MRI evaluation of axillary neurovascular bundle: Implications for minimally invasive proximal humerus fracture fixation

Abstract

Background Percutaneous fixation of proximal humeral fractures places the axillary nerve and posterior humeral circumflex artery at risk for injury. Safe operative zones for the axillary nerve are described based on external measurements from anatomic landmarks, but no study to date has incorporated advanced imaging to help guide surgical procedures in the region of the axillary neurovascular bundle (ANVB). We sought to define the location and trajectory of the ANVB in relation to osseous landmarks using magnetic resonance imaging (MRI) measurements. Methods Retrospective review of 750 consecutive MRI studies was performed with 55 imaging studies meeting inclusion criteria for patient positioning, image alignment, and quality. Five measurements were performed including the distance from mid-lateral acromion to lateral ANVB, mid-lateral acromion to medial ANVB, greater tuberosity to lateral ANVB, vertical distance between inferior anatomic neck and lateral ANVB, and angle the ANVB crosses the humerus. Height, gender, and age were recorded. Analysis was performed using ANOVA and Pearson correlation tests. Results The lateral ANVB was below the inferior articular margin of the humeral head by an average of 12.9 ± 3.9 mm and within a 22 mm window. It was an average of 57.4 ± 5.1 mm from the lateral mid-acromion, and 34.7 ± 4.3 mm below the greater tuberosity. The angle formed by the ANVB crossing the humerus averaged 19.5 ± 3.9 degrees upward from medial to lateral. Height and gender directly impacted measurements. Conclusions The use of the inferior humeral head articular margin provides a radiographic landmark to aid intraoperative lateral ANVB assessment which may be helpful during percutaneous fracture fixation.

Research Progress in Surgical Treatment of Proximal Humeral Fractures in Elderly Osteoporotic Humerus

“…CT angiography can accurately diagnose and guide the interventional treatment of arterial injury [15]. Magnetic resonance arthrogram and angiography are additional high-quality imaging tools used to assess periarticular soft tissue and vascular damage, respectively [16].…”

Which parameters are more reliable in proximal humerus surgery in terms of the axillary nerve?

“…Transosseous suture fixation, closed reduction and percutaneous fixation, open reduction with conventional or locking plate fixation, locking intramedullary nail, hemi, and total shoulder arthroplasty is among the different surgical options for surgically planned proximal humerus fractures. [4] The use of plating systems in the treatment of proximal humerus fractures has become more common owing to the effectiveness of locked plate applications. [5,6] The axillary nerve arises from the posterior cord of the brachial plexus.…”