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Iatrogenic nerve injury during fracture surgery of the upper arm is a well-known complication. Prevention of this type of injuries would be of great value. The literature describes several methods to reduce this type of injury, but no perfect solution is at hand. In this study we introduce a new radiographic evaluation of the course and variation of the radial nerve in the distal part of the humerus in relation to bony landmarks as observed on a plain (trauma) radiographs. Aim of this new approach is to reduce the chance of iatrogenic nerve injury by defining of a danger zone in the distal upper arm regarding the radial nerve and hence give an advise for future implant fabrication.   Methods and findings  Measurements were done on both arms of ten specially embalmed specimens. Arms were dissected and radiopaque wires attached to the radial nerve in the distal part of the upper arm. Digital radiographs were obtained to determine the course of the radial nerve in the distal 20 cm of the humerus in relation to bony landmarks; medial epicondyle and capitellum-trochlea projection (CCT). Analysis was done with ImageJ and Microsoft Excel software. We also compared humeral nail specifications from different companies with the course of the radial nerve to predict possible radial nerve damage.    Results  The distance from the medial epicondyle to point where the radial nerve bends from posterior to lateral was 142 mm on AP radiographs and 152 mm measured on the lateral radiographs. The average distance from the medial epicondyle to point where the radial nerve bends from lateral to anterior on AP radiographs was 66 mm. On the lateral radiographs where the nerve moves away from the anterior cortex 83 mm to the center of capitellum and trochlea (CCT). The distance from the bifurcation of the radial nerve into the posterior interosseous nerve (PIN) and superficial radial nerve was 21 mm on AP radiographs and 42 mm on the lateral radiographs (CCT).    Conclusions  The course of the radial nerve in the distal part of the upper arm has great variety. Lateral fixation is relatively safe in a zone between the center of capitellum-trochlea and 48 mm proximal to this point. The danger zone in lateral fixation is in-between 48–122 mm proximal from CCT. In anteroposterior direction; distal fixation is dangerous between 21–101 mm measured from the medial epicondyle. The more distal, the more medial the nerve courses making it more valuable to iatrogenic damage. The IMN we compared with our data all show potential risk in case of (blind) distal locking, especially from lateral to medial direction.

The course of the radial nerve in the distal humerus: A novel, anatomy based, radiographic assessment