Closed fractures complicated by peripheral nerve injury

Predictive factors for open reduction of operatively treated radial neck fractures in children

INTRODUCTION

Open reduction is a therapeutic option for displaced radial neck fracture in children, which once was considered the last resort because of its potential risk for functional outcomes. This study aimed to identify risk factors for open reduction in operatively treated radial neck fractures in children.

PATIENTS AND METHODS

One hundred and thirty-seven patients with displaced radial neck fractures, treated surgically at our department from January 2010 to December 2021 were retrospectively enrolled. Patients' data of age, sex, injury side, obesity, type of fractures, combined fractures, nerve injury, reduction methods, and delay from injury to surgery were reviewed. Univariate analysis and multivariate logistic regression were used to identify independent risk factors and odds ratios of open reduction.

RESULTS

Overall, 137 patients (62 females and 75 males) with an average of 8.0 ± 2.2 years were analyzed. There were 62 cases of type III fractures and 75 cases of type IV based on the Judet classification. Thirty-two cases had combined fractures and 19 cases presented with nerve injury. The open reduction rate was 24.1 % (33/137). Univariate analysis indicated obesity, fracture type, and combined fractures were significantly associated with open reduction. (P = 0.039, P = 0.000 and P = 0.000, respectively). While multivariate logistic regression analysis showed that only fracture type (OR, 5.18; CI, 1.63-16.46, p = 0.005) and combined fractures (OR, 7.79; CI, 2.97-20.41, p = 0.000) were independent risk factors for open reduction.

CONCLUSIONS

Judet type IV fracture and combined fractures are two significant risk factors for open reduction in operatively treated radial neck fractures in children. These findings will facilitate preoperative decision making, remind surgeons of the risk of failure in closed reduction and the use of new surgical techniques to decrease the open reduction poor outcome rate.

Ultrasound of peripheral nerve injury

Nerve injury in children is important to recognize early given the greater chance for recovery. Both children and adults have better outcomes the sooner nerve injuries are recognized and repaired. Children have even better functional results after surgical repair, thought to be related to their neural plasticity. Ultrasound is a powerful diagnostic tool for grading and mapping peripheral nerve injury and is complementary to electromyography and nerve conduction studies. Nerve injuries can be classified into low and high grade with ultrasound adding essential prognostic information and aiding in patient management. High-grade nerve injuries likely require surgical intervention. This article will review nerve anatomy and injury grading systems that radiologists can learn quickly in order to accurately communicate with their clinical partners. A practical approach to describe the sonographic appearance of nerve injury will be discussed. This article will show radiologists how the added value of ultrasound for peripheral nerve injury can directly affect clinical management.

Two fingerbreadths, one finger's width: on the proximity of the radial nerve to the deltoid tuberosity

INTRODUCTION

The aim of this study was to find a convenient technique to evaluate the location of the radial nerve (RN) with reference to the deltoid tuberosity (DT).

MATERIALS AND METHODS

Sixty-eight upper extremities, embalmed using a modified version of Thiel's method, were included in the study. The interval between the tip of the greater tubercle of the humerus and the distal tip of the lateral humeral epicondyle (LE) was defined as humeral length (HL). The most prominent point of the DT was used as the point of reference. Through this point, a horizontal reference line which met the humeral axis at the dorsal side of the humeral shaft was simulated. The longitudinal distance between the crossing point of the horizontal line and the humeral axis and the RN was measured (distance 1). The interval between the intersection point and the reference point at the DT was measured (distance 2). Data were evaluated in centimeters.

RESULTS

For the whole sample, the HL averaged 31.0 cm (SD: 2.3; range 26.2-36.9). Distance 1 averaged 2.2 cm (SD: 0.3; range 1.6-3.1), and distance 2 averaged 1.2 cm (SD: 1.0; range 0-2.8). The HL was larger in the male group when compared to females (p < 0.001; males mean: 32.2 cm; females mean 29.5 cm). There was no difference regarding distance 2 (p = 0.59; males mean: 1.2 cm; females mean: 1.3 cm) between the sexes. Distance 1 was significantly (p = 0.02) larger in the male group (mean: 2.3 cm) when compared to females (mean: 2.1 cm). Concerning sides, there were no differences regarding all evaluated parameters (HL: p = 0.6; Distance 1: p = 0.6; distance 2: p = 0.8).

CONCLUSIONS

This study provides an easily applicable technique to localize the RN with reference to the DT.

Complete transection of the sciatic nerve following closed femoral fracture

Complete transection of the sciatic nerve following femoral fracture is extremely rare. In the setting of closed injury it has only been reported in two other cases. Here we present a teenage motorcyclist who sustained a closed left, mid-femoral fracture following a road traffic collision with complete transection of the sciatic nerve. Despite being a closed injury, the obvious limb deformity of the patient and extreme pain prompted immediate nerve block during the primary survey making formal neurological assessment difficult. This case highlights the possibility of complete major nerve transection in closed injuries, and the importance of careful clinical examination alongside repeat imaging.

Humeral Shaft Fractures: A Literature Review on Current Treatment Methods

In this review, we aim to provide a concise yet comprehensive summation of the assessment and management of humeral shaft fractures. These are uncommon but prevalent enough that they are part of any trauma surgeon's scope of practice. They have historically been treated using non-operative methods, including braces and casts, supported by published excellent results in the rate of the bone union. However, recently published studies challenge these results and suggest the outcomes might be better with surgery, but the complications of an operation such as infection and nerve injury can not be overlooked. In summary, non-surgical treatment is still the gold standard in the treatment of these fractures, but the indications for surgical management are now clearer and include early signs of delayed union and patients who are unable to have a brace fitted or are uncompliant. It is likely that these new developments will start to change practice, and therefore the treatment of humeral shaft fractures should be a topic of interest of any clinician who deals with them.

Identification of most consistent and reliable anatomical landmark to locate and protect radial nerve during posterior approach to humerus: a cadaveric study

The location of the radial nerve (RN) is described with various bony landmarks, but such may be disturbed in the setting of fracture and dislocation of bone. Alternative soft tissue landmarks would be helpful to locate the nerve in such setting. To recognize certain anatomic landmarks to identify, locate and protect RN from any iatrogenic injury during surgical intervention such as open reduction and internal fixation. Forty arms belonging to 20 adult cadavers were used for this study. We measured the distance of RN from the point of confluence of triceps aponeurosis (TA), tip of the acromion and tip of the lateral epicondyle along the long axis of the humerus. These distances were correlated with the upper arm length (UAL). The average UAL was 32.64±0.64 cm. The distance of the RN from the point of confluence of TA (tricepso-radial distance, TRD), tip of acromion (acromion-radial distance) and tip of lateral epicondyle of humerus (condylo-radial distance, CRD) was 3.59±0.16 cm, 14.27±0.59 cm, and 17.14±1.29 cm respectively. No correlation was found with UAL. Statistically, TRD showed the least variability and CRD showed maximum variability. The minimum TRD was found to be 3.00 cm. So this should be considered as the maximum permissible length of the triceps split. The point of confluence of the TA appears to be the most stable and reliable anatomic landmark for localization of the RN during the posterior approach to the humerus.

Ulnar Nerve Injury in Pediatric Midshaft Forearm Fractures: A Case Series

OBJECTIVES

To describe a midshaft forearm fracture pattern that places the ulnar nerve at risk in the pediatric population and provide 7 clinical case examples describing the injury pattern and treatment methods.

DESIGN

Retrospective observational case series, review of literature, cadaver dissection, and treatment recommendations.

SETTING

Multi-institutional, Southeast United States.

PATIENTS

Seven pediatric patients (5 male and 2 female) with mean age of 8.7 years (range, 3-14) who sustained a significantly displaced closed, or grade I open, middle to distal one-third both-bone forearm fracture with subsequent ulnar nerve dysfunction.

INTERVENTIONS

Manual reduction and casting of both-bone forearm shaft fractures, operative debridement, fracture fixation, nerve exploration, neurolysis, nerve repair, and nerve grafting.

MAIN OUTCOME MEASUREMENTS

Radiographic fracture union, clinical ulnar nerve motor and sensory function testing, along with selective electric nerve testing and advanced imaging were monitored throughout follow-up postinjury.

RESULTS

Five of 7 patients underwent surgical treatment and 2 others were treated with conservative measures. The ulnar nerve was entrapped within the fracture site of one patient with an open fracture along with partial nerve transection, and 4 patients were found to have the nerve encased in hypertrophic scar tissue or bony callus upon surgical exploration at 3-12 months postinjury.

CONCLUSIONS

The ulnar nerve lies in a precarious position in the middle to distal one-third forearm and is bound by anatomic constraints that place the nerve at risk of injury. This article offers a treatment algorithm that includes conservative treatment, acute exploration, early exploration (≤3 months), and late exploration (>3 months).

LEVEL OF EVIDENCE

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

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

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

Humerus shaft fracture complicated by radial nerve palsy: Is surgical exploration necessary?

Fractures of the humerus shaft often are complicated by radial nerve palsy. Controversy still exists in the treatment that includes clinical observation and eventually late surgical exploration or early surgical exploration. Algorithms have been proposed to provide recommendations with regard to management of the injuries. However, advantages and disadvantages are associated with each of these algorithms. The aim of this study was to analyze the indications of each treatment options and facilitate the surgeon in choosing the conduct for each lesion, proposing our own algorithm.

Nerve Transfers for the Restoration of Wrist, Finger, and Thumb Extension After High Radial Nerve Injury

High radial nerve injury is a common pattern of peripheral nerve injury most often associated with orthopedic trauma. Nerve transfers to the wrist and finger extensors, often from the median nerve, offer several advantages when compared to nerve repair or grafting and tendon transfer. In this article, we discuss the forearm anatomy pertinent to performing these nerve transfers and review the literature surrounding nerve transfers for wrist, finger, and thumb extension. A suggested algorithm for management of acute traumatic high radial nerve palsy is offered, and our preferred surgical technique for treatment of high radial nerve palsy is provided.

The effects of tibial fracture and Ilizarov osteosynthesis on the structural reorganization of sciatic and tibial nerves during the bone consolidation phase and after fixator removal

Reactive and adaptive changes in mechanically uninjured nerves during fracture healing have not been studied previously although the status of innervation is important for bone union and functional recovery. This study explores whether subclinical nerve fibre degeneration occurs in mechanically uninjured nerves in an animal fracture model and to quantify its extent and functional significance. Twenty-four dogs were deeply anaesthetized and subjected to experimental tibial shaft fracture and Ilizarov osteosynthesis. Before fracture and during the experiment, electromyography was performed. In 7, 14, 20, 35–37 and 50 days of fixation and 30, 60–90 and 120 days after fixator removal, the dogs were euthanized. Samples from sciatic, peroneal and tibial nerves were processed for semithin section histology and morphometry. On the 37th postoperative day, M-response amplitudes in leg muscles were 70 % lower than preoperative ones. After fixator removal, these increased but were not restored to normal values. There were no signs of nerve injuries from bone fragments or wires from the fixator. The incidence of degenerated myelin fibres (MFs) was less than 12 %. Reorganization of Remak bundles (Group C nerve fibres—principally sensory) led to a temporal increase in numerical nerve fibre densities. Besides axonal atrophy, the peroneal nerve was characterized with demyelination–remyelination, while tibial nerve with hypermyelination. There were changes in endoneural vessel densities. In spite of minor acute MF degeneration, sustained axonal atrophy, dismyelination and retrograde changes did not resolve until 120 days after fracture healing. Correlations of morphometric parameters of degenerated MF with M-response amplitudes from electromyography underlie the subclinical neurologic changes in functional outcomes after tibial fractures even when nerves are mechanically uninjured.

Intraoperative neurophysiological monitoring in peripheral nerve surgery: Technical description and experience in a centre

INTRODUCTION

Intraoperative neurophysiological monitoring has experienced a spectacular development in the past 20 years, particularly in the fields of neurosurgery and spine surgery. it has become a useful, almost indispensable, tool in preventing nerve damage during surgery. The aim of this article is to describe the intraoperative technique and analyze its results in the field of peripheral nerve surgery.

OBJECTIVE

To describe the usefulness of a technique in peripheral nerve surgery, the technique used and the experience in a centre.

PATIENTS AND METHODS

A retrospective study was conducted on 30 cases of peripheral nerve surgery performed in this centre from 2009 to 2013, using the intraoperative monitoring technique.

RESULTS

Of the total of 13 peripheral nerve tumors recorded, there were 11 excellent results and 2 good results, one temporary hypoesthesia and one with almost complete sensory, except for motor, recovery. Traumatic injury was recorded in 17 cases, of which 6 required performing a graft, and the remaining 11 cases only neurolysis was performed, with complete motor and sensory recovery.

CONCLUSIONS

Intraoperative neurophysiological monitoring is a useful tool in the secondary surgery of peripheral nerve injury and the intraneural tumor pathology.

Radial nerve injuries

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.

Peripheral nerve repair and reconstruction

When possible, direct repair remains the current standard of care for the repair of peripheral nerve lacerations. In large nerve gaps, in which direct repair is not possible, grafting remains the most viable option. Nerve scaffolds include autologous conduits, artificial nonbioabsorbable conduits, and bioabsorbable conduits and are options for repair of digital nerve gaps that are <3 cm in length. Experimental studies suggest that the use of allografts may be an option for repairing larger sensory nerve gaps without associated donor-site morbidity.

Management of radial nerve palsy following fractures of the humerus

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

Ultrasound in pediatric peripheral nerve injuries: can this affect our surgical decision making? A preliminary report

BACKGROUND

The treatment of closed fractures with associated peripheral nerve palsy is controversial. Traditionally, the nerve palsy is managed with watchful waiting and subsequent neurophysiological studies if no improvement is seen within 4 months. This may not be necessary if nerve integrity can be imaged acutely with ultrasound scan. We present a case series of pediatric patients with closed upper limb injuries and associated peripheral nerve palsy who underwent ultrasound scanning to assess nerve integrity.

METHODS

A retrospective review of patients attending Starship Children's Hospital between May 2008 and April 2010 with closed upper limb injuries and associated peripheral nerve palsy was undertaken. Those patients up to and including the age of 14 years (skeletally immature) with complete clinical records available were included.

RESULTS

Complete clinical records were available for 24 patients who fit the inclusion criteria for the period of May 2008 to April 2010. Fifteen patients were managed expectantly and showed signs of spontaneous nerve recovery at a mean of 4 weeks. One patient proceeded to theater for early exploration where an intact but kinked nerve was found. Eight patients underwent ultrasound examination of their nerves; on the basis of the ultrasound findings, 3 proceeded to theater for nerve repair or neurolysis and 5 were managed expectantly with first signs of nerve recovery seen at a mean of 12 weeks for the surgical group, and 13.2 weeks for the nonsurgical group.

CONCLUSIONS

Ultrasound examination of peripheral nerves provides pathomorphologic information that can aid our clinical decision-making process and identify those patients who would benefit from early surgical intervention. In our case series, ultrasound findings correlated with intraoperative findings and clinical recovery.

LEVEL OF EVIDENCE

Level III evidence retrospective comparative study.

Posterior interosseous and ulnar nerve motor palsies after a minimally displaced radial neck fracture

Peripheral nerve injury is a serious potential complication following an upper extremity fracture. A rare case of acute posterior interosseous nerve and ulnar nerve palsy following a minimally displaced radial neck fracture is reported. With nonsurgical management, both nerves demonstrated excellent functional recovery. Although rare, nerve palsies can occur during a variety of upper extremity clinical situations, including minimally displaced fractures, and the importance of a detailed neurologic examination cannot be overstated.

Identification of the radial nerve during the posterior approach to the humerus: a cadaveric study

OBJECTIVE

Identification of the radial nerve is necessary during the posterior approach to the humerus in an effort to maintain its integrity. Other than anatomic descriptions of the radial nerve with respect to osseous structures, there are few superficial intraoperative landmarks along the course of the traditional triceps-splitting approach to provide facile nerve identification. The objective of this study was to determine the reliability of using the anatomic intersection of the long and lateral heads of the triceps and the triceps aponeurosis as a superficial reference point for radial nerve identification during the posterior approach to the humerus.

METHODS

Thirty adult human cadaver upper extremities as 15 matched pairs were used. Systematic identification and measurement from the point of intersection between the long and lateral heads of the triceps and the triceps aponeurosis to the distal most aspect of the radial nerve as it coursed the posterior humerus at its midaxial point was performed and recorded.

RESULTS

Mean distance was found to measure 39.0 ± 2.1 mm (range, 36-44 mm), approximating a fixed distance, two finger breadths proximal to our identified point of intersection. Statistical analysis between the two matched pair groups yielded no significant difference in measured distances (P = 0.88).

CONCLUSIONS

Our group has identified the point of intersection among three landmarks forming a point of intersection. This point is the confluence of the long and lateral heads of the triceps and the triceps aponeurosis. This serves as a visualized anatomic reference point during the posterior surgical exposure to the humerus and can be used to identify the radial nerve as it courses the posterior humerus.

Peripheral nerve injuries following gunshot fracture of the humerus

Current best evidence supports observation for peripheral nerve palsies following a fracture of the humerus unless associated with an open fracture. However, the indications for nerve exploration with humerus gunshot fractures are unclear. All patients aged 18 to 89 years who were treated for a gunshot fracture of the humerus at an academic trauma center between 2004 and 2008 were retrospectively reviewed. Patient demographics, fracture characteristics, fracture healing, nerve injury, and intraoperative findings were examined. Twelve patients were identified, of which 6 had nerve palsies at presentation. Three patients had an isolated single nerve palsy, and all recovered spontaneously within 90 days with observation. The other 3 patients had a concomitant brachial artery laceration, and all required a secondary nerve procedure, including 1 primary nerve repair for a near complete transection and 2 re-explorations with neurolysis due to lack of spontaneous recovery by 90 days. Nerve palsies are common after gunshot fractures of the humerus, but nerve transections are uncommon. We observed 1 nerve transection in 12 cases. However, in all 3 cases with a brachial artery injury, a nerve injury required surgical intervention. Subsequently, we recommend continued observation of isolated nerve palsies associated with gunshot fractures of the humerus. However, consider early nerve exploration of palsies when associated with a concomitant vascular injury.

The state of erythrocytes in intact and vagotomized rats of different ages after massive hemorrhage

Acute massive hemorrhage in rats is accompanied by consistent changes in the morphofunctional characteristics of erythrocytes: diameter, area, polarization, form factor, and integral and specific optical density. Thus, young initially intact rats showed significant increases in the mean diameter, area, and integral optical density at particular time points after hemorrhage, along with increases in erythrocyte polarization and form factor. Vagotomized rats of the same age group responded to hemorrhage only with an increase in the form factor. Initially intact aged rats in these conditions showed increases in the integral optical density and form factor. Aged vagotomized rats showed increases in erythrocyte mean diameter and area. The nature and dynamics of responses to hemorrhage in initially intact and vagotomized (14 days post-operative) animals were significantly different and had age-dependent features. Thus, the most marked changes in young initially intact animals were seen 3-10 h after hemorrhage, while maximum changes were seen at 3 and 96 h in vagotomized animals of the same age. In aged initially intact rats, the greatest changes in study parameters were seen at 3 and 96 h, while the greatest changes were seen in vagotomized rats at 3 and 24 h. The physiological mechanisms of these pathological states are discussed.

Nerve disorders of the hallux

Nerve disorders about the hallux can generate remarkable pain and dysfunction. Whether caused by soft tissue entrapment, trauma, iatrogenic injury, or from an idiopathic basis; nerve disorders are approached by careful history and examination followed by nonoperative treatment. In cases that do not respond, meticulous surgical management can be helpful in many cases.

Brachial plexus palsy following proximal humerus fracture in patients who are skeletally immature

From 1998 to 2006, 578 patients who were skeletally immature with proximal humerus fractures were treated at our institution. During that time period, 4 patients (0.7%) had associated brachial plexus and major peripheral nerve palsies. Average age at the time of injury was 12.3 years (range 10-14 years). Two fractures were physeal and 2 were metaphyseal. In all patients, the distal fracture fragment was displaced into the axilla, with resultant adduction and valgus malalignment at the time of injury. Two patients were treated with closed reduction and sling and swathe immobilization. One patient was treated with closed reduction and percutaneous pinning of the fracture. One patient was treated with sling immobilization without fracture reduction. All went on to bony healing with acceptable bony alignment. All patients were evaluated with serial physical examinations and radiographs to assess for neurologic recovery and bony healing. Average clinical and radiographic follow-up was 7.1 months (5-9 months). All patients demonstrated complete neurologic recovery by 5-9 months postinjury. All had neuropathic pain for at least 6 months after injury. No persistent neuropathic pain or functional limitations were seen at follow-up. Although rare, brachial plexus injury may accompany displaced proximal humeral fractures in patients who are skeletally immature. With careful attention to principles of fracture care, complete neurologic recovery may be expected within 9 months.