Plate osteosynthesis of humeral diaphyseal fractures associated with radial palsy: twenty cases

The effect of plate location on radial nerve palsy recovery time associated with humeral shaft fractures

BACKGROUND

This study aims to investigate the influence of plate placement on nerve regeneration in humerus fractures accompanied by radial nerve injury.

METHODS

A retrospective analysis was conducted on a cohort of 94 patients with humerus fractures and concomitant radial nerve injury treated between January 2018 and November 2022. After applying exclusion criteria, 31 patients were included in the study. Clinical outcomes were assessed by comparing demographic data, surgical duration, radial nerve recovery time, the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm Shoulder and Hand (DASH), and the Medical Research Council (MRC) scale.

RESULTS

Two distinct groups were established: lateral plating and anteromedial (AM) plating. These groups demonstrated comparability regarding age, gender, and body mass index (BMI). No statistically significant differences were observed between the groups concerning MEPS and MRC. The AM plating group notably exhibited shorter surgical durations, faster recovery times, and lower DASH scores.

CONCLUSION

According to the findings of this investigation, in cases of humerus fractures accompanied by radial nerve injury, AM plating may be preferable over lateral plating due to its association with reduced surgical durations and expedited nerve recovery.

Radial Nerve Paralysis in Diaphyseal Fractures of the Humerus

One of the most common complications associated with a diaphyseal humeral fracture is the development of a radial nerve injury. We conducted a study to analyze the degree of recovery and prognostic factors associated with radial nerve palsy in patients with diaphyseal humerus fractures. We retrospectively analyzed 28 patients who presented to the Hospital La Fe, Valencia, Spain, with a diaphyseal humerus fracture associated with radial nerve injury between 2010 and 2020. A total of 14.3% (n = 4) of the patients in our cohort had open fractures and 85.7% (n = 24) had closed fractures. There were no statistically significant differences between the type of treatment and the type of fracture (p = .13). There were also no significant differences between the type of treatment and recovery time (p = .42). There was a statistically significant difference (p = .04) in the mean recovery time for patients with preoperative radial nerve injuries (11.9 months) compared with patients who sustained a radial nerve injury secondary to surgical repair of the fracture (8.6 months). The difference in recovery time between patients with open and closed fractures was not statistically significant (p = .3). Results of the study showed that the type of fracture (i.e., open or closed) did not affect radial nerve palsy recovery time. Patients who sustain radial nerve injuries secondary to a surgical repair have a shorter recovery time than patients who sustain primary radial nerve injuries.

Need for early exploration of radial nerve in humeral shaft fractures with radial nerve palsy

INTRODUCTION

Radial nerve palsy (RNP) associated with humeral shaft fracture (HSF) is the most common nerve complication in long bone fractures. There is still controversy over the need for immediate exploration of the radial nerve (RN) in HSF with RNP. The purpose of the current study was to determine which situations of HSF with RNP require early exploration of the RN.

MATERIALS AND METHODS

This is a retrospective study that included 55 patients who had visited the emergency department of the current authors' hospital and had been diagnosed with HSF between March of 2005 and September of 2015. Of these 55 patients, 14 (25.4%) had been diagnosed with HSF with RNP. We reviewed the medical records of those 14 patients and their radiographs to evaluate each fracture's type, location, pattern, energy of trauma, status of RN injury, and time until recovery from RNP.

RESULT

All the 14 RNP patients had suffered high-energy trauma. Three had fractures in the proximal third (21.4%), six in the middle third (42.9%), and five in the distal third (35.7%). The three patients (21.4%) with incomplete recovery of RNP all had proximal third fractures; two of these three patients had RN transection.

CONCLUSION

Early exploration of the radial nerve should be considered in patients with radial nerve palsy associated with proximal third humeral shaft fracture, regardless of the fracture patterns caused by the high-energy trauma.

Incidence and Management of Radial Nerve Palsies in Humeral Shaft Fractures: A Systematic Review

Radial nerve palsies in closed humeral shaft fractures are common, with an incidence of 7%-17%. The management of radial nerve palsies in closed fractures is often expectant, with 70.7% spontaneously recovering within six months. A literature search was conducted for studies on radial nerve palsies in humeral shaft fractures from 2000-2018. A total of 4972 humeral shaft fractures were identified, with an incidence of 12.2% of primary radial nerve palsies. During the exploration, no neurological intervention was performed in nearly 41% of cases, and the most common finding was no evidence of any nerve lesion (35%). Those who underwent neurolysis were more likely to resolve when compared to primary repair or nerve grafting. Overall, there was a high rate of spontaneous radial nerve palsy recovery (85%) with radial nerve exploration increasing rates of resolution. While exploration demonstrates increased resolution, it is yet to be determined which fractures are indicated for nerve exploration.

Radial Nerve Palsy Recovery With Fractures of the Humerus: An Updated Systematic Review

INTRODUCTION

Radial nerve palsies with humeral shaft fractures have historically been treated with expectant management. A previous systematic review by Shao et al, based on studies published from 1964 to 2004, purported no difference in the rate of recovery between patients treated with early surgical intervention versus expectant treatment. However, the authors combined expectant treatment to include patients treated nonsurgically and those with delayed surgery. To better understand the effect of surgery and its timing on radial nerve recovery, an updated analysis was performed with stricter treatment definitions.

METHODS

An updated systematic review of the published literature was undertaken. An electronic database search was performed to identify publications that met specific inclusion criteria. A total of 23 articles published since 2000 met our eligibility requirements. Data were abstracted from these articles and analyzed in conjunction with the results of the systematic review by Shao et al. RESULTS:: The overall prevalence of radial nerve palsy was 12.3% (890/7,262). Patients with radial nerve palsy treated nonsurgically had a rate of spontaneous radial nerve recovery of 77.2%. Patients who failed nonsurgical management and underwent nerve exploration more than 8 weeks after their injury had a rate of recovery of 68.1%. Patients treated with early (within 3 weeks of the injury) surgical exploration and fracture repair had a rate of recovery of 89.8%.

DISCUSSION

From the published data from 1964 to 2017, patients who underwent surgical exploration within 3 weeks of injury had a significantly higher likelihood of regaining radial nerve function than patients who underwent nonsurgical management with or without late surgical exploration.

Fractures of the Humeral Shaft with Primary Radial Nerve Palsy: Do Injury Mechanism, Fracture Type, or Treatment Influence Nerve Recovery?

Adult humeral shaft fractures are associated with primary radial nerve palsy in up to 18% of cases. The purpose of this study was to assess the influence of injury mechanism, fracture type, and treatment on nerve recovery in patients with humeral shaft fractures and primary nerve palsy. Data of fifty patients (age-43.5 ± 21.3; female: male-1:1.8) with humeral shaft fractures and concomitant grade I-II primary radial nerve palsy, who underwent either open reduction and internal fixation (ORIF) or intramedullary nailing at an academic level I trauma center between 1994 and 2013, were evaluated. Factors potentially influencing the time to onset of recovery or full nerve recovery (injury mechanism, fracture type, fracture location and treatment) were analyzed in detail. Thirty patients were treated with ORIF and twenty patients with closed unreamed intramedullary nailing of the humeral shaft, respectively. The mean time to onset of recovery was 10.5 ± 3.4 weeks (2-17 weeks). Twenty-six (52%) patients reported significant clinical improvement within the first 12 weeks. Mean time to full recovery was 26.8 ± 8.9 weeks (4-52 weeks). Twenty-five (50%) patients regained full manual strength within the first six months following the injury. Forty-nine (98%) patients regained full manual strength within the first 52 weeks. Trauma mechanism, fracture type, fracture location, and treatment modality did not influence the time to onset of nerve recovery or time to full recovery following humeral shaft fractures with grade I-II primary radial nerve palsy.

Best care paradigm to optimize functionality after extra-articular distal humeral fractures in the young patient

For younger patients with extra-articular distal humerus fractures closed management is plagued with high rates of malunion, suboptimal functional outcomes, extended immobilization with loss of early motion, a delay in return to work, and a general period of lost productivity. Surgical management offers an appealing alternative. Maintaining respect for the triceps musculature and minimizing iatrogenic injury to the radial nerve are primary concerns with operative treatment. Accordingly, use of a triceps-sparing approach and single column plating may be the optimal treatment paradigm in the young patient presenting with an extra-articular distal humerus fracture.

Radial nerve palsy in humeral shaft fractures with internal fixation: analysis of management and outcome

INTRODUCTION

The incidence of radial nerve injury after humeral shaft fractures is on average 11.8% (Shao et al., J Bone Jt Surg Br 87(12):1647-1652, 2005) representing the most common peripheral nerve injury associated with long bone fractures (Korompilias et al., Injury, 2013). The purpose of this study was to analyze our current policy and long-term outcome, regarding surgically treated humeral shaft fractures in combination with radial nerve palsy.

MATERIALS AND METHODS

We retrospectively analyzed the data of patients with surgically treated humeral shaft fractures from 01/01/2003 to 28/02/2013. The analysis included fracture type, soft tissue injury regarding closed and open fractures, type of fixation, management, and outcome of radial nerve palsy.

RESULTS

A total of 151 humeral shaft fractures were fixed in our hospital. In 20 (13%) cases, primary radial palsy was observed. Primary nerve exploration was performed in nine cases. Out of the 13 patients with follow-up, 10 showed a complete, 2 a partial, and 1 a minimal nerve recovery. Two of them underwent a revision procedure. Secondary radial nerve palsy occurred in 9 (6%) patients postoperatively. In five patients, the radial nerve was not exposed during the initial surgery and, therefore, underwent revision with nerve exploration. In all 5, a potential cause for the palsy was found and corrected as far as possible with full recovery in 3 and minimal recovery in one patient. In four patients with exposure of the nerve during the initial surgery, no revision was performed. All of these 4 showed a full recovery.

CONCLUSION

Our study showed an overall rate of 19% radial nerve palsy in surgically treated humeral shaft fractures. Most of the primary palsies (13%) recovered spontaneously, and therefore, nerve exploration was only exceptionally needed. The incidence of secondary palsy after surgery (6%) was high and mainly seen after plate fixation. In these cases, we recommend early nerve exploration, to detect and treat potential curable neural lesions.

Humeral shaft fractures: results of operative and non-operative treatment

PURPOSE

There has been little direct comparison between non-operative and operative management of humeral shaft fractures. The present study aimed to compare union rates and complication rates between these two modalities of treatment.

METHODS

A retrospective cohort study was performed at a regional level 1 trauma centre. A total of 296 patients with humeral shaft fractures met inclusion criteria; 69 patients were treated with a functional brace and 227 with surgical intervention. The primary end point was radiographic union. Nonunion was defined as failure of radiological union at six months, requiring surgical intervention. Time to union, nerve palsy rate, and rate of infection were also examined.

RESULTS

The nonunion rate was significantly higher in the non-operative group (23.2 % vs 10.2 %) despite higher rates of open fractures and high energy mechanisms of injury in the operative group. No significant difference in time to union was found. Nerve palsy was more common in the operative group (20 % vs 39 %); however, only two cases (1 %) of radial nerve palsy in the operative group were iatrogenic and both were transient. Infection rates were higher for the operative group (3.5 % vs 0 %).

CONCLUSIONS

Conservative treatment of humeral shaft fractures has a higher rate of nonunion, while operative treatment is associated with a low incidence of iatrogenic nerve palsy but higher rates of infection.

Causes of Secondary Radial Nerve Palsy and Results of Treatment

Background

The aim of this study was to analyze the causes that lead to secondary damage of the radial nerve and to discuss the results of reconstructive treatment.

Material/Methods

The study group consisted of 33 patients treated for radial nerve palsy after humeral fractures. Patients were diagnosed based on clinical examinations, ultrasonography, electromyography, or nerve conduction velocity. During each operation, the location and type of nerve damage were analyzed. During the reconstructive treatment, neurolysis, direct neurorrhaphy, or reconstruction with a sural nerve graft was used. The outcomes were evaluated using the Medical Research Council (MRC) scales and the quick DASH score.

Results

Secondary radial nerve palsy occurs after open reduction and internal fixation (ORIF) by plate, as well as by closed reduction and internal fixation (CRIF) by nail. In the case of ORIF, it most often occurs when the lateral approach is used, as in the case of CRIF with an insertion interlocking screws. The results of the surgical treatment were statistically significant and depended on the time between nerve injury and revision (reconstruction) surgery, type of damage to the radial nerve, surgery treatment, and type of fixation. Treatment results were not statistically significant, depending on the type of fracture or location of the nerve injury.

Conclusions

The potential risk of radial nerve neurotmesis justifies an operative intervention to treat neurological complications after a humeral fracture. Adequate surgical treatment in many of these cases allows for functional recovery of the radial nerve.

Newly designed minimally invasive plating of a humerus shaft fracture; a different introduction of the plate

PURPOSE

Open reductions and internal fixations are currently being used the most in surgeries of humeral shaft fractures. However, there are some limitations such as invasive techniques and formation of many operation scars. To overcome these limitations, a minimally invasive plate osteosynthesis has been recently introduced. However, this has technical limitations such as deep dissections of the distal portion and narrowness of the fixation space. To address these problems, we designed another introductory technique of a minimally invasive osteosynthesis and we have examined the clinical usefulness of that.

METHODS

The results were retrospectively analyzed with 83 patients who visited INHA hospital due to a humeral shaft fractures and who had undergone the above said surgery from the beginning of 2010 to the end of 2012. The patients were divided into two groups: patients treated by the MIPO technique using the newly designed dual approaches (group A) and patients treated by open reduction and plating internal fixation (group B).

RESULTS

There was no significant difference in mean duration of injury, the mean fracture union time, range of motion and MEPI for group A and B. There was no statistical significance between the two groups. However, the occurrence of iatrogenic radial nerve palsy in group B, was significantly higher than in group A.

CONCLUSIONS

MIPOs using the dual approaches on the adult humerus shaft fracture show an excellent bony union without nerve injury which is clinically useful.