title: Safe zone for superolateral entry pin into the distal humerus in children: an MRI analysis.
abstract: BACKGROUND
  The radial nerve is at risk for iatrogenic injury during placement of pins, screws, or wires around the distal humerus. Unlike adults, detailed anatomic information about the relationship of the nerve to the distal humerus is lacking in children.
  
  
  OBJECTIVE
  This study evaluates the relationship of the radial nerve to the distal humerus in a pediatric population on conventional MRI and proposes an anatomic safe zone using easily identifiable bony landmarks on an AP elbow radiograph.
  
  
  METHODS
  To determine the course of the radial nerve at the lateral distal humerus, we reviewed 23 elbow radiographs and MRIs of 22 children (mean age, 9 ± 4 years; range, 3-12 years) obtained as part of their workup for various elbow conditions. We described a technique using distance ratios calculated as a percentage of the patient's own transepicondylar distance, defined as the distance measured between the apices of the medial and lateral epicondyles, on the AP elbow radiograph and the midcoronal MR image. The cross-reference tool on a Picture Archiving and Communication System was then used to identify axial MR image at the level where the transepicondylar distance was measured. On this axial image, a line was drawn connecting the medial and lateral epicondyles (the transepicondylar axis) and its midpoint was determined. The radial nerve angle was measured by a line from the radial nerve to the midpoint of the transepicondylar axis and a line along the lateral half of the transepicondylar axis. On this axial slice, the closest distance from the nerve to the underlying cortex of the distal humerus was measured. To further localize the nerve along the distal humerus, predetermined percentages of the transepicondylar distance were projected proximally from the level of the transepicondylar axis along the longitudinal axis of the humerus on the midcoronal MR image. At these designated heights, the corresponding axial MR image was identified using the cross-reference tool and the nerve was mapped in a similar fashion. We then proposed a simpler method using a best-fit line drawn along the lateral supracondylar ridge on the AP radiograph to define the safe zone for lateral pin entry.
  
  
  RESULTS
  On axial MR images, the radial nerve was located in the anterolateral quadrant with a mean radial nerve angle of 54° (range, 35°-87) at 0% transepicondylar distance (23 MRIs), 41° (range, 24°-63°) at 50% transepicondylar distance (23 MRIs), and ≥ 10° at 75% transepicondylar distance (on the 13 MRIs that extended this far cephalad). The mean closest distance between the radial nerve and the underlying humeral cortex was 10 mm (range, 3-26 mm) at 0% transepicondylar distance and 7 mm (3-16 mm) at 50% transepicondylar distance. On the AP elbow radiograph, the height of the lateral supracondylar ridge, determined by a best-fit line drawn along the lateral cortex of the ridge, diverged from the most proximal extent of the ridge at a point located at 60% transepicondylar distance (range, 51%-76%). At the corresponding location on the axial MR image, the nerve was located anterolaterally with a mean radial nerve angle of 39° (range, 15°-61°) and a mean distance of 6 mm (range, 2-10 mm) from the underlying humerus.
  
  
  CONCLUSIONS
  Our data suggest that percutaneous direct lateral entry Kirschner wires and half-pins can be safely inserted in the distal humerus in children along the transepicondylar axis, either at or slightly posterior to the lateral supracondylar ridge, when placed caudal to the point located where the lateral supracondylar ridge line diverges from the proximal extent of the supracondylar ridge on AP elbow radiograph.
authors.affiliation: Department of Orthopedics, Rutgers, New Jersey Medical School, 90 Bergen Street, Doctor's Office Center, Suite 7300, Newark, NJ, 07103, USA, bloomta@rutgers.edu.
authors.forename: Tamir
authors.initials: T
authors.lastname: Bloom
authors.forename: Caixia
authors.initials: C
authors.lastname: Zhao
authors.forename: Alpesh
authors.initials: A
authors.lastname: Mehta
authors.forename: Uma
authors.initials: U
authors.lastname: Thakur
authors.forename: John
authors.initials: J
authors.lastname: Koerner
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Sabharwal
mesh_terms: D000367:Age Factors; D059925:Anatomic Landmarks; D001858:Bone Nails / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D006811:Humerus / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D007049:Iatrogenic Disease; D007090:Image Interpretation, Computer-Assisted; D008279:Magnetic Resonance Imaging; D008297:Male; D059348:Peripheral Nerve Injuries / Q000209:etiology / Q000517:prevention & control*; D011237:Predictive Value of Tests; D011826:Radial Nerve / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000293:injuries; D011859:Radiography; D012189:Retrospective Studies; D012307:Risk Factors