The course of the radial nerve in the distal humerus: A novel, anatomy based, radiographic assessment

Iatrogenic nerve injury during fracture surgery of the upper arm is a well-known complication. Prevention of this type of injuries would be of great value. The literature describes several methods to reduce this type of injury, but no perfect solution is at hand. In this study we introduce a new radiographic evaluation of the course and variation of the radial nerve in the distal part of the humerus in relation to bony landmarks as observed on a plain (trauma) radiographs. Aim of this new approach is to reduce the chance of iatrogenic nerve injury by defining of a danger zone in the distal upper arm regarding the radial nerve and hence give an advise for future implant fabrication. Methods and findings: Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage. Results: The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT). Conclusions: The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48–122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21–101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction

Use of the humeral head as a reference point to prevent axillary nerve damage during proximal fixation of humeral fractures: An anatomical and radiographic study

Introduction: Treatment of proximal humeral fractures with plate osteosynthesis or intramedullary nail fixation in humeral shaft fractures with a proximal locking bolt carries the risk of iatrogenic injury of the axillary nerve. The purpose of this anatomical study is to define a more reliable safe zone to prevent iatrogenic axillary nerve injury using the humeral head instead of the acromion as a (radiographic) reference point during operative treatment. Materials and methods: Anatomical dissection and labeling of the axillary nerve and branches was performed on 10 specially embalmed human specimens. Standard AP and straight lateral radiographs were made. The distances were measured indirectly from the cranial tip of the humerus to the axillary nerve on radiographs. Results: The median distance from the cranial tip of the humerus to the axillary nerve was 52 mm. The mean number of axillary nerve branches was 3. The distances from the cranial tip of the humerus to the nerve (branch) varied from 23 to 78 mm. The median distance from the proximal (anterior) branch was 36 mm, to the second branch 47 mm, 54 mm to the third branch and 73 mm to the fourth branch. The axillary nerve moves along with the humerus in cranial and caudal direction when the subacromial space varies. Conclusion: This study shows that the position of the axillary nerve can be better determent using the cranial tip of the humerus as a reference point instead of the acromion. Furthermore, it is unsafe to place the proximal locking bolts in the zone between 24 mm and 78 mm from the cranial tip of the humerus. The greatest chance to cause a lesion of the main branch of the axillary nerve is in the zone between 48 mm and 58 mm caudal from the tip of the humeral head

Subtalar versus triple arthrodesis after intra-articular calcaneal fractures

Depending upon initial treatment, between 2 and 30% of patients with a displaced intra-articular calcaneal fracture require a secondary arthrodesis. The aim of this study was to investigate the effect of subtalar versus triple arthrodesis on functional outcome. A total of 33 patients with 37 secondary arthrodeses (17 subtalar and 20 triple) with a median follow-up of 116 months were asked to complete questionnaires regarding disease-specific functional outcome (Maryland Foot Score, MFS), quality of life (SF-36) and overall satisfaction with the treatment (Visual Analogue Scale, VAS). Patient groups were comparable considering median age at fracture, initial treatment (conservative or operative), time to arthrodesis, median follow-up, and post-arthrodesis radiographic angles. The MFS score was similar after subtalar versus triple arthrodesis (59 vs. 56 points; P = 0.79). No statistically significant difference was found for the SF-36 (84 vs. 83 points; P = 0.67) and the VAS (5 vs. 6; P = 0.21). Smoking was statistically significantly associated with a non-union (χ2 = 6.60, P = 0.017). The current study suggests that there is no significant difference in functional outcome between an in situ subtalar or triple arthrodesis as a salvage technique for symptomatic arthrosis after an intra-articular calcaneal fracture. Smoking is a risk factor for non-union

What is the clinical course of transient synovitis in children: A systematic review of the literature

Background: Transient synovitis of the hip (TS) is considered to be a self-limiting disease in childhood. However, because the etiology is unclear and some cases precede Legg-Perthes' disease, data on follow-up are important. Our aim was to summarize the knowledge on the clinical course of TS in children. Methods: The study design was a systematic review and a literature search was conducted in Medline and Embase. Studies describing short and/or long-term follow-up of TS in children were included. Case reports, reviews and studies describing traumatic hip pain were excluded. Study quality was scored and data extraction was performed. The main outcome measures were short-term and long-term clinical course, and recurrence of symptoms. Results: A total of 25 studies were included of which 14 were of high quality. At two-week follow-up, almost all children with TS were symptom free. Those with symptoms persisting for over one month were more prone to develop other hip pathology, such as Legg-Perthes' disease. The recurrence rate of TS ranged from 0-26.3%. At long-term follow-up, 0-10% of the children diagnosed with TS developed Legg-Perthes' disease. Hip pain after intensive physical effort and limited range of motion of the hip at long-term follow-up was reported in 12-28% and in 0-18% of the children, respectively.Conclusions: The majority of the studies indicate that children with TS recover within two weeks; recurrence was seen in 0-26% of the cases. Children with TS should be followed at least six months to increase the likelihood of not missing Legg-Perthes' disease

Long-term outcomes of slipped capital femoral epiphysis treated with in situ pinning

PURPOSE: Slipped capital femoral epiphysis (SCFE) is the commonest hip disorder in adolescents. In situ pinning is commonly performed, yet lately there has been an increase in procedures with open reduction and internal fixation. These procedures, however, are technically demanding with relatively high complication rates and unknown long-term outcomes. Nevertheless, reports on long-term results of in situ fixation are not equivocal. This study evaluates the possible higher risk of worse outcome after in situ pinning of SCFE. METHODS: All patients treated for SCFE with in situ fixation between 1980 and 2002 in four different hospitals were asked to participate. Patients were divided into three groups, based on severity of the slip. Patients were invited to the outpatient clinic for physical examination and X-rays, and to fill out the questionnaires HOOS, EQ5D, and SF36. ANOVA and chi-squared tests were used to analyze differences between groups. RESULTS: Sixty-one patients with 78 slips filled out the questionnaires. Patients with severe slips had worse scores on HOOS, EQ5D, and SF36. 75 % of patients with severe slips had severe osteoarthritis, compared to 2 % of mild and 11 % of moderate slips. CONCLUSION: Hips with mild and moderate SCFE generally had good functional and radiological outcome at a mean follow-up of 18 years, and for these hips there seems to be no indication for open procedures. However, severe slips have a significantly worse outcome, and open reduction and internal fixation could therefore be considered

Arthrocentesis, arthroscopy or arthrotomy for septic knee arthritis in children: a systematic review

Purpose Septic knee arthritis in children can be treated by arthrocentesis (articular needle aspiration) with or without irrigation, arthroscopy or arthrotomy followed by antibiotics. The objective of this systematic review was to identify the most effective drainage technique for septic arthritis of the knee in children. Methods The electronic PubMed, Embase and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the knee. The quality of all included studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria. This systematic review was performed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO). Results Out of 2428 articles, 11 studies with a total of 279 knees were included in the systematic review. The quality of evidence was low (MINORS median 4 (2 to 7)). A metaanalysis could not be performed because of the diversity and low quality of the studies. In septic knee arthritis, additional drainage procedures were needed in 54 of 156 (35%) knees after arthrocentesis, in four of 96 (4%) after arthroscopy and in two of 12 (17%) after arthrotomy. Conclusion Included studies on treatment strategies for septic arthritis of the knee in children are diverse and the scientific quality is generally low. Knee arthroscopy might have a lower risk of additional drainage procedures as compared with arthrocentesis and arthrotomy, with acceptable clinical outcomes and no radiological sequelae. Level of evidence: IV