Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, California.
University of California San Diego School of Medicine, La Jolla, California.
J Bone Joint Surg Am. 2022 Jul 20;104(14):1263-1268. doi: 10.2106/JBJS.21.01202. Epub 2022 Mar 28.
Adult literature cites an axillary nerve danger zone of 5 to 7 cm distal to the acromion tip for open or percutaneous shoulder surgery, but that may not be valid for younger patients. This study sought to quantify the course of the axillary nerve in adolescent patients with reference to easily identifiable intraoperative anatomic and radiographic parameters.
A single-institution hospital database was reviewed for shoulder magnetic resonance images (MRIs) in patients 10 to 17 years old. One hundred and one MRIs from patients with a mean age of 15.6 ± 1.2 years (range, 10 to 17 years) were included. Axillary nerve branches were identified in the coronal plane as they passed lateral to the proximal humerus and were measured in relation to identifiable intraoperative surface and radiographic landmarks, including the acromion tip, apex of the humeral head, lateral physis, and central apex of the physis. The physeal apex height (i.e., 1 "mountain") was defined as the vertical distance between the most lateral point of the humeral physis (LPHP) and the central intraosseous apex of the physis.
Axillary nerve branches were found in all specimens, adjacent to the lateral cortex of the proximal humerus. A mean of 3.7 branches (range, 2 to 6) were found. The mean distance from the most proximal branch (BR1) to the most distal branch (BR2) was 11.7 mm. The pediatric danger zone for the axillary nerve branches ranged from 6.6 mm proximal to 33.1 mm distal to the LPHP. The danger zone in relation to percent of physeal apex height included from 62% proximal to 242% distal to the LPHP.
All branches were found distal to the apex of the physis (1 "mountain" height proximal to the LPHP). Distal to the LPHP, no branches were found beyond a distance of 3 times the physeal apex height (3 "valleys"). In children and adolescents, percutaneous fixation of the proximal humerus should be performed with cortical penetration outside of this range. These parameters serve as readily identifiable intraoperative radiographic landmarks to minimize iatrogenic nerve injury.
This study provides valuable landmarks for percutaneous approaches to the proximal humerus. The surgical approach for the placement of percutaneous implants should be adjusted accordingly (i.e., performed at least 1 mountain proximal or 3 valleys distal to the LPHP) in order to prevent iatrogenic injury to the axillary nerve.
成人文献指出，在进行开放或经皮肩关节手术时，腋神经的危险区域为肩峰尖端远端 5 至 7 厘米，但这对于年轻患者可能并不适用。本研究旨在通过术中易于识别的解剖学和影像学参数，定量研究青少年患者腋神经的走行。
对 10 至 17 岁患者的肩关节磁共振成像（MRI）进行单机构医院数据库回顾。共纳入 101 例平均年龄 15.6±1.2 岁（10 至 17 岁）的患者 MRI。在冠状面识别出穿过肱骨近端外侧的腋神经分支，并测量其与术中可识别的表面和影像学标志的关系，包括肩峰尖端、肱骨头顶点、外侧骺板和骺板中央顶点。骺板顶点高度（即 1“山”）定义为肱骨骺板最外侧点（LPHP）与骺板中央骨髓内顶点之间的垂直距离。
所有标本均在肱骨近端外侧皮质附近发现腋神经分支。平均发现 3.7 个分支（范围 2 至 6 个）。最近端分支（BR1）到最远端分支（BR2）的平均距离为 11.7 毫米。腋神经分支的小儿危险区位于 LPHP 近端 6.6 毫米至远端 33.1 毫米处。与 LPHP 相关的危险区包括 LPHP 近端 62%至远端 242%的范围内。
所有分支均位于骺板顶点（LPHP 近端 1“山”高）远端。在 LPHP 远端，在骺板顶点高度的 3 倍距离（3“山谷”）以外，没有发现任何分支。在儿童和青少年中，应在骺板顶点高度的 3 倍距离以外进行肱骨近端的经皮固定，以避免医源性神经损伤。
本研究为经皮治疗肱骨近端提供了有价值的解剖学标志。为了防止腋神经的医源性损伤，应相应调整经皮植入物的手术入路（即至少在 LPHP 近端 1 个“山”或 LPHP 远端 3 个“山谷”处进行）。
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