The anatomical basis for anterior interosseous nerve palsy secondary to supracondylar humerus fractures in children

Abstract

Various studies have found that 6.6 to 31% of supracondylar elbow fractures in children have nerve-related complications. One-third of these are cases of anterior interosseous nerve (AIN) palsy that usually result in a deficit of active thumb and index flexion. The goal of this cadaver study was to describe the course of the AIN to achieve a better understanding of how it may get injured. On 35 cadaver specimens, the median nerve and its collateral branches destined to muscles were dissected at the elbow and forearm levels. The distance at which the various branches arose was measured relative to the humeral intercondylar line. Interfascicular dissection of the AIN was used to map its distribution within the median nerve. The AIN arises at an average of 45 mm from the humeral intercondylar line. Before emerging from the median nerve, the AIN fascicles were always found in the dorsal part of the median nerve. After emerging, the AIN was divided into two zones. Zone 1 was the transitional portion from its exit point until its entrance into the interosseous space, where it changes direction. Zone 2 was the interosseous portion between the radius and ulna that comes into contact with the anterior interosseous membrane to which it is attached over its entire length until it ends in the pronator quadratus (PQ) muscle. The muscle branches of the AIN destined for the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) muscles mostly originated in Zone 1, which is the transitional portion between the median nerve and the fixed Zone 2. The branches destined to the pronator teres (PT) and flexor carpi radialis (FCR) originating from the median nerve are more proximal and superficial. The injury mechanisms leading to selective AIN palsy secondary to supracondylar elbow fracture in children are probably the result of two factors: direct contusion of the posterior aspect of the median nerve, and thereby the AIN fascicles, by the proximal fragment; stretching of AIN in Zone 1, which has less ability to withstand stretching than the median nerve and its other branches because the AIN is fixed in Zone 2. Details about the origin and course of the AIN can explain the high percentage of AIN palsy in supracondylar elbow fractures in children. Level IV. Anatomic study.