Identification of the Radial Nerve During the Posterior Approach to the Humerus

Seigerman, Daniel; Choung, Edward; Yoon, Richard S.; Lu, Michael T.; Frank, M; Gaines, Lcdr Robert J.; Liporace, Frank A.

doi:10.1097/bot.0b013e31821d0200

Cited by 22 publications

(23 citation statements)

References 9 publications

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“…We also stress on nonoperative treatment options now more than ever, which are known to have good union rates with low complications and problems and continue to offer and encourage this treatment modality in most patients with isolated injuries. Considering the incidence of postoperative palsy, we recommend alternate approaches 9 , 10 to the humerus be employed in centers unfamiliar with the brachialis splitting anterolateral approach. We have instituted regular cadaveric dissection training programs and tutorials for our trainee registrars to ensure adequate knowledge on anatomy of surgical exposures.…”

Section: Discussionmentioning

confidence: 99%

Incidence and predictors of radial nerve palsy with the anterolateral brachialis splitting approach to the humeral shaft

Gouse

Albert

Inja

et al. 2016

Chinese Journal of Traumatology

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PurposeFractures of the humeral shaft are common and account for 3%–5% of all orthopedic injuries. This study aims to estimate the incidence of radial nerve palsy and its outcome when the anterior approach is employed and to analyze the predictive factors.MethodsThe study was performed in the department of orthopaedics unit of a tertiary care trauma referral center. Patients who underwent surgery for acute fractures and nonunions of humerus shaft through an anterior approach from January 2007 to December 2012 were included. We retrospectively analyzed medical records, including radiographs and discharge summaries, demographic data, surgical procedures prior to our index surgery, AO fracture type and level of fracture or nonunion, experience of the operating surgeon, time of the day when surgery was performed, and radial nerve palsy with its recovery condition. The level of humerus shaft fracture or nonunion was divided into upper third, middle third and lower third. Irrespective of prior surgeries done elsewhere, the first surgery done in our institute through an anterior approach was considered as the index surgery and subsequent surgical exposures were considered as secondary procedures.ResultsOf 85 patients included, 19 had preoperative radial nerve palsy. Eleven (16%) patients developed radial nerve palsy after our index procedure. Surgeons who have two or less than two years of surgical experience were 9.2 times more likely to induce radial nerve palsy (p = 0.002). Patients who had surgery between 8 p.m. and 8 a.m. were about 8 times more likely to have palsy (p = 0.004). The rest risk factor is AO type A fractures, whose incidence of radial nerve palsy was 1.3 times as compared with type B fractures (p = 0.338). For all the 11 patients, one was lost to follow-up and the others recovered within 6 months.ConclusionContrary to our expectations, secondary procedures and prior multiple surgeries with failed implants and poor soft tissue were not predictive factors of postoperative deficit. From our study, we also conclude that radial nerve recovery can be reasonably expected in all patients with a postoperative palsy following the anterolateral approach.

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Section: Discussionmentioning

confidence: 99%

Incidence and predictors of radial nerve palsy with the anterolateral brachialis splitting approach to the humeral shaft

Gouse

Albert

Inja

et al. 2016

Chinese Journal of Traumatology

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“…36 The utility of a similar landmark was investigated by Siergerman et al in 2012. 37 The nerve's location with reference to the intersection between the lateral head of triceps, long head of triceps and tricipital aponeurosis, was explored. This point, referred to as 'the point of confluence' was found to be 39 mm distal to the radial nerve.…”

Section: Discussionmentioning

confidence: 99%

The Tricipital Aponeurosis — A Reliable Soft Tissue Landmark for Humeral Plating

et al. 2015

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This study aims to identify the relationship of the radial nerve as it descends across the humerus with reference to a reliable soft tissue landmark, the tricipital aponeurosis. Following cadaveric dissection of 10 adult humerii, the radial nerve was located as it crossed the lateral midsagittal point of the humeral diaphysis. A horizontal line was then subtended medially from this point to another line subtended vertically from the lateral border of the tricipital aponeurosis. The vertical distance from this intersection to the lateral apex of the aponeurosis was recorded in three positions (full flexion, 90° of flexion and full extension). The location of the radial nerve on the posterior aspect of the humeral diaphysis to the medial apex of the tricipital aponeurosis was also noted. In 90° of flexion the radial nerve at the lateral midsagittal point of the humerus was 0.9 mm proximal to the lateral apex of the tricipital aponeurosis. Flexion and extension of the elbow changed the interval to 16.3 mm (nerve proximal) in full flexion and 7.1 mm in full extension (nerve distal). On the posterior aspect of the humerus the radial nerve was 21.8 mm proximal to the medial aspect of the tricipital aponeurosis. The aponeurosis provides a reference point from which the nerve can be easily located on the lateral aspect of the humerus intraoperatively in a range of positions, whilst the medial apex provides a guide to the location of the nerve on the posterior aspect of the arm.

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“…Typically, its origin is in the distal third of the humerus at the inferior end of the spiral groove, however, we report an abnormally high branching variant well above even the proximal extent of the spiral groove. We recommend using the confluence of the triceps lateral head, long head and aponeurosis [ 8 ] to identify radial nerve then trace proximally towards spiral groove to locate branches of radial nerve, including the possible anatomic variants. Identifying and reporting anatomic variants is essential to reemphasize the importance of dissection and protection of the major branches in order to avoid iatrogenic injury.…”

Section: Discussionmentioning

confidence: 99%

“…Stress fluoroscopy exhibited gross motion at the fracture site (Figure 2 ). Via the posterior approach to the humerus, the radial nerve was found approximately two fingerbreadths above the confluence of the triceps lateral head, long head and aponeurosis [ 8 ]. Once the main trunk of the radial nerve was found, the surrounding branches were carefully isolated and dissected.…”

Section: Case Presentationmentioning

confidence: 99%

Anatomic variant of the inferior lateral cutaneous branch of the radial nerve during the posterior approach to the humerus: a case report

et al. 2015

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Iatrogenic injury during the posterior approach to the humerus during operative fixation is not an uncommon occurrence. A comprehensive understanding of the normal anatomy and its variants is of paramount importance in order to avoid such injury. Typically, the inferior lateral cutaneous branch of the radial nerve originates towards the distal end of the humerus at the inferior portion of the spiral groove. Here, we report an important variant of this nerve, which originated significantly more proximal than expected, further emphasizing the importance of identification, dissection and protection of the radial nerve and its major branches.

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Identification of the Radial Nerve During the Posterior Approach to the Humerus

Cited by 22 publications

References 9 publications

Incidence and predictors of radial nerve palsy with the anterolateral brachialis splitting approach to the humeral shaft

Incidence and predictors of radial nerve palsy with the anterolateral brachialis splitting approach to the humeral shaft

The Tricipital Aponeurosis — A Reliable Soft Tissue Landmark for Humeral Plating

Anatomic variant of the inferior lateral cutaneous branch of the radial nerve during the posterior approach to the humerus: a case report

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