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Wrist Denervation and the Anterior Interosseous Nerve: Anatomic Considerations
Wrist Denervation and the Anterior Interosseous Nerve: Anatomic Considerations Michael W. Grafe, MD, Paul D. Kim, MD, Melvin P. Rosenwasser, MD, Robert J. Strauch, MD, New York, NY
Purpose: Wrist denervation via resection of the distal anterior interosseous nerve (AIN) and the posterior interosseous nerve (PIN) is an effective treatment for chronic wrist pain. When performing this procedure through a dorsal approach we have been impressed by anatomic variations of the AIN. This has raised concerns about potential denervation of the pronator quadratus (PQ). The purpose of this study was to elucidate the anatomy of the AIN and PIN as encountered through a dorsal distal forearm incision. Methods: Ten fresh-frozen cadavers were dissected. Before dissection radiographs were obtained to ensure accurate localization of the proximal ulnar head with a radiopaque marker. A dorsal approach to the distal forearm was made to identify the anatomy of the PIN and AIN. The location and diameter of all AIN branches were noted by using an operating stereoscopic microscope at ⫻25 magnification and a precision caliper. The PIN anatomy and size also were noted. Results: The anatomy of the AIN was variable. The average AIN diameter proximal to the PQ was 1.5 mm. The average number of AIN motor branches was 4.2. The largest PQ motor branch was the first motor branch and was located at an average distance of 37.9 mm from the proximal ulnar head. The last motor branch was found an average of 23.9 mm from the proximal ulnar head. In 9 of 10 specimens the sensory branch tunneled radially through the distal PQ and innervated the periosteum of the volar distal radius. In 4 of 10 specimens a separate branch to the distal radioulnar joint was present. We found an average PIN diameter of 0.87 mm. Conclusions: Resection of the AIN at a point 4 cm proximal to the proximal point of the ulnar head would denervate completely the PQ in our cadaver population. Division of the AIN 2 cm proximal to the ulnar head would spare most of the PQ motor branches. (J Hand Surg 2005;30A:1221–1225. Copyright © 2005 by the American Society for Surgery of the Hand.) Key words: Anterior interosseous nerve, wrist denervation, pronator quadratus.
One of the many options for the treatment of chronic wrist pain is wrist denervation. Since the first description of the procedure in 1966 by Wilhelm,1 From the Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY. Received for publication December 29, 2004; accepted in revised form June 1, 2005. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Robert J. Strauch, MD, 622 W 168th St, PH-11, Columbia University Medical Center, New York, NY 10032; e-mail: [email protected]. Copyright © 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A06-0016$30.00/0 doi:10.1016/j.jhsa.2005.06.010
other investigators also have reported on total wrist denervation including Buck-Gramcko,2 Ekerot et al,3 and Ferreres et al.4 Subsequent investigators have described partial denervation of the wrist by resection of the posterior interosseous nerve (PIN) or the anterior interosseous nerve (AIN) through separate dorsal and volar approaches, respectively.4 –7 In 1999 Kupfer et al7 described a technique of partial denervation of the wrist through a single dorsal incision. In 2002 Weinstein and Berger8 reported encouraging results with partial denervation of the wrist via a single dorsal incision by resection of the distal PIN and AIN. We also have noted excellent clinical results with this procedure; however, we have observed The Journal of Hand Surgery
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The Journal of Hand Surgery / Vol. 30A No. 6 November 2005
Figure 1. Localization of the proximal ulnar head by placement of a needle, confirmed with x-ray.
a significant amount of variability in the anatomy of the AIN as seen through the dorsal incision. We also have been concerned about denervation of the pronator quadratus (PQ) muscle when resecting a 2-cm segment of the AIN at a level 2 to 7 cm proximal to the ulnar head, as described by Weinstein and Berger.8 The purpose of this study was to clarify the anatomy of the AIN and PIN in the distal forearm with respect to a dorsal approach for wrist denervation.
Methods Ten fresh-frozen cadavers were dissected. Each specimen consisted of a completely intact forearm, wrist, and hand, disarticulated at the elbow. The average age of the specimens was 67 years. There were 3 male and 7 female specimens and 3 right arms and 7 left arms. Before dissection x-rays were performed to ensure accurate localization of the proximal ulnar head with a radiopaque marker (18-gauge needle) (Fig. 1). The proximal ulnar head was selected as a readily palpable landmark for use as the reference point for measuring the branching points of the AIN. A dorsal distal forearm approach as described by Weinstein and Berger8 was performed to identify the anatomy of the PIN and AIN starting 2 cm proximal to the radiopaque marker and extending proximally for 5 cm. As the dissection progressed the incision was lengthened proximally and distally as needed. A deeper dissection was performed between the muscle bellies of the extensor digiti minimi and the extensor digitorum communis. Once these muscle bellies were
retracted all dissections were performed using an operating stereoscopic microscope at ⫻25 magnification. At this point the location and characteristics of the PIN were noted. All measurements were performed with an electronic precision caliper. The interosseous membrane then was divided and the AIN was identified. The location of the AIN, the diameter of the nerve and its branches, and its branching pattern were noted. The origin of the branches from the trunk of the AIN was recorded as a distance in millimeters to the radiopaque marker at the level of the proximal ulnar head.
Results The average PIN diameter was 0.87 mm (range, 0.47–1.21 mm). The diameter of each PIN was constant throughout our field of dissection. The PIN was radial to the posterior interosseous artery in 5 of 10 specimens. The posterior interosseous artery in the distal forearm also is known as the posterior or recurrent branch of the anterior interosseous artery as described by Hubmer et al.9 The AIN consistently was found volar and ulnar to the PIN in 10 of 10 specimens. The AIN was radial to the anterior interosseous artery in 8 specimens. The average AIN diameter was 1.5 mm (range, 1.1– 2.0 mm) before the first PQ motor branch. The average number of AIN motor branches was 4.2 (range, 2–7). The largest PQ motor branch was always the first motor branch (Fig. 2). Its average diameter was 1.0 mm (range, 0.3–2.4 mm). This first motor branch was located an average of 37.9 mm (range, 28 –54.9
Grafe et al / Wrist Denervation and the AIN
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Figure 2. View from a dorsal dissection of the AIN. The fingers are to the left of the figure and the elbow is to the right. The arrow represents the distal sensory branch and the asterisk represents the first motor branch to the PQ. The first motor branch was always the largest motor branch. Its average distance to the proximal ulnar head was 37.9 mm.
mm) from the proximal ulnar head. The last motor branch was found an average of 23.9 mm (range, 17.9 –30.5 mm) from the proximal ulnar head. The sensory branch could be identified clearly only after the division of the last motor branch, an average of 23.9 mm (range, 17.9 –30.5 mm) from the proximal ulnar head (Fig. 3). In 2 of the specimens, however, the sensory branch origin could be isolated 45.0 and 38.0 mm from the proximal ulnar head. In 9 of 10 specimens the sensory branch tunneled through a radially based, intramuscular foramen in the distal PQ. The average diameter of this branch was 0.60 mm (range, 0.25–1.21 mm). This branch consistently terminated by arborizing into the periosteum of the radial volar lip of the distal radius. In 4 of 10 specimens a separate sensory branch going to the distal radial ulnar joint (DRUJ) was present. This sensory branch also was isolated only after the take off of the last motor branch to the PQ. The average diameter of the DRUJ branch was 0.40 mm (range, 0.18 – 0.56 mm).
Discussion Wrist denervation is a worthwhile procedure that can provide pain relief without compromising wrist motion or burning bridges with respect to other reconstructive avenues. The functional importance of the
PQ muscle is debatable. It has been described as a dynamic stabilizer of the DRUJ. Other studies have shown the PQ to be active through the full arc of pronosupination. The function of the PQ muscle is compromised routinely when plating the volar distal radius and it can be transferred as a pedicled flap without adverse functional consequences.10,11 Complete denervation of the PQ therefore may not cause an appreciable clinical deficit. Weinstein and Berger8 reported that the AIN usually is twice the diameter of the PIN and that a 2-cm segment of the nerve should be resected at a level 2 to 7 cm proximal to the ulnar head. They reported that resection of the AIN in this manner would preserve the majority of motor fibers supplying the PQ. We have been impressed with the apparent variability of the AIN when performing their denervation procedure and this study does support great variability in AIN anatomy. We found the distal sensory branch of the AIN to be smaller than the PIN, and that the larger-sized AIN occurs more proximally, before it divides into many motor branches. The removal of a 2-cm segment of the AIN at a level 2 to 7 cm proximal to the ulnar head would denervate most if not all of the motor branches to the PQ in our cadaver population. Our anatomic findings are similar to those of Fu-
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The Journal of Hand Surgery / Vol. 30A No. 6 November 2005
Figure 3. Dorsal view of the AIN. The fingers are to the left of the figure and the elbow is to the right. The black diamond represents the common AIN nerve, the asterisk represents the first motor branch to the PQ, and the arrow points to the sensory branch of the AIN. Notice the change in diameter between the sensory branch (average, 0.6 mm) and the AIN (average, 1.5 mm) before PQ innervation.
kumoto et al.12 They found the proximal AIN diameter to be 1.3 mm and the average number of PQ motor branches to be 4.9. In their study the incidence of sensory branches to the DRUJ was 17%, and in our study 4 of 10 specimens had branches to the DRUJ and to the volar distal radius. Ferreres et al13 also observed terminal branching to the volar distal radius and the DRUJ. Dellon et al6 did not observe any branching to the DRUJ. The location of the PIN that we observed in the distal forearm is in agreement with the observations of Dellon and Seif.14 The identification of the AIN at a more proximal level technically is easier because of the increased size of the nerve; however, a 2-cm resection in this area will denervate most of the PQ muscle. If preservation of the innervation of the PQ is desired then we would recommend the following modification to the procedure described by Weinstein and Berger.8 The proximal extent of the incision still can be made 3 to 5 cm proximal to the ulnar head because it is easier to identify the PIN and AIN at this level and then a 2-cm section of the PIN can be removed at this level. After incising the interosseous membrane the AIN can be found volar and ulnar to the PIN and typically radial to the anterior interosseous artery.
The AIN then may be traced distally to within 2 cm of the ulnar head. Branches traveling radially have the greatest chance of being only sensory branches. Resecting a 1-cm segment of the AIN at this level should give the greatest chance of removing only the sensory component of the nerve while preserving the motor function to the PQ.
References 1. Wilhelm A. [Articular denervation and its anatomical foundation. A new therapeutic principle in hand surgery. On the treatment of the later stages of lunatomalacia and navicular pseudarthrosis]. Hefte Unfallheilkd 1966;86:1–109. 2. Buck-Gramcko D. Denervation of the wrist joint. J Hand Surg 1977;2:54 – 61. 3. Ekerot L, Holmberg J, Eiken O. Denervation of the wrist. Scand J Plast Reconstr Surg 1983;17:155–157. 4. Ferreres A, Suso S, Foucher G, Ordi J, Llusa M, Ruano D. Wrist denervation. Surgical considerations. J Hand Surg 1995;20B:769 –772. 5. Dellon AL. Partial dorsal wrist denervation: resection of the distal posterior interosseous nerve. J Hand Surg 1985;10A: 527–533. 6. Dellon AL, Mackinnon SE, Daneshvar A. Terminal branch of anterior interosseous nerve as source of wrist pain. J Hand Surg 1984;9B:316 –322. 7. Kupfer DM, Lee GW, Shoemaker W, Dellon L, McSweeney J. Simplified approach to wrist denervation for
Grafe et al / Wrist Denervation and the AIN
8.
9.
10. 11.
triangulofibrocartilage complex disruption. J Reconstr Microsurg 1999;15:621. Weinstein LP, Berger RA. Analgesic benefit, functional outcome, and patient satisfaction after partial wrist denervation. J Hand Surg 2002;27A:833– 839. Hubmer MG, Fasching T, Haas F, Koch H, Schwarzl F, Weiglein A, et al. The posterior interosseous artery in the distal part of the forearm. Is the term “recurrent branch of the anterior interosseous artery” justified? Br J Plast Surg 2004;57:638–644. Dellon AL, Mackinnon SE. The pronator quadratus muscle flap. J Hand Surg 1984;9A:423– 427. Gordon KD, Pardo RD, Johnson JA, King GJ, Miller TA. Electromyographic activity and strength during maximum
1225
isometric pronation and supination efforts in healthy adults. J Orthop Res 2004;22:208 –213. 12. Fukumoto K, Kojima T, Kinoshita Y, Koda M. An anatomic study of the innervation of the wrist joint and Wilhelm’s technique for denervation. J Hand Surg 1993; 18A:484 – 489. 13. Ferreres A, Suso S, Ordi J, Llusa M, Ruano D. Wrist denervation. Anatomical considerations. J Hand Surg 1995; 20B:761–768. 14. Dellon AL, Seif SS. Anatomic dissections relating the posterior interosseous nerve to the carpus, and the etiology of dorsal wrist ganglion pain. J Hand Surg 1978;3: 326 –332.
Purpose: Wrist denervation via resection of the distal anterior interosseous nerve (AIN) and the posterior interosseous nerve (PIN) is an effective treatment for chronic wrist pain. When performing this procedure through a dorsal approach we have been impressed by anatomic variations of the AIN. This has raised concerns about potential denervation of the pronator quadratus (PQ). The purpose of this study was to elucidate the anatomy of the AIN and PIN as encountered through a dorsal distal forearm incision. Methods: Ten fresh-frozen cadavers were dissected. Before dissection radiographs were obtained to ensure accurate localization of the proximal ulnar head with a radiopaque marker. A dorsal approach to the distal forearm was made to identify the anatomy of the PIN and AIN. The location and diameter of all AIN branches were noted by using an operating stereoscopic microscope at ⫻25 magnification and a precision caliper. The PIN anatomy and size also were noted. Results: The anatomy of the AIN was variable. The average AIN diameter proximal to the PQ was 1.5 mm. The average number of AIN motor branches was 4.2. The largest PQ motor branch was the first motor branch and was located at an average distance of 37.9 mm from the proximal ulnar head. The last motor branch was found an average of 23.9 mm from the proximal ulnar head. In 9 of 10 specimens the sensory branch tunneled radially through the distal PQ and innervated the periosteum of the volar distal radius. In 4 of 10 specimens a separate branch to the distal radioulnar joint was present. We found an average PIN diameter of 0.87 mm. Conclusions: Resection of the AIN at a point 4 cm proximal to the proximal point of the ulnar head would denervate completely the PQ in our cadaver population. Division of the AIN 2 cm proximal to the ulnar head would spare most of the PQ motor branches. (J Hand Surg 2005;30A:1221–1225. Copyright © 2005 by the American Society for Surgery of the Hand.) Key words: Anterior interosseous nerve, wrist denervation, pronator quadratus.
One of the many options for the treatment of chronic wrist pain is wrist denervation. Since the first description of the procedure in 1966 by Wilhelm,1 From the Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY. Received for publication December 29, 2004; accepted in revised form June 1, 2005. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Corresponding author: Robert J. Strauch, MD, 622 W 168th St, PH-11, Columbia University Medical Center, New York, NY 10032; e-mail: [email protected]. Copyright © 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A06-0016$30.00/0 doi:10.1016/j.jhsa.2005.06.010
other investigators also have reported on total wrist denervation including Buck-Gramcko,2 Ekerot et al,3 and Ferreres et al.4 Subsequent investigators have described partial denervation of the wrist by resection of the posterior interosseous nerve (PIN) or the anterior interosseous nerve (AIN) through separate dorsal and volar approaches, respectively.4 –7 In 1999 Kupfer et al7 described a technique of partial denervation of the wrist through a single dorsal incision. In 2002 Weinstein and Berger8 reported encouraging results with partial denervation of the wrist via a single dorsal incision by resection of the distal PIN and AIN. We also have noted excellent clinical results with this procedure; however, we have observed The Journal of Hand Surgery
1221
1222
The Journal of Hand Surgery / Vol. 30A No. 6 November 2005
Figure 1. Localization of the proximal ulnar head by placement of a needle, confirmed with x-ray.
a significant amount of variability in the anatomy of the AIN as seen through the dorsal incision. We also have been concerned about denervation of the pronator quadratus (PQ) muscle when resecting a 2-cm segment of the AIN at a level 2 to 7 cm proximal to the ulnar head, as described by Weinstein and Berger.8 The purpose of this study was to clarify the anatomy of the AIN and PIN in the distal forearm with respect to a dorsal approach for wrist denervation.
Methods Ten fresh-frozen cadavers were dissected. Each specimen consisted of a completely intact forearm, wrist, and hand, disarticulated at the elbow. The average age of the specimens was 67 years. There were 3 male and 7 female specimens and 3 right arms and 7 left arms. Before dissection x-rays were performed to ensure accurate localization of the proximal ulnar head with a radiopaque marker (18-gauge needle) (Fig. 1). The proximal ulnar head was selected as a readily palpable landmark for use as the reference point for measuring the branching points of the AIN. A dorsal distal forearm approach as described by Weinstein and Berger8 was performed to identify the anatomy of the PIN and AIN starting 2 cm proximal to the radiopaque marker and extending proximally for 5 cm. As the dissection progressed the incision was lengthened proximally and distally as needed. A deeper dissection was performed between the muscle bellies of the extensor digiti minimi and the extensor digitorum communis. Once these muscle bellies were
retracted all dissections were performed using an operating stereoscopic microscope at ⫻25 magnification. At this point the location and characteristics of the PIN were noted. All measurements were performed with an electronic precision caliper. The interosseous membrane then was divided and the AIN was identified. The location of the AIN, the diameter of the nerve and its branches, and its branching pattern were noted. The origin of the branches from the trunk of the AIN was recorded as a distance in millimeters to the radiopaque marker at the level of the proximal ulnar head.
Results The average PIN diameter was 0.87 mm (range, 0.47–1.21 mm). The diameter of each PIN was constant throughout our field of dissection. The PIN was radial to the posterior interosseous artery in 5 of 10 specimens. The posterior interosseous artery in the distal forearm also is known as the posterior or recurrent branch of the anterior interosseous artery as described by Hubmer et al.9 The AIN consistently was found volar and ulnar to the PIN in 10 of 10 specimens. The AIN was radial to the anterior interosseous artery in 8 specimens. The average AIN diameter was 1.5 mm (range, 1.1– 2.0 mm) before the first PQ motor branch. The average number of AIN motor branches was 4.2 (range, 2–7). The largest PQ motor branch was always the first motor branch (Fig. 2). Its average diameter was 1.0 mm (range, 0.3–2.4 mm). This first motor branch was located an average of 37.9 mm (range, 28 –54.9
Grafe et al / Wrist Denervation and the AIN
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Figure 2. View from a dorsal dissection of the AIN. The fingers are to the left of the figure and the elbow is to the right. The arrow represents the distal sensory branch and the asterisk represents the first motor branch to the PQ. The first motor branch was always the largest motor branch. Its average distance to the proximal ulnar head was 37.9 mm.
mm) from the proximal ulnar head. The last motor branch was found an average of 23.9 mm (range, 17.9 –30.5 mm) from the proximal ulnar head. The sensory branch could be identified clearly only after the division of the last motor branch, an average of 23.9 mm (range, 17.9 –30.5 mm) from the proximal ulnar head (Fig. 3). In 2 of the specimens, however, the sensory branch origin could be isolated 45.0 and 38.0 mm from the proximal ulnar head. In 9 of 10 specimens the sensory branch tunneled through a radially based, intramuscular foramen in the distal PQ. The average diameter of this branch was 0.60 mm (range, 0.25–1.21 mm). This branch consistently terminated by arborizing into the periosteum of the radial volar lip of the distal radius. In 4 of 10 specimens a separate sensory branch going to the distal radial ulnar joint (DRUJ) was present. This sensory branch also was isolated only after the take off of the last motor branch to the PQ. The average diameter of the DRUJ branch was 0.40 mm (range, 0.18 – 0.56 mm).
Discussion Wrist denervation is a worthwhile procedure that can provide pain relief without compromising wrist motion or burning bridges with respect to other reconstructive avenues. The functional importance of the
PQ muscle is debatable. It has been described as a dynamic stabilizer of the DRUJ. Other studies have shown the PQ to be active through the full arc of pronosupination. The function of the PQ muscle is compromised routinely when plating the volar distal radius and it can be transferred as a pedicled flap without adverse functional consequences.10,11 Complete denervation of the PQ therefore may not cause an appreciable clinical deficit. Weinstein and Berger8 reported that the AIN usually is twice the diameter of the PIN and that a 2-cm segment of the nerve should be resected at a level 2 to 7 cm proximal to the ulnar head. They reported that resection of the AIN in this manner would preserve the majority of motor fibers supplying the PQ. We have been impressed with the apparent variability of the AIN when performing their denervation procedure and this study does support great variability in AIN anatomy. We found the distal sensory branch of the AIN to be smaller than the PIN, and that the larger-sized AIN occurs more proximally, before it divides into many motor branches. The removal of a 2-cm segment of the AIN at a level 2 to 7 cm proximal to the ulnar head would denervate most if not all of the motor branches to the PQ in our cadaver population. Our anatomic findings are similar to those of Fu-
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The Journal of Hand Surgery / Vol. 30A No. 6 November 2005
Figure 3. Dorsal view of the AIN. The fingers are to the left of the figure and the elbow is to the right. The black diamond represents the common AIN nerve, the asterisk represents the first motor branch to the PQ, and the arrow points to the sensory branch of the AIN. Notice the change in diameter between the sensory branch (average, 0.6 mm) and the AIN (average, 1.5 mm) before PQ innervation.
kumoto et al.12 They found the proximal AIN diameter to be 1.3 mm and the average number of PQ motor branches to be 4.9. In their study the incidence of sensory branches to the DRUJ was 17%, and in our study 4 of 10 specimens had branches to the DRUJ and to the volar distal radius. Ferreres et al13 also observed terminal branching to the volar distal radius and the DRUJ. Dellon et al6 did not observe any branching to the DRUJ. The location of the PIN that we observed in the distal forearm is in agreement with the observations of Dellon and Seif.14 The identification of the AIN at a more proximal level technically is easier because of the increased size of the nerve; however, a 2-cm resection in this area will denervate most of the PQ muscle. If preservation of the innervation of the PQ is desired then we would recommend the following modification to the procedure described by Weinstein and Berger.8 The proximal extent of the incision still can be made 3 to 5 cm proximal to the ulnar head because it is easier to identify the PIN and AIN at this level and then a 2-cm section of the PIN can be removed at this level. After incising the interosseous membrane the AIN can be found volar and ulnar to the PIN and typically radial to the anterior interosseous artery.
The AIN then may be traced distally to within 2 cm of the ulnar head. Branches traveling radially have the greatest chance of being only sensory branches. Resecting a 1-cm segment of the AIN at this level should give the greatest chance of removing only the sensory component of the nerve while preserving the motor function to the PQ.
References 1. Wilhelm A. [Articular denervation and its anatomical foundation. A new therapeutic principle in hand surgery. On the treatment of the later stages of lunatomalacia and navicular pseudarthrosis]. Hefte Unfallheilkd 1966;86:1–109. 2. Buck-Gramcko D. Denervation of the wrist joint. J Hand Surg 1977;2:54 – 61. 3. Ekerot L, Holmberg J, Eiken O. Denervation of the wrist. Scand J Plast Reconstr Surg 1983;17:155–157. 4. Ferreres A, Suso S, Foucher G, Ordi J, Llusa M, Ruano D. Wrist denervation. Surgical considerations. J Hand Surg 1995;20B:769 –772. 5. Dellon AL. Partial dorsal wrist denervation: resection of the distal posterior interosseous nerve. J Hand Surg 1985;10A: 527–533. 6. Dellon AL, Mackinnon SE, Daneshvar A. Terminal branch of anterior interosseous nerve as source of wrist pain. J Hand Surg 1984;9B:316 –322. 7. Kupfer DM, Lee GW, Shoemaker W, Dellon L, McSweeney J. Simplified approach to wrist denervation for
Grafe et al / Wrist Denervation and the AIN
8.
9.
10. 11.
triangulofibrocartilage complex disruption. J Reconstr Microsurg 1999;15:621. Weinstein LP, Berger RA. Analgesic benefit, functional outcome, and patient satisfaction after partial wrist denervation. J Hand Surg 2002;27A:833– 839. Hubmer MG, Fasching T, Haas F, Koch H, Schwarzl F, Weiglein A, et al. The posterior interosseous artery in the distal part of the forearm. Is the term “recurrent branch of the anterior interosseous artery” justified? Br J Plast Surg 2004;57:638–644. Dellon AL, Mackinnon SE. The pronator quadratus muscle flap. J Hand Surg 1984;9A:423– 427. Gordon KD, Pardo RD, Johnson JA, King GJ, Miller TA. Electromyographic activity and strength during maximum
1225
isometric pronation and supination efforts in healthy adults. J Orthop Res 2004;22:208 –213. 12. Fukumoto K, Kojima T, Kinoshita Y, Koda M. An anatomic study of the innervation of the wrist joint and Wilhelm’s technique for denervation. J Hand Surg 1993; 18A:484 – 489. 13. Ferreres A, Suso S, Ordi J, Llusa M, Ruano D. Wrist denervation. Anatomical considerations. J Hand Surg 1995; 20B:761–768. 14. Dellon AL, Seif SS. Anatomic dissections relating the posterior interosseous nerve to the carpus, and the etiology of dorsal wrist ganglion pain. J Hand Surg 1978;3: 326 –332.