Washington University Medical Center, St. Louis, MO 63110, USA.
J Bone Joint Surg Am. 2011 Jan 5;93(1):81-90. doi: 10.2106/JBJS.I.01242.
The posterior interosseous nerve is at risk for iatrogenic injury during surgery involving the proximal aspect of the radius. Anatomic relationships of this nerve in skeletally intact cadavers have been defined, but variations associated with osseous and soft-tissue trauma have not been examined. This study quantifies the effect of a simulated diaphyseal fracture of the proximal aspect of the radius and of a radial neck fracture with an Essex-Lopresti injury on the posterior interosseous nerve.
In twenty unembalmed cadaveric upper extremities, the distance from the radiocapitellar joint to the point where the posterior interosseous nerve crosses the midpoint of the axis of the radius (Thompson approach) was recorded in three forearm positions (supination, neutral, and pronation). Specimens were then treated with either proximal diaphyseal osteotomy (n = 10) or radial head excision with simulated Essex-Lopresti injury (n = 10), and the position of the nerve in each forearm position was remeasured. We evaluated the effect of the simulated trauma on nerve position and correlated baseline measurements with radial length.
In neutral rotation, the posterior interosseous nerve crossed the radius at a mean of 4.2 cm (range, 2.5 to 6.2 cm) distal to the radiocapitellar joint. In pronation, the distance increased to 5.6 cm (range, 3.1 to 7.4 cm) (p < 0.01). Supination decreased that distance to 3.2 cm (range, 1.7 to 4.5 cm) (p < 0.01). Radial length correlated with each of these measurements (r > 0.50, p = 0.01). Diaphyseal osteotomy of the radius markedly decreased the effect of forearm rotation, as the change in nerve position from supination to pronation decreased from 2.13 ± 0.8 cm to 0.24 ± 0.2 cm (p = 0.001). Proximal migration of the radius following radial head excision was accompanied by similar magnitudes of proximal nerve migration in all forearm positions.
Forearm pronation has minimal effect on posterior interosseous nerve position within the surgical window following a displaced diaphyseal osteotomy of the proximal aspect of the radius. The nerve migrates proximally toward the capitellum with proximal migration of the radius in all forearm positions following a simulated Essex-Lopresti lesion. Visualization and protection of the posterior interosseous nerve is recommended when operatively exposing the traumatized proximal aspect of the radius.
在涉及桡骨近端的手术中，后骨间神经有发生医源性损伤的风险。在完整的骨骼尸体中已经确定了该神经的解剖关系，但与骨骼和软组织创伤相关的变异尚未被检查。本研究定量评估了模拟桡骨干近端骨折和伴有 Essex-Lopresti 损伤的桡骨头颈骨折对后骨间神经的影响。
在 20 具未防腐的上肢尸体中，在三种前臂位置（旋前位、中立位和旋后位）记录桡骨小头关节到后骨间神经穿过桡骨轴中点的距离（Thompson 入路）。然后，对标本进行近端骨干切开术（n = 10）或桡骨头切除术合并模拟 Essex-Lopresti 损伤（n = 10），并重新测量每个前臂位置的神经位置。我们评估了模拟创伤对神经位置的影响，并将基线测量值与桡骨长度相关联。
在中立位旋转时，后骨间神经在桡骨小头关节远端平均 4.2 厘米（范围，2.5 至 6.2 厘米）处穿过桡骨。在旋后位时，距离增加到 5.6 厘米（范围，3.1 至 7.4 厘米）（p < 0.01）。旋前使该距离减少到 3.2 厘米（范围，1.7 至 4.5 厘米）（p < 0.01）。桡骨长度与这些测量值均相关（r > 0.50，p = 0.01）。桡骨干切开术明显降低了前臂旋转的效果，因为从旋前到旋后的神经位置变化从 2.13 ± 0.8 厘米减少到 0.24 ± 0.2 厘米（p = 0.001）。桡骨头切除术后桡骨近端迁移伴有所有前臂位置的近端神经迁移。
在桡骨干近端移位性骨折后，在前臂旋后时，后骨间神经在手术窗内的位置几乎不受影响。在模拟 Essex-Lopresti 病变后，在所有前臂位置，桡骨近端向桡骨头近端迁移，神经也向近端迁移。当对创伤后的桡骨近端进行手术暴露时，建议对后骨间神经进行可视化和保护。
