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Incidence of Posterior Interosseous Nerve Injury During Creation of the 3-4 Wrist Arthroscopy Portal
Andre Cheah, MBBS, MBA1; Wei Le, MD2; Jeffrey Yao, MD2
1National University Hospital, Singapore, Singapore, 2Stanford University, Redwood City, CA
Introduction: The 3-4 portal is one of the most important portals that is typically established first and used as a viewing portal for diagnostic arthroscopy of the radiocarpal and ulnocarpal joints. While there have been many studies that have shown injuries to the extensor tendons and the superficial radial nerve during creation of the 3-4 portal, few have mentioned damage to the posterior interosseous nerve (PIN). In this study, we focused on structures that may be injured while establishing this portal and have paid particular attention to possible injury to the PIN.
Materials and Methods: 14 fresh frozen cadaveric upper limbs were harvested at the level of the mid forearm. Each specimen was mounted in turn on a custom built frame that simulates a wrist arthroscopy traction tower and the 3-4 portal was created in the usual manner. After establishing the 3-4 portal, the skin was carefully dissected off to identify possible injury to the extensor tendons, superficial radial nerve and the PIN. In the case of the PIN, we categorized specimens into those where there was clearly no visual injury to the PIN and those where injury was probable. In the cases where injury to the PIN was probable, we harvested the PIN with a cuff of the proximal edge of the portal and examined the cross sectional histology of the most distal sections for axons. We then recorded their presence or absence.
Results: In 3 out of 14 wrists, there was clearly no injury to the PIN during the creation of the 3-4 portal. In the remaining wrists with probable injury to the PIN, we identified axonal tissue on histological examination at the proximal edge of the 3-4 portal in 7 out of 11 of these specimens. There were no other injuries found. In summary, 7 out of 14 or 50% of our specimens had visual and histological evidence of injury to the PIN.
Conclusion: Based on the findings of this study, there may be many more injuries to the PIN during routine wrist arthroscopy than have been previously reported. This may suggest that transection or injury to this nerve may not lead to any clinical sequelae. However, if a patient has persistent, otherwise unexplained dorsal wrist pain following arthroscopy, iatrogenic neuroma of the PIN should be considered.
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