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      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

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          Abstract

          Introduction

          Preventing nerve injury is critical in elbow surgery. Distal extension of medial approaches, required for coronoid fracture fixation and graft-replacement, may endanger the median nerve. This study aims to describe an easily identifiable and reproducible anatomical landmark to localize the median nerve distal to the joint line and to delineate how its relative position changes with elbow flexion and forearm rotation.

          Materials and methods

          The median nerve and the ulnar insertion of the brachialis muscle were identified in eleven fresh-frozen cadaveric specimens after dissection over an extended medial approach. The elbow was brought first in full extension and then in 90° flexion, and the shortest distance between the two structures was measured while rotating the forearm in full pronation, neutral position and full supination.

          Results

          The distance between the median nerve and the brachialis insertion was highest with the elbow flexed and the forearm in neutral position. All distances measured in flexion were larger than those in extension, and all distances measured from the most proximal point of the brachialis insertion were larger than those from the most distal point. Distances in pronation and in supination were smaller than to those in neutral forearm position.

          Conclusions

          The ulnar insertion of the brachialis is a reliable landmark to localize and protect the median nerve at the level of the coronoid base. Elbow flexion and neutral forearm position increase significantly the safety margins between the two structures; this information suggests some modifications to the previously described medial elbow approaches.

          Level of evidence

          Basic Science Study.

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          Most cited references38

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          Reconstruction of the ulnar collateral ligament in athletes.

          Reconstruction of the ulnar collateral ligament using a free tendon graft was performed on sixteen athletes. All participated in sports that involved throwing (mostly professional baseball), and all had valgus instability of the elbow. After reconstruction and rehabilitation, ten of the sixteen patients returned to their previous level of participation in sports, one returned to a lower level of participation, and five retired from professional athletics. Despite precautions, there was a high incidence of complications related to the ulnar nerve. Two patients had postoperative ulnar neuropathy (one late and one early) that required a secondary operation, but they eventually recovered completely. Three others reported some transient postoperative hypoesthesia along the ulnar aspect of the forearm that resolved after a few weeks or months.
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            A muscle-splitting approach to the ulnar collateral ligament of the elbow. Neuroanatomy and operative technique.

            The standard surgical approach for repair or reconstruction of the ulnar collateral ligament of the elbow involves lifting off of the tendon of the common flexor bundle at its origin on the medial epicondyle. However, a more limited muscle-splitting approach may be feasible. A muscle-splitting approach is less traumatic to the flexor-pronator muscle mass, and it could decrease operative time and lessen immediate morbidity after surgery. A proposed muscle-split through the common flexor bundle extends from the medial humeral epicondyle to a point distal to the tubercle of the ulna such that repair or reconstruction can be performed on the ulnar collateral ligament. To examine the feasibility of this approach, we performed a study combining anatomic dissections with clinical observations. We dissected 15 fresh-frozen adult cadaveric elbows to examine the neuroanatomy of the medial side of the elbow. All pertinent nerves were identified and mapped. From these data, we defined a "safe zone" for a muscle-splitting approach to the ulnar collateral ligament that allows adequate room for repair or reconstruction of the ligament without risking denervation of the surrounding musculature. The safe zone extends from the medial humeral epicondyle to approximately 1 cm distal to the insertion of the ulnar collateral ligament on the tubercle of the ulna. Twenty-two patients with ulnar collateral ligament tears underwent either a direct repair or a reconstruction of the ligament using the proposed muscle-splitting approach. With a minimum followup of 1 year, there was no clinical evidence of muscle denervation. From the combined anatomic study and clinical data, we believe that a less traumatic muscle-splitting approach to the ulnar collateral ligament affords a safe and simple surgical approach for repair or reconstruction of the ligament.
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              Anatomic relationship of the radial nerve to the elbow joint: clinical implications of safe pin placement.

              The percutaneous placement of lateral distal humeral pins risks injury to the radial nerve. We aimed to provide a reliable and safe parameter for the insertion of lateral distal humeral pins. A secondary aim of this study was to investigate the effect of pin/screw placement in the intended zone of fixation at the lateral distal humerus. We dissected 70 fresh cadaveric upper limbs and the radial nerve was identified and its course followed into the anterior compartment. The point where the radial nerve crosses humerus in mid lateral plane was identified and the distance between this point and lateral epicondyle was measured, as was the maximum trans-epicondylar distance, along with the olecranon fossa height. Statistical analysis was performed using the Pearson correlation coefficient. The average trans-epicondylar distance was measured at 62 +/- 6 mm (range 52-78 mm), and the average lateral radial nerve height was 102 +/- 10 mm (range 75-129 mm). The ratio of the lateral nerve height to the trans-epicondylar distance was an average of 1.7 +/- 0.2 (range 1.4-2.0). The Pearson correlation coefficient between the lateral nerve height and the trans-epicondylar distance was r = 0.95. A relative dimension, the trans-epicondylar distance is both reliable and easily accessible to the operating surgeon. The absolute safe zone for pin entry into the lateral distal humerus is that area lying within the caudad 70% of a line, equivalent in length to the patient's own trans-epicondylar distance, when projected proximally from the lateral epicondyle.
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                Author and article information

                Contributors
                d.cucchi@gmail.com
                Journal
                Arch Orthop Trauma Surg
                Arch Orthop Trauma Surg
                Archives of Orthopaedic and Trauma Surgery
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0936-8051
                1434-3916
                23 January 2021
                23 January 2021
                2022
                : 142
                : 5
                : 813-821
                Affiliations
                [1 ]GRID grid.15090.3d, ISNI 0000 0000 8786 803X, Department of Orthopaedics and Trauma Surgery, , Universitätsklinikum Bonn, ; Venusberg-Campus 1, 53127 Bonn, Germany
                [2 ]U.O.C. 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari 1, Milan, 20122 Italy
                [3 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, , Università degli Studi di Milano, ; Via Mangiagalli 31, 20133 Milan, Italy
                [4 ]GRID grid.4708.b, ISNI 0000 0004 1757 2822, REsearch Center for Adult and Pediatric Rheumatic Diseases (RECAP-RD), Department of Biomedical Sciences for Health, , Università degli Studi di Milano, ; Via Mangiagalli 31, 20133 Milan, Italy
                [5 ]GRID grid.14778.3d, ISNI 0000 0000 8922 7789, Center for Orthopedic and Trauma Surgery, , University Medical Center, Cologne, ; Kerpener Straße 62, 50937 Cologne, Germany
                [6 ]GRID grid.6190.e, ISNI 0000 0000 8580 3777, Faculty of Medicine and University Hospital, , University of Cologne, ; Kerpener Straße 62, 50937 Cologne, Germany
                Author information
                http://orcid.org/0000-0001-6284-7977
                http://orcid.org/0000-0003-2786-8099
                Article
                3753
                10.1007/s00402-021-03753-y
                8994731
                33484309
                bc5b5ac7-0369-4313-9233-12f77c4393c5
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                : 29 September 2020
                : 1 January 2021
                Funding
                Funded by: Projekt DEAL
                Categories
                Trauma Surgery
                Custom metadata
                © Springer-Verlag GmbH Germany, part of Springer Nature 2022

                Orthopedics
                elbow surgery,median nerve,nerve injury,brachialis,coronoid process
                Orthopedics
                elbow surgery, median nerve, nerve injury, brachialis, coronoid process

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