Arch Orthop Trauma Surg
DOI 10.1007/s00402-015-2300-0
TRAUMA SURGERY
Radial nerve location at the posterior aspect of the humerus:
an anatomic study of 100 specimens
Michael Hackl1,2,3 Deborah Damerow1 Tim Leschinger1,2 Martin Scaal2,4
Lars Peter Muller1,2 Kilian Wegmann1,2
Received: 26 April 2015
Springer-Verlag Berlin Heidelberg 2015
Abstract
Purpose Radial neuropathy represents a devastating
complication in a posterior approach to the distal humerus.
This study aimed to propose safe zones regarding the at the lateral edge of the posterior aspect of the humeral
radial nerve (RN) location at the posterior aspect of the
humerus to minimize the risk of iatrogenic injury.
Methods In 100 embalmed specimens, the distances of
the proximal edge of the olecranon fossa (OF) to the radial
nerve at the medial edge (R1), at the center (R2) and at the
lateral edge (R3) of the posterior aspect of humeral shaft
were measured. Humeral length (HL) and transcondylar
width (TW) were evaluated and correlated to R1, R2 and
R3.
Results R1 was 15.0 (2.1; 10.619.5) cm, R2 averaged
12.7 (1.6; 8.915.7) cm, R3 was 10.6 (1.3; 7.613.7) humerus posteriorlyas in distal humeral fractures and in
cm. HL was 30.8 (1.9) cm. TW averaged 6.3 (0.6) cm.
TW and HL correlate with R1, R2, R3 (r = 0.451-0.565
[95 % CI 0.279-0.685]). The mean ratio was 2.3 (0.18)
for HL/R1, 2.6 (0.23) for HL/R2 and 3.1 (0.31) for HL/
R3. The ratio averaged 2.2 (0.20) for R1/TW, 1.9
(0.18) for R2/TW and 1.6 (0.15) for R3/TW.
Conclusions We present the OF as an osseous landmark
to reduce the risk of iatrogenic radial neuropathy. HL and
& Michael Hackl
michaelhackl@live.de
1
Center for Orthopedic and Trauma Surgery, University
Medical Center, Cologne, Germany
2
Cologne Center for Musculoskeletal Biomechanics, Medical
Faculty, University of Cologne, Cologne, Germany
3
Institute of Anatomy I, University of Cologne, Cologne,
Germany
4
Institute of Anatomy II, University of Cologne, Cologne,
Germany
TW can be reliably used to estimate the RN location. The
consistent safe zones of the RN in relation to the OF are
10.5 cm at the medial edge, 9 cm at the center and 7.5 cm
shaft.
Keywords Radial nerve
Anatomy
Humerus

Olecranon fossa
Radial neuropathy
Fracture
Introduction
Wrist drop as a result of injury to the radial nerve repre-
sents a serious complication when approaching the distal
total elbow arthroplastywhich might reflect poorly on the
clinical outcome of the patient [19]. Therefore, iatrogenic
radial nerve lesions as a direct result of surgical exposure
and dissection have to be avoided (Fig. 1).
Due to the clinical relevance, many anatomic studies
have focused on the anatomy of the radial nerve [1016].
Carlan et al. [15] described the deltoid tuberosity as a
potential landmark to determine the location of the radial
nerve at the posterior midshaft level of the humerus. The
deltoid tuberosity might be precisely identified when
approaching the dorsal aspect of the humeral shaft. In a
posterior approach to the distal humerus on the other hand,
this landmark may not be suitable for intraoperative
guidance.
Hence, we present an anatomic study regarding the
course of the radial nerve at the posterior aspect of the
humeral shaft in relation to the olecranon fossa. The goal of
this study was to establish a safe zone to minimize the
risk of iatrogenic radial neuropathy when approaching the
distal humerus posteriorly.
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was achieved. The nerve was carefully followed on its

course along the posterior aspect of the humeral shaft. The
brachial intermuscular septum was preserved at both the
lateral and medial aspect of the humerus to avoid mobi-
lization of the radial nerve from its native path.

Macroscopic measurements

Upon completion of specimen preparation, a measuring

device was used to manually assess the length of the
humerus (HL) from the tip of the humeral head to the
trochlea along the longitudinal axis of the humerus.
Moreover, the distance between the medial and lateral
epicondyle was measured. In the following, this distance is
called the transcondylar width (TW) (Fig. 2a). The proxi-
mal edge of the olecranon fossa was now identified. The
distance of the olecranon fossa to the radial nerve at the

Fig. 1 Intraoperative view of a right elbow. Dorsal approach to the

distal humerus. The posterolateral distal humerus plate is placed
underneath the exposed radial nerve (RN). OL olecranon, LE lateral
epicondyle

Materials and methods

Specimen data

Approval for this study was obtained through the institu-

tional review board of the Medical University of Cologne.
100 upper extremity specimens of 98 embalmed Europid
human body donors were used. 53 body donors (54 %)
were female, 45 (46 %) were male. 55 right-sided and 45
left-sided specimens were available. The mean age of
donors was 81.6 (11.2) years and ranged from 45 to
99 years.

Specimen preparation

Exarticulation of the glenohumeral joint was performed in

all specimens. The skin and the subcutaneous tissue of the
specimens were then removed. Subsequently, the distal
triceps tendon was fenestrated by use of sharp dissection to
expose the posterior aspect of the capsule of the elbow
joint. The capsule was excised along with the surrounding
fat tissue to expose the underlying olecranon fossa. The Fig. 2 a Measurement of the transcondylar width. OT olecranon tip,
lateral and the long head of the triceps were then identified OF olecranon fossa, ME medial epicondyle, LE lateral epicondyle,
TR triceps. b Measurement of the distance of the proximal edge of the
at the midshaft level of the humerus. They were separated olecranon fossa to the radial nerve at the center of the dorsal aspect of
by blunt dissection. Thereby, exposure of the radial nerve the humeral shaft

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Arch Orthop Trauma Surg
medial edge (R1), at the center (R2) and at the lateral edge
(R3) of the posterior humeral shaft was analyzed by means
of manual measurements (Fig. 2b).
Statistical analysis
Mean and standard deviation as well as minimum and
maximum of all measured values were obtained. The Sha-
piroWilks test was applied to confirm normal distribution of
the data. A two-sided analysis of variance was performed to
evaluate significant differences of the values R1, R2 and R3.
A one-sided analysis of variance was obtained to provide
information on significant differences between male and
female specimens regarding humeral length and
transcondylar width as well as the values R1, R2 and R3. The
level of significance was set to p \ 0.05. The correlation of
transcondylar width and humeral length with the values R1,
R2 and R3 was analyzed using Spearmans correlation
coefficient (r). A confidence interval (CI) of 95 % was used
to assess significant correlation of the data. Finally, the ratios
of humeral and transcondylar width to R1, R2 and R3 were
calculated. Mean, minimum and maximum values as well as
standard deviations were obtained.
Fig. 3 Illustration of obtained
data. Yellow line Mean value;
Red area standard deviation
Results
The average length of the humerus was 30.8 cm
(1.9 cm). It ranged from 25.6 to 34.9 cm. The
transcondylar width averaged 6.3 cm (0.6 cm; range
5.17.6 cm). The distance of the olecranon fossa to the
radial nerve at the medial edge of the posterior aspect of
the humeral shaft (R1) was 15.0 cm (2.1 cm; range
10.619.5 cm). At the center of the humeral shaft, the
distance (R2) was 12.7 cm (1.6 cm; range 8.915.7 cm).
The mean distance of the olecranon fossa to the radial
nerve at the lateral border of the posterior aspect of the
humeral shaft (R3) was 10.6 cm (1.3 cm) and ranged
from 7.6 to 13.7 cm. Figure 3 outlines the obtained data.
Values R1, R2 and R3 differ significantly from each
other with R1 being the highest and R3 providing the
lowest distance (p \ 0.0001). The humeral length and the
transcondylar width were significantly larger in male
specimens when compared to female specimens
(p \ 0.0001). Yet, values R1, R2 and R3 did not show
gender-specific differences (0.10 B p B 0.72).
The humeral length correlated with the values R1, R2
and R3. Spearmans correlation coefficient was 0.565
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Fig. 4 Correlation of values R1, R2, R3 with humeral length and transcondylar width according to Spearmans correlation coefficient with 95 %
confidence intervals
[95 % CI 0.415; 0.685] for value R1, 0.467 [95 % CI
0.293; 0.604] for R2 and 0.451 [95 % CI 0.279; 0.595] for
R3. The mean HL/R1 ratio was 2.3 (0.18, range 1.92.8).
The ratio HL/R2 averaged 2.6 (0.23, range 2.23.3). The
HL/R3 ratio was 3.1 (0.31, range 2.53.9).
Similarly, the transcondylar width correlated with the
distance of the radial nerve to the olecranon fossa. Spear-
mans correlation coefficient was 0.505 [95 % CI 0.349;
0.642] for R1, 0.481 [95 % CI 0.316; 0.620] for R2 and
0.546 [95 % CI 0.413; 0.671] for R3. The R1/TW ratio was
2.2 (0.20, range 1.82.6). The ratio of R2/TW averaged
1.9 (0.18, range 1.52.3). The mean R3/TW ratio was
found to be 1.6 (0.15, range 1.31.8).
Figures 4 and 5 illustrate the correlation of the values
R1, R2 and R3 with humeral length and transcondylar
width.
Discussion
The results of our study provide a precise description of the
radial nerve anatomy at the posterior aspect of the humeral
shaft. At average, the distance of the nerve to the olecranon
fossa declines from 15 cm at the medial edge of the
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Arch Orthop Trauma Surg
humeral shaft to 10 cm at the lateral edge. Humeral length
and transcondylar width correlate well with the distance of
the radial nerve to the olecranon fossa. Multiplying the
transcondylar width with 1.6, 1.9 and 2.2 can provide a
good estimation of the location of the radial nerve at the
lateral edge, at the center and at the medial edge of the
humeral shaft. Regardless of the size of the respective
specimen, the radial nerve is located more than 7.5 cm
proximal of the olecranon fossa at the lateral border and
more than 10.5 cm proximal at the medial border of the
humerus. At the midshaft level, the minimum distance
between radial nerve and olecranon fossa is around 9 cm.
Previous anatomic studies have already focused on the
course of the radial nerve [1016]. Carlan et al. [15] per-
formed a cadaveric study regarding the anatomy of the
radial nerve at the humerus. They found that the deltoid
tuberosity could be used for orientation to approximate the
location of the radial nerve. Moreover, they described that
the nerve is located 10.9 cm (1.5 cm) proximal to the
lateral epicondyle at the lateral border of the humeral shaft.
At the medial edge, the distance of the radial nerve to the
lateral epicondyle averaged 17.1 cm (1.6 cm). Similarly,
Artico et al. [10] found an average distance of the radial
nerve to the lateral epicondyle of 12.1 cm (1.3 cm) at the
Arch Orthop Trauma Surg
Fig. 5 Mean ratio of humeral length (a) and transcondylar width (b) to values R1, R2 and R3
lateral edge of the humeral shaft. Both studies [10, 15]
provide valuable information considering the course of the
radial nerve along the brachium. Yet, their results [10, 15]
do not seem suitable for intraoperative guidance during a
posterior approach to the distal humerus. For one, the
sample size of those studies is limited. While Carlan et al.
[15] performed a study on 27 cadaveric specimens, Artico
et al. [10] used 20 specimens for their evaluation. Addi-
tionally, both studies only present mean values and standard
deviations [10, 15]. Consistent safe zones cannot be
reported since minimum and maximum values are missing.
Additionally, the lateral epicondyle might not be suitable as
an osseous landmark in distal humerus fractures because of
possible displacement. The olecranon fossaas proposed
in our studyseems to be more fitting to serve as a point of
reference during surgery. In case of a comminuted fracture
proximal to the olecranon fossa, the latter might also be
unavailable for intraoperative orientation. Due to its close
relation to the olecranon though, the tip of the olecranon
could be used to approximate the proximal edge of the
olecranon fossa whenever the latter is not readily available.
The current study is limited by the fact that manual
measurements were performed. Even though measure-
ments were performed consecutively in a standardized
fashion, manual measuring remains prone to errors, which
could influence the study results. Moreover, dissection of
the radial nerve to reach sufficient exposurealthough
performed cautiouslymight have slightly altered the
native path of the nerve. The use of embalmed cadaveric
specimens also potentially limits our data since specimen
fixation leads to dehydration and shrinkage of soft tissues.
We do not believe though that these factors limit our
conclusion. Compared to other studies, we used a large
sample size of 100 specimens. This provides us with reli-
able information on the anatomic course of the radial nerve
with potential benefit for the clinical practice.
In conclusion, this study presents the proximal edge of
the olecranon fossa as an osseous landmark for intraoper-
ative orientation to avoid iatrogenic radial neuropathy
especially when approaching the distal humerus at its
posterior aspect. Humeral length and transcondylar width
can be reliably used for approximation of the location of
the radial nerve. At the medial and lateral edge of the
humerus, the absolute safe zones of the radial nerve in
relation to the olecranon fossa are 10.5 and 7.5 cm,
respectively. At the midshaft level, the nerve is located at a
minimum of 9 cm proximal to the olecranon fossa.
Knowledge of these safe zones could potentially be
useful for intraoperative guidance and might contribute to
reduce the risk of radial neuropathy.
Acknowledgments None.
Compliance with ethical standards
Conflict of interest No benefits of any kind have been received
related to the subject of this article.
Ethical approval Approval for this study was obtained through the
institutional review board of the Medical University of Cologne.
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