Anterolateral approach with two incisions versus posterior median approach in the treatment of middle- and distal-third humeral shaft fractures

Systematic review of humeral shaft fracture (OTA/AO 12) complicated with iatrogenic radial nerve injury

OBJECTIVES

To compare the iatrogenic radial nerve injury (iRNI) rate of different implant (plate vs. intramedullary nail) and surgical approaches during humeral shaft fracture surgery.

METHODS

The online PubMed database was used to search for articles describing iRNI after humeral fracture with a publication date from Jan 2000 to October 2023. The following types of articles were selected: (1) case series associating with adult humeral shaft fracture, preoperative radial nerve continuity, non-pathological fracture and non-periprosthetic fracture; (2) involving humeral shaft (OTA/AO 12) fractures. Articles where we were unable to judge surgical approach or fracture pattern (OTA/AO 12) were excluded. The data were analyzed by SPSS 27.0 and Chi-square test was performed to identify incidence of iRNI associated with different implant and surgical approaches.

RESULTS

Fifty-four articles with 5063 cases were included, with 3510 cases of the plate, 830 cases of intramedullary nail and 723 cases of uncertain internal fixation. The incidences of iRNI with plate and intramedullary nail were 5.95% (209/3510) and 2.77% (23/830) (p < 0.05). And iRNI incidences of different surgical approaches were 3.7% (3/82) for deltopectoral approach, 5.74% (76/1323) for anterolateral approach, 13.54% (26/192) for lateral approach and 6.68% (50/749) for posterior approach. The iRNI rates were 0.00% (0/33) for anteromedial MIPO, 2.67% (10/374) for anterolateral MIPO and 5.40% (2/37) for posterior MIPO (p > 0.05). The iRNI rates were 2.87% (21/732) for anterograde intramedullary nail and 2.04% (2/98) for retrograde intramedullary nail (p > 0.05). In humeral bone nonunion surgery, the rate of iRNI was 15.00% (9/60) for anterolateral approach, 16.7% (2/12) for lateral approach and 18.2% (6/33) for posterior approach (p  > 0.05).

CONCLUSION

Intramedullary nailing is the preferred method of internal fixation for humeral shaft fractures that has the lowest rate of iRNI. Compared with anterolateral and posterior approaches, the lateral surgical approach had a higher incidence of iRNI. The rate of iRNI in MIPO was lower than that in open reduction and internal fixation.

LEVEL OF EVIDENCE

Level IV.

Humerus shaft fractures, approaches and management

Humeral shaft fracture is a common injury which can be treated either conservatively with functional bracing or with surgical fixation. Current evidence shows an increase in the rate of nonunion after conservative treatment, suggesting that indications for conservative treatment may need to be re-examined. This article updates trends in treatment for humeral shaft fracture. Indications for surgery, both for plate osteosynthesis with open reduction and internal fixation (ORIF) as well as for minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are described. Recognition of the advantages and disadvantages of each technique can better define the role of the plate or nail and can aid in the selection of an appropriate surgical approach. ORIF with compression plate continues to have a role in the treatment of simple or AO/OTA type A fractures. The primary goal of minimal invasive osteosynthesis, a surgical technique involving small incisions, closed reduction or mini-open reduction that minimizes soft tissue dissection and helps preserve the periosteal blood supply, is to achieve bone union and the best possible functional outcomes. MIPO of the humerus is now well accepted as being less invasive and providing relative stability to allow indirect (secondary) bone healing with callus formation. MIPO approaches can be performed circumferentially to the humerus, including the proximal, middle and distal shaft. The classic MIPO approach is anterior MIPO, followed by posterior, anterolateral and anteromedial MIPO. IMN is also an option for treating humerus fractures. In the past, IMN was not widely used due to the potential for complications such as shoulder impingement and elbow problems as well as the limited availability of implants and the steep learning curve of this surgical technique. Over the past decade, the launch of a new design of straight antegrade and retrograde IMN with established techniques has encouraged more surgeons to use IMN as an alternative option. Methods of dealing with concomitant and post-treatment radial nerve palsy have also been evolving, including the use of ultrasound for diagnosis of radial nerve conditions. Radial nerves with contusion, entrapment or laceration can be detected using ultrasound with reliability comparable to intraoperative findings. Trends in treatment of radial nerve palsy are described below. Future larger randomized controlled trials comparing conservative and operative management are necessary to further develop appropriate guidelines.

Humeral shaft fracture: systematic review of non-operative and operative treatment

INTRODUCTION

Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome.

METHODS

Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc.

RESULTS

A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group.

CONCLUSION

This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.

Iatrogenic radial nerve palsy in the surgical treatment of humerus shaft fracture -anterolateral versus posterior approach: A systematic review and meta-analysis

BACKGROUND

Although many studies have investigated iatrogenic radial nerve palsy (RNP) in humerus shaft fracture, there is inconsistent evidence on which approach leads to iatrogenic RNP. Moreover, no meta-analysis has directly compared the anterolateral and posterior approaches regarding iatrogenic RNP.

METHODS

In this systematic review and meta-analysis, the MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before March 30, 2021. We included studies that (1) assessed the RNP in the surgical treatment of humerus shaft fracture and (2) directly compared the anterolateral and posterior approaches regarding the RNP. We performed synthetic analyses of the incidence of iatrogenic RNP and the recovery rate of iatrogenic RNP in humerus shaft fracture between the anterolateral and posterior approaches.

RESULTS

Our study enrolled nine studies, representing 1303 patients who underwent surgery for humerus shaft fracture. After exclusion of traumatic RNP, iatrogenic RNP was reported in 35 out of 678 patients in the anterolateral approach and in 69 out of 497 patients in the posterior approach. Pooled analysis revealed that the incidence of iatrogenic RNP was significantly higher in the posterior approach than in the anterolateral approach (OR = 2.72; 95% confidence interval (CI), 1.70-4.35; P < 0.0001, I² = 0%), but there was no significant difference in the recovery rates of iatrogenic RNP between the two approaches (OR = 1.55; 95% CI, 0.26-9.18; P = 0.63, I² = 0%).

CONCLUSION

In this meta-analysis, the posterior approach showed a higher incidence of iatrogenic RNP than the anterolateral approach in the surgical treatment of humerus shaft fracture. With limited studies, it is difficult to anticipate if any particular approach favors the recovery of iatrogenic RNP.

Preoperative position and protection of radial nerve by B-ultrasound combined with MIPPO for treatment of middle-inferior humerus fractures

Background and purpose

Open reduction and internal fixation through the posterior approach are standard methods for treating middle-inferior humerus fractures. Given the limited operative field and difficulty in locating the radial nerve, the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique via the posterior approach to treat middle-inferior humerus fractures has rarely been reported. This study aims to evaluate the clinical effect of the preoperative study of the radial nerve position by B-ultrasound and its intraoperative protection combined with MIPPO in managing middle-inferior humerus fractures.

Methods

The data were studied retrospectively involving 64 participants who had surgery for middle-inferior humerus fractures from the start of 2017 to the end of 2020. Participants were divided into two groups, those treated with the MIPPO technique, including newly developed dual procedures and preoperative position and protection of radial nerve by B-ultrasound (group A), and those treated with open reduction and internal plating fixation (group B).

Results

All the cases were followed up for 12–34 months (an average of 25.6 ± 8.76 months), and there was no significant difference in the mean operative duration, surgical incision infection, range of motion (ROM) and MEPS (Mayo elbow performance score) for groups A and B. However, the occurrence of complications (radial nerve palsy, bone nonunion and flexible internal fixation or ruptures) in group B was significantly higher than the group A. A statistically significant difference was observed in the intraoperative blood loss, hospital stay and fracture nonunion time between the two groups. All the cases gained bone union within the MIPPO group.

Conclusion

MIPPO via the posterior dual approach associated with preoperative position and protection of radial nerve by B-ultrasound does not increase radial nerve injury, however, it exhibits obvious advantages in the bone union, which is worthy of clinical application.