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Gunsoy Z, Sayer G, Dinc M, Soydemir OC, Oguzkaya S. The effect of plate location on radial nerve palsy recovery time associated with humeral shaft fractures. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02524-9. [PMID: 39008113 DOI: 10.1007/s00068-024-02524-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/04/2024] [Indexed: 07/16/2024]
Abstract
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.
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Affiliation(s)
- Zeki Gunsoy
- Department of Hand Surgery, Bursa City Hospital, Bursa, Turkey.
| | - Gokhan Sayer
- Department of Orthopedics and Traumatology, Bursa City Hospital, Bursa, Turkey
| | - Mustafa Dinc
- Department of Orthopedics and Traumatology, Bursa City Hospital, Bursa, Turkey
| | | | - Sinan Oguzkaya
- Department of Orthopedics and Traumatology, Bursa City Hospital, Bursa, Turkey
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Böhringer A, Cintean R, Schütze K, Gebhard F. Primary Radial Nerve Lesions in Humerus Shaft Fractures-Revision or Wait and See. J Clin Med 2024; 13:1893. [PMID: 38610658 PMCID: PMC11012818 DOI: 10.3390/jcm13071893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/13/2024] [Accepted: 03/17/2024] [Indexed: 04/14/2024] Open
Abstract
Background: This study investigates the surgical state-of-the-art procedure for humeral shaft fractures with primary radial nerve palsy based on its own case series in relation to the current and established literature. Methods: Retrospective review of treated cases between January 2018 and December 2022 describing radial nerve palsy after humerus shaft fractures, radiological fracture classification, intraoperative findings, surgical procedure, patient follow-up and functional outcome. Results: A total of 804 patients (463 women and 341 men) with humerus shaft fractures were identified. A total of 33 patients showed symptomatic lesions of the radial nerve (4.1%). The primary lesion was identified in 17 patients (2.1%). A broad and inhomogeneous distribution of fractures according to the AO classification was found. According to the operative reports, the distraction of the radial nerve was found eleven times, bony interposed three times and soft tissue constricted/compressed three times. In every case the radial nerve was surgically explored, there was no case of complete traumatic nerve transection. Four intramedullary nails and thirteen locking plates were used for osteosynthesis. Complete recovery of nerve function was seen in 12 cases within 1 to 36 months. Three patients still showed mild hypesthesia in the thumb area after 18 months. Two patients were lost during follow-up. Conclusions: With this study, we support the strategy of early nerve exploration and plate osteosynthesis in humeral fractures with primary radial nerve palsy when there is a clear indication for surgical fracture stabilisation. In addition, early exploration appears sensible in the case of palsies in open fractures and secondary palsy following surgery without nerve exposure as well as in the case of diagnostically recognisable nerve damage. Late nerve exploration is recommended if there are no definite signs of recovery after 6 months. An initial wait-and-see strategy with clinical observation seems reasonable for primary radial nerve palsies without indication for surgical fracture stabilisation.
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Affiliation(s)
- Alexander Böhringer
- Department of Trauma Hand and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Van Bergen SH, Van Lieshout EM, Verhofstad MH, Den Hartog D. Recovery and functional outcome after radial nerve palsy in adults with a humeral shaft fracture: a multicenter prospective case series. JSES Int 2023; 7:516-522. [PMID: 37266182 PMCID: PMC10229417 DOI: 10.1016/j.jseint.2023.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Background The consequences of radial nerve palsy associated with a humeral shaft fracture are unclear. The aim of this study was to examine the functional recovery of radial nerve palsy, at presentation or postoperatively, in patients with a humeral shaft fracture. Methods Data from patients who participated in the HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER) study, a multicenter prospective cohort study including adults with a closed humeral shaft fracture Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 12A or 12B, and had radial nerve palsy at presentation or postoperatively, were extracted from the HUMMER database. The primary outcome measure was clinically assessed recovery of motor function of the radial nerve. Secondary outcomes consisted of treatment, functional outcome (Disabilities of the Arm, Shoulder, and Hand and Constant-Murley Score), pain level, quality of life (Short Form-36 and EuroQoL-5D-3L), activity resumption, and range of motion of the shoulder and elbow joint at 12 months after trauma. Results Three of the 145 nonoperatively treated patients had radial nerve palsy at presentation. One recovered spontaneously and 1 after osteosynthesis. Despite multiple surgical interventions, the third patient had no recovery after entrapment between fracture fragments. Thirteen of the 245 operatively treated patients had radial nerve palsy at presentation; all recovered. Nine other patients had postoperative radial nerve palsy; 8 recovered. One had ongoing recovery at the last follow-up, after nerve release and suture repair due to entrapment under the plate. At 12 months, the functional outcome scores of all patients suggested full recovery regarding functional outcome, pain, quality of life, activity resumption, and range of motion. Conclusion Radial nerve palsy in patients with a humeral shaft fracture at presentation or postoperatively functionally recovers in 94% and 89%, respectively.
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Affiliation(s)
- Saskia H. Van Bergen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther M.M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael H.J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Carney J, Cantrell C, Goedderz C, Weissman J, Gerlach E, Marx J, Butler B, Lamberti P. Radial nerve transection after ballistic humeral shaft fractures: A retrospective cohort study. Injury 2023; 54:S0020-1383(23)00284-X. [PMID: 36967297 DOI: 10.1016/j.injury.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/11/2023] [Accepted: 03/19/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Radial nerve palsy following fracture of the humeral shaft is common. However, the incidence of nerve transection in the setting of ballistic trauma is unknown. The purpose of this study was to estimate the incidence of radial nerve transection after ballistic fracture of the humerus. METHODS Patients presenting to an urban, level-1 trauma center with a ballistic fracture of the humeral shaft were retrospectively reviewed. Patient demographics, clinical exam on presentation, and operative data were reviewed to determine the incidence of radial nerve palsy on initial examination, the incidence of operative treatment, the incidence of how frequently the nerve was directly visualized, and the incidence of radial nerve transection. RESULTS One-hundred and thirteen ballistic humeral shaft fractures were identified. Of these, 30 (26.5%) patients had a complete radial nerve palsy on exam. Of patients with a radial nerve palsy, on exam 20 were taken to the operating room and the nerve was visualized in 17 of those cases. There 2 were partially lacerated nerves and 12 nerves were completely transected. Thus, in patients with a complete nerve deficit on examination who underwent operative treatment with nerve exploration, the rate of nerve transection was 70.6%. The lower bound rate of nerve transection for all patients with radial nerve palsy (assuming all unexplored nerves were intact) was 40.0%. CONCLUSION The rate of nerve transection in patients with humerus shaft fractures with associated radial nerve palsies is likely higher than the rate of nerve transection in similar injuries caused by blunt mechanisms. The authors recommend early exploration and fixation of these injuries.
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Affiliation(s)
- John Carney
- Feinberg School of Medicine of Northwestern University. Department of Orthopaedic Surgery, USA.
| | - Colin Cantrell
- Feinberg School of Medicine of Northwestern University. Department of Orthopaedic Surgery, USA
| | - Cody Goedderz
- Feinberg School of Medicine of Northwestern University. Department of Orthopaedic Surgery, USA
| | - Joshua Weissman
- Feinberg School of Medicine of Northwestern University. Department of Orthopaedic Surgery, USA
| | - Erik Gerlach
- Feinberg School of Medicine of Northwestern University. Department of Orthopaedic Surgery, USA
| | - Jeremy Marx
- Feinberg School of Medicine of Northwestern University. Department of Orthopaedic Surgery, USA
| | - Bennet Butler
- Feinberg School of Medicine of Northwestern University. Department of Orthopaedic Surgery, USA
| | - Paul Lamberti
- John H. Stroger Hospital of Cook County, Department of Orthopaedic Surgery, USA
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Letter to the Editor: Reading Between the Lines: Evidence-Based Medicine Shows What You Want to See. J Am Acad Orthop Surg 2023; 31:e169-e170. [PMID: 34125736 DOI: 10.5435/jaaos-d-21-00236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 02/01/2023] Open
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Ortega-Yago A, Ferràs-Tarragó J, Jover-Jorge N, Baixauli-Garcia F. Radial Nerve Paralysis in Diaphyseal Fractures of the Humerus. PLASTIC AND AESTHETIC NURSING 2022; 42:156-162. [PMID: 36450058 DOI: 10.1097/psn.0000000000000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Amparo Ortega-Yago
- Amparo Ortega-Yago, MD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Joan Ferràs-Tarragó, MD, PhD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Nadia Jover-Jorge, MD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Francisco Baixauli-Garcia, MD, PhD , is Chief of Orthopedics, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
| | - Joan Ferràs-Tarragó
- Amparo Ortega-Yago, MD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Joan Ferràs-Tarragó, MD, PhD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Nadia Jover-Jorge, MD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Francisco Baixauli-Garcia, MD, PhD , is Chief of Orthopedics, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
| | - Nadia Jover-Jorge
- Amparo Ortega-Yago, MD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Joan Ferràs-Tarragó, MD, PhD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Nadia Jover-Jorge, MD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Francisco Baixauli-Garcia, MD, PhD , is Chief of Orthopedics, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
| | - Francisco Baixauli-Garcia
- Amparo Ortega-Yago, MD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Joan Ferràs-Tarragó, MD, PhD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Nadia Jover-Jorge, MD , is Orthopedic Surgeon, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
- Francisco Baixauli-Garcia, MD, PhD , is Chief of Orthopedics, Department of Orthopaedic and Traumatology Surgery, Hospital Universitari i Politècnic la Fe, València, Spain
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Rasulić L, Djurašković S, Lakićević N, Lepić M, Savić A, Grujić J, Mićić A, Radojević S, Puzović V, Maletić M, Mandić-Rajčević S. Surgical Treatment of Radial Nerve Injuries Associated With Humeral Shaft Fracture-A Single Center Experience. Front Surg 2022; 8:774411. [PMID: 34977143 PMCID: PMC8716365 DOI: 10.3389/fsurg.2021.774411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/22/2021] [Indexed: 12/05/2022] Open
Abstract
Radial nerve injuries are often associated with humeral shaft fractures. The results of treatment of these injuries, by contemporary surgical approaches, remain diverse. In this paper we presented the outcomes and analyzed the patient, clinical, and surgical procedure related characteristics and factors that may influence the outcome overall, in 77 patients treated at Clinic for Neurosurgery, Clinical Center of Serbia during a 20 years period. The nerve injuries were verified by US and EMNG. The majority of patients were treated by neurolysis or sural nerve grafting, while only few were treated by direct suture. The final recovery was evaluated by muscle strength assessment and classified using MRC. We analyzed extension of the wrist, extension of the fingers including the thumb, and abduction of the thumb. There was a significant statistical difference in MRC grade following the treatment. The total rate of useful functional recovery was achieved in 69 (89.61%) out of all studied patients, out of whom 20 (28.99%) achieved excellent recovery, 26 (37.68%) achieved good recovery and 23 (33.33%) achieved fair recovery. Only 8 (10.39%) out of all studied patients achieved poor recovery. The injured nerves, that were preserved in continuity, acquired by a low-energy trauma, and treated earlier than the 6 months were associated with better functional outcome following the surgery. In addition, there was a trend of better functional improvement with aging, keeping in mind that the old were subjected to lower energy trauma. The expectant management followed by surgery of radial nerve injury associated with humeral shaft fracture should be around 3 months, and the surgical nerve repair should not be performed later than the 6 months after injury. The energy of trauma may be a factor predicting patient's final recovery following the treatment.
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Affiliation(s)
- Lukas Rasulić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Slavko Djurašković
- Clinic for Neurosurgery, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Novak Lakićević
- Clinic for Neurosurgery, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Milan Lepić
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
| | - Andrija Savić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Jovan Grujić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksa Mićić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Vladimir Puzović
- College of Higher Vocational Studies "Sports Academy", Belgrade, Serbia
| | - Miloš Maletić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Stefan Mandić-Rajčević
- School of Public Health and Health Management and Institute of Social Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Im JH, Moon DK, Gwark JY, Park HB. Need for early exploration of radial nerve in humeral shaft fractures with radial nerve palsy. Arch Orthop Trauma Surg 2021; 141:1189-1195. [PMID: 32852594 DOI: 10.1007/s00402-020-03580-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 08/16/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jin-Hyung Im
- Department of Orthopaedic Surgery, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro Seongsan-gu, Changwon, 51472, Republic of Korea
| | - Dong Kyu Moon
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Ji-Yong Gwark
- Department of Orthopaedic Surgery, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro Seongsan-gu, Changwon, 51472, Republic of Korea
| | - Hyung Bin Park
- Department of Orthopaedic Surgery, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro Seongsan-gu, Changwon, 51472, Republic of Korea. .,Institute of Health Science and School of Medicine, Gyeongsang National University, Jinju, Republic of Korea.
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Hegeman EM, Polmear M, Scanaliato JP, Nesti L, Dunn JC. Incidence and Management of Radial Nerve Palsies in Humeral Shaft Fractures: A Systematic Review. Cureus 2020; 12:e11490. [PMID: 33335819 PMCID: PMC7736027 DOI: 10.7759/cureus.11490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Erik M Hegeman
- Orthopaedic Surgery, Brooke Army Medical Center, San Antonio, USA
| | - Michael Polmear
- Orthopaedics, William Beaumont Army Medical Center, El Paso, USA
| | - John P Scanaliato
- Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, USA
| | - Leon Nesti
- Orthopaedic Surgery, Uniformed Services University of the Health Sciences, Bethesda, USA
| | - John C Dunn
- Orthopaedic Hand Surgery, William Beaumont Army Medical Center, El Paso, USA
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Bertelli JA, Nehete S, Winkelmann Duarte EC, Ghizoni MF. Transfer of the Distal Anterior Interosseous Nerve for Thumb Motion Reconstruction in Radial Nerve Paralysis. J Hand Surg Am 2020; 45:877.e1-877.e10. [PMID: 32209268 DOI: 10.1016/j.jhsa.2020.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 12/30/2019] [Accepted: 02/11/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE With nerve or tendon surgery, the results of thumb reconstruction to treat radial nerve paralysis are suboptimal. The goals of this study were to describe the anatomy of the deep branch of the posterior interosseous nerve (PIN) to the thumb extensor muscles (DBPIN), and to report the clinical results of transferring the distal anterior interosseous nerve (DAIN) to the DBPIN. METHODS The PIN was dissected in 12 fresh upper limbs. Myelinated nerve fibers in the DBPIN and DAIN were counted. Five patients with radial nerve paralysis underwent transfer of the motor branch to the flexor carpi radialis to the PIN and a motor branch of the pronator teres to the extensor carpi radialis brevis. In addition, these patients had selective reconstruction of thumb motion by transferring the DAIN to the DBPIN, through either a combined volar and dorsal approach (n = 2) or a single dorsal approach (n = 3) with division of the interosseous membrane. RESULTS At the origin of the abductor pollicis longus, the DBPIN divided into a lateral branch that innervated the abductor pollicis longus and extensor pollicis brevis, and a medial branch that innervated the extensor pollicis longus and extensor index proprius. The number of myelinated nerve fibers in the DAIN corresponded to 65% of that of the DBPIN. In each of the 5 patients, full thumb motion at the trapeziometacarpal joint was restored with no, or minimal, extension lag at the metacarpophalangeal (MCP) joint. CONCLUSIONS The anatomy of the DBPIN is predictable. Transferring the DAIN to the DBPIN is feasible through a single dorsal approach, allowing full recovery of thumb motion. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Jayme Augusto Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil.
| | - Sushil Nehete
- Wockhardt Hospital, The Umrao IMSR, Thane, Maharashtra, India
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Sadek AF, Ahmed MA, Kader MA, El-Shafie MBE. Lateral condylar retrograde humeral nail for management of high-energy distal humeral fractures. J Orthop Surg (Hong Kong) 2020; 27:2309499019847922. [PMID: 31104585 DOI: 10.1177/2309499019847922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Distal metaphyseo-diaphyseal humeral fractures are challenging particularly if open, comminuted, or associated with nerve injury. In cases of open distal complex metaphyseo-diaphyseal humeral fractures inamenable for traditional methods of fixation, retrograde intramedullary locked humeral nail with a new lateral condylar point of entry has been proposed. METHODS Two phases of study were conducted; phase I comprised computerized tomography evaluation of right humeri of 120 adult subjects, while phase II entailed prospective analysis of 18 patients who sustained firearm injuries resulting in open distal metaphyseo-diaphyseal humeral fractures associated with radial nerve injuries. All patients were surgically managed using lateral condylar retrograde humeral nailing with primary radial nerve exploration. RESULTS Distal sagittal medullary diameter of the humeral medulla was the narrowest in comparison to axial and coronal medullary diameters in phase II, which matched the results of phase I. The mean postoperative disability of the arm, shoulder, and hand score was 11.2 ± 6.4. Only five patients underwent subsequent successful tendon transfer. CONCLUSIONS Lateral condylar retrograde humeral nail with early radial nerve exploration in cases of high-energy distal metaphyseo-diaphyseal humeral fractures yielded good results regarding union and spontaneous radial nerve recovery or later on reconstruction.
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Affiliation(s)
- Ahmed Fathy Sadek
- 1 Department of Orthopaedic Surgery, Minia University Hospital, Minia, Egypt
| | - Mohamed Atef Ahmed
- 1 Department of Orthopaedic Surgery, Minia University Hospital, Minia, Egypt
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Radial Nerve Palsy Recovery With Fractures of the Humerus: An Updated Systematic Review. J Am Acad Orthop Surg 2020; 28:e263-e269. [PMID: 31714418 DOI: 10.5435/jaaos-d-18-00142] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
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.
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Dolan RT, Giele HP. Radial nerve palsies associated with paediatric supracondylar humeral fractures: a caution in the interpretation of neurophysiological studies. J Pediatr Orthop B 2020; 29:126-132. [PMID: 31567895 DOI: 10.1097/bpb.0000000000000680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Traumatic and iatrogenic neurological complications associated with paediatric supracondylar humeral fractures are well recognised. The severity of the nerve injury associated with supracondylar humeral fractures can be difficult to assess clinically and relies upon clinical progression or absence of recovery and neurophysiology. It is accepted that complete nerve palsy with neurophysiological complete block and absence of clinical recovery after three months requires surgical exploration and reconstruction. However, we argue that even a partial nerve palsy that is failing to recover as expected by 3 months should be explored even when the neurophysiology suggests the nerve is in continuity. We report two cases of closed Gartland type III paediatric extension-type supracondylar humeral fractures treated with closed reduction and percutaneous pinning and open reduction and internal fixation, respectively. Both children developed persistent postoperative radial nerve motor palsy. Neurophysiological studies sought prior to exploration indicated a degree of sensory nerve function in both cases, indicating a nerve in continuity. Subsequent surgical exploration revealed interfragmentary radial nerve compression at the fracture site at two levels in one case and at one level in the second case. The site of compression was excised and the nerve grafted. Excellent near-normal radial nerve recovery was achieved except for the persistent loss of extensor carpi radialis function in the first child. We publish these findings to highlight the possibility of misinterpreting the incomplete nerve lesion and the neurophysiology of a nerve in continuity, as a nerve that would spontaneously recover. At exploration, in these two cases, it was clear by the level of interfragmentary compression that the nerve would not have recovered without surgical intervention. We recommend exploration and repair of the radial nerve, when function to the nerve is compromised, even in the face of neurophysiological evidence of an intact nerve.
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Affiliation(s)
- Roisin T Dolan
- Department of Plastic, Reconstructive and Hand Surgery, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, UK
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Fractures of the Humeral Shaft with Primary Radial Nerve Palsy: Do Injury Mechanism, Fracture Type, or Treatment Influence Nerve Recovery? J Clin Med 2019; 8:jcm8111969. [PMID: 31739459 PMCID: PMC6912221 DOI: 10.3390/jcm8111969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/06/2019] [Accepted: 11/10/2019] [Indexed: 01/10/2023] Open
Abstract
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.
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Giordano V, Belangero W, Pires RE, Labronici PJ. Humerus shaft fracture associated with traumatic radial nerve palsy: An international survey among orthopedic trauma surgeons from Latin America and Asia/Pacific. J Orthop Surg (Hong Kong) 2018; 25:2309499017727914. [PMID: 28847240 DOI: 10.1177/2309499017727914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The purpose of this article is to explore the real-life practice of clinical management of humeral shaft fracture associated with traumatic radial nerve palsy among orthopedic trauma surgeons. METHODS Two hundred seventy-nine orthopedic surgeons worldwide reviewed 10 real cases of a humeral shaft fracture associated with traumatic radial nerve palsy answering two questions: (1) What treatment would you choose/recommend: nonoperative or operative? (2) What are the reasons for your decision-making? The survey was developed in an online survey tool. All participants were active members from AOTrauma International. RESULTS Two hundred sixty-six (95.3%) participants were from Latin America and Asia/Pacific. One hundred sixty-two participants (58.1%) had more than 10 years in practice and 178 (63.8%) of them did trauma as the main area of interest. One hundred fifty-one (54.1%) participants treated less than three humeral shaft fractures a month. Traumatic radial nerve palsy was the main reason (88.4%) for surgeons to recommend surgical treatment. Open reduction and internal fixation (ORIF) or percutaneous fixation of the fracture associated with acutely explore of radial nerve was the first option in 62.0% of the cases. A combination of morphology and level of the fracture and the presence of the radial nerve palsy was the most suggested reason to surgically treat the humerus fracture. The main isolated factor was the morphology of the fracture. CONCLUSION Our survey highlight the tendency for a more aggressive management of any humeral shaft fracture associated with a traumatic radial nerve palsy, with surgeons preferring to use ORIF with acute exploration of the radial nerve. Nonsurgical management was the less chosen option among the 279 respondents. Fracture morphology, level of the fracture, and the presence of the radial nerve palsy were most influential for guiding their treatment.
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Affiliation(s)
- Vincenzo Giordano
- 1 Serviço de Ortopedia e Traumatologia Professor Nova Monteiro, Hospital Municipal Miguel Couto, Gávea Rio de Janeiro, Brazil
| | - William Belangero
- 2 Departamento de Ortopedia e Traumatologia, Universidade Estadual de Campinas, Campinas, Brazil
| | - Robinson Esteves Pires
- 3 Departamento de Ortopedia e Traumatologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Pedro José Labronici
- 4 Departamento de Ortopedia e Traumatologia, Universidade Federal Fluminense, Niteroi, Brazil
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Keighley G, Hermans D, Lawton V, Duckworth D. Radial nerve palsy in mid/distal humeral fractures: is early exploration effective? ANZ J Surg 2017; 88:228-231. [PMID: 29266635 DOI: 10.1111/ans.14259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 08/27/2017] [Accepted: 09/05/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Radial nerve palsies are a common complication with displaced distal humeral fractures. This case series examines the outcomes of early operative exploration and decompression of the nerve with fracture fixation with the view that this provides a solid construct for optimisation of nerve recovery. METHODS A total of 10 consecutive patients with a displaced distal humeral fracture and an acute radial nerve palsy were treated by the senior author by open reduction and internal fixation of the distal humerus and exploration and decompression of the radial nerve. Motor function and sensation of the radial nerve was assessed in the post-operative period every 2 months or until full recovery of the radial nerve function had occurred. RESULTS All patients (100%) had recovery of motor and sensation function of their upper limb in the radial nerve distribution over a 12-month period. Recovery times ranged between 4 and 32 weeks, with the median time to recovery occurring at 26 weeks and the average time to full recovery being 22.9 weeks. Wrist extension recovered by an average of 3 months (range 2-26 weeks) and then finger extension started to recover 2-6 weeks after this. Disability of the arm, shoulder and hand scores ranged from 0 to 11.8 at greater than 1 year post-operatively. DISCUSSION Our study demonstrated that early operative exploration of the radial nerve when performing an open stabilization of displaced distal humeral fractures resulted in a 100% recovery of the radial nerve.
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Affiliation(s)
- Geffrey Keighley
- Orthopaedic Department, Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia
| | - Deborah Hermans
- Orthopaedic Department, Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Vidya Lawton
- Orthopaedic Department, Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - David Duckworth
- Orthopaedic Department, Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia.,Orthopaedic Department, Sydney Adventist Hospital, Sydney, New South Wales, Australia
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Theeuwes HP, van der Ende B, Potters JW, Kerver AJ, Bessems JHJM, Kleinrensink GJ. The course of the radial nerve in the distal humerus: A novel, anatomy based, radiographic assessment. PLoS One 2017; 12:e0186890. [PMID: 29073240 PMCID: PMC5658097 DOI: 10.1371/journal.pone.0186890] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 10/09/2017] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- H. P. Theeuwes
- Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Surgery, VieCuri Medical Center, Tegelseweg BL Venlo, The Netherlands
- * E-mail:
| | - B. van der Ende
- Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Orthopedic Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg AD Delft, The Netherlands
| | - J. W. Potters
- Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - A. J. Kerver
- Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg PM, Rotterdam, The Netherlands
| | - J. H. J. M. Bessems
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - G-J. Kleinrensink
- Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Nachef N, Bariatinsky V, Sulimovic S, Fontaine C, Chantelot C. Predictors of radial nerve palsy recovery in humeral shaft fractures: A retrospective review of 17 patients. Orthop Traumatol Surg Res 2017; 103:177-182. [PMID: 28065869 DOI: 10.1016/j.otsr.2016.10.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/12/2016] [Accepted: 10/20/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Radial nerve injury is common in humeral shaft fractures and fails to recover spontaneously in 30% of cases. Few studies have evaluated predictors of recovery. The objectives of this study were to identify predictors of radial nerve palsy recovery and to assess the usefulness of surgical radial nerve exploration in patients with preoperative radial nerve palsy. HYPOTHESIS Factors predicting the outcome of radial nerve palsy can be identified. METHODS Of 373 patients with humeral shaft fractures between 2005 and 2012, 43 had radial nerve palsy, including 23 who were lost to follow-up and 17 who were evaluated retrospectively at a mean of 26 months (range, 12-84 months) after internal fixation. The following were studied: age, smoking history, energy of the trauma, fracture type and displacement, skin integrity and intra-operative appearance of the radial nerve. RESULTS Of the 17 palsies, 13 were present preoperatively, including 10 that recovered (PreR group) and 3 that did not recover (PreNR group). Plate fixation and radial nerve exploration were performed in all patients. Of the 10 PreR patients, 6 had nerve contusion and 2-nerve entrapment. Of the 3 PreNR patients, 2 had gross nerve damage and 1 nerve contusion and a history of spinal muscular atrophy. Only age and presence of gross nerve damage differed significantly between the PreR and PreNR groups; trends towards significant differences were noted for skin breach and fracture displacement. Of the 4 postoperative radial nerve palsies, 2 recovered fully and 2 partially; mean age was higher in the 2 patients with partial recovery. DISCUSSION These findings are consistent with the few previous studies of outcome predictors in radial nerve palsy. Factors such as major fracture displacement and high-grade skin wounds probably promote the occurrence of gross nerve lesions. The high incidence of nerve entrapment and stretching supports routine nerve exploration during internal fixation in patients with preoperative radial nerve palsy. LEVEL OF EVIDENCE IV, retrospective study with no control group.
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Affiliation(s)
- N Nachef
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service d'orthopédie B, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France.
| | - V Bariatinsky
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service d'orthopédie B, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France
| | - S Sulimovic
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France
| | - C Fontaine
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service d'orthopédie B, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Laboratoire d'anatomie, faculté de médecine Henri-Warembourg, université de Lille 2, 59045 Lille cedex, France
| | - C Chantelot
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service d'orthopédie B, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France
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Yu BF, Liu LL, Yang GJ, Zhang L, Lin XP. Comparison of minimally invasive plate osteosynthesis and conventional plate osteosynthesis for humeral shaft fracture: A meta-analysis. Medicine (Baltimore) 2016; 95:e4955. [PMID: 27684839 PMCID: PMC5265932 DOI: 10.1097/md.0000000000004955] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The objective of this meta-analysis was to compare the efficacy and safety of minimally invasive plate osteosynthesis (MIPO) and conventional plate osteosynthesis (CPO) for humeral shaft fracture. METHODS Potential academic articles were identified from the Cochrane Library, Medline (1966-2016.3), PubMed (1966-2016.3), Embase (1980-2016.3), and ScienceDirect (1966-2016.3). Gray studies were identified from the references of the included literature. Randomized controlled trials (RCTs) and non-RCT involving MIPO and CPO for humeral shaft fracture were included. Two independent reviewers performed independent data abstraction. I statistic was used to assess heterogeneity. Fixed or random effects model was used for meta-analysis. RESULTS Two RCTs and 3 non-RCTs met the inclusion criteria. There was a lower incidence of iatrogenic radial nerve palsy in patients with MIPO (P = 0.006). There was no statistically significant difference in in the risk of developing nonunion, delay union, malformation, screw loosening, infection, operation time, UCLA, and MEPS function score between the 2 groups. CONCLUSION MIPO decreased incidence of iatrogenic radial nerve palsy and is an efficacy and safety technique for humeral shaft fracture. Due to the limited quality and data of the evidence currently available, more high-quality RCTs are required.
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Affiliation(s)
| | | | - Guo-jing Yang
- Department of Orthopedics, The Third Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang Province, People's Republic of China
- Correspondence: Guo-jing Yang, Department of Orthopedics, The Third Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang Province 325200, People's Republic of China (e-mail: )
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Lang NW, Ostermann RC, Arthold C, Joestl J, Platzer P. Retrospective case series with one year follow-up after radial nerve palsy associated with humeral fractures. INTERNATIONAL ORTHOPAEDICS 2016; 41:191-196. [DOI: 10.1007/s00264-016-3186-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/27/2016] [Indexed: 12/13/2022]
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Pieber K, Herceg M, Paternostro-Sluga T, Schuhfried O. Optimizing stimulation parameters in functional electrical stimulation of denervated muscles: a cross-sectional study. J Neuroeng Rehabil 2015; 12:51. [PMID: 26048812 PMCID: PMC4458019 DOI: 10.1186/s12984-015-0046-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 06/02/2015] [Indexed: 01/05/2023] Open
Abstract
Background To counteract denervation atrophy long-term electrical stimulation with a high number of muscle contractions has to be applied. This may lead to discomfort of the patient and negative side effects like burns. A functional effective muscle contraction induced by the lowest possible stimulation intensity is desirable. In clinical practice a selective stimulation of denervated muscles with triangular pulses is used. The aim of the study was to evaluate the influence of polarity and pulse duration on the stimulation intensity of triangular pulses in denervated muscles in patients with peripheral nerve lesions. Methods Twenty-four patients with denervated extensor digitorum communis muscle and twenty-four patients with denervated tibialis anterior muscle due to peripheral nerve lesions were included. Four different combinations of triangular pulses with various duration and polarity were delivered randomly to the denervated muscles. The threshold intensity to induce a functional effective muscle contraction was noted. One-way within subject ANOVA was used to assess changes in intensity. An alpha level of p less than or equal to 0.05 was the criterion for statistical significance. Results Patients with a denervated tibialis anterior muscle presented significant lower intensities inducing a functional effective muscle contraction in favor of the stimulation with a duration of 200 ms and a polarity with the cathode proximally applied. No significant differences could be shown between the different stimulation protocols in case of denervated extensor digitorum communis muscle. Conclusions We recommend electrical stimulation of the denervated tibialis anterior muscle with triangular current with a duration of 200 ms and a polarity with the cathode proximally applied.
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Affiliation(s)
- Karin Pieber
- Department of Physical Medicine and Rehabilitation, Medical University of Vienna, General Hospital of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Malvina Herceg
- Department of Physical Medicine and Rehabilitation, Medical University of Vienna, General Hospital of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | | | - Othmar Schuhfried
- Department of Physical Medicine and Rehabilitation, Medical University of Vienna, General Hospital of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Plate osteosynthesis of humeral diaphyseal fractures associated with radial palsy: twenty cases. INTERNATIONAL ORTHOPAEDICS 2015; 39:1653-7. [PMID: 25813460 DOI: 10.1007/s00264-015-2745-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 03/07/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND Surgical management of humeral fractures associated with radial nerve palsy remains controversial. Some advocate surgical treatment in emergency while others recommend nonoperative treatment. PURPOSE The aim of the study was to assess nerve recovery in a series of patients treated with open reduction and internal fixation (ORIF) with plate for humeral fracture associated with radial nerve palsy. We hypothesised that surgical treatment with ORIF in emergency allows good nerve recovery. METHODS We conducted a retrospective study on 20 patients out of 225 humeral shaft fractures operated between 1995 and 2012. There were 11 women and nine men, with a mean age of 51 ± 22 years (23-93). The fractures were located in mid third of the shaft in 15 cases (75 %), distal third in four (20 %) and superior third in one (5 %). Mean delay for surgical treatment was three days (zero to 15). The plate was positioned at the medial face in 16 cases (80 %) and posterior face in four (20 %). In six cases, the radial nerve was not seen (30 %). In the 14 cases where it was seen (70 %), it was continuous. Neurolysis was performed in seven cases (35 %). RESULTS Fifteen patients (75 %) had a good nerve palsy recovery, with a mean delay of ten months (six to 12). Statistically significant correlation was observed between delay of surgical treatment and delay of radial recovery (p = 0.0166 ; Rho = - 0.53). Early osteosynthesis was correlated with better nerve recovery. One patient required complementary nerve surgery and another tendon transfer. Bone healing was obtained in all cases. Concerning functional outcomes, mean QuickDASH, a shortened version of the Disabilities of the Arm, Shoulder and Hand (DASH) score, was 9 ± 17 (0-59), and 85 % of patients were able to recover their previous physical activities. CONCLUSION ORIF by plate of humeral shaft fracture with radial nerve palsy in emergency allows good palsy recovery (75 %) with a short delay (about three days). LEVEL OF EVIDENCE Level IV, retrospective study.
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Ricci FPFM, Barbosa RI, Elui VMC, Barbieri CH, Mazzer N, Fonseca MDCR. Radial nerve injury associated with humeral shaft fracture: a retrospective study. ACTA ORTOPEDICA BRASILEIRA 2015; 23:19-21. [PMID: 26327789 PMCID: PMC4544514 DOI: 10.1590/1413-78522015230100823] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 12/06/2013] [Indexed: 01/10/2023]
Abstract
Objective: To determine the profile of patients with humeral diaphyseal fractures in a tertiary hospital. Methods: We conducted a survey from January 2010 to July 2012, including data from patients classified under humeral diaphyseal fracture (S42.3) according to the International Classification of Diseases (ICD-10). The variables analyzed were: age, gender, presence of radial nerve injury, causal agent and the type of treatment carried out. Results: The main causes of trauma were car accidents. The radial nerve lesion was present in some cases and was caused by the same trauma that caused the fracture or iatrogenic injury. Most of these fractures occurred in the middle third of humeral diaphysis and was treated conservatively. Conclusion: The profile of patients with fracture of humeral shaft, in this specific sample, was composed mainly of adult men involved in traffic accidents; the associated radial nerve lesion was present in most of these fractures and its cause was strongly related to the trauma mechanism. Level of Evidence II, Retrospective Study.
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Ebrahimpour A, Nazerani S, Tavakoli Darestani R, Khani S. Spontaneous radial nerve palsy subsequent to non-traumatic neuroma. Trauma Mon 2013; 18:98-100. [PMID: 24350162 PMCID: PMC3860672 DOI: 10.5812/traumamon.9851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 05/04/2013] [Accepted: 05/27/2013] [Indexed: 12/14/2022] Open
Abstract
Introduction Spontaneous radial palsy is a not rare finding in hand clinics. The anatomy of the radial nerve renders it prone to pressure paralysis as often called “Saturday night palsy”. This problem is a transient nerve lesion and an acute one but the case presented here is very unusual in that it seems this entity can also occur as an acute on chronic situation with neuroma formation. Case Presentation A 61 year-old man presented with the chief complaint of inability to extend the wrist and the fingers of the left hand which began suddenly the night before admission, following a three-week history of pain, numbness and tingling sensation of the affected extremity. He had no history of trauma to the extremity. Electromyography revealed a severe conductive defect of the left radial nerve with significant axonal loss at the upper arm. Surgical exploration identified a neuroma of the radial nerve measuring 1.5 cm in length as the cause of the paralysis. The neuroma was removed and an end-to-end nerve coaption was performed. Conclusions Complete recovery of the hand and finger extension was achieved in nine months.
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Affiliation(s)
- Adel Ebrahimpour
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | | | - Reza Tavakoli Darestani
- Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Reza Tavakoli Darestani, Imam Hossein Hospital, Shahid Madani St., Tehran, IR Iran. Tel.: +98-2188306564, Fax: +98-2122569149, E-mail:
| | - Salim Khani
- Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
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Review of literature of radial nerve injuries associated with humeral fractures-an integrated management strategy. PLoS One 2013; 8:e78576. [PMID: 24250799 PMCID: PMC3826746 DOI: 10.1371/journal.pone.0078576] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 09/16/2013] [Indexed: 01/04/2023] Open
Abstract
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.
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Prodromo J, Goitz RJ. Management of radial nerve palsy associated with humerus fracture. J Hand Surg Am 2013; 38:995-8; quiz 998. [PMID: 23561727 DOI: 10.1016/j.jhsa.2013.02.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 02/03/2013] [Indexed: 02/06/2023]
Affiliation(s)
- John Prodromo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical School, Pittsburgh, PA, USA
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Lee HJ, Oh CW, Oh JK, Apivatthakakul T, Kim JW, Yoon JP, Lee DJ, Jung JW. Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator. Arch Orthop Trauma Surg 2013; 133:649-57. [PMID: 23463256 DOI: 10.1007/s00402-013-1708-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND Minimally invasive plate osteosynthesis (MIPO) has become a popular option for treatment of humeral shaft fractures. However, indirect reduction might risk unpromising results, with mal-alignment/mal-union or nonunion. The purpose of this study was to describe a reproducible MIPO technique that used an external fixator during the procedure as a tool for reduction and maintenance, and to assess the outcomes in patients with humeral shaft fracture. METHODS Of 31 consecutive cases of humeral shaft fracture in 30 patients, 29 were included in this study. There were seven simple (type A) and 22 comminuted (type B or C) fractures. After the insertion of one Schanz pin on each proximal and distal humerus, a provisional reduction was achieved by connecting the pins with a monolateral external fixator. The MIPO procedure was then performed over the anterior aspect of the humerus. To evaluate the efficacy of the provisional reduction by external fixator, coronal and sagittal alignments were assessed. We also assessed bony and functional results, including complications, from this technique. RESULTS There was no case of mal-union >10°, and mean angulation was 1.3° (range 0°-9°) in the coronal plane and 1.2° (range 0°-8°) in the sagittal plane. Twenty-eight of 29 fractures were united, including three delayed unions, with a mean union time of 19.1 weeks (range 12.3-38.4 weeks) and a mean follow-up of 20.8 months (range 13.5-31.0 months). There was one hypertrophic nonunion that healed after fixing with two additional screws. Except one patient with associated injury in the elbow, all patients recovered to pre-injury joint motion. There were two cases of postoperative radial nerve palsy that both recovered completely. We attributed them to manipulation, and not to the Schanz pins or plate fixation. CONCLUSIONS Surgical treatment of humeral shaft fractures with external fixator-assisted reduction and MIPO resulted in excellent reductions and high union rates.
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Affiliation(s)
- Hyun-Joo Lee
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, Korea
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Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Vekris MD, Soucacos PN, Beris AE. Approach to radial nerve palsy caused by humerus shaft fracture: is primary exploration necessary? Injury 2013; 44:323-6. [PMID: 23352153 DOI: 10.1016/j.injury.2013.01.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION While recommendations for early exploration and nerve repair in cases of open fractures of the humeral shaft associated with radial nerve palsy are clear, the therapeutic algorithm for the management of closed humeral shaft fractures complicated by radial nerve palsy is still uncertain. The purpose of this study was to determine whether patients with complete sensory and motor radial nerve palsy following a closed fracture of the humeral shaft should be surgically explored. PATIENTS AND METHODS Twenty-five patients with closed humeral shaft fractures complicated by complete radial nerve palsy were retrospectively reviewed during a 12-year period. Surgical intervention was indicated if functional recovery of the radial nerve was not present after 16 weeks of expectant management. RESULTS Surgical exploration was performed in 12 patients (48%) after a mean period of expectant management of 16.8 weeks (range: 16-18 weeks). In 2 of them (10%) total nerve transection was found. In the rest 10 patients underwent surgical exploration the radial nerve was found to be macroscopically intact. All intact nerves were fully recovered after a mean time of 21.6 weeks (range: 20-24 weeks) post-injury. In 13 patients (52%) in whom surgical exploration was not performed the mean time to full nerve recovery was 12 weeks (range: 7-14 weeks) post-injury. CONCLUSIONS We proposed immediate exploration of the radial nerve in case of open fractures of the humeral shaft, irreducible fractures or unacceptable reduction, associated vascular injuries, radial nerve palsy after manipulation or intractable neurogenic pain. Due to high rate of spontaneous recovery of the radial nerve after closed humeral shaft fractures we recommend 16-18 weeks of expectant management followed by surgical intervention.
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Affiliation(s)
- Anastasios V Korompilias
- Department of Orthopaedic Surgery, University of Ioannina School of Medicine, Ioannina, PC 45110, Greece.
| | - Marios G Lykissas
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY 10021, USA
| | - Ioannis P Kostas-Agnantis
- Department of Orthopaedic Surgery, University of Ioannina School of Medicine, Ioannina, PC 45110, Greece
| | - Marios D Vekris
- Department of Orthopaedic Surgery, University of Ioannina School of Medicine, Ioannina, PC 45110, Greece
| | - Panayiotis N Soucacos
- Center for Orthopaedic Research and Education, University of Athens, School of Medicine, 1 Rimini Street, 12462 Chaidari, Athens, Greece
| | - Alexandros E Beris
- Department of Orthopaedic Surgery, University of Ioannina School of Medicine, Ioannina, PC 45110, Greece
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Suganuma S, Tada K, Hayashi H, Segawa T, Tsuchiya H. Ulnar nerve palsy associated with closed midshaft forearm fractures. Orthopedics 2012; 35:e1680-3. [PMID: 23127466 DOI: 10.3928/01477447-20121023-33] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ulnar nerve palsy is a rare complication of closed midshaft forearm fractures; only 8 cases have been reported. This article describes a case of ulnar nerve palsy associated with a midshaft forearm fracture. A 12-year-old girl sustained a right midshaft forearm fracture. Whether she had a peripheral nerve injury was unknown due to strong pain. She underwent emergency manual reduction and intramedullary pinning. However, ulnar nerve palsy was remarkable postoperatively and gradually worsened. Therefore, neurolysis was performed 9 weeks later. The nerve had adhered to surrounding scar tissue. Six months after a second surgery, she had no motor dysfunction. The pathogenesis of ulnar nerve palsy complicated with midshaft forearm fractures varies and may be the result of direct contusion, direct damage by a bony spike, bony entrapment after closed reduction, and entrapment by a scar. In the current case, the patient was uncooperative at initial examination. Therefore, it is unknown whether she presented with immediate ulnar nerve palsy after the fracture. However, the ulnar nerve was not entrapped at the fracture site, and the surrounding muscle was intact but adhered to the surrounding scar tissue. The etiology of this case was considered to be entrapment by scar formation. According to a literature search, the authors recommend exploring the nerve approximately 8 to 10 weeks after primary surgery, after which neurological symptoms do not tend to improve.
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Affiliation(s)
- Seigo Suganuma
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.
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