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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Integrated Physical Therapy in a Unique Case of Holstein-Lewis Fracture With Radial Palsy: A Case Report

The term "Holstein-Lewis fracture" describes a spiral fracture that occurs in the shaft of the humerus at its distal third, which has been linked to radial nerve palsy in adults, and operative treatment is the preferred method of treating the trapped nerve at the fracture site. This paper describes a clinical case involving a 20-year-old male patient demonstrating a humeral fracture syndrome accompanied by complications associated with radial nerve palsy. After the necessary investigation, he was diagnosed with a Holstein-Lewis fracture with radial nerve paralysis; he underwent open reduction internal fixation (ORIF), after which he was referred to physical therapy. Developing a successful postoperative rehabilitation program that consists mostly of functional physical therapy interventions is essential for the treatment of this condition. Outcome measures like the Numerical Pain Rating Scale (NPRS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were recorded before and after rehabilitation, and pain reduction, improvement in strength, range of motion (ROM), grip strength, and activities of daily living (ADL) were found. The purpose of this case report is to present a comprehensive treatment plan that includes ROM exercises, cryotherapy, and strengthening of grip using a robotic glove for a patient who had a wrist drop and underwent ORIF surgery. This tailored intervention was effective in speeding up the return of functional abilities and improving function in ADLs.

Secondary radial neuropathy after closed intramedullary nailing of humeral shaft fractures. Results over a 10-year period

Background. Retrospective study to examine secondary radial nerve palsy after humeral shaft fixation with closed locked intramedullary nailing. Materials and methods. Patients were identified from the hospitals’ registration systems for humeral shaft fractures, nerve lesions, plating, nailing and external fixation during a 10-year period from January 2007 to December 2016. All radial nerve lesions were registered and followed-up in patient files. Results. 89 patients with locked intramedullary nailing were available for an outpatient follow-up. Mean age was 67 years at the time of injury. 72 fractures were non-pathological. Of these, 31 were nonunions. 28, 61 and zero were identified in the proximal, middle and distal thirds of the humeral shaft respectively. 76 procedures were closed and 13 were with open reduction. Six radial nerves had nerve exploration. Eight patients developed immediate postoperative radial nerve palsies. Of these, six developed after closed surgery, two after nerve exploration. Of seven available patients with a radial nerve palsy, six of these remitted. Two patients were later surgically explored. One patient out of 89 sustained a verifiable permanent radial nerve paralysis. Conclusions. In this study, the risk of a radial nerve palsy was 7.9 % with closed locked intramedullary nailing. This study suggests that exploration of the radial nerve is not necessary routinely in order to prevent radial nerve lesions when performing closed intramedullary nailing for humeral shaft fractures in adults with a preoperative normal radial nerve function. Level of Evidence : Level IV.

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

INTRODUCTION

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

METHODS

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

DISCUSSION

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

Radial nerve palsy in mid/distal humeral fractures: is early exploration effective?

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.

Application of a Modified Pedicled Adipofascial Lateral Arm Flap in the Prevention and Treatment of Radial Nerve Injuries

The fasciocutaneous lateral arm flap is a workhorse flap in upper extremity reconstruction. However, its adipofascial variant is not widely used. The technique can be used in various clinical scenarios. The adipofascial flap can be transposed to circumferentially wrap the radial nerve with a pliable, vascularized fat and fascial envelope, mimicking the natural fatty environment of peripheral nerves. This technique has the advantage of providing a scar tissue barrier, a barrier to hardware irritation and a milieu for vascular regeneration of the nerve. Suggested applications include nerve coverage in the setting of posterior humerus plating to prevent adhesions; anticipation of bone grafting in the setting of an open fractures with bone loss, infection, or with the use of the Masquelet technique; in revision total elbow arthroplasty or endoprosthetic humerus replacement; and in the setting of neurolysis, repair or nerve grafting. The technique is straightforward and does not require microvascular expertise.

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

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.