Risk Of Radial Nerve Injury Research Articles

Minimally Invasive Plate Osteosynthesis (MIPO) Through the Posterior Approach for the Humerus: A Cadaveric Study.

Background Minimally invasive plate osteosynthesis (MIPO) has been effectively used in femur and tibia fractures. MIPO in the humerus is conducted by anterior (most commonly used), lateral, and posterior approaches. However, in the anterior approach, in distal humeral diaphyseal fractures, there is a lack of adequate room for screw placement in the distal fragment for good stability. In such cases, the posterior approach for MIPO may be a propitious treatment method. However, the literatureon MIPO using the posterior approach for humeral diaphyseal fractures is limited. This study aimed to evaluate the feasibility of MIPOthrough the posterior approachand study the association of radial nerve injury with MIPOthrough the posterior approach for the humerus. Methodology This experimental study was conducted in the Department of Orthopedics, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India, and 20 cadaveric arms (10 right and 10 left) of 11 embalmed (formalin) cadavers were included (seven males and four females). Cadavers were placed prone on the dissection table. The posterolateral tip of the acromion and lateral epicondyle of the humerus were used as bony landmarks that were marked under C-Arm (Ziehm Imaging, Orlando, FL, USA) using K wires (Kirschner wires, Surgical Holdings, Essex, UK). Two incisions on theposterior part of the arm were made, and the radial nerve was identified at the proximal incision. After creating a submuscular tunnel, a 3.5 mm extraarticular distal humerallocking compression plate (LCP) was introduced over the posterior surface of the humerus and fixed to the humerus distally with one screw and then adjusted proximally and fixed to the humerus with another screw in the proximal window, followed by placement of couple more screws under C-Arm. After plate fixation, the dissection was completed to meticulously explore the radial nerve. The radial nerve was examined thoroughly for any injury sustained after completion of dissection, from the triangular interval to the lateral intermuscular septum where the nerve enters the anteriorchamber. The position of the radial nerve with respect to plate holes was noted.The distance from the posterolateral tip of the acromion to the lateral epicondyle was measured as humeral length.The medial and lateral points where radial nerve passed over the posterior surface of the humerus were measured from the posterolateral tip of the acromion and compared with the humeral length. Results In this study, the radial nerve was lying over the posterior surface of the humerus for a mean distance of 52.161 ± 5.16 mm. The mean distance at which the radial nerve crossed the medial and lateral borders of the posterior surface of the humerus, measured from the posterolateral tip of the acromion, was 118.34 ± 10.86 mm (40.07% of humeral length) and 170 ± 12.30 mm (57.57% of humeral length), respectively, and the mean humeral length in this study was 295.27 ± 17.94 mm. The radial nerve and its branches were found to be intact in all cases. The radial nerve was related to the fifth, sixth, and seventh holes, with the nerve lying most commonly over the sixth hole (3.5 mm extraarticular distal humerus locking plate). Conclusions The posterior approach of MIPO in humeral fractures is a safe and reliable treatment modality with minimal risk of radial nerve injury. The radial nerve can be safely identified at the spiral groove using the bony landmarks described in our study.

A modified trans-anconeus approach to facilitate fixation of a posterior radial head fracture: a cadaveric feasibility study.

Fixation of radial head fracture with minimally invasive posterior approach remains a significant challenge. The aim of this study was to determine the feasibility of trans-anconeus posterior elbow approach and to observe lateral ulnar collateral ligament (LUCL) in extended elbows. This cadaveric study was performed in twenty upper limbs of fresh fixed adult male cadavers. An oblique incision was made in the middle segment of anconeus until the lateral ligament complex and the joint capsule had been revealed. A deep dissection was explored to observe the anatomical relationship of the LUCL to the anconeus. Measurements of the LUCL were recorded while the elbow was fully extended. The mean distance between the edge of the radial head and the proximal insertion of the LUCL was 13.3 mm (11.5-16.2 mm); the mean distance between the edge of the radial head and the distal insertion of the LUCL was 20.9 mm (19.2-23.4 mm); the distance between the edge of the radial head and the distal edge of the annular ligament was 11.2 mm (8.22-11.7 mm). By estimate correlation of the previous measurements, the direct and accessible way to expose the posterolateral articular capsule of the elbow joint was through a window in medial 2/3 of the middle segment of anconeus muscle. These trans-anconeus approach is useful. It provides good visualization, facilitates applying the implants, and lessens the risk of radial nerve injury. Awareness of the anatomy is mandatory to avoid injury of LUCL.

Functional outcome of limited contact dynamic compression plating and interlocking nailing for fracture shaft of humerus in adults

ABSTRACT Background: Fractures of shaft of humerus are common, accounting 3% of all fractures. They have historically been managed conservatively with hanging casts or a functional brace. However, a lack of fracture reduction with these conservative measures resulted in malunion. Two surgical techniques under study include intramedullary nailing and limited contact dynamic compression plating. This study aims to analyze the functional outcome between the two surgical techniques. Materials and Methods: In this prospective randomized study, 38 patients were treated surgically for shaft of humerus fracture from August 2016 to August 2018 at a tertiary care center. Twenty patients underwent limited contact dynamic compression plate (LCDCP) plating and 18 underwent intramedullary nailing. All were assessed for radiological union, complications, and functional outcome at 6 weeks, 12 weeks, and 1 year using disabilities of arm, shoulder, and hand (DASH) questionnaire. Results: Thirty-eight patients completed the study of which 18 cases (47.5%) with fractures that were treated with interlocking nail and 20 cases that were treated with LCDCP plating. The mean duration to complete radiological healing was 15.06 weeks. The healing rate was relatively faster in the interlocking group as compared to the LCDCP group (P = 0.144). Complications such as shoulder impingement 8 (44.4%), shoulder pain 3 (16.7%), nonunion 1 (5.6%), and shoulder stiffness 1 (5.6%) were found to be more common in interlocking group as compared to LCDCP group, respectively. Whereas, complications such as superficial infection - 1(5%) and radial nerve deficits - 2(10%) were less common in the interlocking group compared to LCDCP group, respectively. The mean follow-up was 11.556 weeks, and the overall DASH score analysis showed better results in LCDCP group. Conclusion: In our study, LCDCP plating showed lower incidence of complications, particularly periarticular complications around the shoulder joint such as shoulder pain, stiffness, and impingement but carried a higher risk of radial nerve injury. Fracture union rates were found to be almost similar between both groups. DASH score analysis showed better functional outcome among the LCDCP plating group. The overall outcome of LCDCP plating over interlocking nailing was found to be better.

Postoperative radial nerve palsy in humeral shaft nonunion reconstruction: Can the lateral paratricipital approach prevent this common complication?

BackgroundPostoperative radial nerve palsy (RNP) is a well-known complication of nonunion reconstruction of the humerus. The purpose of the current study is to determine if the surgical approach for nonunion reconstruction of the humerus influences the rate of postoperative radial nerve palsy. MethodsA retrospective case-control study of all humeral shaft and extraarticular distal humerus nonunion reconstructions performed between January 1, 2004, and August 31, 2021, was conducted. Patients included were over 18 years of age, had a non-pathologic humerus fracture nonunion and had intact radial nerve function prior to nonunion reconstruction. Exclusion criteria consisted of nonunions involving the proximal humerus, intraarticular fractures, and reconstructive treatment procedures with either intramedullary nail or external fixation methods. Perioperative variables were recorded and analyzed in regard to the development of postoperative RNP. A subgroup analysis was performed to assess the interaction of significant variables on the development of postoperative RNP. ResultsThe overall rate of postoperative RNP in this series was 6/53 (11%). However, no cases of postoperative radial nerve palsy were observed in patients who underwent nonunion reconstruction with a lateral paratricipital approach. A new RNP was seen in 4/9 (44%) of those patients who underwent a triceps splitting approach, which was significantly higher than those utilizing either an anterolateral approach (2/28, 7%) or a lateral paratricipital approach (0/16, 0%, p = 0.007). Discussion and conclusionOur data suggests that the lateral paratricipital exposure decreases the risk of radial nerve injury with nonunion reconstruction of the humerus. The lateral paratricipital exposure offers the benefit of radial nerve exploration, decompression, neurolysis and protection prior to fracture manipulation and instrumentation. This study shows conventional approaches may predispose patients to a high rate of postoperative RNP, similar to that in the literature.

Risk of Radial Nerve Injury in Anterolateral Humeral Shaft Plating.

The purpose of this study was to evaluate and compare the risk of iatrogenic radial nerve injury between arm positionings of 45° and 60° abduction in anterolateral humeral plating using a 4.5-mm narrow dynamic compression plate. Fifty-six humeri of cadavers in the supine position with 45° of arm abduction were exposed through the anterolateral approach. A hypothetical fracture line was marked at the middle of the humerus, and a precontoured ten-hole 4.5-mm narrow dynamic compression plate was applied and fixed to the anterolateral surface. After the fixation, the radial nerve was exposed through a triceps-splitting approach. Screws in contact with or which had penetrated the radial nerve were deemed to be injuries. Then, the screws and plate were removed, the arm changed to the 60° arm abduction position, and the steps of applying the plate and inserting the screws were followed as in the 45° arm abduction step. The screws which could potentially injure the radial nerve were those of the second to sixth screw holes in both the 45° and 60° of arm abduction positions. The incidences of iatrogenic radial nerve injury of the second to sixth screw holes in the 45° position were 5.36%, 39.29%, 80.36%, 60.71%, and 10.71%, respectively, and at the 60° position were 5.36%, 53.57%, 83.93%, 60.71%, and 7.14%, respectively. There were no statistically significant differences in risk of injury between the two positions in all screw holes (all P-values > 0.05). In anterolateral humeral shaft fixation, arm abduction position did not affect the risk of iatrogenic radial nerve injury, with the main risk from certain screw holes. The surgeon should be careful in screw insertion, especially at the fourth and fifth screw holes. IV; cadaveric study.

How to Treat Proximal and Middle One-Third Humeral Shaft Fractures: The Role of Helical Plates

Complex proximal third diaphyseal humeral fractures are uncommon patterns of injury mainly caused by high energy trauma. The anatomical shape of the humerus, the presence of the deltoid tuberosity and the close proximity of the radial nerve into the radial groove represent challenge elements to deal with. Historically, straight plates were manually twisted; subsequently, helical plates created for other anatomical sites (as distal tibia) were used in humeral fractures. In both these experiences surgeons observed several disadvantages. More recently, dedicated helical plates have been created. In this study, we expose our surgical technique for using helical humeral plates (A.L.P.S.® Proximal Humeral Plating System, Zimmer Biomet), with its advantages and operative recommendation. From 2019 to 2021, nine patients who were admitted to our institution for humeral fractures involving the proximal third diaphysis have been treated with humeral helical plates. At one and six months after surgery, standard antero-posterior and lateral radiographs were obtained, and at last follow-up (fourteen months on average) clinical evaluation was performed through range of motion assessment, Constant score and DASH score questionnaires. At six months, all fractures have healed. At last follow-up (fourteen months on average, 6–22) the average range of motion were flexion 135° (90–180°); abduction 124° (85–180°); external rotation 52° (20–80°), internal rotation at L3 (between scapulae-trochanter). Average Constant Shoulder Score was 70 (33–96), average Dash score was 21 (range 1,7–63). Three patients experienced temporary radial nerve palsy from injury, with subsequently improvement at EMG analysis within eight months from surgery. In our opinion this strategy avoids the deltoid tuberosity and reduces the risk of radial nerve injury, increasing the possibility of a rapid functional recovery after surgery.

New, Minimally Invasive, Anteromedial-Distal Approach for Plate Osteosynthesis of Distal-Third Humeral Shaft Fractures: An Anatomical Study.

Background:Fractures of the distal third of the humeral shaft remain a challenge today. Plate osteosynthesis is the most commonly used method of treatment. Current minimally invasive plate osteosynthesis (MIPO) techniques applied to the distal part of the humerus have shown a high risk of radial nerve injury, and they are unable to adequately fix distal-most fractures. Our hypothesis was that using a new MIPO approach, distal humeral shaft fractures can be safely fixed. The aim of this study was to develop this new anteromedial-distal MIPO approach.Methods:We conducted a laboratory descriptive study using 16 arms from adult human specimens. A new anteromedial-distal MIPO approach, starting distally through a small window in the pronator teres muscle, was developed. A premolded plate was introduced in the anterior side of the medial epicondylar area, through the anterior face of the humerus, up to the proximal part of the humeral shaft. Several anatomical parameters were measured on dissection to define the distances of the plate and screws to the neurovascular structures that could be at risk.Results:The radial nerve was not at risk because of its pathway through the posterior and lateral aspects of the arm. The mean distance from the most distal border of the medial epicondyle to the proximal border of the coronoid fossa was 3.36 cm (95% confidence interval [CI], 3.23 to 3.50 cm). At least 3 screws could be inserted in all specimens in this area and up to 5 when the fixation area was extended 2 cm proximally. The mean width of the medial epicondylar area was 2.19 cm (95% CI, 2.03 to 2.33 cm), space enough for the distal fixation of the plate. The ulnar nerve was at risk only from the tip of the most distal screw (mean distance of 2.50 mm; 95% CI, 1.60 to 3.40 mm) in specimens with a very narrow medial epicondylar area.Conclusions:This approach provides adequate fixation for distal humeral shaft fractures, but proper clinical studies must be undertaken.Clinical Relevance:This new approach avoids the risk of radial nerve injury.

Effect of minimally invasive plate osteosynthesis through two approaches on bone metabolic activity and radial nerve injury in patients with humeral midshaft fracture

To compare application of minimally invasive plate osteosynthesis (MIPO) through two approaches for patients with humeral midshaft fracture, and analyzes the effect on bone metabolic activity and radial nerve injury. From April 2014 to May 2017, 76 patients with humeral midshaft fracture treated by MIPO were selected and randomly divided into group A (anterior approache group) and group B (lateral approach group) according to random number stable. In group A, there were 38 patients including 22 males and 16 females, aged from 18 to 74 years old with an average age of(48.21±5.79) years old; 24 patients were caused by traffic accidents, 6 patients were caused by heavy object crushing, 8 patients were caused by falling down; 20 patient were on the right side, 18 patients were on the left side; 15 patients were type A, 17 patients were type B, 6 patients were type C according to AO classification; the patients were treated by MIPO through anterior approach. In group B, there were 38 patients including 23 males and 15 females, aged from 20 to 73 years old with an average age of(48.40±5.81) years old; 26 patients were caused by traffic accidents, 5 patients were caused by heavy object crushing, 7 patients were caused by falling down; 17 patients were on the right side, 21 patients were on the left side; 15 patients were type A, 18 cases were type B, 5 cases were type C according to AO classification; the patients were treated by MIPO through lateral approach. Intraoperative blood loss, operative time, hospital stays, fracture healing time between two groups were compared. Bone gla protein (BGP), collagen C-terminal peptide (CTX) and osteoprotegerin (OPG) were tested before and after operation. The incidence of radial nerve injury after operation was observed. All patients were followed-up from 12 to 18 months with an average of (15.4±2.1) months. There were no statistical differences in operative time, intraoperative blood loss between two groups. Hospital stays, fracture healing time in group A were(6.52±1.81) d, (13.27±3.01) weeks respectively, while in group B were(9.61±1.99) d, (14.83±3.08) weeks; and had differences between two groups. There were no differences in BGP, OPG and CTX, BGP between two groups and OPG in group A at 1 month after operation were(7.10±0.58) ng/ml, (173.67±9.12) pg/ml and higher than that of group B(6.63±0.62) ng/ml, (152.80±9.23) pg/ml; while CTX in group A (224.52±12.67) μg/ml was lower than that of group B(259.13±13.54) μg/ml(P<0.05). No patient occurred radial nerve injury in group A, 4 patients occurred radial nerve injury in group B, and had statistical differences between two groups(χ²=4.220, P<0.05). Compared with lateral approach, anterior approach has much more effective in minimally invasive MIPO for humeral shaft fractures, which could improve bone metabolism and reduce risk of radial nerve injury.

The safety and feasibility of minimal invasive plate osteosynthesis (MIPO) of the posterior aspect of the humerus: A cadaveric study.

The aim of this study was to determine the feasibility of applying MIPO of the humerus via the posterior approach and to observe the tension of the radial nerve in different elbow positions. Two separate incisions were made on the posterior aspect of the humerus in ten fresh cadavers (20 humeri). The radial nerve was identified at the proximal incision and the distances through which the nerve could be elevated from the bone with the elbow in flexion and extension were measured. A 10-hole extra-articular distal humeral locking compression plate was inserted and fixed through the submuscular tunnel. The tunnel was then explored to identify any entrapment of the radial nerve and to observe the anatomical relationship of the radial nerve to the plate and bone. There was no entrapment of the radial nerve or its branches. The distances through which the radial nerve could be elevated were greater with the elbow in extension than in flexion (P < 0.01). The radial nerve crossed the medial and lateral borders of the posterior surface of the humerus at 80.1-132 mm (average 104.7 mm) and 116.6-175.5 mm (average 142.7 mm) of its total length, respectively. The axillary nerve was located at 38.7-61.7 mm (average 47.9 mm) of total humeral length. MIPO of the humerus using the posterior approach is an alternative option for treating distal humeral shaft fracture. The risk of radial nerve injury can be minimized by careful dissection in the proximal incision. Clin. Anat. 32:176-182, 2019. © 2018 Wiley Periodicals, Inc.

Surgical anatomy of the radial nerve in the deltopectoral approach for revision shoulder arthroplasty and periprosthetic fracture fixation: a cadaveric study

Radial nerve injury is a rare but clinically significant complication of revision shoulder arthroplasty and fixation of native and periprosthetic proximal humeral fractures. Understanding of the anatomic relationship between the radial nerve as it enters the humeral spiral groove and anterior shoulder landmarks in a deltopectoral approach is necessary to avoid iatrogenic radial nerve injury. Eight forequarter cadaveric specimens were dissected through a deltopectoral approach. Distances between the radial nerve entry into the proximal spiral groove and the coracoid process, distal lesser tuberosity/inferior subscapularis insertion, superior latissimus insertion, and inferior latissimus insertion were measured. Means, standard deviations, and ranges were determined for each distance. The radial nerve entry into the proximal spiral groove averaged 133.1 mm (range, 110.3-153.0 mm) from the coracoid process, 101.9 mm (range, 76.5-124.3 mm) from the distal lesser tuberosity/inferior subscapularis insertion, 81.0 mm (range, 63.4-101.5 mm) from the superior latissimus insertion, and 39.6 mm (range, 25.5-55.4 mm) from the inferior latissimus insertion. The proximal spiral groove was distal to the inferior latissimus insertion in all specimens. The risk of iatrogenic injury to the radial nerve at the spiral groove may be minimized through proper identification and protection or avoidance of circumferential fixation. However, if encircling fixation with cerclage cables is necessary, instrumentation proximal to the inferior edge of the latissimus dorsi insertion may reduce the risk of radial nerve injury.

Posterior Minimally Invasive Plate Osteosynthesis for Humeral Shaft Fractures

Fractures of the humeral shaft are common. Most of them can be successfully treated without surgery. In some cases, an operative intervention may offer faster and better functional results. One of the major problems with the open plating osteosynthesis is the extensive soft tissue stripping and disruption of periosteal circulation, caused by extensive surgical exposure, resulting in a relatively high rate of nonunion. Minimally invasive plate osteosynthesis (MIPO) techniques were developed to achieve a biologic fixation, although minimizing the complications of an open reduction. The incisions are small and remote from the fracture site to avoid direct fracture exposure. Thereby, MIPO technique obtains, theoretically, higher rates of union, lower infection risk, and decreases the need for bone graft. In the last years, MIPO has gained popularity with satisfactory clinical outcomes in the treatment of long bone fractures, especially in lower extremity. MIPO for humeral shaft fractures, however, could be a surgically dangerous procedure because of the risk of radial nerve injury. It was described by anterior and lateral approach. Humeral middle shaft fractures are possible to treat with a MIPO technique through an anterior, lateral, or a posterior approach. However, when the fracture is near the olecranon fossa, anterior approach is not possible as there is not enough space in the distal fragment to insert the amount of screws required to achieve stability. In this case, the posterior approach may be a good option for treatment. This article describes the MIPO technique through a posterior approach for the treatment of humeral shaft fractures.

Long PHILOS plate fixation in a series of humeral fractures

The purpose of the article is to highlight a specific fracture pattern encountered by us in the osteoporotic upper humerus. We present our results of management of such metadiaphyseal fractures of the upper humerus with less invasive plating. The additional steps taken to improve final outcome and the reasoning behind each are discussed. In our department, a total of 13 fractures (in 12 patients) were managed for a metadiaphyseal fracture of the upper humerus between 2010 and 2013. There were 2 males and 10 females. The average age in the cohort was 74.3 (52-95) years. In 9 fractures, the fracture line was extending above the surgical neck. All patients were managed with a locking compression plate (long PHILOS or LCP) using two approach windows (proximal deltopectoral and a distal anterior or lateral). Patients were evaluated for clinical outcome using the Quick DASH score and assessed for radiological union, complications or re-operations retrospectively. The mean follow-up was 14.3 months (4-36). All fractures were united, and there was no evidence of avascular necrosis or non-union. Two patients showed varus collapse of the anatomical head of which one patient needed change of screws at 12 weeks from index surgery. In patients, when a distal lateral window was used, 2 patients out of 4 had radial nerve palsy post-operatively. In the rest, when the plate was twisted by 45° to allow anterior placement using the brachialis split, none had radial nerve injury. The osteoporotic bone failing under a low-energy mechanism seemed to dictate this fracture pattern. The fracture is either a bending wedge or a long spiral with or without a large butterfly and often extends into the humeral head. The fractures are better managed surgically, a primary reduction allowing contact of fragments is essential, and using an anterior window distally with a 45° contoured plate will achieve good plate placement as well as decreases the risk of radial nerve injury considerably compared to total lateral plate positioning.

Comment on An et al.: Plating osteosynthesis of mid-distal humeral shaft fractures: minimally invasive versus conventional open reduction technique

Dear Editor, We commend the excellent paper entitled “Plating osteosynthesis of mid-distal humeral shaft fractures: minimally invasive versus conventional open reduction technique” [1]. This innovation will definitely revolutionise our understanding of fracture care. In our experience minimally invasive plate osteosynthesis (MIPO) for mid-distal humeral shaft fractures, however, could be a surgically dangerous procedure because of the risk of radial nerve injury [2]. The humeral shaft fractures by the MIPO method approached anteriorly is a safer approach in our experience. Moreover, to reduce the risk of radial nerve injury, the forearm must be kept in full supination during plate insertion, and excessive force should be avoided during retraction of the lateral half of the brachialis muscle together with the radial nerve in the distal incision. The principle of biological fracture fixation and implementation of locking plates in traumatology is suitable for long bones such as femur and tibia. Moreover, in polytrauma patients the risk of fat embolism is minimised. The ultrasonographic study in MIPO done in humerus fractures postoperatively revealed that the implant is quite close to the radial nerve and make it vulnerable to traction injury [3]. The MIPO technique is not applicable to every fracture so absolute indications should be defined [4]. We would like to note that this technique requires experience, as there are variable danger zones for the musculocutaneous and radial nerves which should be determined as a percentage of the humeral length [5].

Anatomical basis of the risk of radial nerve injury related to the technique of external fixation applied to the distal humerus

Stabilization of humeral shaft and elbow fractures can be achieved with an external-fixator. Reports about nerve injuries associated with this procedure are rare in literature. Purpose of this anatomical study was to examine the relation of the radial nerve to distal humeral half pins. Percutaneous insertion of external-fixator half pins was performed in 20 upper limbs of 20 cadavers, according to established technique, laterally in the distal humerus. Dissection of the upper limbs showed radial nerve injury in four of the 40 placed half pins. The proximal half pin impaled the nerve in one case and the distal half pin in three cases. Moreover the nerve was directly in contact with the pins in nine cases (five proximally, four distally). Insertion of external-fixator half pins in the distal humerus can easily injure the radial nerve. Thus we advocate a larger skin incision, blunt dissection to the lateral cortex of the humerus and retraction of soft tissue during half pin insertion.

The relation of sulcus nervi radialis with the fracture line of humerus fracture and radial nerve injury

Radial nerve is closely in contact with the bone in sulcus nervi radialis (SNR). Location of SNR shows ethnic differences. Radial nerve is a big problem in humerus fractures and its surgery. In this study, we aimed to examine if humerus fractures of this region increases the probability of radial nerve injury. Total length of humerus and the distance of SNR to proximal and distal anatomical points were measured on 57 human dry cadaver bones. The mean values of these data were calculated. The 58 cases of treated humerus fractures in our orthopedics department, whose radiological film techniques were available, were involved in the study and their measurements were made at the same anatomic reference points, retrospectively. Proximal and distal safe zones to total length ratios of both groups were determined. The ratios of the cases were compared with the confidence intervals of dry bones. Location of the fracture line according to SNR and the relationship between radial nerve injury and this location were evaluated. Sulcus nervi radialis region was located at the middle of humerus. Of 24 cases which had radial nerve injury, only nine cases had fracture of SNR region. Of the 34 cases which had no radial nerve injury, 16 had fracture of SNR region. As a result; radial nerve injury rate was 37.5% for the fractures of SNR region and it was higher compared to other studies. We concluded that the fractures of SNR region do not increase the risk of radial nerve injury.

Medial transposition of the radial nerve for anterolateral plate fixation of the humerus: Cadaveric study

In the operative treatment of humeral shaft fractures the radial nerve may be injured during the reduction of fracture fragments or the application of plate and screws. Also, secondary surgical explorations due to delayed or non-union carry a high risk of radial nerve injury because of the scarring of the neighboring tissue and proximity of the nerve to the implants. Consequently, the need for the transposition of the radial nerve to a safer position arises. A total of 22 (11 right, 11 left) cadaveric upper extremities were studied to evaluate the medial transposition of the radial nerve during the open reduction and anterolateral plate fixation of humeral fractures. The radial nerve was transposed medially in a distal plate fixated humeral fracture model. Distance measurements of the radial nerve and the division points of its branches were carried out in the transposed position and in the original course of the nerve. There was no statistically significant difference between the original course and medially transposed measurements. The distances from the reference point to the division points of other branches (posterior antebrachial cutaneous nerve, motor branch to brachioradialis, most distal motor branch to triceps) were not altered. The mean length of the radial nerve was 185.2 +/- 14.3 mm in its original course and 183.7 +/- 13.8 mm in the medially transposed course. In conclusion, the present study shows that medial transposition of the radial nerve through the fracture line does not increase the nerve's length and may be utilized in cases in which anterolateral plate fixation is indicated.

Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture: Is it possible? A cadaveric study and preliminary report

Minimally Invasive Plate Osteosynthesis (MIPO) has gained popularity with satisfactory clinical outcomes in the treatment of long bone fractures. MIPO for humeral shaft fractures, however, could be a surgically dangerous procedure because of the risk of radial nerve injury. An anatomical study was performed to evaluate the feasibility of MIPO for the humeral shaft fractures, and to study the relationship between the radial nerve and the plate with the forearm in full pronation and in supination. The study was performed on ten arms from five fresh cadavers. Two separate incisions, one proximal and one distal, were made in each arm with the forearm in full supination. A 9-hole narrow DCP was inserted into a tunnel using an anterior approach and fixed with 2 screws each on the proximal and distal humerus. The tunnel was then explored to identify the relationship between the radial nerve and the plate. No radial nerve compression or entrapment by the plate was found. The distance measured from the closest part of the plate to the radial nerve was 2.0-4.9 mm (average 3.2 mm). When the forearm was pronated, the radial nerve moved closer to the plate by a distance of 0-3 mm. The results of this study showed that it is possible to treat humeral shaft fractures by the MIPO method using an anterior approach. To reduce the risk of radial nerve injury, the forearm must be kept in full supination during plate insertion, and excessive force should be avoided during retraction of the lateral half of the brachialis muscle together with the radial nerve in the distal incision. The results of using this MIPO approach for humeral shaft fractures in 4 patients were also reviewed.

Risk of Radial Nerve Injury during Distal Interlocking of Short Humeral Nails

Risk of Radial Nerve Injury during Distal Interlocking of Short Humeral Nails

BICEPS-TO-TRICEPS TRANSFER IN TETRAPLEGIA. The medial route

Eight tetraplegic patients (13 elbows) were treated by biceps-to-triceps transfer. To avoid the risk of radial nerve injury, we chose a medial routing of the biceps. The mean follow-up after surgery was 17.8 months (range, 4–47 months). No complications were encountered. Active extension of the elbow was achieved in each case. The mean postoperative active range of motion of the elbow was 6 °extension and 137 °flexion. After the biceps-to-triceps transfer mean extension torque of the elbow was 3.7 Nm and mean flexion torque was 10 Nm. In eight elbows in which it was measured, there was a 47% reduction in elbow flexion power. Nevertheless no patient complained about that reduction, and all of them were satisfied.