title: Deep branch of the radial nerve in lateral surgical approaches to the radial head - A cadaveric study.
abstract: The traditional Kocher approach for lateral radial head exposure may be complicated by injury to the deep branch of the radial nerve (DBRN) and the radial collateral ligament. Kaplan approach is less commonly used, due to its known proximity to the DBRN. Extensor Digitorum Communis (EDC) splitting approach allows possible wide surgical exposure and low risk of radial collateral ligament injury. The comparison of the proximity of the DBRN to the surgical dissection at the level of radial head among approaches to the radial head has not previously been evaluated. We aimed to determine the anatomical proximity of the DBRN in these 3 common radial head approaches and to define a safe zone of dissection for the surgical exposure.
  
  
  
  Cadaveric dissections of 9 pairs of fresh frozen upper extremities were performed using EDC splitting, Kaplan and Kocher approach to the radial head sequentially in a randomized order. A mark was made on the radial head upon initial exposure during dissection. Measurements from the marked point of the radial head to the DBRN were made at the level of radial head.
  
  
  
  The distance of DBRN to the radial head was 20 (17-22) mm in EDC splitting approach, 7 (3-11) mm in Kaplan approach and 29 (25-33) mm in Kocher approach. The EDC splitting approach was associated with a significantly lower chance of encountering the DBRN at the level of radial head as compared to the Kaplan approach (P<0.001). In all cases, lateral ligamentous complex was not exposed in Kaplan and EDC approaches, but were encountered in Kocher approach, risking injury to the radial collateral ligament.
  
  
  
  The EDC splitting approach provides adequate exposure without the need to elevate or retract the EDC and ECU muscle mass that could risk injuring the DBRN. The Kaplan approach should be done by experienced surgeons who are familiar with the anatomy in this region, with extreme caution due to proximity of the DBRN to the surgical dissection at the level of the radial head. Caution of the DBRN should be taken during anterior elevation and retraction of the muscle mass in Kocher approach.
  
  
  
  IV.
authors.affiliation: Department of Orthopaedic Surgery, University Orthopaedic Hand and Reconstructive Surgery, National University Hospital, 1E, Kent Ridge Road, 119228 Singapore, Singapore. Electronic address: fucai_han@nuhs.edu.sg.
authors.forename: F
authors.initials: F
authors.lastname: Han
authors.affiliation: Department of Orthopaedic Surgery, University Orthopaedic Hand and Reconstructive Surgery, National University Hospital, 1E, Kent Ridge Road, 119228 Singapore, Singapore.
authors.forename: C T
authors.initials: CT
authors.lastname: Lim
authors.affiliation: Department of Orthopaedic Surgery, University Orthopaedic Hand and Reconstructive Surgery, National University Hospital, 1E, Kent Ridge Road, 119228 Singapore, Singapore.
authors.forename: J C
authors.initials: JC
authors.lastname: Lim
authors.affiliation: Department of Orthopaedic Surgery, University Orthopaedic Hand and Reconstructive Surgery, National University Hospital, 1E, Kent Ridge Road, 119228 Singapore, Singapore.
authors.forename: B H
authors.initials: BH
authors.lastname: Tan
authors.affiliation: Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, 1E, Kent Ridge Road, 119228 Singapore, Singapore.
authors.forename: L
authors.initials: L
authors.lastname: Shen
authors.affiliation: Department of Orthopaedic Surgery, University Orthopaedic Hand and Reconstructive Surgery, National University Hospital, 1E, Kent Ridge Road, 119228 Singapore, Singapore; Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, 1E, Kent Ridge Road, 119228 Singapore, Singapore.
authors.forename: V P
authors.initials: VP
authors.lastname: Kumar
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004210:Dissection / Q000379:methods*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000379:methods*; D059348:Peripheral Nerve Injuries / Q000209:etiology / Q000517:prevention & control*; D011826:Radial Nerve / Q000033:anatomy & histology* / Q000293:injuries / Q000601:surgery; D011884:Radius / Q000294:innervation / Q000601:surgery*
keywords: Anatomy; Iatrogenic nerve injury; Posterior interosseous nerve; Radial head fractures; Radial nerve