Distance of the Posterior Interosseous Nerve from the Radial Head during Elbow Arthroscopy: An Anatomical Study
04 August 2017 (online)
Purpose The aims of this study were to measure the distance of the posterior interosseous nerve (PIN) from the radial head (RH) and its variations with forearm movements.
Methods Five fresh frozen cadaver specimens were dissected under arthroscopy. An anterior capsulectomy extended to the entire lateral compartment was performed. The need of soft tissue dissection to isolate the nerve in the extracapsular space was recorded. The distance between the nerve and the anterior part of the RH was then measured with a graduated caliper inserted via the midlateral portal with the forearm in neutral position, full pronation, and full supination.
Results The PIN was identifiable in all the specimens. In four cases, it was surrounded by a thick layer of adipose tissue, and further dissection was necessary to isolate it. Damage of the PIN during dissection occurred in one case, in which the proximal part of the nerve was accidentally cut. In three of the remaining cases, an increased distance was measured with the forearm in supination, as compared with neutral and full pronation position.
Conclusion This anatomical study suggests that in most of the cases, the PIN does not lay just extracapular at the level of the radiocapitellar joint, but is surrounded by a thick layer of adipose tissue. Furthermore, its distance from the RH appears to increase with forearm supination. This position could increase the safe working space between RH and PIN.
Clinical Relevance Knowledge of PIN position in relation to the anterior elbow capsule and its changes with forearm movements can help reduce the iatrogenic injuries during elbow arthroscopy.
* P. Arrigoni and D. Cucchi contributed equally to this work.
- 1 Daurka J, Chen A, Akhtar K, Kamineni S. Tardy posterior interosseous nerve palsy associated with radial head fracture: a case report. Cases J 2009; 2 (01) 22
- 2 Erra C, De Franco P, Granata G. , et al. Secondary posterior interosseous nerve lesions associated with humeral fractures. Muscle Nerve 2016; 53 (03) 375-378
- 3 Van Geertruyden JP, Vico PG. Iatrogenic posterior interosseous nerve palsy following an elbow fracture. Acta Orthop Belg 1996; 62 (04) 222-224
- 4 Saldua N, Carney J, Dewing C, Thompson M. The effect of drilling angle on posterior interosseous nerve safety during open and endoscopic anterior single-incision repair of the distal biceps tendon. Arthroscopy 2008; 24 (03) 305-310
- 5 Lo EY, Li CS, Van den Bogaerde JM. The effect of drill trajectory on proximity to the posterior interosseous nerve during cortical button distal biceps repair. Arthroscopy 2011; 27 (08) 1048-1054
- 6 Gupta A, Sunil Tm Tm. Complete division of the posterior interosseous nerve after elbow arthroscopy: a case report. J Shoulder Elbow Surg 2004; 13 (05) 566-567
- 7 Mercer DM, Baldwin ED, Moneim MS. Posterior interosseous nerve laceration following elbow arthroscopy. J Hand Surg Am 2015; 40 (03) 624-626
- 8 Diliberti T, Botte MJ, Abrams RA. Anatomical considerations regarding the posterior interosseous nerve during posterolateral approaches to the proximal part of the radius. J Bone Joint Surg Am 2000; 82 (06) 809-813
- 9 Tornetta III P, Hochwald N, Bono C, Grossman M. Anatomy of the posterior interosseous nerve in relation to fixation of the radial head. Clin Orthop Relat Res 1997; (345) 215-218
- 10 Ozkan M, Bacakoğlu AK, Gül O, Ekin A, Mağden O. Anatomic study of posterior interosseous nerve in the arcade of Frohse. J Shoulder Elbow Surg 1999; 8 (06) 617-620
- 11 Mazurek MT, Shin AY. Upper extremity peripheral nerve anatomy: current concepts and applications. Clin Orthop Relat Res 2001; (383) 7-20
- 12 Clavert P, Lutz JC, Adam P, Wolfram-Gabel R, Liverneaux P, Kahn JL. Frohse's arcade is not the exclusive compression site of the radial nerve in its tunnel. Orthop Traumatol Surg Res 2009; 95 (02) 114-118
- 13 Lawton JN, Cameron-Donaldson M, Blazar PE, Moore JR. Anatomic considerations regarding the posterior interosseous nerve at the elbow. J Shoulder Elbow Surg 2007; 16 (04) 502-507
- 14 Thomas SJ, Yakin DE, Parry BR, Lubahn JD. The anatomical relationship between the posterior interosseous nerve and the supinator muscle. J Hand Surg Am 2000; 25 (05) 936-941
- 15 Spinner M. The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. J Bone Joint Surg Br 1968; 50 (04) 809-812
- 16 Kaplan E. Surgical approach to the proximal end of the radius and its use in fractures of the head and neck of the radius. J Bone Joint Surg 1941; 23: 86-92
- 17 Heidari N, Kraus T, Weinberg AM, Weiglein AH, Grechenig W. The risk injury to the posterior interosseous nerve in standard approaches to the proximal radius: a cadaver study. Surg Radiol Anat 2011; 33 (04) 353-357
- 18 Strauch RJ, Rosenwasser MP, Glazer PA. Surgical exposure of the dorsal proximal third of the radius: how vulnerable is the posterior interosseous nerve?. J Shoulder Elbow Surg 1996; 5 (05) 342-346
- 19 Schimizzi A, MacLennan A, Meier KM, Chia B, Catalano III LW, Glickel SZ. Defining a safe zone of dissection during the extensor digitorum communis splitting approach to the proximal radius and forearm: an anatomic study. J Hand Surg Am 2009; 34 (07) 1252-1255
- 20 Calfee RP, Wilson JM, Wong AH. Variations in the anatomic relations of the posterior interosseous nerve associated with proximal forearm trauma. J Bone Joint Surg Am 2011; 93 (01) 81-90
- 21 Strachan JC, Ellis BW. Vulnerability of the posterior interosseous nerve during radial head resection. J Bone Joint Surg Br 1971; 53 (02) 320-323
- 22 Kelly EW, Morrey BF, O'Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am 2001; 83-A (01) 25-34
- 23 Carofino BC, Bishop AT, Spinner RJ, Shin AY. Nerve injuries resulting from arthroscopic treatment of lateral epicondylitis: report of 2 cases. J Hand Surg Am 2012; 37 (06) 1208-1210
- 24 Desai MJ, Mithani SK, Lodha SJ, Richard MJ, Leversedge FJ, Ruch DS. Major peripheral nerve injuries after elbow arthroscopy. Arthroscopy 2016; 32 (06) 999-1002.e8
- 25 Chaware PN, Santoshi JA, Pakhare AP, Rathinam BA. Risk of nerve injury during arthroscopy portal placement in the elbow joint: a cadaveric study. Indian J Orthop 2016; 50 (01) 74-79
- 26 Blonna D, Wolf JM, Fitzsimmons JS, O'Driscoll SW. Prevention of nerve injury during arthroscopic capsulectomy of the elbow utilizing a safety-driven strategy. J Bone Joint Surg Am 2013; 95 (15) 1373-1381
- 27 Marshall PD, Fairclough JA, Johnson SR, Evans EJ. Avoiding nerve damage during elbow arthroscopy. J Bone Joint Surg Br 1993; 75 (01) 129-131
- 28 Pederzini LA, Nicoletta F, Tosi M, Prandini M, Tripoli E, Cossio A. Elbow arthroscopy in stiff elbow. Knee Surg Sports Traumatol Arthrosc 2014; 22 (02) 467-473
- 29 Savoie III FH. Guidelines to becoming an expert elbow arthroscopist. Arthroscopy 2007; 23 (11) 1237-1240
- 30 Jackson RW, Chow JCY. Advanced Arthroscopy. New York: Springer; 2012
- 31 Links AC, Graunke KS, Wahl C, Green III JR, Matsen III FA. Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: a possible mechanism of palsy after two-incision repair for distal biceps rupture--clinical experience and a cadaveric investigation. J Shoulder Elbow Surg 2009; 18 (01) 64-68