Elbow Positioning and Joint Insufflation Substantially Influence Median and Radial Nerve Locations

Abstract

Background The median and radial nerves are at risk of iatrogenic injury when performing arthroscopic arthrolysis with anterior capsulectomy. Although prior anatomic studies have identified the position of these nerves, little is known about how elbow positioning and joint insufflation might influence nerve locations. Questions/purposes In a cadaver model, we sought to determine whether (1) the locations of the median and radial nerves change with variation of elbow positioning; and whether (2) flexion and joint insufflation increase the distance of the median and radial nerves to osseous landmarks after correcting for differences in size of the cadaveric specimens. Methods The median and radial nerves were marked with a radiopaque thread in 11 fresh-frozen elbow specimens. Three-dimensional radiographic scans were performed in extension, in 90°flexion, and after joint insufflations in neutral rotation, pronation, and supination. Trochlear and capitellar widths were analyzed. The distances of the median nerve to the medial and anterior edge of the trochlea and to the coronoid were measured. The distances of the radial nerve to the lateral and anterior edge of the capitulum and to the anterior edge of the radial head were measured. We analyzed the mediolateral nerve locations as a percentage function of the trochlear and capitellar widths to control for differences regarding the size of the specimens. Results The mean distance of the radial nerve to the lateral edge of the capitulum as a percentage function of the capitellar width increased from 68% ± 17% in extension to 91% ± 23% in flexion (mean difference = 23%; 95% confidence interval [CI], 5%-41%; p = 0.01). With the numbers available, no such difference was observed Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research 1 neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. This work was performed at the Department of Anatomy, University of Cologne, Cologne, Germany. regarding the location of the median nerve in relation to the medial border of the trochlea (mean difference = 5%; 95% CI, À13% to 22%; p = 0.309). Flexion and joint insufflation increased the distance of the nerv...

A prospective comparison of short-term results after arthroscopic and open elbow procedures in elbow stiffness

“…These results are supported by several studies reporting the arthroscopic procedure to be effective in patients with posttraumatic elbow contracture [2,[9][10][11][12][13]. However, due to the proximity of neurovascular structures, arthroscopic arthrolysis is a challenging procedure of high technical complexity [4,8]. Therefore, the open procedure is considered by several authors to be the standard treatment for managing contracted elbows, especially in elbows with large intrinsic and extrinsic components [3,6].…”

Anatomic relations of the median nerve to the ulnar insertion of the brachialis muscle: safety issues and implications for medial approaches to the elbow joint

“…The role of elbow flexion in changing the nerve distances to bony landmarks has been extensively investigated in relation to portal placement for elbow arthroscopy. Hackl et al demonstrated that the distance of the median nerve to the anterior tip of the coronoid and to the anterior border of the trochlea significantly increases from extension to 90° flexion [25]. These findings were supported by a recent review of cadaveric studies, which concluded that the distended elbow in a 90° flexed position minimizes the risk for neurovascular injury with the arthroscope [26].…”

“…For the median nerve, reliable landmarks have scarcely been reported, mostly by studies performed in arthroscopic settings and focused on defining anatomical relations at the level of the joint line, without investigating more distal regions. [13,17,18,[25][26][27][28][29]. Nevertheless, knowledge of median nerve position and behavior is essential in complex open surgery and revision cases and constitutes a precious help for all surgeons dealing with medial approaches, especially if lacking in a dedicated subspecialistic training on elbow surgery.…”

Basics of Elbow Arthroscopy Part III: Positioning and Diagnostic Arthroscopy in the Lateral Decubitus Position

“…[7][8][9] While advances in arthroscopic techniques have allowed improved access and better treatment of intra-articular pathology, proper patient positioning remains a key component of the procedure (Table 2). Lateral decubitus positioning avoids the potential downsides of prone positioning, including limited airway access, while offering the advantages of access to both the anterior and posterior compartments and the ability for dynamic motion (flexion, extension, pronation, and supination) and intraoperative assessment of all structures 1 (Table 1).…”