Radial nerve palsy caused by open humeral shaft fractures

Unveiling the spiral groove: a journey through clinical anatomy, pathology, and imaging

AIM

To review the anatomy of the spiral groove, its clinical significance, and the imaging characteristics of common pathologies affecting this area, highlighting the strengths of different imaging modalities.

MATERIALS AND METHODS

A comprehensive review of the spiral groove anatomy and its clinical implications and an evaluation of various imaging techniques, including radiography, ultrasound, MRI, and CT, was conducted. The review covers pathologic conditions such as Saturday night palsy, humeral fractures, tumours, and infections, with an emphasis on their imaging findings and clinical implications.

RESULTS

The spiral groove provides a pathway for the radial nerve and the deep brachial artery, both crucial for upper limb function. Each imaging modality offers unique advantages: radiography is useful for initial assessment, ultrasound provides dynamic visualisation, MRI offers high-resolution soft tissue imaging, and CT is ideal for detailed bone anatomy. Understanding these imaging characteristics is essential for diagnosing fractures, assessing humeral alignment, and detecting nerve entrapment or injury.

CONCLUSION

Accurate imaging of the spiral groove is essential for diagnosing and treating pathologies related to this anatomical feature. The integrative approach of using appropriate imaging modalities enhances diagnostic precision and informs therapeutic strategies, ultimately improving patient outcomes.

No Differences in Clinical, Functional, or Patient-Reported Outcomes Following Trial of Nonoperative Management Before Open Reduction and Internal Fixation of Humeral Shaft Fractures

OBJECTIVES

To test the hypothesis that primary osteosynthesis of humeral shaft fractures may lead to more favorable clinical, functional, and patient-reported outcomes than fixation following a trial of nonoperative management.

METHODS

DESIGN

Retrospective cohort review.

SETTING

Academic level I trauma center.

PATIENT SELECTION CRITERIA

Adult patients who presented with humeral shaft fractures and ultimately underwent open reduction and internal fixation (ORIF) from May 2011 to May 2021. Patients who underwent ORIF within 2 weeks of injury were grouped into the primary osteosynthesis cohort, and patients who underwent ORIF >4 weeks from the date of injury were grouped into the trial of nonoperative cohort.

OUTCOME MEASURES AND COMPARISONS

Postoperative complications, elbow arc of motion, time to radiographic union, and patient-reported outcomes were investigated and compared between the primary osteosynthesis and trial of nonoperative management cohorts.

RESULTS

One hundred twenty-seven patients fit the study criteria, 84 underwent primary osteosynthesis and 43 trialed initial nonoperative treatment. No differences were found in patient demographics between the primary osteosynthesis and trial of nonoperative management cohorts, including age (53 ± 19 vs. 57 ± 18; P = 0.25), sex (39% vs. 44% male, 61% vs. 56% female; P = 0.70), and Body Mass Index (BMI) (30 ± 6 vs. 32 ± 9; P = 0.38). The average time to operative intervention in the primary osteosynthesis group was 4 days (0-14 days) and 105 days (28-332 days) in the trial of nonoperative treatment group ( P < 0.01). No differences were found with regard to intraoperative blood loss, total operative time, time to radiographic union (determined using the Radiographic Union Scores for Humeral scoring system), or overall complication rates, including primary and secondary radial nerve injuries ( P = 0.23 and 0.86, respectively). Patients reported similar patient-reported outcomes measurement information system pain interference ( P = 0.73), depression (D) ( P = 0.99), and physical function ( P = 0.66) scores at their 6-month postsurgical follow-up visits.

CONCLUSIONS

Patients who attempted a trial of nonoperative management for humeral shaft fractures before ORIF had similar clinical, functional, and patient-reported outcomes as those who underwent primary osteosynthesis.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radial Nerve Palsy Associated with Humeral Shaft Fractures in Children

Background

This is the first systematic review of the relationship between humeral shaft fractures and radial nerve palsy in children. The present comprehensive review is aimed at identifying important clinical findings between humeral diaphysis fractures and radial nerve injuries and assessing the effects of treatment.

Methods

We searched electronic bibliographic databases, including PubMed, the Cochrane Library, Scopus, and Web of Knowledge, until March 2022. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the patients, interventions, comparisons, outcomes guidelines.

Results

We identified 23 original papers, of which 10 were eligible for further analysis. Cases of 32 young patients with radial nerve palsy were identified and analyzed. The prevalence of radial nerve palsy was 4.34% (eight cases out of 184 patients with humeral shaft fractures). The radial nerve was most often associated with a simple transverse fracture (12A3, 17 cases (65.4%)).

Conclusions

Radial nerve injury in humeral shaft fractures in children is rare, with a frequency of 4.34%. We highly recommend early surgical nerve exploration with transverse fractures in the distal third segment combined with primary radial palsy. Furthermore, we recommend making thoughtful decisions regarding early nerve exploration in the Holstein-Lewis fractures. In addition, consideration of early surgical nerve exploration in fractures resulting from high-energy trauma and open fractures despite their morphology is recommended.

Percutaneous Intramedullary Nailing of Complex Humeral Shaft Fractures: A Retrospective Case Series

BACKGROUND

Humeral diaphyseal fractures have been traditionally stabilized with plates and screws. However, surgical morbidity can be quite extensive, particularly in more complex segmental and comminuted fracture patterns. An intramedullary nail (IMN) has the biomechanical advantage of being a load-sharing device and can be placed with a more minimally invasive technique. The purpose of this study was to evaluate the clinical and radiographic outcomes of complex humeral shaft fractures treated with an IMN utilizing a percutaneous surgical technique.

METHODS

A retrospective review was performed on a consecutive series of patients who underwent treatment of a complex humeral shaft fracture with an IMN placed with a percutaneous technique. Clinical outcome scores and radiographic analysis were performed at a minimum one-year follow-up.

RESULTS

Of the 14 patients included, 12 had clinical and radiographic follow-ups at one year. The majority (64%) were obese and involved polytrauma (50%), and 79% were AO Foundation/Orthopaedic Trauma Association (AO/OTA) type C fractures. Union after the index procedure was 93%, with one nonunion requiring a secondary operation. The average operative time was 103 minutes. There were no other complications or additional procedures. The mean clinical outcome scores included American Shoulder and Elbow Society (ASES): 78.2, Constant Score: 72.1, Single Assessment Numerical Evaluation (SANE): 81.9, and Penn Shoulder Score: 82.7.

CONCLUSION

This study demonstrates complex comminuted and segmental humeral shaft fractures in a higher-risk patient population can be effectively managed with IMN. Percutaneous placement of an IMN should be considered as a treatment option in complex humeral shaft fractures, particularly in patients with secondary comorbidities such as obesity and polytrauma.

Primary radial nerve palsy associated with humeral shaft fractures according to injury mechanism: is early exploration needed?

BACKGROUND

Radial nerve palsy is a common complication associated with humeral shaft fractures. The purposes of this study were (1) to evaluate the status of primary radial nerve palsy in patients with humeral shaft fracture according to injury mechanism, (2) to estimate the risk factors of primary RNP, and (3) to evaluate whether early exploration is helpful for radial nerve recovery.

METHODS

This study analyzed 162 patients with humeral shaft fractures from January 2014 to December 2019. All patients were surgically treated in our hospital. Of these, 109 high-energy injuries were identified and compared with 53 low-energy injuries. The risk factors of radial nerve palsy were analyzed, and the prevalence of radial nerve palsy and status of radial nerve exploration according to injury mechanism were evaluated. Nerve recovery rate according to early nerve exploration was investigated.

RESULTS

There were 31 cases of radial nerve palsy among 162 patients: 27 in the high-energy humeral shaft fracture group and 4 in the low-energy humeral shaft fracture group. Logistic regression analysis for risk factors showed that the injury mechanism was significantly associated with primary radial nerve palsy. Among 31 radial nerve palsy patients, 21 radial nerves were explored and 19 radial nerves recovered completely (80.6%). In the high-energy humeral shaft fracture group, 18 radial nerves were explored during surgery among 27 radial nerve palsy cases, and 16 cases recovered (88.9%). The other 9 radial nerves were not explored, and only 5 cases recovered (55.6%).

CONCLUSIONS

This study confirmed that the incidence of radial nerve paralysis was higher in high-energy humeral shaft fractures than in low-energy fractures. The more common fracture patterns were oblique, transverse, wedge, and comminuted in high-energy humeral shaft fracture. This study suggests that these patterns are not directly associated with radial nerve palsy, but that high-energy injury is associated with a specific fracture pattern. Early nerve exploration during surgical treatment in patients with radial nerve palsy associated with humeral shaft fracture was helpful especially after high-energy injury.

Anterior Minimally Invasive Plate Osteosynthesis for Humeral Shaft Fractures Is Safer Than Open Reduction Internal Fixation: A Matched Case-Controlled Comparison

OBJECTIVE

Compare anterior minimally invasive plate osteosynthesis (MIPO) to open reduction/internal fixation (ORIF) for humeral shaft fractures, assessing complications and clinical outcomes.

DESIGN

Retrospective matched case-controlled cohort.

SETTING

Tertiary referral trauma centre.

PATIENTS/PARTICIPANTS

Humeral shaft fractures identified retrospectively over 5 years; 31 were treated by MIPO and 54 by ORIF. Matched-case cohort assembled according to fracture pattern, sex, age, and comorbidities, with 56 total patients (28 per group).

INTERVENTIONS

MIPO and ORIF.

MAIN OUTCOME MEASURES

Complication rate was the primary outcome (radial nerve injury, nonunion, infection, and reoperation). Radiographic alignment and the Disabilities of the Arm, Shoulder and Hand Score were secondary outcomes.

RESULTS

Cumulative complication rates were 3.6% after anterior MIPO and 35.7% after ORIF (P = 0.0004). The only complication after anterior MIPO was a nonunion, managed with revision ORIF and bone graft. The ORIF group had 10 complications, including 5 superficial infections, 4 iatrogenic radial nerve injuries, and 1 nonunion. The mean Disabilities of the Arm, Shoulder and Hand score after MIPO was 17.0 ± 18.0 and after ORIF was 24.9 ± 19.5. The mean coronal plane angulation after MIPO was 1.8 ± 1.3 degrees and after ORIF was 1.0 ± 1.2 degrees. The mean sagittal plane angulation after MIPO was 3.0 ± 2.9 degrees and after ORIF was 1.0 ± 1.2 degrees.

CONCLUSIONS

The cumulative complication rate was 10 times higher after ORIF of humeral shaft fractures compared with the MIPO technique. MIPO achieved nearly equivalent radiographic alignment, with no clinically meaningful differences observed. MIPO is the safer option and should be considered for patients with humeral shaft fractures that would benefit from surgical intervention.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

New Functional Evaluation Scheme - Modality of the Results of Forearm Tendon Transfers Evaluation in Cases of Irreparable Radial Nerve Injury

Introduction

There are several evaluation schemes for the results of tendon transfers in case of radial nerve paralysis, and the most logical and commonly used are evaluation schemes that use the range of active joint movements to evaluate the results.

Aim

Present an original evaluation scheme for tendon transfer results based on functional wrist and fingers joint movements. The aim of the article is to present the advantages of our own Functional scheme in comparison with other schemes, its simplicity and applicability in the evaluation of all clinical cases of different postoperative outcome of the variables being evaluated, and to present the ease of comparison of the achieved results with other authors who would possibly use our scheme because it minimizes the subjective error of the examiner. The secondary aim is to compare the results of flexor carpi radialis (FCR) vs. flexor carpi ulnaris (FCU) tendon transfers (TT).

Methods

The study was conducted as clinical and retrospective. The study included 60 patients with isolated radial nerve palsy operated by two tendon transfer surgical methods (FCR and FCU) over a 10-year period. The evaluation of the results was performed by using Zachary, Neimann-Pertecke, Tajima evaluation schemes, our own Functional Evaluation Scheme as well as subjective patient evaluation.

Results

The time elapsed from injury to surgery ranged from 105 to 956 days in case of FCR tendon transfer and from 109 to 712 days in cases of FCU tendon transfer. The overall average age of patients is 36.71 years. A statistically significant difference in values with t -test based on the Functional Evaluation Scheme was found in the variables of ulnar deviation (p=0.000731), extension of the MP fingers joints II-V (p=0.04610) and extension of the MP of the thumb joint (p=0.0475). Evaluation of the total results with t-test (p=0.007532) and with U-test (p=0,00433) showed statistically better FCR tendon transfer results. A statistically significant difference in value measured by the t-test was found in the evaluation of the overall results (p=0.022) with Zachary and Neumann-Pertecke schemes and by the Tajima evaluation Scheme (p=0.042) in favor of better FCR tendon transfer results. With a use of Functional Evaluation Scheme, it is possible to evaluate all the results unlike most available schemes.

Conclusion

The functional evaluation scheme is based on the functional joint movements evaluated and incorporating radial and ulnar deviation of the wrist (RD and UD), extension of the metacarpophalangeal (MCP) joint and flexion of the intephalangeal (IP)joint of the thumb in the final evaluation becomes completely original. A functional evaluation scheme is simply applicable for the evaluation of all clinical cases of different postoperative outcome of the variables being evaluated. FCR tendon transfer achieves better results than FCU TT.

Humeral Shaft Fracture Healing Rates in Older Patients

Nonoperative treatment has become the standard of care for the majority of humeral shaft fractures. Published studies have mainly come from trauma centers with a young cohort of patients. The purpose of this study was to determine the nonunion rate of humeral shaft fractures in patients older than 55 years. A retrospective study was performed on a group of orthopedic trauma group treated at a level I trauma center during a 10-year period (2007-2017). Patients 55 years or older and treated for a humeral shaft fracture nonoperatively, with or without manipulation, were identified. Nonunion was defined by no bridging callus radiographically or by gross motion at the fracture at least 12 weeks from injury. There were 31 patients identified with humeral shaft fractures who met the inclusion criteria. The cohort included 21 (67.7%) females and 10 (32.3%) males with a mean age of 72.5 years (range, 55-92 years). Twenty-one fractures went on to union, and there were 10 nonunions, with no significant differences in the demographics or comorbidities. There was no correlation between AO/OTA fracture classification or fracture location and union status. There was a tendency toward higher risk of nonunion in proximal third humeral shaft fractures (45%) compared with middle (26%) and distal third (20%) humeral shaft fractures, although this was not statistically significant. The overall nonunion rate for humeral shaft fractures was 32% for patients older than 55 years. The authors found a significant correlation between age and union rate: as age increased, union rate decreased (R=-0.9, P=.045). The incidence of humeral shaft nonunion in patients older than 55 years was significantly higher than that of younger adults. To the authors' knowledge, this study is the first to report a significant correlation between nonunion and increased age. [Orthopedics. 2020;43(3);168-172.].

Humeral shaft fracture: a randomized controlled trial of nonoperative versus operative management (plate fixation)

Purpose

This randomized controlled trial was conducted to investigate the outcomes of humeral shaft–fracture management with the functional Sarmiento brace (nonoperative) versus open reduction internal fixation (ORIF).

Methods

Sixty humeral shaft–fracture patients with a minimum age of 18 years were randomly assigned into two groups: operative treatment with open reduction–internal fixation (ORIF) or functional brace (Sarmiento). A similar postoperative rehabilitation program was applied for all subjects for the next 12 months. The outcomes of each method were measured in terms of nonunion rate, union time, “quick” Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire scores, and rate of complications, such as malunion, infection, and radial nerve injury.

Results

The two groups had similar baseline characteristics, including age, sex, smoking status, and type and mechanism of fracture. The mean union time was about 4.8 weeks shorter in the ORIF group (13.9 weeks in operative group versus 18.7 weeks in nonoperative group), indicating a definite significant superiority (p=0.001) of ORIF management to functional Sarmiento bracing. However, a comparison of quick DASH scores revealed a borderline-significant difference between the groups (p=0.065). Additionally, we found that treatment of humeral shaft fractures using functional bracing was associated with slightly higher risk of nonunion; however this was not significant (p=0.492).

Conclusion

According to the present findings, there is remarkable superiority of ORIF over functional Sarmiento bracing in the management of patients with humeral shaft fracture.

Radial Nerve Palsy After Humeral Shaft Fractures: The Case for Early Exploration and a New Classification to Guide Treatment and Prognosis

Radial nerve palsies are a common complication associated with humeral shaft fractures. The authors propose classifying these injuries into 4 types based on intraoperative findings: type 1 stretch/neuropraxia, type 2 incarcerated, type 3 partial transection, and type 4 complete transection. The initial management of radial nerve palsies associated with closed fractures of the humerus remains a controversial topic, with early exploration reserved for open fractures, fractures that cannot achieve an adequate closed reduction requiring fracture repair, fractures with associated vascular injuries, and polytrauma patients. Outside of these recommendations, expectant observation for spontaneous recovery is recommended.

Minimally Invasive Osteosynthesis with a Bridge Plate Versus a Functional Brace for Humeral Shaft Fractures: A Randomized Controlled Trial

BACKGROUND

Nonoperative treatment has historically been considered the standard for fractures of the shaft of the humerus. Minimally invasive bridge-plate osteosynthesis for isolated humeral shaft fractures has been proven to be a safe technique, with good and reproducible results. This study was designed to compare clinical and radiographic outcomes between patients who had been treated with bridge plate osteosynthesis and those who had been managed nonoperatively with a functional brace.

METHODS

A prospective randomized trial was designed and included 110 patients allocated to 1 of 2 groups: surgery with a bridge plate or nonoperative treatment with a functional brace. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 6 months. The score on the Short Form-36 (SF-36) life-quality questionnaire, complications of treatment, Constant-Murley score for the shoulder, pain level, and radiographic results were assessed as secondary outcomes. Participants were assessed at 2 weeks; 1, 2, and 6 months; and 1 year after the interventions.

RESULTS

The mean DASH score of the bridge plate group was statistically superior to that of the functional brace group (mean scores, 10.9 and 16.9, respectively; p = 0.046) only at 6 months. The bridge plate group also had a significantly more favorable nonunion rate (0% versus 15%) and less mean residual angular displacement seen on the anteroposterior radiograph (2.0° versus 10.5°) (both p < 0.05). No difference between the groups was detected with regard to the SF-36 score, pain level, Constant-Murley score, or angular displacement seen on the lateral radiograph.

CONCLUSIONS

This trial demonstrates that, compared with functional bracing, surgical treatment with a bridge plate has a statistically significant advantage, of uncertain clinical benefit, with respect to self-reported outcome (DASH score) at 6 months, nonunion rate, and residual deformity in the coronal plane as seen on radiographs.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Acute Limb Shortening for Major Near and Complete Upper Extremity Amputations with Associated Neurovascular Injury: A Review of the Literature

In the setting a near or complete upper extremity amputations with significant soft tissue loss and neurovascular compromise, upper extremity surgeons are faced with the challenge of limb salvage. There are a multitude of treatment options for managing skeletal and soft tissue injuries including provisional fixation, staged reconstruction, and an acute shortening osteotomy with primary rigid internal fixation. However, many complications are associated with these techniques. Complications of provisional fixation include pin tract infection and loosening, tethering of musculotendinous units, nonunion, and additional surgeries. Staged reconstruction includes a variety of techniques: distraction osteogenesis, bone transport, or vascularized and non-vascularized structural autograft or allograft, but the risks often outweigh the benefits. Risks include nonunion, postoperative vascular complications necessitating reoperation, and the inability to return to the previous level of function at an average of 24 months. Acute shortening osteotomy with internal fixation offers the advantage of a single-stage procedure that provides for decreasing the soft tissue loss, provides a rigid platform to protect the delicate neurovascular repair, and alleviates unwanted tension at the repair sites. This review discusses the literature on the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and aims to evaluate the indications, surgical techniques, clinical and functional outcomes, and complications associated with acute shortening osteotomy with rigid internal fixation. Although this technique is not without risks, it is well-tolerated in the acute setting with a complication profile comparable to other techniques of fixation while remaining a single procedure.

Factors associated with radial nerve palsy after operative treatment of diaphyseal humeral shaft fractures

BACKGROUND

The radial nerve is at risk after diaphyseal humeral fracture or surgery to repair the fracture. We hypothesized that there are no factors associated with iatrogenic radial nerve palsy and, secondarily, that there are no factors associated with traumatic radial nerve palsy or radial nerve palsy of any type.

METHODS

We analyzed 325 adult patients who underwent operative treatment of a diaphyseal humerus fracture at 6 hospitals between January 2002 and November 2014 to determine factors associated with a radial nerve palsy. We excluded patients with pathologic fractures, fractures with massive bone loss, prior surgery in another hospital, periprosthetic fractures, and if no operative note was available.

RESULTS

In patients without a traumatic radial nerve palsy, an iatrogenic radial nerve palsy occurred in 18 of 259 diaphyseal humeral fractures (7%). The surgical approach was associated with iatrogenic radial nerve palsy (P = .034). No factors were associated with traumatic radial nerve palsy (66 of 325 patients [20%]) of the humeral diaphysis. Open fractures, location of fracture, and high-energy trauma were significantly associated with radial nerve palsy of any type (84 of 325 patients [26%]).

CONCLUSIONS

Patients and surgeons should keep in mind that iatrogenic transient dysfunction of the radial nerve will occur in approximately 1 in 5 patients treated with lateral exposure of the humerus, in 1 in 9 patients treated with posterior exposure, and in 1 in 25 patients with an anterolateral exposure.

Evaluation of the reproducibility of the AO/ASIF classification for humeral shaft fractures

OBJECTIVE

To evaluate the reproducibility of the AO/Asif classification for humeral shaft fractures.

METHODS

Consecutive radiographs of the arm in both anteroposterior and lateral view from 60 patients with humeral shaft fractures were analyzed. Six observers who were familiar with the AO/Asif classification (three shoulder and elbow surgery specialists and three general orthopedists) were selected to make the analysis, which was done at three different times. The data were subjected to statistical analysis using the kappa coefficient.

RESULTS

The intra and interobserver concordance was statistically significant in all the analyses.

CONCLUSIONS

All the evaluators showed concordance between the three evaluations that was considered to be statistically significant. However, the highest values were found among the specialists.

Review of literature of radial nerve injuries associated with humeral fractures-an integrated management strategy

Background

Radial nerve palsy associated with fractures of the shaft of the humerus is the most common nerve lesion complicating fractures of long bones. However, the management of radial nerve injuries associated with humeral fractures is debatable. There was no consensus between observation and early exploration.

Methods and Findings

The PubMed, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, CINAHL, International Bibliography of the Social Sciences, and Social Sciences Citation Index were searched. Two authors independently searched for relevant studies in any language from 1966 to Jan 2013. Thirty studies with 2952 humeral fractures participants were identified. Thirteen studies favored conservative strategy. No significant difference between early exploration and no exploration groups (OR, 1.03, 95% CI 0.61, 1.72; I² = 0.0%, p = 0.918 n.s.). Three studies recommend early radial nerve exploration in patients with open fractures of humerus with radial nerve injury. Five studies proposed early exploration was performed in high-energy humeral shaft fractures with radial nerve injury.

Conclusions

The conservative strategy was a good choice for patients with low-energy closed fractures of humerus with radial nerve injury. We recommend early radial nerve exploration (within the first 2 weeks) in patients with open fractures or high-energy closed fractures of humerus with radial nerve injury.

Treatment of the humeral shaft fractures--minimally invasive osteosynthesis with bridge plate versus conservative treatment with functional brace: study protocol for a randomised controlled trial

Background

Humeral shaft fractures account for 1 to 3% of all fractures in adults and for 20% of all humeral fractures. Non-operative treatment is still the standard treatment of isolated humeral shaft fractures, although this method can present unsatisfactory results. Surgical treatment is reserved for specific conditions. Modern concepts of internal fixation of long bone shaft fractures advocate relative stabilisation techniques with no harm to fracture zone. Recently described, minimally invasive bridge plate osteosynthesis has been shown to be a secure technique with good results for treating humeral shaft fractures. There is no good quality evidence advocating which method is more effective. This randomised controlled trial will be performed to investigate the effectiveness of surgical treatment of humeral shaft fractures with bridge plating in comparison with conservative treatment with functional brace.

Methods/Design

This randomised clinical trial aims to include 110 patients with humeral shaft fractures who will be allocated after randomisation to one of the two groups: bridge plate or functional brace. Surgical treatment will be performed according to technique described by Livani and Belangero using a narrow DCP plate. Non-operative management will consist of a functional brace for 6 weeks or until fracture consolidation. All patients will be included in the same rehabilitation program and will be followed up for 1 year after intervention. The primary outcome will be the DASH score after 6 months of intervention. As secondary outcomes, we will assess SF-36 questionnaire, treatment complications, Constant score, pain (Visual Analogue Scale) and radiographs.

Discussion

According to current evidence shown in a recent systematic review, this study is one of the first randomised controlled trials designed to compare two methods to treat humeral shaft fractures (functional brace and bridge plate surgery).

Trial registration

Current Controlled Trials: ISRCTN24835397

Management of radial nerve palsy following fractures of the humerus

Radial nerve palsy is the most common peripheral nerve injury following a humerus fracture, occurring in 2% to 17% of cases. Radial nerve palsies associated with closed humerus fractures have traditionally been treated with observation, with late exploration restricted to cases without spontaneous nerve recovery at 3 to 6 months. Advocates for early exploration believe that late exploration can result in increased muscular atrophy, motor endplate loss, compromised nerve recovery upon delayed repair, and significant interval loss of patient function and livelihood. In contrast, early exploration can hasten nerve injury characterization and repair, and facilitate early fracture stabilization and rehabilitation.

Management of humeral shaft fractures

Humeral shaft fractures account for approximately 3% of all fractures. Nonsurgical management of humeral shaft fractures with functional bracing gained popularity in the 1970s, and this method is arguably the standard of care for these fractures. Still, surgical management is indicated in certain situations, including polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical options include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing. Each of these techniques has advantages and disadvantages, and the rate of fracture union may vary based on the technique used. A relatively high incidence of radial nerve injury has been associated with surgical management of humeral shaft fractures. However, good surgical outcomes can be achieved with proper patient selection.

Radial nerve palsy associated with humeral shaft fracture. Is the energy of trauma a prognostic factor?

BACKGROUND

Radial nerve palsy associated with humeral shaft fractures is the most common nerve lesion complicating fractures of long bones. The purpose of the study was to review the outcome of surgical management in patients with low energy and high energy radial nerve palsy after humeral shaft fractures.

METHODS

Eighteen patients were treated operatively for a humeral shaft fracture with radial nerve palsy. The mean age was 32.2 years and the mean follow up time was 66.1 months (range: 30-104). The surgical management included fracture fixation with early nerve exploration and repair if needed. The patients were divided in two groups based on the energy of trauma (low vs. high trauma energy). The prevalence of injured and unrecovered nerves and time to nerve recovery were analysed.

RESULTS

Five patients sustained low and 13 high energy trauma. All patients with low energy trauma had an intact (4) or entrapped (1) radial nerve and recovered completely. Full nerve recovery was also achieved in five of 13 patients with high energy trauma where the nerve was found intact or entrapped. Signs of initial recovery were present in a mean of 3.2 weeks (range: 1-8) for the low energy group and 12 weeks (range: 3-23) for the high energy group (p=0.036). In these patients, the average time to full recovery was 14 and 26 weeks for the low and high energy trauma group respectively. Eight patients with high energy trauma had severely damaged nerves and failed to recover, although microsurgical nerve reconstruction was performed in 4 cases. Patients with high energy trauma had a prolonged fracture healing time (18.7 weeks on average) compared to those with low energy fractures (10.4 weeks), (p=0.003).

CONCLUSIONS

The outcome of the radial nerve palsy following humeral fractures is associated to the initial trauma. Palsies that are part of a low energy fracture uniformly recover and therefore primary surgical exploration seems unnecessary. In high energy fractures, neurotmesis or severe contusion must be expected. In this case nerve recovery is unfavourable and the patients should be informed of the poor prognosis and the need of tendon transfers.

Limb salvage with major nerve injury: current management and future directions

Major peripheral nerve injuries are often associated with devastating functional deficits. Current management techniques fail to achieve adequate functional neural regeneration, and the development of adjunct therapies is necessary to improve outcomes. Recent efforts at enhancing the regeneration rate of peripheral nerves and developing axonal guidance channels or conduits have had limited success. The neuromuscular junction serves as the interface between the peripheral nerves and muscle. This critical area undergoes significant changes following peripheral nerve injury and induces end-organ atrophy after denervation, which limits the chance of true functional regeneration. Stabilization of the neuromuscular junction may be an important adjunct in peripheral nerve repair and should be explored as a method of managing major nerve injuries.

Immediate plate osteosynthesis of open fractures of the humeral shaft

BACKGROUND

The aim of this study was to assess the outcome of immediate plate osteosynthesis in the surgical treatment of open humeral shaft fractures.

METHODS

In a Level I trauma center and teaching hospital, we reviewed 53 patients with open humeral diaphyseal fractures who were treated with immediate open reduction and plate fixation from April 1988 to August 1998. Forty-six patients were available for adequate follow-up and assessment. All fractures were treated with a standard protocol that included irrigation and debridement, intravenous antibiotics, and immediate open reduction and plate fixation. Patients were assessed to determine whether bone grafts were needed during surgery, whether bone union was achieved, the state of the radial nerve, and postoperative complications. No quantitative functional outcomes were assessed, because this was beyond the scope of the study. It was hypothesized that immediate plate osteosynthesis would achieve safe and acceptable clinical results.

RESULTS

The 46 patients with adequate final follow-up were assessed at a mean time of 37.5 weeks (13-156 weeks). All fractures united primarily in satisfactory angulation <5 degrees in coronal and sagittal planes. There were 6 delayed unions with a mean time to union of 42.5 weeks (30-72 weeks). The remaining 40 patients united at a mean of 18.4 weeks (12-26 weeks). No patient required subsequent surgery to obtain union of the fracture. Complications were rare, with no deep infections, nonunions, or iatrogenic nerve injuries. Complications included amputation in three patients and dysesthesia in one patient. Two patients had implants removed because of discomfort.

CONCLUSIONS

Immediate plate osteosynthesis for open humeral shaft fractures has been shown to produce excellent results regarding bone union and absence of deep infections and is a safe technique in the management of these injuries.

The management of humeral shaft fractures with associated radial nerve palsy: a review of 117 cases

PATIENTS AND METHODS

This single center retrospective study reviews the management and outcomes of 117 consecutive patients with humeral shaft fractures and associated radial nerve palsy (RNP) treated over a 20-year period (1986-2006). A total of 101 fractures were managed conservatively and 16 fractures underwent external fixation for poor bony alignment. Sixteen grade 1 and 2 open fractures underwent wound toileting alone. No patients underwent initial radial nerve exploration or opening of the fracture sites.

RESULTS

All patients achieved clinical and radiological bony union at a mean of 8 weeks (range 7-12 weeks). There were no complications or pin tract infections in the operated patients. A total of 111 cases had initial spontaneous RNP recovery at a mean of 6 weeks (range 3-24 weeks) with full RNP recovery at a mean of 17 weeks (range 3-70 weeks) post-injury. Fourteen patients had no clinical/EMG signs of nerve activity at 12 weeks and 6 subsequently failed to regain any radial nerve recovery; 2 had late explorations and the lacerated nerves underwent sural nerve cable neurorraphy; and 4 patients underwent delayed tendon transposition 2-3 years after initial injury, with good/excellent functional outcomes.

CONCLUSIONS

Humeral fractures with associated RNP may be treated expectantly. With low rates of humeral nonunion, 95% spontaneous nerve recovery in closed fractures and 94% in grade 1 and 2 open fractures, one has the opportunity of waiting. If at 10-12 weeks there are no clinical/EMG signs of recovery, then nerve exploration/secondary reconstruction is indicated. Late tendon transfers may also give good/excellent functional results.

Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model

PURPOSE

When managing radial nerve palsy associated with a humerus fracture, both surgeon and patient must balance the risks and benefits of performing an invasive surgical procedure to address a functional deficit that is likely, but not certain, to recover with nonsurgical management. The purpose of this study was to better understand the determinants of optimal management strategy using expected-value decision analysis.

METHODS

Probabilities for the occurrences of the potential outcomes after initial observation or early surgery were determined from a systematic review of the literature. Scores for these outcomes were obtained from a questionnaire on patient preferences completed by 82 subjects without a history of humerus fracture and radial nerve palsy and used in the model as a measure of utility. A decision tree was constructed, fold-back analysis was performed to determine optimal treatment, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities.

RESULTS

Observation was associated with a value of 8.4 and early surgery a value of 6.7 given the outcome probabilities and utilities studied in this model, making observation the optimal management strategy. When parameters were varied in sensitivity analysis, it was noted that when the rate of recovery after initial observation falls below 40% or when the utility value for successful early surgery rises above 9.4, early surgery is the preferred management strategy.

CONCLUSIONS

Initial observation was the preferred strategy. In clinical settings in which the likelihood of spontaneous recovery of nerve function is low or when an informed patient has a strong preference for surgery, early surgery may optimize outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis II.

Early surgical exploration of radial nerve injury associated with fracture shaft humerus

The series included 36 patients, predominantly male, mean age 30.3 years. The most common cause of injury was motor car accident in 20 patients. Postreduction radial nerve injury occurred in nine cases. Open fracture humerus with radial nerve injury in seven cases. The fractures were situated in the middle or distal third of the humeral shaft. Most were transverse fractures. Twelve patients had surgery on the day of injury and the other 24 at a mean of 8 days later (3-14). Narrow dynamic compression plate was generally used for fixation. Exploration of the radial nerve demonstrated compression at the lateral intermuscular septum in 19 cases, entrapment in the fracture site in nine cases, and loss of its continuity in eight cases. Neurolysis was required in 20 cases, epineurorrhaphy in nine cases, interfascicular nerve grafts in five, and first-intention tendon transfer in two. Results of nerve surgery were assessed with the MRC (Medical Research Council) at a mean follow-up of 8.2 years. Outcome was rated good to excellent in 28 patients, fair in 1, and poor (failure) in 3. First-intention tendon transfers were performed in 2 patients and 2 patients were lost to follow-up. Mean delay to recovery was 7 months after neurolysis and nerve repair and 15 months after nerve grafts. The fracture was united in all cases. The mean time of union was 5 months.

Surgical anatomy of the radial nerve at the elbow

An anatomical study of the brachial portion of the radial nerve with surgical implications is proposed. Thirty specimens of arm from 20 fresh cadavers (11 male, 9 female) were used to examine the topographical relations of the radial nerve with reference to the following anatomical landmarks: acromion angle, medial and lateral epicondyles, point of division between the lateral and long heads of the triceps brachii, lateral intermuscular septum, site of division of the radial nerve into its superficial and posterior interosseous branches and entry and exit point of the posterior interosseous branch into the supinator muscle. The mean distances between the acromion angle and the medial and lateral levels of crossing the posterior aspect of the humerus were 109 (+/-11) and 157 (+/-11) mm, respectively. The mean length and calibre of the nerve in the groove were 59 (+/-4) and 6 (+/-1) mm, respectively. The division of the lateral and long heads of the triceps was found at a mean distance of 126 (+/-13) mm from the acromion angle. The mean distances between the lateral point of crossing the posterior aspect of the humerus and the medial and lateral epicondyles were 125 (+/-13) and 121 (+/-13) mm, respectively. The mean distance between the lateral point of crossing the posterior aspect of the humerus and the entry point in the lateral intermuscular septum (LIS) was 29 (+/-6) mm. The mean distances between the entry point of the nerve in the LIS and the medial and lateral epicondyles were 133 (+/-14) and 110 (+/-23) mm, respectively. Our study provides reliable and objective data of surgical anatomy of the radial nerve which should be always kept in mind by surgeons approaching to the surgery of the arm, in order to avoid iatrogenic injuries.

Primary radial nerve palsy in patients with acute humeral shaft fractures

OBJECTIVE

The primary aim was to report on the recovery of radial nerve function in patients with acute closed humeral shaft fractures and associated primary radial nerve palsy. The secondary aim was to report on the long-term functional outcome and health-related quality of life (HRQoL) in patients with this specific injury.

SETTING

Six major hospitals in Stockholm County.

DESIGN

Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome and HRQoL.

PATIENTS

Thirty-three patients with acute radial nerve palsy and a closed humeral shaft fracture in a population of 358 patients with 361 humeral shaft fractures.

INTERVENTION

Nonoperative or operative treatment as per decision of the attending orthopedic surgeon.

MAIN OUTCOME MEASUREMENTS

Recovery of the radial nerve, fracture healing, functional outcome according to the Short Musculoskeletal Function Assessment (SMFA) and the Disabilities of the Arm, Shoulder and Hand (DASH). HRQoL according to Short Form 36 (SF-36).

RESULTS

Among the 18 patients treated nonoperatively, 16 (89%) displayed a complete recovery from their radial nerve palsy while 2 (11%) presented minor sequelae. In 11 (73%) of the 15 patients treated primarily operatively, the nerve function recovered completely while 2 patients (13%) had minor sequelae and 2 (13%) had major sequelae, i.e. 1 partial nerve palsy and 1 total radial nerve palsy. Sixteen patients (48%) were available for assessment of the long-term functional outcome and HRQoL at a mean of 7 years (range, 6 to 8 years). The range of motion and the muscular strength of the injured arm, the functional outcome according to the SMFA, and HRQoL according to the SF-36 showed results comparable to those previously reported for patients with healed humeral shaft fractures without associated radial nerve palsy.

CONCLUSION

This study confirms the high spontaneous recovery rate of primary radial nerve palsies in patients with closed humeral shaft fractures. Primary radial nerve palsy should not be regarded as an isolated indication for primary surgical intervention.

Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus

Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.

Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: review and evaluation of the long-term results of 52 cases

This study was undertaken to determine the efficacy of delayed surgical treatment in cases of persistent radial nerve paralysis after fractures of the middle third of the humerus. We have limited this study to patients who had absolutely no functional recovery of the radial nerve 3 to 4 months after middle third humeral fractures. The fractures were treated by a variety of orthopaedic methods, conservative and surgical, in other departments and hospitals. Surgical exploration of the radial nerve was carried out 3 to 4 months after primary orthopaedic treatment. The outcome of this study concurs with data in the literature in showing that delayed nerve surgery (neurolysis or nerve grafts) in the absence of functional recovery of the radial nerve after humeral fracture can be useful in achieving good functional recovery and subjectively satisfying results.

Complete division of the radial nerve associated with a closed fracture of the humeral shaft in a child

The management of closed fractures of the humerus with an associated nerve palsy remains controversial. With very little written about this injury in children, we present the case of a three-year-old child with a closed humeral shaft fracture in whom surgical exploration and reconstruction of the radial nerve with a sural nerve graft was performed three months after injury. The child regained full function. To the best of our knowledge, this is the first such case to be reported in the English literature.

Hyperbaric oxygen therapy facilitates surgery on complex open elbow injuries: preliminary results

Complex open elbow injuries present a significant challenge to orthopaedic surgeons because of the poor potential for achieving a good functional level, even given good anatomic realignment. Associated massive soft-tissue damage impedes surgical fixation, delays rehabilitation, and therefore, further deteriorates the functional outcome. We studied a prospective, consecutive series of 16 patients with complex open elbow injuries who were treated with a combination of treatment modalities including early bony stabilization, debridement of soft tissue, and early coverage. The treatment protocol also used hyperbaric oxygen therapy to facilitate immediate internal fixation. The median value of the Mangled Extremity Severity Score was 5.5 (range, 3-10). Successful reconstruction was achieved in all 16 patients. No deep infection occurred, but there were 3 self-limited superficial infections. The average elbow functional result at 12 months after surgery, based on the Mayo score system, was good (mean value, 80.9; range, 55-100). Of the patients, 75% achieved satisfactory functional results for the elbow. The results of this study demonstrate that the studied treatment protocol provides a promising alternative for managing these complex open elbow injuries.

Radial nerve injuries associated with humeral fractures

A radial nerve injury associated with a humeral shaft fracture is an important injury pattern among trauma patients. It is the most common peripheral nerve injury associated with this fracture. Although treatment for this injury pattern is a controversial subject among upper-extremity surgeons, certain principles of management need to be applied in all cases. As our understanding of the pathoanatomy of the humerus and surrounding neurovascular structures has evolved, surgeons have adapted their strategies to improve outcome and avoid long-term morbidity. The principles of management and the clinical outcomes of various treatment strategies, defined in the literature, are reviewed in this article.

Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis

BACKGROUND

The choice of plates or intramedullary nails for operatively treated humeral shaft fractures remains controversial, since randomized controlled trials have lacked sufficient power. A meta-analysis of existing trials would improve inferences regarding the treatment effect.

METHODS

We reviewed randomized trials in Medline, Cochrane and SciSearch, along with other sources of published randomized trials from 1969-2000. Of 215 citations identified, only 3 studies were included.

RESULTS

The 3 studies (involving 155 patients) were pooled, since they were homogeneous (p > 0.1). Plate fixation gave a lower relative risk of reoperation than intramedullary nailing (RR = 0.26, 95% CI 0.007-0.9, p = 0.03). This translated to a risk reduction of 74% for reoperation when plate fixation was employed. Thus, 1 reoperation could be prevented for every 10 patients treated with plates. Plate fixation also reduced the risk of shoulder problems in comparison to intramedullary nails (RR = 0.10, 95% CI 0.03-0.4, p = 0.002).

INTERPRETATION

Plate fixation of humeral shaft fractures may reduce the risk of reoperation and shoulder impingement. The cumulative evidence remains inconclusive, and a larger trial is needed in order to confirm these findings.

Radial nerve palsy associated with fractures of the shaft of the humerus

The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol.

The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p < 0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors.

Radial nerve palsy associated with high-energy humeral shaft fractures

PURPOSE

To determine whether the radial nerve should be explored when there is a complete sensory and motor deficit after a high-energy fracture of the humeral diaphysis.

METHODS

Twenty-four patients aged 16 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. Eleven fractures were open-6 of these were part of a very complex upper-extremity injury (multiple ipsilateral fractures in 3 patients and near amputation in 3). All 11 patients with open fractures and 3 of 13 patients with closed injuries had radial nerve exploration.

RESULTS

All 6 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. Five of 6 had primary repair of the radial nerve, and none recovered. All 8 intact explored nerves and 9 of 10 unexplored nerves recovered; the only nonrecovery occurred in a patient treated with closed intramedullary rod fixation who may have had iatrogenic nerve injury. The average time to initial signs of recovery was 7 weeks (range, 1-25 weeks). The average time to full recovery was 6 months (range, 1-21 months).

CONCLUSIONS

Transection of the radial nerve is usually associated with open fractures of the humerus that are part of a very complex upper-extremity injury. The results of primary nerve repair in this circumstance are poor, likely related to an extensive zone of injury and the need for nerve grafting. Intact nerves and nerve palsies that are part of a closed fracture nearly always recover, even after high-energy injuries. Because the first signs of nerve recovery and complete recovery of the nerve can be quite delayed, patience is merited before considering tendon transfers.

Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates

OBJECTIVES

To compare the clinical and radiographic results for locked intramedullary (IM) nails and plates used in the treatment of humeral diaphyseal fractures.

DESIGN

Prospective randomization by sealed-envelope technique of eighty-four patients into two study groups: those treated by intramedullary nailing (IMN group; n = 38) and those treated by compression plating (PLT group; n = 46).

SETTING

Patients admitted consecutively to a university-affiliated Level I trauma center.

PATIENT/PARTICIPANTS

All skeletally mature patients admitted to Harborview Medical Center with acute humeral shaft fractures requiring surgical stabilization. Fractures of the diaphysis were defined as being at least three centimeters distal to the surgical neck and at least five centimeters proximal to the olecranon fossa.

INTERVENTION

Treatment with locking antegrade intramedullary humeral nails (Russell-Taylor design [Smith and Nephew Richards]) or with 4.5-millimeter dynamic compression and limited contact dynamic compression plates (AO design [Synthes]).

MAIN OUTCOME MEASUREMENTS

Clinical outcome measurements included fracture healing, radial nerve recovery, infection, and elbow and shoulder discomfort. Radiographic measurements included fracture alignment, time to healing, delayed union, and nonunion.

RESULTS

Follow-up averaged thirteen months. Forty-two fractures (93 percent) in the PLT group were healed by sixteen weeks versus thirty-three fractures (87 percent) in the IMN group (p = 0.70). Shoulder pain and a decrement in shoulder range of motion (ROM) were significant associations with IMN (p = 0.007 for both variables) but not with PLT. A decrement in elbow ROM was significantly associated with PLT (p = 0.03), especially for fractures of the distal third of the diaphysis, whereas elbow pain was not (p = 0.123). The sum of other complications demonstrated nearly equal prevalence for both treatment groups.

CONCLUSIONS

For patients requiring surgical treatment of a humeral shaft fracture, intramedullary nailing and compression plating both provide predictable methods for achieving fracture stabilization and ultimate healing.

The assessment and treatment of nerve dysfunction after trauma around the elbow

Nerve dysfunction after trauma around the elbow can lead to significant long-term pain and functional deficit. Fortunately, most of these injuries are neurapraxias that will recover spontaneously after conservative treatment. The necessity and time frame for surgical intervention for specific patterns of nerve dysfunction remains controversial. Often surgical exploration exacerbates rather than alleviates the presenting nerve problem. Distal humeral shaft fractures, elbow dislocations, Monteggia fracture-dislocations, supracondylar fractures in children, and proximal forearm trauma all have been associated with various types of nerve injuries with a variable degree of recovery. The early recognition of nerve dysfunction combined with appropriate treatment measures is the key to successful outcome.