Perkütan uygulanan kilitli proksimal humerus plağı ve aksiller sinir arasındaki ilişki: Kadavra çalışması

Abstract

Amaç: Bu çalışmamızda perkütan plak yerleşimi sırasında aksiller sinir hasarlanma riskini ve aksiller sinir ile plak delikleri arasındaki ilişkiyi araştırmayı amaçladık.

Çalışma planı: Yirmi beş taze donmuş kadavranın 50 omuzu çalışmaya dahil edildi. Akromionun anterolateral köşesinden kola inen 5 cm bir kesi yapıldı. Beş delikli 3,5 mm proksimal humerus plağı yerleştirildi. Sonrasında aksiller sinir diseke edildi. Aksiller sinire gelen plak delikleri not edildi. Aksiller sinir ile akromiyon lateral köşesi arası mesafe ve kol uzunluğu ölçüldü. Aralarındaki ilişki korelasyon testi ile değerlendirildi.

Bulgular: Ortalama kol uzunluğu 319 mm idi. Aksiller sinir ile akromion lateral köşesi arası mesafe ortalama 60 mm idi. Kol uzunluğu ile akromion-aksiller sinir mesafesi arasında belirgin korelasyon vardı (pÐ0.05). Bir omuz haricinde tüm omuzlarda plak deltoid fasya altına yerleştirildi. Aksiller sinir lezyonu tespit edilmedi. Bir vakada plağın alt ucu deltoid içine yerleşmişti. Plak delikleri ile aksiller sinir arasında sabit bir ilişki yoktu.

Çıkarımlar: Perkütan plak yerleştirme sırasında aksiller sinir yaralanma riski vardır. Cerrahi girişim sırasında plağın deltoidin fasyası altına yerleştirildiğinden emin olunmalıdır. Hangi deliklerin aksiller sinire karşılık geldiğinin bilinmesi imkansız olduğu için vidalama sırasında aksiller sinir görülmelidir.

Keywords

• Aksiller sinir; aksiller sinir hasarı; kırık; perkütan; perkütan plak; plakla tespit; proksimal humerus; proksimal humerus kırığı.

Relationship between axillary nerve and percutaneously inserted proximal humeral locking plate: a cadaver study

Abstract

Objective: The aim of this study was to investigate the relationship between the axillary nerve and the percutaneously inserted proximal humeral locking plate and to evaluate the risk of axillary nerve injury during percutaneous plate insertion.

Methods: The study included 50 shoulders of 25 fresh frozen cadavers. A 5 cm incision was made from the anterolateral border of the acromion to the arm and a 5-hole 3.5-mm proximal humeral plate was inserted. The axillary nerve was then dissected. Plate holes which crossed the axillary nerve were noted. The distance between the axillary nerve and the lateral edge of the acromion and the length of the arm were measured and their relations evaluated with a correlation test.

Results: The average arm length was 319 mm. The average distance between the axillary nerve and the lateral edge of the acromion was 60 mm. There was a significant correlation between the arm length and acromion-axillary nerve distance (p<0.05). The plate was inserted under the deltoid fascia in all shoulders except one. There were no axillary nerve lesions. In 1 case, the distal end of the plate was inserted in the deltoid muscle. No constant relationship between the plate holes and the axillary nerve was detected.

Conclusion: There is a risk of axillary nerve injury during percutaneous plate insertion. It must be ensured that the plate is inserted under the deltoid fascia during the surgery. The axillary nerve must be visible during application of the screws due to the impossibility of knowing which holes cross the axillary nerve.

Keywords

• Axillary nerve
• axillary nerve injury
• fracture
• percutaneous
• percutaneous plate
• plate fixation
• proximal humeral fracture
• proximal humerus

References

1. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001;72:365-71.
2. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Management of proximal humeral fractures based on current literature. J Bone Joint Surg Am 2007;89 Suppl 3:44-58.
3. Helmy N, Hintermann B. New trends in the treatment of proximal humerus fractures. Clin Orthop Relat Res 2006;442:100-8.
4. Resch H, Beck E, Bayley I. Reconstruction of the valgusimpacted humeral head fracture. J Shoulder Elbow Surg 1995;4:73-80.
5. Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ. Proximal humeral fractures. Management techniques and expected results. Clin Orthop Relat Res 1993;(292):13-25.
6. Cuomo F, Flatow EL, Maday MG, Miller SR, McIlveen SJ, Bigliani LU. Open reduction and internal fixation of two- and three-part displaced surgical neck fractures of the proximal humerus. J Shoulder Elbow Surg 1992;1:287
7. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4(2):81-6.
8. Moeckel BH, Dines DM, Warren RF, Altchek DW. Modular hemiarthroplasty for fractures of the proximal part of the humerus. J Bone Joint Surg Am 1992;74:884-9.

9. Laflamme GY, Rouleau DM, Berry GK, Beaumont PH, Reindl R, Harvey EJ. Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial. J Orthop Trauma 2008;22(3):153-8.
10. Naidu SH, Bixler B, Capo JT, Moulton MJ, Radin A. Percutaneous pinning of proximal humerus fractures: a biomechanical study. Orthopedics 1997;20:1073-6.
11. Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res 2005;434:123-9.
12. Smith J, Berry G, Laflamme Y, Blain-Pare E, Reindl R, Harvey E. Percutaneous insertion of a proximal humeral locking plate: an anatomic study. Injury 2007;38:206-11.
13. Lau TW, Leung F, Chan CF, Chow SP. Minimally invasive plate osteosynthesis in the treatment of proximal humeral fracture. Int Orthop 2007;31:657-64.
14. Resch H, Hübner C, Schwaiger R. Minimally invasive reduction and osteosynthesis of articular fractures of the humeral head. Injury 2001;32 Suppl 1:SA25-32.
15. Resch H, Povacz P, Fröhlich R, Wambacher M. Percutaneous fixation of three- and four-part fractures of the proximal humerus. J Bone Joint Surg Br 1997;79:295300.
16. Sturzenegger M, Fornaro E, Jakob RP. Results of surgical treatment of multifragmented fractures of the humeral head. Arch Orthop Trauma Surg 1982;100:249-59.
17. Kristiansen B, Christensen SW. Plate fixation of proximal humeral fractures. Acta Orthop Scand. 1986;57:320-3.
18. Röderer G, Abouelsoud M, Gebhard F, Böckers TM, Kinzl L. Minimally invasive application of the non-contact-bridging (NCB) plate to the proximal humerus: an anatomical study. J Orthop Trauma 2007;21:621-7.
19. Rouleau DM, Laflamme GY, Berry GK, Harvey EJ, Delisle J, Girard J. Proximal humerus fractures treated by percutaneous locking plate internal fixation. Orthop Traumatol Surg Res 2009;95:56-62.
20. Saran N, Bergeron SG, Benoit B, Reindl R, Harvey EJ, Berry GK. Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide. Injury 2010;41:1037-40.
21. Bono CM, Grossman MG, Hochwald N, Tornetta P 3rd. Radial and axillary nerves. Anatomic considerations for humeral fixation. Clin Orthop Relat Res 2000;373:259
22. Cetik O, Uslu M, Acar HI, Comert A, Tekdemir I, Cift H. Is there a safe area for the axillary nerve in the deltoid muscle? A cadaveric study. J Bone Joint Surg Am 2006;88:2395-9.
23. Hoppenfeld S, deBoer P. Surgical exposures in orthopaedics: The anatomic approach. 2nd ed. Philadelphia: JB Lippincott; 1994. p. 32.
24. Kontakis GM, Steriopoulos K, Damilakis J, Michalodimitrakis E. The position of the axillary nerve in the deltoid muscle. A cadaveric study. Acta Orthop Scand 1999;70:9
25. Kulkarni RR, Nandedkar AN, Mysorekar VR. Position of the axillary nerve in the deltoid muscle. Anat Rec 1992;232:316-7.
26. Chen YF, Zhu NF, Zhang CQ, Wang L, Wei HF, Lu Y. The relevance of the anatomical basis of fracture for the subsequent treatment of the anterior humeral circumflex artery and the axillary nerve. Int Orthop 2012;36:783-7.
27. Vathana P, Chiarapattanakom P, Ratanalaka R, Vorasatit P. The relationship of the axillary nerve and the acromion. J Med Assoc Thai 1998;81:953-7.
28. Burkhead WZ Jr, Scheinberg RR, Box G. Surgical anatomy of the axillary nerve. J Shoulder Elbow Surg 1992;1:31-6.
29. Liu KY, Chen TH, Shyu JF, Wang ST, Liu JY, Chou PH. Anatomic study of the axillary nerve in a Chinese cadaveric population: correlation of the course of the nerve with proximal humeral fixation with intramedullary nail or external skeletal fixation. Arch Orthop Trauma Surg 2011;131:669-74.
30. Gallo RA, Hughes T, Altman G. Percutaneous plate fixation of two- and three-part proximal humerus fractures. Orthopedics 2008;31:237-42.