Gerwin (1996) — Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve.

Alternative Operative Exposures of the Posterior Aspect of the Humeral Diaphysis with Reference to the Radial Nerve.

·J Bone Joint Surg Am·1996·250 citations·Shoulder & Elbow

Cadaveric anatomical study (n=10 specimens) mapping the radial nerve's precise course across the posterior humerus and evaluating three posterior surgical approaches — standard triceps splitting, triceps splitting with proximal nerve mobilization, and a modified posterior approach with medial triceps reflection — to determine how much humeral diaphysis each safely exposes. Includes a clinical series of seven patients treated with the modified approach.

Study Snapshot

Design

Cadaveric + retrospective series

Setting: Hospital for Special Surgery, New York

Funding: None

Objective

Whether modified posterior approach improves humeral diaphysis exposure while protecting the radial nerve

Outcome(s)

Length of posterior humeral diaphysis exposed per approach

Subjects

10 cadaveric specimens + 7 clinical patients

10 cadavericPosterior triceps-splitting approach
10 cadavericTriceps-splitting + radial nerve mobilization
10 cadaveric + 7 patientsModified posterior approach: triceps reflected medially

Inclusion

Middle/distal third humeral fracture or non-union

Follow-up

Mean 29 months (range 21–38)

Key Findings

The radial nerve crosses the posterior humerus from 20.7 ± 1.2 cm proximal to the medial epicondyle to 14.2 ± 0.6 cm proximal to the lateral epicondyle, lying directly on bone (no intervening muscle) for ~6.5 cm
No branches to the medial triceps head arise along the posterior humerus — the nerve gives multiple branches to the lateral head, then trifurcates at the lateral cortex into a medial triceps branch, the lower lateral brachial cutaneous nerve, and the forearm continuation
Standard triceps splitting exposes only 55% of the diaphysis (15.4 ± 0.8 cm); proximal nerve mobilization reaches 76% (21.4 ± 1.2 cm); the modified posterior approach reaches 94% (26.2 ± 0.4 cm)
In 7 clinical patients treated with the modified approach, zero had radial nerve dysfunction or triceps weakness at mean 29-month follow-up; union achieved in 6 of 7
The radial nerve pierces the intermuscular septum 10.2 ± 0.4 cm proximal to the lateral epicondyle. The lower lateral brachial cutaneous nerve at this septum is the key distal landmark for safe nerve identification

Clinical Relevance

When your standard posterior triceps-splitting exposure is inadequate for a proximal or comminuted humeral shaft fracture, identify the radial nerve distally via the lower lateral brachial cutaneous nerve at the lateral intermuscular septum, divide the septum 3 cm, and reflect both triceps heads medially — the medial head has no posterior innervation, so this reflection is safe and nearly doubles your working length of exposed humerus.

Supplemental

Alternative Operative Exposures of the Posterior Aspect of the Humeral Diaphysis with Reference to the Radial Nerve.

Gerwin, Weiland, et al.·J Bone Joint Surg Am·1996·250 citations·Shoulder & Elbow

Alternative Operative Exposures of the Posterior Aspect of the Humeral Diaphysis with Reference to the Radial Nerve.

Study Snapshot

Key Findings

Clinical Relevance

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Alternative Operative Exposures of the Posterior Aspect of the Humeral Diaphysis with Reference to the Radial Nerve.

Study Snapshot

Key Findings

Clinical Relevance

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Alternative Operative Exposures of the Posterior Aspect of the Humeral Diaphysis with Reference to the Radial Nerve.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Alternative Operative Exposures of the Posterior Aspect of the Humeral Diaphysis with Reference to the Radial Nerve.

Study Snapshot

Key Findings

Clinical Relevance

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