To The Editor:
In the article "Anatomical Considerations Regarding
the Posterior Interosseous Nerve During Posterolateral Approaches
to the Proximal Part of the Radius" (82-A: 809-13, June
2000), Diliberti et al. stated that specific guidelines for safe
exposure of the proximal part of the radius had not been clearly
delineated, which is not strictly true. The conclusions of a previously published
article were that the forearm should be fully pronated, the interval between
the extensor carpi ulnaris and the anconeus must be carefully identified,
the supinator should be released close to the ulna, and the proximal
part of the radius can be safely exposed as far as the distal extent
of the bicipital tuberosity of the radius1.
The whole purpose of this article was to provide specific guidelines
for safe exposure of the proximal part of the radius. In particular,
the authors thought it most useful to identify a specific anatomical
landmark for the safe distal extent of the exposure rather than to
rely on measurements that would vary from individual to individual
and according to the fracture pattern. This landmark was found to
be the distal aspect of the bicipital tuberosity.
Given the interest of Diliberti et al. in the subject, it was
rather suprising that they were not aware of this study, particularly
since the source is not obscure.
T. Diliberti, M.J. Botte, and R.A. Abrams reply:
We apologize for not acknowledging Mr. Witt’s contribution
to the literature regarding the anatomy of the radial nerve on the
lateral aspect of the elbow. His article appeared in the British
volume of The Journal of Bone and Joint Surgery in 1998. Unfortunately,
this was after we had completed our literature search and submitted
our manuscript. Had we redone our literature search during the period
of revision and eventual publication, we would have been able to
concur with Mr. Witt’s notion that the literature is replete
with references to the vulnerability of the posterior interosseous
nerve in the region of the elbow but that there are no specific
guidelines on the safe distal extension of an incision on the lateral aspect
of the elbow. Witt and Kamineni found that the radial tuberosity
is a practical landmark for the safe dissection of the distal end
of the radius. According to their article, this landmark is only
useful with the forearm in pronation. Our article provides additional
guidance for exposure of the proximal end of the radius, including
its most distal exposure with the forearm in pronation and in supination
(2 cm distal to the capitellum in supination and 4 cm distal to
the capitellum in pronation).
Unlike Mr. Witt, we did not use the radial head as a reference
point for measurement, since frequently the radial head is distorted
secondary to trauma. Mr. Witt also used the lateral epicondyle as
an alternative reference point, but we felt that this landmark was suboptimal,
since it is a somewhat large region on the lateral aspect of the elbow.
We chose the anterior tangent of the capitellum as our reference
for measurement, since it was more easily defined than a locus on
the lateral epicondyle.
We feel that the contribution of Witt and Kamineni to the literature
is worthy of acknowledgment and provides a useful surgical pearl.
We believe that our contribution adds further information that is
not redundant.