, Slovenia
Radiol Oncol 2024; 58(4): 480-485.
Received 20 April 2024 
Accepted 21 June 2024
Correspondence to: Assist. Prof. Bojan Rojc, M.D., General Hospital Izola, Slovenia. E-mail: bojan.rojc@sb-izola.si
Disclosure: No potential conflicts of interest were disclosed. 
This is an open access article distributed under the terms of the CC-BY license (https://creativecommons.org/licenses/by/4.0/).
Background. Posterior interosseous nerve lesion is a rare mononeuropathy of the upper limb. Atraumatic posterior 
interosseous nerve lesions are commonly caused by lipomas of the forearm, manifesting as slow-progressing wrist and 
finger drop.
Patients and methods. In this review and case report study, we present a systematic review of the literature for 
patients presenting with posterior interosseous palsy due to lipomas and a rare case of patient with acute posterior 
interosseous nerve lesion caused by a lipoma. Our primary interest was in the timing of clinical presentation. For the 
review process, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.
Results. After reviewing the literature, we identified thirty patients with posterior interosseous nerve lesions caused by 
lipomas. In 28 patients, the symptoms presented progressively, ranging from 1 month to a maximum of 240 months. 
We found only one case of a patient with acute presentation and another patient with acute worsening of chronic 
weakness due to trauma.
Conclusions. Atraumatic posterior interosseous nerve lesions are frequently secondary to forearm lipomas. In the 
majority of cases, the symptoms will develope progressively. However, in this study, we also report a rare case of a 
patient presenting with acute posterior interosseous nerve lesion due to a lipoma.
Key words: posterior interosseus nerve; lipoma; compression; acute
Introduction
Upper arm mononeuropathies are common pathol-
ogies, particularly entrapment neuropathies affect-
ing median and ulnar nerves.1 While radial nerve 
lesions are less frequent, but they still occur, often 
presenting as radial neuropathy at spiral groove 
due to extrinsic compression. In rare cases, a lesion 
of the radial nerve can occur at the forearm.1
At the lateral epicondyle level, the radial nerve 
bifurcates into two branches: the superficial radial 
sensory nerve and the deep radial motor branch. 
The motor branch enters the supinator muscle be-
neath the Arcade of Frohse, where it is known as 
the Posterior Interosseus Nerve (PIN). PIN is al-
most exclusively a motor nerve providing inner-
vation to the extensor carpi ulnaris, extensor digi-
torum communis, extensor digiti quinti, abductor 
pollicis longus, extensor pollicis longus, extensor 
pollicis brevis, and extensor indicis proprius mus-
cle.2
Nontraumatic PIN neuropathy at the elbow 
is a rare condition with an annual incidence of 
0.003%.1,3 However, some confusion and controver-
sies exist regarding the nomenclature of nontrau-
matic PIN neuropathy in the elbow. Radial tunnel 
syndrome (RTS) is defined as a compressive neu-
ropathy of the PIN, causing pain and tenderness 
Radiol Oncol 2024; 58(4): 480-485.
Rojc B and Golob P / Posterior interosseous nerve palsy due to lipoma 481
3–5 cm distal to the lateral epicondyle, without 
motor signs.4,5 Despite the belief that RTS results 
from PIN compression, most cases do not show ab-
normalities on medical imaging or electrodiagnos-
tic testing.6 On the other hand, PIN lesion or PIN 
syndrome (PINS) presents most often with slow 
onset weakness of the muscles innervated by the 
PIN, without sensory findings.2 PIN lesion can be 
further categorized in compressive and non-com-
pressive (neuralgic amyotrophy, hourglass-like 
fascicular constriction).7
There are five potential sites of intrinsic com-
pression of the PIN at the proximal forearm: 
1. fibrous bands of tissue anterior to the radio-
capitellar joint between the brachialis and 
brachioradialis muscle;
2. the recurrent radial vessels that fan out 
across the PIN (“leash of Henry”);
3. the leading edge of the extensor carpi radia-
lis brevis muscle;
4. arcade of Frohse;
5. and the distal edge of the supinator mus-
cle.1,7–9
Occupations involving repetitive pronation and 
supination movements are considered to be a risk 
factor for PINS.7 Extrinsic compression of the PIN 
can result from various pathologies, with as many 
as 30 different pathologies described.7 Among 
these, lipoma is the most reported pathology caus-
ing extrinsic compression of PIN.9–11
Lipomas are slow-growing benign tumours 
composed of adipose cells encapsulated by a thin 
layer of fibrous tissue.12 They can be classified 
based on their anatomical site into dermal, sub-
cutaneous and sub-fascial lipomas, or tumours 
directly related to muscle, bone, synovium or 
nerve.13 In the context of PINS, parosteal, inter-
muscular and intramuscular types of lipomas 
have been most often reported. Due to their slow 
growth, lipomas predominantly cause progressive 
PIN palsy.
Patients and methods
For the review process, we adhered to the Preferred 
Reporting Items for Systematic Reviews and 
Meta-Analysis (PRISMA) guidelines. The authors 
conducted searches on PubMed, MEDLINE and 
Google scholar using keywords: posterior interos-
seus nerve, palsy, and lipoma. Through this proce-
dure, we identified 47 studies. Only full-text articles 
in English or translated versions were accepted for 
further screening. Our search encompassed stud-
ies published up to February 2024. Subsequently, 
we analysed these studies to identify those report-
ing patients with PINS due to lipoma. We included 
only studies where the manifestation of symptoms 
(whether progressive or acute) was clearly stated. 
Ultimately, we reviewed 24 studies, which collec-
tively reported on 30 patients (Table 1).
Case
A 68-year-old female patient presented to the 
emergency room of our hospital with weakness of 
left wrist and fingers extension. In her past medi-
cal history, she reported having diabetes and ar-
terial hypertension. The current symptoms had 
started 3 days prior to her visit. The patient men-
tioned strenuous work involving her arms due to 
cleaning, which included repetitive pronation and 
supination movements. A few hours after this ac-
tivity she suddenly noticed weakness extending 
her fingers, without experiencing pain or paraes-
thesia. Clinical examination revealed weakness in 
left wrist extension accompanied by slight radial 
deviation (Muscle Power Scale - MRC 3) and more 
pronounced weakness in left fingers extension 
(MRC 2), the strength of other muscle groups of 
the left arm was preserved (MRC 5). There were no 
sensory deficits. To rule out possible brain vascular 
lesions brain computer tomography (CT) and CT 
angiography of cerebral arteries were performed, 
but the imaging did not show acute stroke or ar-
terial narrowing. Based on these findings and pa-
tient’s history a clinical diagnosis of left PIN palsy 
due to intrinsic entrapment caused by repetitive 
movements was made. Electromyography (EMG) 
performed a week after symptoms onset confirmed 
PIN lesion, showing denervation with fibrillations 
potentials and positive sharp waves (on scale 2 out 
of 3) and motor unit potential reduction in PIN 
innervated extensor indicis proprius muscle, bra-
chioradial muscle did not show any signs of den-
ervation. The superficial sensory radial nerve con-
duction study was normal. At the follow-up visit 
after 4 weeks, there was no improvement of muscle 
strength. Consequently, we decided to perform a 
magnetic resonance imaging (MRI) scan of the left 
elbow, which revealed a 50 x 40 x 25 mm lipoma as 
a probable cause of nerve compression (Figure 1). 
The patient included in this study provided writ-
ten informed consent for the publication of an-
onymized data in accordance with the declaration 
of Helsinki.
Subsequently, after 2 months, surgery was per-
formed on the left forearm to remove the lipoma. 
Radiol Oncol 2024; 58(4): 480-485.
Rojc B and Golob P / Posterior interosseous nerve palsy due to lipoma482
During the surgical procedure, the patient was 
placed in supine position arm resting on a side ta-
ble. Our dissection began above the elbow, in the 
groove between brachialis/biceps muscles medi-
ally and brachioradialis muscle laterally, aiming 
to expose common radial nerve. We followed the 
nerve distally into the proximal forearm, where 
the brachioradialis muscle was retracted laterally, 
providing exposure to the tumorous mass. The 
tumour was situated between cutaneous branches 
on its lateral and anterior side and PIN on its me-
dial and posterior side. Cutaneous branches were 
then dissected off the tumour and retracted lat-
erally allowing for further dissection going from 
lateral to medial and anterior to posterior. This 
gave us exposure to the PIN lying below the tu-
mour tethered to its pseudo-capsule at the point of 
PIN entry into the supinator muscle (Figure 2). We 
released the PIN and continued resection towards 
the neck of the radius, where the tumor reached 
into the depth and terminated. The tumour was 
removed en-bloc and sent to histopathological ex-
TABLE 1. Twenty-four studies reported 30 patients with posterior interosseous palsy due to lipomas
Patient Ref Year Age (years) Sex Onset
Duration 
(months) Lipoma Recovery
1 Vikas14 2020 54 F Progressive 5 Parosteal Complete
2 Allagui15 2014 28 F Progressive 6 Intramuscular Complete
3 Maldonado16 2017 78 M Progressive 8 Parosteal Incomplete
4 Maldonado16 2017 65 F Progressive 30 Parosteal Incomplete
5 Yamamoto17 2016 60 F No symptoms ? Intermuscular Complete
6 Rishab18 2021 47 M No symptoms ? Intramuscular Complete
7 Flores Robles19 2017 40 M Progressive 1 ? Complete
8 Salama20 2010 83 F Acute Trauma Parosteal Complete
9 Saaiq21 2017 53 M Progressive 7 Parosteal Complete
10 Patel22 2018 66 M Progressive 4 Intraneural Near Complete
11 Murphy23 2009 58 M Progressive <1 Intramuscular Near Complete
12 Nishida24 1998 60 F Progressive 2 Parosteal Complete
13 Nishida24 1998 61 F Progressive ? Parosteal Complete
14 Ganapathy25 2006 54 M Progressive 144 Intramuscular Near Complete
15 Colasanti26 2016 59 F Progressive 6 Intermuscular Complete
16 Avram27 2004 69 M Progressive 4 Parosteal Partial
17 Hamdi28 2010 59 M Progressive 2 Parosteal Complete
18 Matsuo29 2007 60 M Progressive 240 Intraneural Poor
19 Seki30 2012 67 F Progressive 2 Parosteal Complete
20 Eralp31 2006 45 M Progressive ? ? Complete
21 Fitzgerald32 2002 71 F Progressive 1 ? No recovery
22 Fitzgerald32 2002 62 M Progressive 2 ? Complete
23 Fitzgerald32 2002 64 M Progressive 3 ? Complete
24 Fitzgerald32 2002 68 F Progressive 5 ? Complete
25 Fitzgerald32 2002 63 F Progressive 2 ? No recovery
26 Narayan33 2016 46 F Progressive 6 Parosteal ?
27 El Hyaoui34 2014 68 F Progressive 14 Parosteal ?
28 Borman35 2010 69 F Progressive 6 Parosteal Partial
29 Richmond36 1953 62 M Progressive 3 Intramuscular Near Complete
30 Bugnicourt37 2009 48 M Acute ? ?
F = female; M = male; ? = no data
Radiol Oncol 2024; 58(4): 480-485.
Rojc B and Golob P / Posterior interosseous nerve palsy due to lipoma 483
amination, which confirmed the diagnosis of li-
poma (Figure 3 and 4).
At the follow-up visit after 11 months the pa-
tient demonstrated substantial clinical improve-
ment. Remarkably after 24 months there was no 
weakness in left finger and wrist extension.
To our knowledge, this case represents a rare 
instance of acute nontraumatic PINS caused by a 
lipoma.
Results 
We identified 30 patients with PIN palsy caused by 
lipoma compression. The median age of these pa-
tients was 59.6 years, ranging from 28 to 83 years. 
Among the 30 patients 28 experienced a progres-
sive build-up of symptoms, which varied from less 
than a month to a maximum 240 months. Only one 
FIGURE 1. MRI of left elbow. FIGURE 2. Lateral dissection along the common radial nerve 
and posterior interosseus nerve (PIN).
FIGURE 3. Medial dissection away from posterior interosseus 
nerve (PIN).
FIGURE 4. Local situation after lipoma removal
PIN = posterior interosseus nerve.
Radiol Oncol 2024; 58(4): 480-485.
Rojc B and Golob P / Posterior interosseous nerve palsy due to lipoma484
patient was reported to have an acute manifesta-
tion of symptoms, while another patient had acute 
worsening of chronic weakness after trauma and 
immobilisation. Both female and male patients 
were equally represented, 15 females and 15 males. 
The most predominant type of lipoma observed 
was parosteal occurring in 13 patients. In most 
cases, the recovery was complete or near complete 
(Table 1).
Discussion
Entrapment neuropathies of upper arm are com-
mon conditions, primary manifesting as carpal 
tunnel or cubital tunnel syndrome.3 In contrast, 
nontraumatic PIN palsy is a rare condition, with 
prevalence of only around 0.003 %.1,3,38 Patients 
with PIN palsy present with motor symptoms due 
to weakness of PIN innervated muscles in the fore-
arm.1 Clinically, it can resemble the lesion of radial 
nerve at the spiral groove. Both conditions present 
with wrist and finger drop, sparing the elbow ex-
tension. However, two important differences set 
them apart. In a PIN lesion, the muscles innervated 
above the take-off of the PIN are spared, allowing 
these patients to weakly extend the wrist with ra-
dial deviation, and there are no sensory findings.
Atraumatic PIN lesions most commonly result 
from compressive pathology at the level of upper 
forearm.2 There are 5 well-known sites at the elbow 
that can cause intrinsic compression - entrapment 
of the PIN, with repetitive pronation and supina-
tion movements being a well-established predis-
posing factor.1,7 Conversely extrinsic compression 
of the PIN is most often due to lipoma.9–11 In both 
cases a slow progressive build-up of symptoms is 
expected.2
Our patient presented with acute PIN lesion 
caused by a parosteal lipoma. She also reported 
repetitive pronation and supination movements 
in the preceding days. In the reviewed litera-
ture, we found only one case of acute PIN lesion 
caused by lipoma, mimicking stroke. In that case, 
the symptoms started suddenly, and no predis-
posing activities were reported.37 Another case 
involved a 83-year-old woman who had a combi-
nation of chronic PIN lesion caused by a lipoma 
and an acute worsening after forearm immobilisa-
tion due to distal radius fracture.20 We suggest that 
the acute presentation in our patient is most likely 
due to nerve traction caused by lipoma movement 
during repetitive arm pronation and supination. 
Based on EMG findings, showing denervation a 
week after symptoms onset, we can assume that 
there was some longstanding axonal nerve injury 
due to lipoma growth. We suppose that the acute 
manifestation of symptoms was caused by nerve 
demyelination block. This would also explain the 
good recovery. Unfortunately, we do not have mo-
tor conduction studies to prove this suggestion.
The recommended treatment for patients with 
PIN lesion due to lipoma is surgical excision.1,7,39 
Fortunately, most patients recover well and the 
symptom duration serves as a predictor for good 
recovery.39 After surgery and removal of the li-
poma, our patients showed complete restitution of 
function after 24 months.
PIN lesion due to lipoma is rarely encountered 
in clinical practice. The most common clinical 
scenario involves progressive weakness of wrist 
and finger extension, accompanied by a palpable 
mass at the proximal forearm. As presented in 
our review, the acute presentations are very rare. 
Nevertheless, it is advisable to perform imaging 
studies of elbow in all patients with PIN lesion, 
as a substantial proportion of cases are second-
ary to expansive masses surrounding the nerve. 
We propose as imaging method of choice nerve 
ultrasonography8 or MR imaging. This recommen-
dation holds true, especially considering the good 
prognosis associated with surgical removal.
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