Systematic review of nerves at risk at the wrist in common surgical approaches to the forearm: Anatomical variations and surgical implications

IF 2.3 4区 医学 Q1 ANATOMY & MORPHOLOGY
Clinical Anatomy Pub Date : 2023-12-07 DOI:10.1002/ca.24129
Hannah Bridgwater, Tamara Mertz, Cecilia Brassett, Neil Ashwood
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Abstract

Three commonly used approaches to the forearm in orthopedic surgery are Henry's, Thompson's, and the ulnar approach, each of which has the potential to cause injury to nerves around the wrist. Preserving these nerves is important to prevent complications such as neuroma formation and motor and sensory changes to the hand. We conducted a review of the literature to assess the nerves at risk and whether ‘safe zones’ exist to avoid these nerves. An independent reviewer conducted searches in Embase and MEDLINE of the literature from 2010 to 2020. A total of 68 papers were identified, with 18 articles being included in the review. Multiple nerves were identified as being at risk for each of the approaches described. In the anterior approach, the palmar cutaneous branch of the median nerve (PCBMN) is most at risk of injury. An incision immediately radial to the flexor carpi radialis (FCR) or directly over the FCR is most likely to avoid injury to both superficial branch of the radial nerve (SBRN) and PCBMN. With Thompson's approach, the safest zone for an incision is directly over or slightly radial to Lister's tubercle to avoid injury to SBRN and lateral cutaneous nerve of the forearm. For the ulnar approach, a safe zone was shown to be on the ulnar side of the wrist around the ulnar styloid (US) when the forearm was in supination or a neutral position to avoid injury to the dorsal branch of the ulna nerve (DBUN). Care must be taken around the US due to the density of nerves and the proximity of the last motor branch of the posterior interosseous nerve to the ulnar head. This review highlighted the proximity of nerves to the three most common surgical incisions used to access the forearm. In addition, anatomical variations may exist, and each of the nerves identified as being at risk has multiple branches. Both factors increase the potential of intraoperative damage if the anatomy is not properly understood. The surgeon must adhere carefully to the established approaches to the wrist and distal forearm to minimize damage to nerves and optimize surgical outcomes for the patient.

系统回顾常见前臂手术入路中腕部神经的危险:解剖变异和手术意义。
在骨科手术中,有三种常用的前臂入路是亨利入路、汤普森入路和尺侧入路,每一种入路都有可能对手腕周围的神经造成损伤。保存这些神经对于预防并发症如神经瘤的形成和手部运动和感觉的改变是很重要的。我们对文献进行了回顾,以评估处于危险中的神经,以及是否存在“安全区”来避免这些神经。一位独立审稿人在Embase和MEDLINE中检索了2010年至2020年的文献。共有68篇论文被确定,其中18篇被纳入综述。对于所描述的每一种方法,多个神经被确定为处于危险之中。在前路手术中,正中神经掌皮支(PCBMN)最容易受到损伤。直接桡侧腕屈肌(FCR)或直接在桡侧腕屈肌上方的切口最有可能避免桡神经浅支(SBRN)和PCBMN的损伤。采用Thompson入路时,最安全的切口区域在Lister结节正上方或略向桡骨方向,以避免损伤SBRN和前臂外侧皮神经。对于尺侧入路,当前臂处于旋后位或中立位时,安全区域位于手腕尺侧尺茎突(US)周围,以避免损伤尺神经背支(DBUN)。由于神经的密度和骨间后神经的最后一个运动分支与尺头的接近,在US周围必须小心。这篇综述强调了接近神经的三个最常见的手术切口用于进入前臂。此外,可能存在解剖学上的差异,每一个被确定为有危险的神经都有多个分支。如果解剖结构不正确,这两个因素都会增加术中损伤的可能性。外科医生必须谨慎地遵循手腕和前臂远端的既定入路,以尽量减少对神经的损伤,并优化患者的手术效果。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Clinical Anatomy
Clinical Anatomy 医学-解剖学与形态学
CiteScore
5.50
自引率
12.50%
发文量
154
审稿时长
3 months
期刊介绍: Clinical Anatomy is the Official Journal of the American Association of Clinical Anatomists and the British Association of Clinical Anatomists. The goal of Clinical Anatomy is to provide a medium for the exchange of current information between anatomists and clinicians. This journal embraces anatomy in all its aspects as applied to medical practice. Furthermore, the journal assists physicians and other health care providers in keeping abreast of new methodologies for patient management and informs educators of new developments in clinical anatomy and teaching techniques. Clinical Anatomy publishes original and review articles of scientific, clinical, and educational interest. Papers covering the application of anatomic principles to the solution of clinical problems and/or the application of clinical observations to expand anatomic knowledge are welcomed.
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