The course of the radial nerve in the distal humerus: A novel, anatomy based, radiographic assessment
Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in rela...
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| Published in | PloS one Vol. 12; no. 10; p. e0186890 |
|---|---|
| Main Authors | , , , , , |
| Format | Journal Article |
| Language | English |
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United States
Public Library of Science
26.10.2017
Public Library of Science (PLoS) |
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| Abstract | Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage.
The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT).
The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48-122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21-101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction. |
|---|---|
| AbstractList | Iatrogenic nerve injury during fracture surgery of the upper arm is a well-known complication. Prevention of this type of injuries would be of great value. The literature describes several methods to reduce this type of injury, but no perfect solution is at hand. In this study we introduce a new radiographic evaluation of the course and variation of the radial nerve in the distal part of the humerus in relation to bony landmarks as observed on a plain (trauma) radiographs. Aim of this new approach is to reduce the chance of iatrogenic nerve injury by defining of a danger zone in the distal upper arm regarding the radial nerve and hence give an advise for future implant fabrication.
Methods and findings
Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage.
Results
The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT).
Conclusions
The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48–122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21–101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction. Iatrogenic nerve injury during fracture surgery of the upper arm is a well-known complication. Prevention of this type of injuries would be of great value. The literature describes several methods to reduce this type of injury, but no perfect solution is at hand. In this study we introduce a new radiographic evaluation of the course and variation of the radial nerve in the distal part of the humerus in relation to bony landmarks as observed on a plain (trauma) radiographs. Aim of this new approach is to reduce the chance of iatrogenic nerve injury by defining of a danger zone in the distal upper arm regarding the radial nerve and hence give an advise for future implant fabrication. Methods and findings Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage. Results The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT). Conclusions The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48-122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21-101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction. Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage.The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT).The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48-122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21-101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction. Iatrogenic nerve injury during fracture surgery of the upper arm is a well-known complication. Prevention of this type of injuries would be of great value. The literature describes several methods to reduce this type of injury, but no perfect solution is at hand. In this study we introduce a new radiographic evaluation of the course and variation of the radial nerve in the distal part of the humerus in relation to bony landmarks as observed on a plain (trauma) radiographs. Aim of this new approach is to reduce the chance of iatrogenic nerve injury by defining of a danger zone in the distal upper arm regarding the radial nerve and hence give an advise for future implant fabrication. The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT). The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48-122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21-101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction. Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage. The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT). The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48-122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21-101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction. Iatrogenic nerve injury during fracture surgery of the upper arm is a well-known complication. Prevention of this type of injuries would be of great value. The literature describes several methods to reduce this type of injury, but no perfect solution is at hand. In this study we introduce a new radiographic evaluation of the course and variation of the radial nerve in the distal part of the humerus in relation to bony landmarks as observed on a plain (trauma) radiographs. Aim of this new approach is to reduce the chance of iatrogenic nerve injury by defining of a danger zone in the distal upper arm regarding the radial nerve and hence give an advise for future implant fabrication. METHODS AND FINDINGSMeasurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage.RESULTSThe distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT).CONCLUSIONSThe course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48-122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21-101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction. |
| Audience | Academic |
| Author | Bessems, J H J M Potters, J W Kerver, A J Kleinrensink, G-J Theeuwes, H P van der Ende, B |
| AuthorAffiliation | 5 Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg PM, Rotterdam, The Netherlands 1 Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands 4 Department of Anesthesiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands 3 Department of Orthopedic Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg AD Delft, The Netherlands 6 Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands Georgia Regents University, UNITED STATES 2 Department of Surgery, VieCuri Medical Center, Tegelseweg BL Venlo, The Netherlands |
| AuthorAffiliation_xml | – name: Georgia Regents University, UNITED STATES – name: 5 Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg PM, Rotterdam, The Netherlands – name: 2 Department of Surgery, VieCuri Medical Center, Tegelseweg BL Venlo, The Netherlands – name: 3 Department of Orthopedic Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg AD Delft, The Netherlands – name: 6 Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands – name: 1 Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands – name: 4 Department of Anesthesiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands |
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| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/29073240$$D View this record in MEDLINE/PubMed |
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| Copyright | COPYRIGHT 2017 Public Library of Science 2017 Theeuwes et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. 2017 Theeuwes et al 2017 Theeuwes et al |
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| DOI | 10.1371/journal.pone.0186890 |
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| References_xml | – volume: 24 start-page: 331 year: 2014 ident: ref5 article-title: Secondary radial nerve palsy after internal fixation of humeral shaft fractures publication-title: Eur J Orthop Surg Traumatol doi: 10.1007/s00590-013-1197-y contributor: fullname: X Wang – volume: 45 start-page: 825 year: 1998 ident: ref6 article-title: Median nerve palsy after humeral shaft fracture: case report publication-title: J Trauma doi: 10.1097/00005373-199810000-00040 contributor: fullname: E Apergis – start-page: CD005959 year: 2011 ident: ref9 article-title: Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults publication-title: Cochrane Database Syst Rev contributor: fullname: H Kurup – volume: 23 start-page: 222 year: 2010 ident: ref19 article-title: The surgical anatomy of the radial nerve and the triceps aponeurosis publication-title: Clin Anat doi: 10.1002/ca.20903 contributor: fullname: T Chaudhry – volume: 469 start-page: 2638 year: 2011 ident: ref11 article-title: A method to localize the radial nerve using the 'apex of triceps aponeurosis' as a landmark publication-title: Clin Orthop Relat Res doi: 10.1007/s11999-011-1791-4 contributor: fullname: S Arora – volume: 12 start-page: 363 year: 1998 ident: ref8 article-title: Ulnar nerve palsy following fracture of the shaft of the humerus publication-title: J Orthop Trauma doi: 10.1097/00005131-199806000-00013 contributor: fullname: S Stahl – volume: 9 start-page: 671 year: 2012 ident: ref17 article-title: NIH Image to ImageJ: 25 years of image analysis publication-title: Nat Methods doi: 10.1038/nmeth.2089 contributor: fullname: CA Schneider – start-page: 259 year: 2000 ident: ref18 article-title: 3rd. 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Is the energy of trauma a prognostic factor? publication-title: Injury doi: 10.1016/j.injury.2011.01.020 contributor: fullname: AI Venouziou – volume: 64 start-page: 407 year: 2012 ident: ref2 article-title: Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008 publication-title: Arthritis Care Res (Hoboken) doi: 10.1002/acr.21563 contributor: fullname: SH Kim – volume: 31 start-page: 1754 year: 2017 ident: ref15 article-title: Training for endoscopic surgical procedures should be performed in the dissection room: a randomized study publication-title: Surg Endosc doi: 10.1007/s00464-016-5168-3 contributor: fullname: PJ Klitsie – volume: 3 start-page: 5 year: 2017 ident: ref14 article-title: A New Model for Training on Human Specimens in Surgical-Anatomical Skills Labs publication-title: Anatomy Physiol Biochem Int J doi: 10.19080/APBIJ.2017.03.555604 contributor: fullname: HP Theeuwes – volume: 34 start-page: 991 year: 2009 ident: ref3 article-title: Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model publication-title: J Hand Surg Am doi: 10.1016/j.jhsa.2008.12.029 contributor: fullname: J Bishop – start-page: 149 year: 1995 ident: ref13 article-title: The surgical anatomy of the radial nerve around the humerus publication-title: Clin Orthop Relat Res contributor: fullname: TR Guse – volume: 17 start-page: 139 year: 2009 ident: ref10 article-title: Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures publication-title: J Orthop Surg (Hong Kong) doi: 10.1177/230949900901700202 contributor: fullname: AB Putti |
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| Snippet | Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal... Iatrogenic nerve injury during fracture surgery of the upper arm is a well-known complication. Prevention of this type of injuries would be of great value. The... METHODS AND FINDINGSMeasurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial... |
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| SubjectTerms | Aged Aged, 80 and over Anatomy Bends Bifurcations Biology and Life Sciences Bone surgery Care and treatment Diagnosis Dissection Distal locking Elbow Fabrication Female Fixation Forecasting Hazards Humans Humerus Humerus - anatomy & histology Humerus - diagnostic imaging Humerus - innervation Injury prevention Male Measurement methods Medical radiography Medicine and Health Sciences Methods Middle Aged Neurological disorders Neurosciences Orthopedics Peripheral nervous system diseases Prevention Radial Nerve - anatomy & histology Radial Nerve - diagnostic imaging Radiographs Radiography Software Surgery Trauma |
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| Title | The course of the radial nerve in the distal humerus: A novel, anatomy based, radiographic assessment |
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