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Movassaghi K, Locker P, Kunze KN, Khoo KM, Hoekzema N. Predictors of Adverse Events in the Surgical Treatment of Adult Distal Humerus Fractures. Orthopedics 2023; 46:352-357. [PMID: 37018621 DOI: 10.3928/01477447-20230329-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
The purpose of this study was to identify surgical complications after distal humerus fracture fixation as well as correlations between these complications and patient variables. A total of 132 patients underwent open reduction and internal fixation of traumatic distal humerus fractures between October 2011 and June 2018. Included were adult patients who underwent surgical fixation and had more than 6 months of follow-up. Excluded were patients with inadequate radiographic imaging, less than 6 months of follow-up, and previous distal humerus surgery. Multivariate logistic regression models controlling for age and body mass index were used to determine preoperative factors predictive of postoperative complications. A total of 73 patients were included in this analysis. Surgical complications were reported for 17 patients. Reoperation was required for 13 patients. Open injury at presentation was predictive of delayed union. Predictors of subsequent elbow surgery included younger age, polytrauma, open fracture, and ulnar nerve injury at the time of injury. Radial nerve injury at the time of presentation was also a risk factor for postoperative radial nerve symptoms. Predictors of postoperative heterotopic ossification included older age. Thirty-one patients had an olecranon osteotomy during their open reduction and internal fixation and none went on to nonunion. There were 13 patients with ulnar nerve complications. Of these patients, 3 had undergone an ulnar nerve transposition. None of the other studied variables were predictors of complications, malunion, or nonunion at latest follow-up. Although open reduction and internal fixation is effective in treating distal humerus fractures, its complications cannot be overlooked. Open fractures are more likely to go on to delayed union. Ulnar nerve injury, open fracture, and polytrauma were predictive for reoperation. Older patients were less likely to have subsequent surgery but more likely to develop heterotopic ossification. By identifying at-risk patients, managing physicians can better prognosticate and counsel patients on their recovery. [Orthopedics. 2023;46(6):352-357.].
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Ajwani SH, Singh J, Ng CY. A review of 100 iatrogenic nerve injuries: delays in referrals remain significant. Ann R Coll Surg Engl 2023; 105:390-393. [PMID: 35175099 PMCID: PMC10149243 DOI: 10.1308/rcsann.2021.0300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This is a retrospective study of 100 consecutive patients with iatrogenic nerve injuries, as seen in a tertiary referral centre over a six-year period. MATERIALS AND METHODS Patients who presented with new-onset nerve palsy involving a motor or mixed motor/sensory nerve following an operation were studied. RESULTS There were 44 male and 56 female patients with a mean age of 53 years (range 5-87 years). The median duration from the index procedures to referral was six months (range 0 days to 12 years). Approximately one third of referrals were made over 12 months since the index procedures. Twenty patients recovered spontaneously and were managed expectantly. Eighty patients underwent secondary interventions. DISCUSSION There remains a significant delay in referring postoperative nerve palsy to a nerve specialist. The majority of these cases will warrant secondary reconstructive surgery and delay in treatment may have a negative effect on the ultimate outcomes.
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Affiliation(s)
| | - J Singh
- Wrightington Hospital, Wigan, UK
| | - CY Ng
- Wrightington Hospital, Wigan, UK
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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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Cho E, Taylor A, Olson JJ, Entezari V, Vallier HA. Complications Are Infrequent After Humeral Shaft Fractures Due to Low-Energy Gunshot Injuries. J Orthop Trauma 2023; 37:149-153. [PMID: 36150061 DOI: 10.1097/bot.0000000000002491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe humerus shaft fractures after low-energy gunshot wound (GSW) and compare with blunt injuries. We hypothesized that nerve injury, infection, and fracture union would be similar. DESIGN Retrospective. SETTING Urban Level 1 trauma center. PATIENTS/PARTICIPANTS Four hundred three patients were treated for a humeral shaft fracture over 18 years. Sixty-two patients sustained injury due to GSW. INTERVENTION Primary open reduction and internal fixation was pursued in 59%, including 32% after GSW. MAIN OUTCOME MEASUREMENTS Rates of nerve injury, infection, and fracture union. RESULTS Patients with GSW were younger with a mean age of 30 years, more likely male (90%), with isolated injuries (84%), and less likely to have simple fractures (84%). Both groups experienced high rates of union (98% of GSW fractures vs. 99% of closed high-energy fractures). Deep infection occurred in 1 patient (1.6%) after GSW. Rates of deep infection in the closed and open blunt trauma fracture groups were similarly low at 1% and 4.5%, respectively. Nerve injury on presentation after GSW was more common than after low-energy and high-energy closed fractures (47% vs. 13% and 27%), but similar to blunt open fracture (52%). Despite higher rates of nerve injury, nerve recovery occurred at similarly high rates after both GSW and blunt injuries (78% vs. 86%). CONCLUSIONS Nerve injuries are more common after GSW, but most recover without intervention. Infection is uncommon after GSW, and secondary unplanned operations are rare. Initial nonoperative care of most GSW humerus fractures, even with radial nerve injury at the time of presentation, seems appropriate. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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MOURARIA GUILHERMEGRISI, MENDONÇA BERNARDOCOUTONUNES, DIAS ADÉLIOLIMA, ZOGBI DANIELROMANO, CRUZ MÁRCIOALVES, ETCHEBEHERE MAURÍCIO. EPIDEMIOLOGICAL STUDY OF SURGICALLY TREATED HUMERAL SHAFT FRACTURES - A 10-YEAR REVIEW. ACTA ORTOPEDICA BRASILEIRA 2022; 30:e256500. [PMID: 36561473 PMCID: PMC9757718 DOI: 10.1590/1413-785220223006e256500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/08/2021] [Indexed: 12/23/2022]
Abstract
Most epidemiological studies do not exclusively address fractures treated surgically but include those with conservative treatment. In Brazil, few epidemiological studies address fractures prevalence undergoing surgical treatment. Objective To assess the prevalence, demographics, and associated injuries of surgically treated humeral shaft fractures. Methods A retrospective study between 2009 and 2019 with patients undergoing osteosynthesis of humeral shaft fracture. Categorical variables were assessed using Fisher's chi-square or exact test, and non-categorical variables were assessed using the unpaired t-test. A significance level of 5% was adopted. Results A total of 115 patients were evaluated. Mean age was 37.9 ± 15.6 years, with a male predominance (66.9%) due to car accidents. The most prevalent fracture type was 12 A3. Open fracture prevalence was 11.3%. Radial nerve damage prevalence was 33% and low-energy trauma was twice as likely. Conclusion Surgically treated humeral shaft fractures were more prevalent in men, young, and related to high-energy trauma, with a transverse line pattern. Fractures secondary to low-energy trauma had a greater association with radial nerve injury. Level of Evidence III, Epidemiological, Retrospective Study.
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Affiliation(s)
- GUILHERME GRISI MOURARIA
- Universidade Estadual de Campinas, School of Medical Sciences, Department of Orthopedics, Rheumatology and Traumatology, Shoulder Service Group, Campinas, SP, Brazil
| | - BERNARDO COUTO NUNES MENDONÇA
- Universidade Estadual de Campinas, School of Medical Sciences, Department of Orthopedics, Rheumatology and Traumatology, Campinas, SP, Brazil
| | - ADÉLIO LIMA DIAS
- Universidade Estadual de Campinas, School of Medical Sciences, Department of Orthopedics, Rheumatology and Traumatology, Campinas, SP, Brazil
| | - DANIEL ROMANO ZOGBI
- Universidade Estadual de Campinas, Hospital Estadual de Sumaré, Sumaré, SP, Brazil
| | - MÁRCIO ALVES CRUZ
- Universidade Estadual de Campinas, School of Medical Sciences, Graduate Course in Surgical Sciences, Campinas, SP, Brazil
| | - MAURÍCIO ETCHEBEHERE
- Universidade Estadual de Campinas, School of Medical Sciences, Department of Orthopedics, Rheumatology and Traumatology, Campinas, SP, Brazil
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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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Abstract
Radial nerve injury with humeral shaft fracture is common. Treatment options include expectant management, early exploration and repair, delayed reconstruction, nerve transfers, and tendon transfers. Knowledge of the appropriate application of these treatments will assist orthopedic surgeons and nerve surgeons in coordinating care for these patients.
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Affiliation(s)
- Michael Daly
- Department of Orthopaedic Traumatology, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Chris Langhammer
- Department of Orthopaedic Traumatology, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA.
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Singh VK, Haq A, Tiwari M, Saxena AK. Approach to management of nerve gaps in peripheral nerve injuries. Injury 2022; 53:1308-1318. [PMID: 35105440 DOI: 10.1016/j.injury.2022.01.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023]
Abstract
Peripheral nerve injuries (PNI) are a major clinical problem. In general, PNI results from motor vehicle accidents, lacerations with sharp objects, penetrating trauma (gunshot wounds) and stretching or crushing trauma and fractures. They can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Currently, the standard surgical technique for complete nerve transection is end-to-end neurorrhaphy. Unfortunately, there is segmental loss of the nerve trunk in some cases where nerve mobilization may permit end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. But in light of limited availability and concerned donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers and end-to-side neurorrhaphy. This review intends to present an overview of the literature on the applications of these techniques in repair of peripheral nerve injuries. This article also focuses on preoperative assessment, surgical timing, available options and future perspectives.
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Affiliation(s)
- Veena K Singh
- Department of Burns & Plastic surgery, All India Institute of Medical Sciences, Patna, Bihar, India.
| | - Ansarul Haq
- Department of Burns & Plastic surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Meenakshi Tiwari
- Department of Pathology/Lab Medicine, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Ajit K Saxena
- Department of Pathology/Lab Medicine, All India Institute of Medical Sciences, Patna, Bihar, India
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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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Primary radial nerve palsy associated with humeral shaft fractures according to injury mechanism: is early exploration needed? J Shoulder Elbow Surg 2021; 30:2862-2868. [PMID: 34411723 DOI: 10.1016/j.jse.2021.07.013] [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] [Received: 03/18/2021] [Revised: 07/13/2021] [Accepted: 07/18/2021] [Indexed: 02/01/2023]
Abstract
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.
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Entezari V, Olson JJ, Vallier HA. Predictors of traumatic nerve injury and nerve recovery following humeral shaft fracture. J Shoulder Elbow Surg 2021; 30:2711-2719. [PMID: 33964428 DOI: 10.1016/j.jse.2021.04.025] [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: 10/26/2020] [Revised: 04/06/2021] [Accepted: 04/18/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Nerve palsy is common after humeral shaft fracture, with the radial nerve being the most commonly injured nerve. Isolated nerve injuries usually recover spontaneously, and operative intervention is rarely indicated. Our goal was to study the predictors of traumatic nerve injury and recovery in a large cohort of patients with humeral shaft fractures. METHODS A total of 376 patients with humeral shaft fracture, including 96 patients with documented traumatic nerve palsy and 280 with intact neurovascular examination on presentation, were retrospectively included in the study. The primary outcome was incidence of a traumatic nerve palsy, and the secondary outcome was nerve recovery. RESULTS Nerve palsy was present in 96 patients (25.5%) at the time of injury. Radial nerve was the most commonly injured nerve (93.6%), followed by the ulnar (5.1%) and axillary (1.2%) nerves. Seventeen patients (17.7%) had multiple nerves palsies. A multivariable regression analysis revealed that the concomitant vascular injury (odds ratio [OR] 52, 95% confidence interval [CI] 5.6-480.6), distal one-third fractures (OR 6.3, 95% CI 2.7-14.7), and middle one-third (OR 2.8, 95% CI 1.2-6.5) vs. proximal fractures, open fracture (OR 2.1, 95% CI 1.1-4.4), and high-energy trauma (OR 1.7, 95% CI 1.1-2.9) were independent predictors of nerve palsy. Iatrogenic nerve injury was detected in 7 patients (4.6%), all affecting the radial nerve. Spontaneous recovery of traumatic nerve injuries was detected in 87 patients (91%), with 19% partial and 72% complete recovery. The initial sign of recovery was observed at median times of 7 and 9 weeks for those managed conservatively or fracture fixation. Operative treatment of the fracture had no effect on the outcome of nerve recovery (88.5% vs. 100%, P = .14). Ten patients (14.1%) had transected nerves at the time of exploration and open fractures (22.7% vs. 6.8%, P = .04), and concomitant vascular injury (33.3% vs. 7.3%, P = .02) were associated with nerve transection, portending a worse prognosis for nerve recovery compared with nerves in continuity (40% vs. 95.3%, P = .004). DISCUSSION The incidence of nerve injury after humeral shaft fracture was 25%, reflecting an abundance of high-energy and open injuries in this cohort. Ninety-one percent of patients experienced improvement in their nerve function with a median time to recovery of 7-9 weeks. Operative treatment of the fracture did not change the rate of nerve recovery. Patients with multiple nerve palsies and concurrent vascular insult had worse nerve recovery. We recommend nerve studies if no sign of recovery is observed by 9 weeks.
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Affiliation(s)
- Vahid Entezari
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey J Olson
- Harvard Combined Orthopaedic Surgery Program, Boston, MA, USA
| | - Heather A Vallier
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA.
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Bäcker HC, Freibott CE, Swart E, Perka C, Jobin CM, Rosenwasser MP. A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial. Acta Orthop Belg 2021. [DOI: 10.52628/87.3.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness.
Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).
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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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Bertelli JA, Nehete S, Winkelmann Duarte EC, Patel N, Ghizoni MF. Distal pronator teres motor branch transfer for wrist extension restoration in radial nerve paralysis. J Neurosurg 2021; 134:251-257. [PMID: 31952044 DOI: 10.3171/2019.10.jns192110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors describe the anatomy of the motor branches of the pronator teres (PT) as it relates to transferring the nerve of the extensor carpi radialis brevis (ECRB) to restore wrist extension in patients with radial nerve paralysis. They describe their anatomical cadaveric findings and report the results of their nerve transfer technique in several patients followed for at least 24 months postoperatively. METHODS The authors dissected both upper limbs of 16 fresh cadavers. In 6 patients undergoing nerve surgery on the elbow, they dissected the branches of the median nerve and confirmed their identity by electrical stimulation. Of these 6 patients, 5 had had a radial nerve injury lasting 7-12 months, underwent transfer of the distal PT motor branch to the ECRB, and were followed for at least 24 months. RESULTS The PT was innervated by two branches: a proximal branch, arising at a distance between 0 and 40 mm distal to the medial epicondyle, responsible for PT superficial head innervation, and a distal motor branch, emerging from the anterior side of the median nerve at a distance between 25 and 60 mm distal to the medial epicondyle. The distal motor branch of the PT traveled approximately 30 mm along the anterior side of the median nerve; just before the median nerve passed between the PT heads, it bifurcated to innervate the deep head and distal part of the superficial head of the PT. In 30% of the cadaver limbs, the proximal and distal PT branches converged into a single trunk distal to the medial epicondyle, while they converged into a single branch proximal to it in 70% of the limbs. The proximal and distal motor branches of the PT and the nerve to the ECRB had an average of 646, 599, and 457 myelinated fibers, respectively.All patients recovered full range of wrist flexion-extension, grade M4 strength on the British Medical Research Council scale. Grasp strength recovery achieved almost 50% of the strength of the contralateral side. All patients could maintain their wrist in extension while performing grasp measurements. CONCLUSIONS The distal PT motor branch is suitable for reinnervation of the ECRB in radial nerve paralysis, for as long as 7-12 months postinjury.
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Affiliation(s)
- Jayme Augusto Bertelli
- 1Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão
- 2Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Sushil Nehete
- 3Department of Plastic Surgery, Wockhardt Hospital, Mumbai, Maharashtra, India
| | | | - Neehar Patel
- 5Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India
| | - Marcos Flávio Ghizoni
- 1Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão
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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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Tanaka Y, Gotani H, Maeyama M, Nishino K, Sasaki K, Yagi H. Effectiveness of ultrasonographic evaluation under general anesthesia for radial nerve palsy associated with humeral fractures during the first operation. J Ultrasound 2020; 23:327-334. [PMID: 32474854 DOI: 10.1007/s40477-020-00480-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/13/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the effectiveness of sonographic evaluation of the radial nerve at the first operation for closed humeral fracture cases. METHODS Seventeen cases of closed humeral fractures were included in this study. These cases were categorized into two groups: Group P, consisting of seven cases with complete radial nerve palsy after the injuries; and Group C, consisting of ten cases without radial nerve palsy after the injuries. Sonographic evaluation of the condition of the radial nerve was performed before or after open or closed reduction and internal fixation (ORIF or CRIF) during the first operation. RESULTS Five of seven Query ID="Q2" Text=" As keywords are mandatory for this journal, please provide 3-6 keywords." cases in Group P showed entrapment or compression of the radial nerve at fracture sites with sonography. Simultaneous radial nerve exploration (SRNE) confirmed sonographic findings in these five cases. The other two cases showed no abnormal sonographic findings except swelling of the radial nerve. CLIF without SRNE was selected and additional sonographic reevaluation of the nerve after CRIF confirmed there were no iatrogenic nerve injuries in these two cases. All of the ten cases in Group C showed no abnormal sonographic findings of the radial nerve. Five of these ten cases selected ORIF, exposed the nerve at the time of approaching the fracture site, and matched sonographic findings. The other five cases without exposure of the nerve confirmed no iatrogenic radial nerve injuries with additional sonographic reevaluation after ORIF or CRIF. All cases in Group P had complete resolution of radial nerve palsy within 4 months postoperatively, and no case in Group C had postoperative iatrogenic radial nerve palsy. CONCLUSIONS Sonographic evaluation of the radial nerve at the first operation was a useful method to detect conditions of the nerve which can prevent compression or entrapment of the nerve and the need for secondary nerve exploration.
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Affiliation(s)
- Yoshitaka Tanaka
- Department of Orthopaedic Hand and Microsurgery Center, Osaka Ekisaikai Hospital, 2-1-10 Honden, Nishi-ku, Osaka, 550-0022, Japan.
| | - Hiroyuki Gotani
- Department of Orthopaedic Hand and Microsurgery Center, Osaka Ekisaikai Hospital, 2-1-10 Honden, Nishi-ku, Osaka, 550-0022, Japan
| | - Misato Maeyama
- Department of Orthopaedic Hand and Microsurgery Center, Osaka Ekisaikai Hospital, 2-1-10 Honden, Nishi-ku, Osaka, 550-0022, Japan
| | - Kazuya Nishino
- Department of Orthopaedic Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori Miyakojima, Osaka, 534-0021, Japan
| | - Kosuke Sasaki
- Department of Orthopaedic Hand and Microsurgery Center, Osaka Ekisaikai Hospital, 2-1-10 Honden, Nishi-ku, Osaka, 550-0022, Japan
| | - Hirohisa Yagi
- Department of Orthopaedic Hand and Microsurgery Center, Osaka Ekisaikai Hospital, 2-1-10 Honden, Nishi-ku, Osaka, 550-0022, Japan
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Bertelli JA. Nerve Versus Tendon Transfer for Radial Nerve Paralysis Reconstruction. J Hand Surg Am 2020; 45:418-426. [PMID: 32093993 DOI: 10.1016/j.jhsa.2019.12.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 10/23/2019] [Accepted: 12/17/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE With radial nerve lesions, the results of nerve transfers and how they objectively compare with the outcomes of tendon transfers remain unstudied. We compared the results after nerve transfer in patients with less than 12 months since radial nerve injury with the results after tendon transfer in patients not eligible for nerve surgery because of longstanding paralysis (minimum of 15 months). METHODS In 14 patients with radial nerve lesions incurred less than 12 months previously, we transferred the anterior interosseous nerve to the nerve of the extensor carpi radialis brevis (ECRB), while the nerve to the flexor carpi radialis was transferred to the posterior interosseous nerve. In 13 patients with lesions of longer duration, we transferred the pronator teres tendon to the ECRB, the flexor carpi ulnaris tendon to the extensor digitorum communis, and the palmaris longus to the rerouted extensor pollicis longus (EPL) tendon. At a final evaluation, we measured passive and active range of motion (ROM) of the wrist, finger, and thumb and grasp strength. RESULTS In a comparison of wrist flexion-extension ROM and grasp strength, we observed better recovery in the nerve transfer than in the tendon transfer group. In the tendon transfer group, we observed limitations in wrist flexion in 9 of the 13 patients and permanent radial deviation in 5. Half of the patients in the tendon transfer group needed to flex their wrist to fully extend their fingers, whereas finger extension was possible with the wrist either extended or at neutral in all patients following nerve transfer. After nerve transfer, extension at the first carpometacarpal joint was restored in 11 of the 14 patients, whereas this occurred in just 4 of the 13 patients following tendon transfer. In both groups, we observed a 30° lag in thumb metacarpophalangeal extension, which reflects poor recovery of EPL function. CONCLUSIONS Overall, we observed better outcomes in those who underwent nerve transfer versus tendon transfer procedures. However, room still remains for improved thumb motion with both procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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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; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, SC, Brazil.
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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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Abstract
OBJECTIVE To determine if surgical approach impacts the rate of nerve palsy after plate fixation of humerus shaft fractures and whether or not iatrogenic nerve palsy recovers in similar ways to preoperative palsy. DESIGN Retrospective. SETTING Two trauma centers. PATIENTS Patients 18+ years of age with nonpathologic, extra-articular humerus shaft fractures (OTA/AO 12A/B/C and 13A2-3) treated with plate fixation. INTERVENTION Plate fixation of humerus shaft fractures, from 2008 to 2016. MAIN OUTCOME MEASUREMENT Rate of iatrogenic nerve palsy by a surgical approach and injury characteristics. RESULTS Two hundred sixty-one humeral shaft fractures were included. The rate of preoperative palsy was 19%. Radial nerve palsy (RNP) was present in 18%. Iatrogenic RNP occurred in 12.2% and iatrogenic ulnar palsy in 1.2%. Iatrogenic palsy occurred in 15.6% of middle and 15% of distal fractures, with fracture location significantly different in those developing RNP (P = 0.009). Iatrogenic RNP occurred in 7.1% of anterolateral, 11.7% of posterior triceps-splitting, and 17.9% of posterior triceps-sparing approaches (P = 0.11). Follow-up data were available for 139 patients at an average of 12 months. Preoperative RNP resolved less often than iatrogenic RNP, in 74% versus 95% (P = 0.06). Time to resolution was longer for preoperative RNP, at 5.5 versus 4.1 months (P = 0.91). Twenty-two percent with preoperative RNP underwent tendon transfer or wrist fusion, versus 0% after iatrogenic RNP (P = 0.006). CONCLUSION Iatrogenic RNP is not uncommon with humeral fracture fixation and occurs at similar rates in anterior and posterior approaches and with midshaft and distal fractures. Iatrogenic RNP had a high rate of recovery. Preoperative RNP more often requires surgery for unresolved palsy. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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20
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Ucak M. Surgical restoration of drop-hand syndrome with tendon transfer in patients injured in the Syrian civil war. Mil Med Res 2019; 6:35. [PMID: 31739804 PMCID: PMC6862848 DOI: 10.1186/s40779-019-0225-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 11/05/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The radial nerve is one of the most common war-related injury sites due to penetrating cutting tool injuries or gunshot wounds, resulting in drop-hand syndrome. The aim of this study was to evaluate the outcomes of tendon transfer in patients with drop-hand syndrome who had been injured in the Syrian Civil War. METHODS This level-II, prospective, comparative study included 13 civilians injured in the Syrian Civil War 2015 and 2017. The palmaris longus tendon was used for transfer to the extensor pollicis longus for thumb extension. The pronator teres was transferred to the extensor carpi radialis brevis for wrist extension. The flexor carpi radialis was transferred to the extensor digiti communis for 2nd, 3rd, 4th, and 5th finger extension. All outcomes of thumb abduction and extension, wrist extension, wrist flexion, and finger extension were assessed. RESULTS There was a high level of radial nerve injury in all patients included in the study. The time from injury to treatment ranged from 1.5 months to 9 months. The mechanism of injury most commonly observed was a gunshot wound, which was observed in 8 patients (61.5%), followed by a penetrating cutting tool injury (n = 3; 23.1%) and humerus fracture (n = 2; 15.4%). CONCLUSIONS In radial nerve injuries, successful results can be achieved with tendon transfer. All patients regained thumb abduction of up to approximately 60°. All the patients were able to bend the wrist, grip, and extend the fingers while in wrist flexion, neutral wrist and wrist extension positions. Although the reason for the radial injury varied, the postoperative outcomes were good for all patients, and the rehabilitation period progressed successfully in patients who underwent tendon transfer repair within 90 days of injury.
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Affiliation(s)
- Murat Ucak
- Plastic and Reconstructive Aesthetic Surgery, Hatay Defne State Hospital, 31000, Antakya, Hatay, Turkey.
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21
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Frantz TL, Meschbach NT, Niedermeier SR, Pettit RJ, Plummer DR, Harrison RK. Factors influencing time to union of diaphyseal humeral fractures after plate fixation: A retrospective cohort study. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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O’Shaughnessy MA, Parry JA, Liu H, Stans AA, Larson AN, Milbrandt TA. Management of paediatric humeral shaft fractures and associated nerve palsy. J Child Orthop 2019; 13:508-515. [PMID: 31695818 PMCID: PMC6808073 DOI: 10.1302/1863-2548.13.190012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of this study is to review the management of all paediatric humerus diaphyseal fractures treated at a single institution over a 20-year period. METHODS Retrospective review from between 1996 and 2016 identified 96 humerus shaft fractures in paediatric patients (0 to 17 years). After excluding those deceased from inciting trauma, pathological and perinatal fractures, 80 patients remained for analysis. Data collected included age, fracture type, displacement, nerve palsy, treatment, complications and time to union. Radiographs were reviewed at the time of injury and at latest follow-up. RESULTS Of 80 paediatric humeral diaphyseal fractures, 65 (81%) were treated with immobilization. In all, 15 (19%) fractures were treated with surgical stabilization. Most common indications were fracture displacement, open fractures and to improve mobilization in patients with multiple injuries. Fractures were stabilized with a plate (eight), flexible nails (five), external fixation (one) and percutaneous pinning (one). The operative group, compared with the nonoperative group, was older, had more high-energy mechanisms, more open fractures and increased fracture displacement. All patients in the nonoperative and operative groups went on to union with minimal complications. A nerve palsy was present in five patients (6%)with three of the five involving the radial nerve (4%). All nerve palsies were observed and had full neurological recovery. CONCLUSION Over a 20-year period nonoperative management of paediatric humerus shaft fractures was successful in the majority of patients. Operative stabilization, when rarely indicated, had a low complication rate and improved radiographic alignment. All nerve injuries fully recovered without surgical intervention. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- M. A. O’Shaughnessy
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - J. A. Parry
- Department of Orthopedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado, USA
| | - H. Liu
- Department of Pediatric Orthopedics, Luoyang Orthopedic Hospital, Luoyang, Henan Province, China
| | - A. A. Stans
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - A. N. Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - T. A. Milbrandt
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA,Correspondence should be sent to T. A. Milbrandt, Mayo Clinic, 200 First St SW, Rochester MN 55905, USA. E-mail:
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Thakar A, Gupta MP, Srivastava A, Agrawal D, Kumar A. Nonsurgical Treatment for Posttraumatic Complete Facial Nerve Paralysis. JAMA Otolaryngol Head Neck Surg 2019; 144:315-321. [PMID: 29470563 DOI: 10.1001/jamaoto.2017.3147] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Current recommendations envisage early surgical exploration for complete facial nerve paralysis associated with temporal bone fracture and unfavorable electrophysiologic features (response to electroneuronography, <5%). However, the evidence base for such a practice is weak, with the potential for spontaneous improvement being unknown, and the expected results from alternative nonsurgical treatment also undefined. Objective To document the results of nonsurgical treatment for posttraumatic complete facial paralysis with undisplaced temporal bone fracture and unfavorable electrophysiologic features. Design, Setting, and Participants Prospective cohort study recruiting from April 2010 to April 2013 at a tertiary care university hospital. Follow-up continued until 9 months or until complete recovery if earlier. Study group included 28 patients with head injury-associated complete unilateral facial nerve paralysis with unfavorable results of electroneuronography (<5% response) with or without undisplaced temporal bone fracture. Undisplaced temporal bone fractures were documented in 26 patients (24 longitudinal fractures and 2 transverse fractures). Interventions Patients received prednisolone, 1 mg/kg, for 3 weeks combined with clinical monitoring every 2 weeks and electromyography monitoring every 4 weeks. As per study protocol, surgical exploration was limited to patients demonstrating motor end plate degeneration on results of electromyography, or having no improvement until 18 weeks. Main Outcomes and Measures Facial nerve function was evaluated by the House-Brackmann grading system; Forehead, Eye, Mouth, and Associated defect grading system; and the modified Adour system. Observations were completed at 40 weeks. Results Among the 28 patients in the study (3 women and 25 men; mean [SD] age, 32.2 [8.7] years), facial nerve recovery with conservative treatment alone was noted in all patients. No recovery was seen in any patient at the initial 4-week review. The first signs of clinical recovery were noted in 4 patients by 8 weeks, in 27 patients by 12 weeks, and in all patients by 20 weeks. No patient required surgical exploration. At 40 weeks, 27 patients recovered to House-Brackmann grade I/II and 1 patient to grade III. All 24 patients with longitudinal fractures had grade I/II recovery. Conclusions and Relevance For undisplaced temporal bone fractures, nonsurgical treatment leads to near-universal recovery to House-Brackmann grade I/II and is superior to reported surgical results. Recovery is delayed and usually first manifests at 8 to 12 weeks after the fracture. In the current era of high-resolution computed tomography, surgical exploration should not be first-line treatment for undisplaced longitudingal temporal bone fractures associated with complete facial nerve paralysis and unfavorable electrophysiologic features.
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Affiliation(s)
- Alok Thakar
- Department of Otolaryngology-Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Madan P Gupta
- Department of Otolaryngology-Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Achal Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Larson EL, Santosa KB, Mackinnon SE, Snyder-Warwick AK. Median to radial nerve transfer after traumatic radial nerve avulsion in a pediatric patient. J Neurosurg Pediatr 2019; 24:209-214. [PMID: 31151095 PMCID: PMC7191611 DOI: 10.3171/2019.3.peds18550] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/26/2019] [Indexed: 11/06/2022]
Abstract
This case report describes an isolated radial nerve avulsion in a pediatric patient, treated by combination sensory and motor median to radial nerve transfers. After traumatic avulsion of the proximal radial nerve, a 12-year-old male patient underwent end-to-end transfer of median nerve branches to flexor carpi radialis and flexor digitorum superficialis to the posterior interosseous nerve and extensor carpi radialis nerve, respectively. He underwent end-to-side sensory transfer of the superficial radial sensory to the median sensory nerve. Pronator teres to extensor carpi radialis brevis tendon transfer was simultaneously performed to power short-term wrist extension. Within months after surgery, the patient had regained 9-10/10 sensation in the hand and forearm. In the following months and years, he regained dexterity, independent fine-finger and thumb motions, and 4-5/5 strength in all extensors except the abductor pollicis longus muscle. He grew 25 cm without extremity deformity or need for secondary orthopedic procedures. In appropriate adult and pediatric patients with proximal radial nerve injuries, nerve transfers have advantages over tendon transfers, including restored independent fine finger motions, regained sensation, and reinnervation of multiple muscle groups with minimal donor sacrifice.
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Affiliation(s)
| | - Katherine B Santosa
- 2Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Susan E Mackinnon
- 2Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alison K Snyder-Warwick
- 2Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Bassilios Habre S, Bond G, Jing XL, Kostopoulos E, Wallace RD, Konofaos P. The Surgical Management of Nerve Gaps: Present and Future. Ann Plast Surg 2019; 80:252-261. [PMID: 29166306 DOI: 10.1097/sap.0000000000001252] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Peripheral nerve injuries can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Nowadays, the gold standard for the treatment of nerve section is end-to-end neurorrhaphy. Unfortunately, in some cases, there is segmental loss of the nerve trunk. Nerve mobilization allows primary repair of the sectioned nerve by end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. To overcome the limited availability and the donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers, and end-to-side neurorrhaphy. The purpose of this review is to present an overview of the literature on the applications of these techniques in peripheral nerve repair. Furthermore, preoperative evaluation, timing of repair, and future perspectives are also discussed.
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Vaishya R, Kandel IS, Agarwal AK, Vijay V, Vaish A, Acharya K. Is early exploration of secondary radial nerve injury in patients with humerus shaft fracture justified? J Clin Orthop Trauma 2019; 10:535-540. [PMID: 31061585 PMCID: PMC6494759 DOI: 10.1016/j.jcot.2018.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Radial nerve is commonly injured with a fracture of the shaft of the humerus. Primary radial nerve injury occurs at the time of fracture, and secondary nerve injuries are seen after closed reduction or operative management. Management of these secondary nerve injuries is controversial regarding conservative approach verses early exploration. MATERIALS AND METHODS The PubMed, Science Direct, Scopus, and Google Scholar were used to find out relevant studies in the English language from October 2007 to October 2017. After a search of total 114 articles, we excluded 107 articles which did not meet our inclusion criteria, and only seven studies were thoroughly reviewed. RESULTS Among the seven studies, three studies by Wang JP, Wang X, and Reichert P have included only secondary radial nerve injuries. Studies by Noaman H, Gouse M, Schwab TR and Bhardwaj A have included both primary as well as secondary radial nerve injury cases. Four studies used a conservative strategy and late exploration was advocated only if no nerve recovery was found within three to five months. Three studies recommended early radial nerve exploration (within the first two weeks) in patients with secondary radial nerve injury. CONCLUSIONS The pattern and duration of radial nerve recovery in secondary nerve injury was similar to that seen in primary radial nerve palsy. No advantage was seen in the early exploration of the radial nerve in most of these studies. If there is no misplaced instrumentation, macroscopic laceration of nerve or fracture displacement in the postoperative radiograph, secondary radial nerve injury can be treated as a primary radial nerve injury, and we recommend observation for a minimum of four to five months before exploration.
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Affiliation(s)
- Raju Vaishya
- Department of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076, India
| | - Ishwar Sharma Kandel
- Department of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076, India
| | - Amit Kumar Agarwal
- Department of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076, India,Corresponding author. Orthopaedic Surgeon, Indraprastha Apollo Hospitals, New Delhi, 110076, India.
| | - Vipul Vijay
- Department of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076, India
| | - Abhishek Vaish
- Department of Orthopaedics, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi, 110076, India
| | - Karuna Acharya
- Department of Emergency, Gandaki Medical College, Pokhara, Nepal
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Laulan J. High radial nerve palsy. HAND SURGERY & REHABILITATION 2018; 38:2-13. [PMID: 30528552 DOI: 10.1016/j.hansur.2018.10.243] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/16/2018] [Accepted: 10/02/2018] [Indexed: 12/30/2022]
Abstract
High radial palsy is primarily associated with humeral shaft fractures, whether primary due to the initial trauma, or secondary to their treatment. The majority will spontaneously recover, therefore early surgical exploration is mainly indicated for open fractures or if ultrasonography shows severe nerve damage. Initial signs of nerve recovery may appear between 2 weeks and 6 months. Otherwise, the decision to explore the nerve is based on the patient's age, clinical examination and electroneuromyography, as well as ultrasonography findings. If recovery does not occur, an autograft is indicated only in younger patients, before 6 months, if local conditions are suitable. Otherwise, nerve transfers performed by an experienced team give satisfactory results and can be offered up to 10 months post-injury. Tendon transfers are the gold standard treatment and the only option available beyond 10 to 12 months. The results are reliable and fast.
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Affiliation(s)
- J Laulan
- CHRU de Tours, hôpital Trousseau, services d'orthopédie 1 et 2, unité de chirurgie de la main et du membre supérieur, 37044 Tours cedex 9, France.
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Martin AR, Gittings DJ, Levin LS, Donegan DJ, Gray BL. Acute Radial Nerve Repair with Humeral Shaft Shortening and Fixation Following a Closed Humeral Shaft Fracture: A Case Report. JBJS Case Connect 2018; 8:e109. [PMID: 30601279 DOI: 10.2106/jbjs.cc.18.00074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
CASE A 65-year-old woman sustained a closed segmental humeral shaft fracture with a complete radial nerve palsy. Radial nerve neurotmesis was found during acute surgical exploration and fixation. Treatment included a 2-cm shortening osteotomy of the humeral shaft and osteosynthesis in order to obtain a tension-free primary end-to-end repair of the radial nerve. CONCLUSION Tension-free primary nerve repair can be technically challenging with humeral shaft fractures. A shortening osteotomy of the humeral shaft and osteosynthesis are feasible to achieve tension-free neurorrhaphy without nerve-grafting.
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Affiliation(s)
- Anthony R Martin
- Department of Orthopaedics, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania
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Akhavan-Sigari R, Mielke D, Farhadi A, Rohde V. Study of Radial Nerve Injury Caused By Gunshot Wounds and Explosive Injuries among Iraqi Soldiers. Open Access Maced J Med Sci 2018; 6:1622-1626. [PMID: 30337976 PMCID: PMC6182541 DOI: 10.3889/oamjms.2018.346] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Gunshot wounds and blast injuries to the upper limbs produce complex wounds requiring management by multiple surgical specialities. AIM We sought to determine the pattern of peripheral nerve injuries among Iraqi soldiers in the war. METHODS We performed a 3 year retrospective cohort analysis based on medical records of patients with sustaining gunshot wounds and blast injuries to the upper limbs. Ethical approval was obtained from the institutional review board. The patients included were male, serving military personnel of all age groups and ranks presenting with weakness or sensory loss of radial nerve. Three hundred eighteen patients aged 24 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. In these patients, the physical examination and electrodiagnostic study were carried out by experienced neurologists. Seddon's classification system was used to assess the severity of the injury. The data related to the types of fracture, the type of damage, the factors causing damage and the failure of treatment were entered into the IBM SPSS 23 software after extraction of files. Based on mid-range indicators and data distribution, traumatic injuries among Iraqi soldiers in the war against ISIL were then investigated. RESULTS A group of 318 patients with mean age of 25.41 ± 6 years were enrolled in the study, of which 127 patients were included with an open fracture and 191 patients with closed lesions. All 127 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. 113 of 127 subjects had primary repair of the radial nerve and recovered well. 14 of 127 subjects were not recovered. 3 of them had iatrogenic radial nerve injury due to the internal fixation device. Furthermore, all 191 patients with closed injuries recovered well. The average time to initial signs of recovery was 8 weeks (range, 1-27 weeks). Axonotmesis and Neurotmesis were found in 283 (89%) subjects. The average time to full recovery was determined to be 6 months (range, 1-22 months). The blast was found to be the main cause of nerve injury in 236 (74.2%) cases, followed by gunshot damage (21.4%, 68 subjects), falling from height and motor vehicle accidents (4.4%, 14 subjects) and multiple injuries (17%, 54 cases). CONCLUSIONS Trauma caused by factors such as explosions and gunshot worsens the condition of the injuries and presents the treatment conditions with many challenges. However, the success rate in post-surgical recovery of humerus fracture and injured radial nerve can be remarkably higher in young people as compared to other age groups.
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Affiliation(s)
- Reza Akhavan-Sigari
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
- Department of Neurosurgery, Bouali Hospital, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Afshin Farhadi
- Department of Orthopedic Surgery, Tehran Medical Sciences Branch, Islamic Azad University, Bouali Hospital, Tehran, Iran
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
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Bertelli JA, Ghizoni MF. Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord. J Neurosurg 2018; 2016:179-185. [PMID: 28306410 DOI: 10.3171/2014.12.jns141944.test] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.
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Affiliation(s)
- Jayme Augusto Bertelli
- Department of Neurosurgery, Southern University of Santa Catarina [Unisul], Avenida José Acácio Moreira, Tubarão, Brazil
| | - Marcos Flávio Ghizoni
- Department of Neurosurgery, Southern University of Santa Catarina [Unisul], Avenida José Acácio Moreira, Tubarão, 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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Time From Injury to Surgical Fixation of Diaphyseal Humerus Fractures Is Not Associated With an Increased Risk of Iatrogenic Radial Nerve Palsy. J Orthop Trauma 2017; 31:491-496. [PMID: 28459772 DOI: 10.1097/bot.0000000000000875] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether time from injury to fixation of diaphyseal humeral fractures and nonunions is associated with the risk of iatrogenic radial nerve palsy. DESIGN Retrospective review. SETTING Two Level 1 trauma centers. PATIENTS/PARTICIPANTS Between 2001 and 2015, 325 patients who had documented intact radial nerve function preoperatively were treated with fixation of a humerus fracture or humerus nonunion. INTERVENTION Open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS Development of an iatrogenic radial nerve injury. Those with an injury were followed to either resolution of the nerve palsy or definitive treatment. RESULTS The risk of iatrogenic radial nerve palsy was 7.7% (25/325). Time to surgery was not significantly associated with iatrogenic radial nerve palsy. In a multiple variable analysis, when comparing patients treated within 4 weeks to those treated 4-8 weeks (P = 0.41), 8-12 weeks (P = 0.94), and over 12 weeks (0.20), there were no significant associations. Independent risk factors for iatrogenic radial nerve palsy included distal location of fracture (P = 0.04, odds ratio 3.71) and previous fixation (P = 0.03, odds ratio 3.80). Of the 25 iatrogenic nerve injuries, 22 recovered fully with expectant management, 1 was lost to follow-up, and 2 required either nerve graft or tendon transfers. CONCLUSIONS Time from injury to surgery does not seem to be a risk factor for developing an iatrogenic radial nerve palsy when treating diaphyseal humerus fractures. Patients with distal fractures, and those with previous fracture implants, are at increased risk of iatrogenic radial nerve palsy. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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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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Samson D, Ng CY, Power D. An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2017; 1:362-367. [PMID: 28461914 PMCID: PMC5367548 DOI: 10.1302/2058-5241.160012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Traumatic knee dislocation is a complex ligamentous injury that may be associated with simultaneous vascular and neurological injury.Although orthopaedic surgeons may consider CPN exploration at the time of ligament reconstruction, there is no standardised approach to the management of this complex and debilitating complication.This review focusses on published evidence of the outcomes of common peroneal nerve (CPN) injuries associated with knee dislocation, and proposes an algorithm for the management. Cite this article: Deepak Samson, Chye Yew Ng, Dominic Power. An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2016;1:362-367. DOI: 10.1302/2058-5241.160012.
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Affiliation(s)
- Deepak Samson
- The Centre for Nerve Injury and Paralysis, The Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Chye Yew Ng
- The Upper Limb Unit, Wrightington Hospital, UK
| | - Dominic Power
- The Centre for Nerve Injury and Paralysis, The Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
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Abstract
As a result of its proximity to the humeral shaft, as well as its long and tortuous course, the radial nerve is the most frequently injured major nerve in the upper limb, with its close proximity to the bone making it vulnerable when fractures occur.Injury is most frequently sustained during humeral fracture and gunshot injuries, but iatrogenic injuries are not unusual following surgical treatment of various other pathologies.Treatment is usually non-operative, but surgery is sometimes necessary, using a variety of often imaginative procedures. Because radial nerve injuries are the least debilitating of the upper limb nerve injuries, results are usually satisfactory.Conservative treatment certainly has a role, and one of the most important aspects of this treatment is to maintain a full passive range of motion in all the affected joints.Surgical treatment is indicated in cases when nerve transection is obvious, as in open injuries or when there is no clinical improvement after a period of conservative treatment. Different techniques are used including direct suture or nerve grafting, vascularised nerve grafts, direct nerve transfer, tendon transfer, functional muscle transfer or the promising, newer treatment of biological therapy. Cite this article: Bumbasirevic M, Palibrk T, Lesic A, Atkinson HDE. Radial nerve palsy. EFORT Open Rev 2016;1:286-294. DOI: 10.1302/2058-5241.1.000028.
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Affiliation(s)
- Marko Bumbasirevic
- Orthopaedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia.,School of Medicine, University of Belgrade, Serbia
| | - Tomislav Palibrk
- Orthopaedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia
| | - Aleksandar Lesic
- Orthopaedic and Traumatology University Clinic, Clinical Center of Serbia, Serbia.,School of Medicine, University of Belgrade, Serbia
| | - Henry DE Atkinson
- Department of Trauma and Orthopaedics, University College, London Medical School, North Middlesex University Hospital, UK
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Ultrasonographic and Surgical Findings of Acute Radial Neuropathy Following Blunt Trauma. Am J Phys Med Rehabil 2016; 95:e177-e182. [PMID: 27763908 DOI: 10.1097/phm.0000000000000506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Ultrasonographic study is useful for decision making of treatment for focal neuropathy with unusual electrodiagnostic findings. We present a patient with severe acute radial neuropathy with sensory sparing around the distal arm secondary to twisting of the radial nerve following blunt trauma. A 24-year-old man with a 2-week history of left wrist drop and severe pain around the left elbow presented after hitting the left distal arm on the doorknob. The left wrist and finger extensions were grade 0, but elbow extension could not be tested because of severe pain during this action. The left superficial radial sensory territory was intact. Electrodiagnostic findings suggested severe left radial neuropathy around the distal arm with sensory sparing. Ultrasonographic study demonstrated 2 stenotic lesions around the distal arm and absence of the left superficial radial sensory nerve. Surgical exploration revealed 2 stenotic lesions with twisting of the nerve, concordant with ultrasonographic study. End-to-end anastomosis was performed in the proximal lesion. Sixteen months later, wrist and finger extension was grade 3, and reinnervation signs in the radial-innervated muscles except extensor indicis muscle were observed. The complementary relationship between electrophysiologic and ultrasonographic examinations is very important for precise lesion location and decision making for treatment of peripheral nerve injury.
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Ropars M, Dréano T, Siret P, Belot N, Langlais F. Long-Term Results of Tendon Transfers in Radial and Posterior Interosseous Nerve Paralysis. ACTA ACUST UNITED AC 2016; 31:502-6. [PMID: 16928411 DOI: 10.1016/j.jhsb.2006.05.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2005] [Accepted: 05/29/2005] [Indexed: 10/24/2022]
Abstract
Eighteen cases of tendon transfer for isolated radial or posterior interosseous nerve palsy have been carried out in our unit over a period of 21 years. Fifteen patients were reviewed with a mean follow-up of 9.5 years. Nine had sustained high and six low radial nerve injury. We achieved 11 excellent, two good, one fair and one bad result. The main problems were loss of power of gripping and the occurrence of radial deviation, particularly in patients with flexor carpi ulnaris transfer to the extensor digitorum communis. During this time, our technique has evolved, including changes of the tendons transferred. Our final preference is a modified Tsuge procedure, using the pronator teres to restore extension of the wrist, the flexor carpi radialis for extension of the fingers and the palmaris longus for extension of the thumb. Abduction of the thumb is restored by a tenodesis of the abductor pollicis longus to the brachioradialis. This review justifies the final policy, in particular the preservation of flexor carpi ulnaris to maintain wrist stability and flexion.
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Affiliation(s)
- M Ropars
- Orthopaedic and Reconstructive Surgery Unit, Hospital Sud University, Rennes, France.
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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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Reichert P, Wnukiewicz W, Witkowski J, Bocheńska A, Mizia S, Gosk J, Zimmer K. Causes of Secondary Radial Nerve Palsy and Results of Treatment. Med Sci Monit 2016; 22:554-62. [PMID: 26895570 PMCID: PMC4762296 DOI: 10.12659/msm.897170] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background The aim of this study was to analyze the causes that lead to secondary damage of the radial nerve and to discuss the results of reconstructive treatment. Material/Methods The study group consisted of 33 patients treated for radial nerve palsy after humeral fractures. Patients were diagnosed based on clinical examinations, ultrasonography, electromyography, or nerve conduction velocity. During each operation, the location and type of nerve damage were analyzed. During the reconstructive treatment, neurolysis, direct neurorrhaphy, or reconstruction with a sural nerve graft was used. The outcomes were evaluated using the Medical Research Council (MRC) scales and the quick DASH score. Results Secondary radial nerve palsy occurs after open reduction and internal fixation (ORIF) by plate, as well as by closed reduction and internal fixation (CRIF) by nail. In the case of ORIF, it most often occurs when the lateral approach is used, as in the case of CRIF with an insertion interlocking screws. The results of the surgical treatment were statistically significant and depended on the time between nerve injury and revision (reconstruction) surgery, type of damage to the radial nerve, surgery treatment, and type of fixation. Treatment results were not statistically significant, depending on the type of fracture or location of the nerve injury. Conclusions The potential risk of radial nerve neurotmesis justifies an operative intervention to treat neurological complications after a humeral fracture. Adequate surgical treatment in many of these cases allows for functional recovery of the radial nerve.
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Affiliation(s)
- Pawel Reichert
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wrocław Medical University, Wrocław, Poland
| | - Witold Wnukiewicz
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wroclaw Medical University, Wrocław, Poland
| | - Jarosław Witkowski
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wroclaw Medical University, Wrocław, Poland
| | - Aneta Bocheńska
- Centre of Veterinary Medicine JU-UAK, The University of Agriculture, Cracow, Poland
| | - Sylwia Mizia
- Faculty of Health Science, Department of Public Health, Wrocław Medical University, Wrocław, Poland
| | - Jerzy Gosk
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wrocław Medical University, Wrocław, Poland
| | - Krzysztof Zimmer
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wrocław Medical University, Wrocław, Poland
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Bertelli JA, Ghizoni MF. Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord. J Neurosurg 2016; 124:179-85. [DOI: 10.3171/2014.12.jns141944] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord.
METHODS
The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients’ average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength).
RESULTS
After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6.
CONCLUSIONS
The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.
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Claessen FMAP, Peters RM, Verbeek DO, Helfet DL, Ring D. Factors associated with radial nerve palsy after operative treatment of diaphyseal humeral shaft fractures. J Shoulder Elbow Surg 2015; 24:e307-11. [PMID: 26341025 DOI: 10.1016/j.jse.2015.07.012] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 07/21/2015] [Accepted: 07/23/2015] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
| | - Rinne M Peters
- Hand Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Diederik O Verbeek
- Combined Orthopaedic Trauma, Hospital for Special Surgery, New York, NY, USA
| | - David L Helfet
- Combined Orthopaedic Trauma, Hospital for Special Surgery, New York, NY, USA
| | - David Ring
- Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Attum B, Obremskey W. Treatment of Humeral Shaft Fractures: A Critical Analysis Review. JBJS Rev 2015; 3:01874474-201509000-00005. [PMID: 27490668 DOI: 10.2106/jbjs.rvw.n.00119] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Basem Attum
- Vanderbilt University Medical Center, 1215 21st Avenue South, MCE South Tower, Suite 4200, Nashville, TN 37232
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Shah J, Marson BA. A case report of periprosthetic fracture left proximal humerus with radial nerve palsy following pectoralis major repair. Clin Case Rep 2015; 3:468-71. [PMID: 26185650 PMCID: PMC4498864 DOI: 10.1002/ccr3.278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/09/2015] [Accepted: 03/12/2015] [Indexed: 12/05/2022] Open
Abstract
Primary repair of pectoralis major tendon with bony tunnels and anchor sutures in the proximal humerus creates a potential weakness and stress riser leading to increased risk of periprosthetic fracture and nerve damage at the site of weakness with subsequent injury, if not allowed to heal satisfactorily with adequate period of rest.
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Affiliation(s)
- Jaydeep Shah
- Princess of Wales Hospital, ABM University NHS Health Board Bridgend, UK
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45
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Abstract
This article provides an overview of the management of traumatic peripheral nerve injuries. It examines the basic pathophysiology of peripheral nerve injuries, along with the clinical presentation, diagnostic work-up, and treatment options and outcomes for the various classifications of traumatic peripheral nerve injuries.
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Affiliation(s)
- Matthew T Houdek
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Alexander Y Shin
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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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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47
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Koulaxouzidis G, Stark GB, Lampert FM. [Motor replacement surgery via tendon transfer in radial nerve palsy]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2015; 27:47-62. [PMID: 25621954 DOI: 10.1007/s00064-014-0322-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/28/2014] [Accepted: 06/30/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Restoration of active extension of wrist, thumb and digits by muscle-tendon transposition. INDICATIONS Radial nerve palsy due to peripheral nerve injury. Peripheral nerve disease. Muscle or tendon injury. Restoration of wrist extension in high radial nerve palsy. CONTRAINDICATIONS Reversible distal radial nerve palsy, absence of suitable donor muscles, spasticity, limited range of motion of affected joints, extensive scarring and inappropriate soft tissue conditions, unjustifiable loss of function at donor site. Reinnervated donor muscles, progressive muscle disease, insufficient patient compliance. SURGICAL TECHNIQUE Dissection of the flexor carpi ulnaris, palmaris longus and pronator teres tendon insertion. Transposition of the tendons. Interweaving of tendons of the pronator teres and extensor carpi radialis brevis muscles, the extensor digitorum communis and flexor carpi ulnaris muscles, as well as the extensor pollicis longus and palmaris longus muscles using the Pulvertaft technique. POSTOPERATIVE MANAGEMENT 3 Weeks immobilization in forearm splint. Additional immobilization for 2 weeks at night. Subsequently, intensive physical and occupational therapy for another 4-6 weeks is required, starting 3 weeks postoperatively. RESULTS The procedure was carried out in 12 patients over the past 14 years. We treated proximal radial nerve palsy in nine cases. In accordance with the current medical literature, we consider the described motor replacement surgery a reliable procedure.
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Affiliation(s)
- G Koulaxouzidis
- Klinik für Plastische und Handchirurgie, Chirurgische Universitätsklinik Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland,
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48
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Abstract
Radial nerve injuries continue to challenge hand surgeons. The course of the nerve and its intimate relationship to the humerus place it at high risk for injury with humerus fractures. We present a review of radial nerve injuries with emphasis on their etiology, workup, diagnosis, management, and outcomes.
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Affiliation(s)
- Karin L Ljungquist
- Hand and Microsurgery, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
| | - Paul Martineau
- Hand and Microsurgery, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
| | - Christopher Allan
- Hand and Microsurgery, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA.
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49
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Moore AM, Franco M, Tung TH. Motor and sensory nerve transfers in the forearm and hand. Plast Reconstr Surg 2014; 134:721-730. [PMID: 25357031 DOI: 10.1097/prs.0000000000000509] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peripheral nerve injury is a significant problem affecting more than 1 million people around the world each year and poses major challenges to the plastic and reconstructive surgeon. For high upper extremity nerve injuries, distal muscle reinnervation and functional outcomes are generally poor. Tendon transfer has been the traditional reconstructive option in these cases to restore hand function. More recently, nerve transfers have been described in the forearm and hand to recover hand and wrist function and critical sensation. METHODS This article reviews the surgical principles, donor nerve options, indications, and outcomes of distal nerve transfers for high upper extremity nerve injuries. RESULTS The functional results of nerve transfers to date have been comparable to tendon transfers. The primary advantage is the potential for individual finger motion from a donor nerve with singular function. The disadvantage is the longer recovery time required for muscle reinnervation. CONCLUSIONS Nerve transfers are a viable option for peripheral nerve injuries distal to the brachial plexus. The choice of management will depend on the patient's individual goals and priorities in terms of the need or desire for individual finger movement and the length of the recovery period.
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Affiliation(s)
- Amy M Moore
- St. Louis, Mo. From the Division of Plastic and Reconstructive Surgery, Washington University School of Medicine
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50
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Moore AM, Novak CB. Advances in nerve transfer surgery. J Hand Ther 2014; 27:96-104; quiz 105. [PMID: 24513183 DOI: 10.1016/j.jht.2013.12.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 12/15/2013] [Accepted: 12/15/2013] [Indexed: 02/09/2023]
Abstract
Peripheral nerve injuries are devastating injuries and can result in physical impairments, poor functional outcomes and high levels of disability. Advances in our understanding of peripheral nerve regeneration and nerve topography have lead to the development of nerve transfers to restore function. Over the past two decades, nerve transfers have been performed and modified. With the advancements in surgical management and recognition of importance of cortical plasticity, motor-reeducation and perioperative rehabilitation, nerve transfers are producing improved functional outcomes in patients with nerve injuries. This manuscript explores the recent literature as it relates to current nerve transfer techniques and advances in post-operative rehabilitation protocols, with a focus on indications, techniques and outcomes.
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Affiliation(s)
- Amy M Moore
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Christine B Novak
- Hand & Upper Extremity Program, Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada.
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