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Choi MJ, Murgai RR, Jose J, Hernandez GM, Hui-Chou HG. Combined Median, Ulnar, and Radial Nerve Injury after a Spiral Humeral Shaft Fracture. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6087. [PMID: 39171247 PMCID: PMC11338251 DOI: 10.1097/gox.0000000000006087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 07/01/2024] [Indexed: 08/23/2024]
Abstract
We report the case of a 43-year-old woman who presented with combined radial, median, and ulnar nerve palsies and a spiral humeral shaft fracture after falling down stairs. Postinjury, the patient did not recover full median, ulnar, and radial nerve function despite aggressive hand therapy. Electrodiagnostic studies and imaging findings were concerning for traction neuropraxia or transection, radial nerve neuroma, and scar encasement of the radial, median, and ulnar nerves. The patient underwent radial, median, ulnar, and musculocutaneous nerve neuroplasty, nerve wrap application, nerve stimulation and laser angiography. Surgical exploration revealed no transection injuries to the median, ulnar, or musculocutaneous nerves. The radial nerve was tethered to the fracture site and enlarged, but no neuroma was observed. Laser angiography demonstrated intact perfusion to all nerves. The patient went on to recover full nerve function. Although isolated radial nerve palsies associated with closed humeral shaft fractures are typically observed initially, management of combined nerve palsies is controversial. This case serves to caution surgeons to perform a thorough neurovascular examination on patients with humeral shaft fractures to identify combined nerve palsies.
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Affiliation(s)
- Melinda J. Choi
- From the Division of Plastic Surgery, Department of Surgery, University of Miami, Miami, Fla
| | - Rajan R. Murgai
- Division of Hand, Peripheral Nerve & Upper Extremity Reconstructive Surgery, Department of Orthopaedic Surgery, University of Miami, Miami, Fla
| | - Jean Jose
- Department of Radiology, University of Miami
| | - Giselle M. Hernandez
- Division of Trauma, Department of Orthopaedic Surgery, University of Miami, Miami, Fla
| | - Helen G. Hui-Chou
- From the Division of Plastic Surgery, Department of Surgery, University of Miami, Miami, Fla
- Division of Hand, Peripheral Nerve & Upper Extremity Reconstructive Surgery, Department of Orthopaedic Surgery, University of Miami, Miami, Fla
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Gunsoy Z, Sayer G, Dinc M, Soydemir OC, Oguzkaya S. The effect of plate location on radial nerve palsy recovery time associated with humeral shaft fractures. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02524-9. [PMID: 39008113 DOI: 10.1007/s00068-024-02524-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/04/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND This study aims to investigate the influence of plate placement on nerve regeneration in humerus fractures accompanied by radial nerve injury. METHODS A retrospective analysis was conducted on a cohort of 94 patients with humerus fractures and concomitant radial nerve injury treated between January 2018 and November 2022. After applying exclusion criteria, 31 patients were included in the study. Clinical outcomes were assessed by comparing demographic data, surgical duration, radial nerve recovery time, the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm Shoulder and Hand (DASH), and the Medical Research Council (MRC) scale. RESULTS Two distinct groups were established: lateral plating and anteromedial (AM) plating. These groups demonstrated comparability regarding age, gender, and body mass index (BMI). No statistically significant differences were observed between the groups concerning MEPS and MRC. The AM plating group notably exhibited shorter surgical durations, faster recovery times, and lower DASH scores. CONCLUSION According to the findings of this investigation, in cases of humerus fractures accompanied by radial nerve injury, AM plating may be preferable over lateral plating due to its association with reduced surgical durations and expedited nerve recovery.
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Affiliation(s)
- Zeki Gunsoy
- Department of Hand Surgery, Bursa City Hospital, Bursa, Turkey.
| | - Gokhan Sayer
- Department of Orthopedics and Traumatology, Bursa City Hospital, Bursa, Turkey
| | - Mustafa Dinc
- Department of Orthopedics and Traumatology, Bursa City Hospital, Bursa, Turkey
| | | | - Sinan Oguzkaya
- Department of Orthopedics and Traumatology, Bursa City Hospital, Bursa, Turkey
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3
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Iwanaga R, Mihara A, Sakai T, Muramatsu K, Hashimoto T. Radial Nerve Palsy Caused by Desmoid-Type Fibromatosis: A Case Report and Review of the Literature. Cureus 2024; 16:e65008. [PMID: 39161522 PMCID: PMC11333107 DOI: 10.7759/cureus.65008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2024] [Indexed: 08/21/2024] Open
Abstract
Radial nerve palsy (RNP) is classified as traumatic, non-traumatic, or iatrogenic. The most frequent etiologic agent is the fracture of the humerus of the shaftand distal. We experienced a case of RNP caused by desmoid-type fibromatosis around the radial nerve. The RNP caused by desmoid-type fibromatosis has not been reported in the literature. We present this case here with a review of the RNP literature. The patient is a 16-year-old female, right-hand dominant, who became aware of the difficulty in extending her right little finger without any triggers five months ago. She was also aware of the difficulty in extending the ring finger, and her symptoms gradually worsened. She was referred to our hospital after consulting a home doctor. MRI of the elbow showed a high-intensity occupying lesion on T2-weighted images (T2WI) slightly proximal to the elbow joint. Ultrasonography (US) showed a partial nerve constriction and radial nerve enlargement on the distal side of the constriction. The approach was made from the posterior lateral side of the distal upper arm, and the radial nerve was exposed. There was a 1 cm white tissue strongly adherent on the radial nerve, which was compressing the radial nerve, and it was resected piece by piece. After the resection, the radial nerve was indented. The pathological diagnosis of the resected tissue was fibromatosis. Gradually, she was able to extend her fingers after the surgery and recovered completely in six months.
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Affiliation(s)
- Ryuta Iwanaga
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, JPN
| | - Atsushi Mihara
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, JPN
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, JPN
| | - Keiichi Muramatsu
- Department of Hand and Microsurgery, Nagato General Hospital, Nagato, JPN
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Weisberg ZS, Wolf JM. Radial Nerve Palsy in the Setting of Humeral Shaft Fracture. J Hand Surg Am 2024; 49:690-697. [PMID: 38713112 DOI: 10.1016/j.jhsa.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/17/2024] [Accepted: 03/31/2024] [Indexed: 05/08/2024]
Abstract
The upper limb has a complex anatomy comprised of many nerve and vascular structures, making humeral shaft fractures extremely important. Injury to the humeral shaft commonly occurs due to trauma and affects younger male or older female patients. The radial nerve travels along the spiral groove of the humerus, placing it at an increased risk of damage in humeral shaft fractures. If injured, there are a variety of classifications of radial nerve injury, different indications for exploration, and treatment methods that orthopedic surgeons have available in treating these injuries. This review aims to discuss the etiology of humeral shaft fracture-associated radial nerve palsy, tools for diagnosis, and treatment.
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Graham JG, Davis DE. Augmented Fixation in Transverse Midshaft Humerus Fractures Using a Nitinol Staple: Surgical Technique and Case Series. Tech Hand Up Extrem Surg 2024; 28:80-87. [PMID: 38305354 DOI: 10.1097/bth.0000000000000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Maintaining the reduction of a transverse humeral shaft fracture can be particularly challenging while applying a compression plate for definitive fixation. Nitinol compression staples are being increasingly utilized in orthopedic surgery due to their unique ability to apply continuous compression between staple legs at body temperature. We have found them to be particularly useful in the maintenance of the reduction of transverse humeral shaft fractures before compression plate application. This simple technique allows for the removal of reduction clamps and precise plate placement. We describe our technique for using nitinol compression staples to augment fracture fixation in transverse humeral shaft fractures as well as our experience using this technique in a case series of 4 patients.
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Affiliation(s)
- Jack G Graham
- The Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Böhringer A, Cintean R, Schütze K, Gebhard F. Primary Radial Nerve Lesions in Humerus Shaft Fractures-Revision or Wait and See. J Clin Med 2024; 13:1893. [PMID: 38610658 PMCID: PMC11012818 DOI: 10.3390/jcm13071893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/13/2024] [Accepted: 03/17/2024] [Indexed: 04/14/2024] Open
Abstract
Background: This study investigates the surgical state-of-the-art procedure for humeral shaft fractures with primary radial nerve palsy based on its own case series in relation to the current and established literature. Methods: Retrospective review of treated cases between January 2018 and December 2022 describing radial nerve palsy after humerus shaft fractures, radiological fracture classification, intraoperative findings, surgical procedure, patient follow-up and functional outcome. Results: A total of 804 patients (463 women and 341 men) with humerus shaft fractures were identified. A total of 33 patients showed symptomatic lesions of the radial nerve (4.1%). The primary lesion was identified in 17 patients (2.1%). A broad and inhomogeneous distribution of fractures according to the AO classification was found. According to the operative reports, the distraction of the radial nerve was found eleven times, bony interposed three times and soft tissue constricted/compressed three times. In every case the radial nerve was surgically explored, there was no case of complete traumatic nerve transection. Four intramedullary nails and thirteen locking plates were used for osteosynthesis. Complete recovery of nerve function was seen in 12 cases within 1 to 36 months. Three patients still showed mild hypesthesia in the thumb area after 18 months. Two patients were lost during follow-up. Conclusions: With this study, we support the strategy of early nerve exploration and plate osteosynthesis in humeral fractures with primary radial nerve palsy when there is a clear indication for surgical fracture stabilisation. In addition, early exploration appears sensible in the case of palsies in open fractures and secondary palsy following surgery without nerve exposure as well as in the case of diagnostically recognisable nerve damage. Late nerve exploration is recommended if there are no definite signs of recovery after 6 months. An initial wait-and-see strategy with clinical observation seems reasonable for primary radial nerve palsies without indication for surgical fracture stabilisation.
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Affiliation(s)
- Alexander Böhringer
- Department of Trauma Hand and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Abboud J, Sader Z, Flouzat-Lachaniette CH, Dubory A, Moussa MK, Facca S, Zeaiter N, Souleiman B, Jaber MH, Tannous A, Dagher T, Ghandour M. The comparative efficacy of nerve transfer versus tendon transfer in the management of radial palsy: A systematic review and meta-analysis. J Orthop 2024; 48:25-31. [PMID: 38059217 PMCID: PMC10696201 DOI: 10.1016/j.jor.2023.11.026] [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: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 12/08/2023] Open
Abstract
Background There is no clear census as to which operative technique provides better recovery for radial nerve injuries. Therefore, in this systematic review, we examined the functional recovery, patient-reported outcomes, and complications of tendon transfer (TT) and nerve transfer (NT). Methods Five electronic databases were searched for studies (>10 cases per study) comparing NT and TT regardless of the study design (observational or experimental). Manual search was also conducted. The quality was assessed by the NIH tool. Outcomes included functional recovery, patient-reported outcomes (DASH score, satisfaction, and inability to return to work), and complications. The prevalence was pooled across studies using STATA software, and then, a subgroup analysis based on the intervention type. Results Twenty-one studies (542 patients) were analyzed. Excellent recovery, assessed by the Bincaz scale, was higher in the TT group (29 % vs. 11 %) as well as failure to extend the fingers (49 % vs. 9 %). No significant difference was noted between both groups regarding DASH score (mean difference = -2.76; 95 % CI: -12.66: 6.93). Satisfaction was great in the TT group (89 %) with a limited proportion of patients unable to return to work (7 %). Complications were slightly higher in the TT group (8 % vs. 7 %) while 18 % of patients undergoing TT requiring revision surgery. Radial deviation was encountered in 18 % of patients in the TT group and 0 % in the NT group. The quality was good, fair, and poor in 2, 13, and 6, respectively. Conclusions In radial nerve injuries, although tendon transfer may seem to provide better functional motor recovery than nerve transfer, it is associated with a higher rate of failure to extend the finger. Given the large confidence interval, the accuracy of this finding is questioned. However, a great proportion of those patients require revision surgery afterward. Additionally, tendon transfer is associated with a greater complication rate than nerve transfer, particularly radial deviation.
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Affiliation(s)
- Johnny Abboud
- CHU Henri Mondor, Université Paris Est, 1 rue Gustave Eiffel, 94000, Créteil, France
| | - Ziad Sader
- Service d’Orthopédie et Traumatologie, Hôpitaux Civils de Colmar, France
| | | | - Arnaud Dubory
- CHU Henri Mondor, Université Paris Est, 1 rue Gustave Eiffel, 94000, Créteil, France
| | | | - Sybille Facca
- Orthopedic and Hand Surgery Dept, SOS Hand Group Practice, Strasbourg University Hospitals, 10, avenue Achille-Baumann, 67403, Illkirch cedex, France
| | - Nancy Zeaiter
- Plastic Surgery Department, Lebanese University, Beirut, Lebanon
| | | | | | | | - Tanios Dagher
- Orthopedic Department, Lebanese University, Beirut, Lebanon
| | - Maher Ghandour
- Orthopedic Department, Lebanese University, Beirut, Lebanon
- Orthopedic Department, Heidelberg University Hospital, Germany
- Department of Orthopedics Surgery, CHU Grenoble Alpes, 38000, Grenoble, France
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8
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Chalk C. Radial neuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:127-134. [PMID: 38697735 DOI: 10.1016/b978-0-323-90108-6.00015-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Radial neuropathy is the third most common upper limb mononeuropathy after median and ulnar neuropathies. Muscle weakness, particularly wrist drop, is the main clinical feature of most cases of radial neuropathy, and an understanding of the radial nerve's anatomy generally makes localizing the lesion straightforward. Electrodiagnosis can help confirm a diagnosis of radial neuropathy and may help with more precise localization of the lesion. Nerve imaging with ultrasound or magnetic resonance neurography is increasingly used in diagnosis and is important in patients lacking a history of major arm or shoulder trauma. Radial neuropathy most often occurs in the setting of trauma, although many other uncommon causes have been described. With traumatic lesions, the prognosis for recovery is generally good, and for patients with persistent deficits, rehabilitation and surgical techniques may allow substantial functional improvement.
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Affiliation(s)
- Colin Chalk
- Department of Neurology and Neurosurgery, McGill University, Montreal, QC, Canada.
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9
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Farid AR, Friend TH, Atarere J, Gustin M, Suneja N, Weaver MJ, Von Keudell AG. Operative and Nonoperative Treatment of Humeral Shaft Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am 2023; 105:1420-1429. [PMID: 37478297 DOI: 10.2106/jbjs.22.01386] [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: 07/23/2023]
Abstract
BACKGROUND Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures. METHODS We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold. RESULTS The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective. CONCLUSIONS Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option. LEVEL OF EVIDENCE Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander R Farid
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tynan H Friend
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joseph Atarere
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Gustin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
| | - Arvind G Von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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10
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Zhu S, Lei GW, Pang Z, Gao ZR, Shen YD, Xu WD. Outcomes and prognostic factors for nerve grafting following high radial nerve injury. J Hand Surg Eur Vol 2023; 48:747-754. [PMID: 36708214 DOI: 10.1177/17531934221147651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In this study, we examined the prognostic factors affecting outcomes following nerve grafting in high radial nerve injuries. Thirty-three patients with radial nerve injuries at a level distal to the first branch to the triceps and proximal to the posterior interosseous nerve were retrospectively studied. After a follow-up of at least 1 year, 24 patients (73%) obtained M3+ wrist extension, 16 (48%) obtained M3+ finger extension and only ten (30%) obtained M3+ thumb extension. Univariate, multivariate and receiver operating characteristic analyses showed that a delay in the repair of less than 6 months, a defect length of less than 5 cm or when grafted with three or more donor nerve cables achieved better recovery. Number of cables used was related to muscle strength recovery but not time to reinnervation. Nerve grafting for high radial nerve injury achieved relatively good wrist extension but poor thumb extension and is affected by certain prognostic factors. Level of evidence: IV.
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Affiliation(s)
- Shuai Zhu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Gao-Wei Lei
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhen Pang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zheng-Run Gao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yun-Dong Shen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-Dong Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Orapiriyakul W, Apivatthakakul V, Theppariyapol B, Apivatthakakul T. Humerus shaft fractures, approaches and management. J Clin Orthop Trauma 2023; 43:102230. [PMID: 37588079 PMCID: PMC10425411 DOI: 10.1016/j.jcot.2023.102230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/30/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023] Open
Abstract
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.
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Affiliation(s)
- Wich Orapiriyakul
- Department of Orthopedics, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Varat Apivatthakakul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Bodin Theppariyapol
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
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Greiner F, Kaiser G, Kleiner A, Brugger J, Aldrian S, Windhager R, Hajdu S, Schreiner M. Distal locking technique affects the rate of iatrogenic radial nerve palsy in intramedullary nailing of humeral shaft fractures. Arch Orthop Trauma Surg 2023; 143:4117-4123. [PMID: 36316427 PMCID: PMC10293438 DOI: 10.1007/s00402-022-04665-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/12/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intramedullary humeral nailing is a common and reliable procedure for the treatment of humeral shaft fractures. Radial nerve palsy is a common complication encountered in the treatment of this pathology. The radial nerve runs from posterior to anterior at the lateral aspect of the distal humerus. Hence, there is reason to believe that due to the anatomic vicinity of the radial nerve in this area, lateral-medial distal locking in intramedullary nailing of the humerus may be associated with a greater risk for iatrogenic radial nerve injury compared to anterior-posterior locking. QUESTIONS/PURPOSE To assess whether the choice of distal locking (lateral-medial versus anterior-posterior distal locking) in intramedullary humeral nailing of humeral shaft fractures affects the risk for iatrogenic radial nerve injury. PATIENTS AND METHODS Overall, 203 patients (116 females, mean age 64.3 ± 18.6 years), who underwent intramedullary nailing of the humerus between 2000 and 2020 at a single level-one trauma center, met the inclusion criteria and were analyzed in this retrospective case-control study. Patients were subdivided into two groups according to the distal locking technique. RESULTS Anterior-posterior locking was performed in 176 patients versus lateral-medial locking in 27 patients. We observed four patients with iatrogenic radial nerve palsy in both groups. Risk for iatrogenic radial nerve palsy was almost 7.5 times higher for lateral-medial locking (OR 7.48, p = 0.006). There was no statistically significant difference regarding intraoperative complications, union rates or revision surgeries between both groups. CONCLUSIONS Lateral-medial distal locking in intramedullary nailing of the humerus may be associated with a greater risk for iatrogenic radial nerve palsy than anterior-posterior locking. Hence, we advocate for anterior-posterior locking. LEVEL OF EVIDENCE Level III retrospective comparative study.
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Affiliation(s)
- Fabian Greiner
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Georg Kaiser
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Anne Kleiner
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Jonas Brugger
- Center for Medical Statistics, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Silke Aldrian
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Stefan Hajdu
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Markus Schreiner
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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13
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Dowlut N, Horlick S, Ather S, Gwilym S. Humeral shaft fractures: a practical guide to assessment and management. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37127420 DOI: 10.12968/hmed.2020.0653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Fractures of the humeral shaft represent roughly 5% of all fractures. They occur in an approximate bimodal distribution, typically affecting young adults following trauma and older females after low energy falls in the presence of osteoporosis. Humeral shaft fractures are associated with pain, temporary disability and a reduced quality of life for the duration of treatment. Treatment goals are directed towards achieving and maintaining a fracture environment conducive to healing, pain relief and early restoration of function. While most humeral shaft fractures are conservatively managed, operative management is indicated in certain circumstances. This article provides an overview of these fractures, including their initial management approach and definitive treatment.
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Affiliation(s)
- Naeem Dowlut
- Joint Reconstruction Unit, Royal National Orthopaedic Hospital, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK
| | - Serena Horlick
- Department of Trauma and Orthopaedics, Kingston Hospital, Kingston Hospital NHS Foundation Trust, Kingston, UK
| | - Sarim Ather
- Department of Radiology, John Radcliffe Hospital, Oxford, UK
| | - Steve Gwilym
- Nuffield Department of Orthopaedics and Rheumatology (NDORMS), University of Oxford, Oxford, UK
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14
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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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Ali MA, Freilich S. Wrist drop after a fall onto the shoulder. BMJ 2023; 380:e070708. [PMID: 36634961 DOI: 10.1136/bmj-2022-070708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- M Adam Ali
- Royal Free Hospital, Royal Free London NHS Foundation Trust, UK
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16
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Wiktor Ł, Tomaszewski R. Treatment of Radial Nerve Palsy in Paediatric Humeral Shaft Fractures. STROBE-Compliant Investigation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1571. [PMID: 36363527 PMCID: PMC9697801 DOI: 10.3390/medicina58111571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/09/2022] [Accepted: 10/29/2022] [Indexed: 12/25/2023]
Abstract
Background and Objectives:Due to the rarity of radial nerve palsy in humeral shaft fractures in the paediatric population and the lack of data in the literature, the purpose of our study was to report the treatment results of six children who sustained a radial nerve injury following a humeral shaft fracture. Materials and Methods: We treated six paediatric patients with radial nerve palsy caused by a humeral shaft fracture in our department from January 2011 to June 2022. The study group consisted of four boys and one girl aged 8.6 to 17.2 (average 13.6). The mean follow-up was 18.4 months. To present our results, we have used the STROBE protocol designed for retrospective observational studies. Results:We diagnosed two open and four closed humeral shaft fractures. Two simple transverse AO 12A3c; one simple oblique AO 12A2c; two simple spiral AO 12A1b/AO 12A1c and one intact wedge AO 12B2c were recognized. The humeral shaft was affected in the distal third five times and in the middle third one time. In our study group, we found two cases of neurotmesis; two entrapped nerves within the fracture; one stretched nerve over the bone fragments and one case of neuropraxia. We found restitution of the motor function in all cases. For all patients, extensor muscle strength was assessed on the grade M4 according to the BMRC scale (except for a patient with neuropraxia-M5). The differences in patients concerned the incomplete extension at the radiocarpal and metacarpophalangeal (MCP) joints. Conclusions: In our small case series, humeral shaft fractures complicated with radial nerve palsy are always challenging medical issues. In paediatric patients, we highly recommend an US examination where it is possible to be carried out to improve the system of decision making. Expectant observation with no nerve exploration is reasonable only in close fractures caused by low-energy trauma. Early surgical nerve exploration related with fracture stabilisation is highly recommended in fractures after high-energy trauma, especially in open fractures and where symptoms of nerve palsy appear at any stage of conservative treatment.
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Affiliation(s)
- Łukasz Wiktor
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children’s Health Centre, 40-752 Katowice, Poland
- Department of Trauma and Orthopedic Surgery, ZSM Hospital, 41-500 Chorzów, Poland
| | - Ryszard Tomaszewski
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children’s Health Centre, 40-752 Katowice, Poland
- Institute of Biomedical Engineering, Faculty of Science and Technology, University of Silesia in Katowice, 40-007 Katowice, Poland
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17
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Risk of Radial Nerve Injury in Anterolateral Humeral Shaft Plating. J Am Acad Orthop Surg 2022; 30:903-909. [PMID: 36166385 DOI: 10.5435/jaaos-d-21-00970] [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] [Received: 09/17/2021] [Accepted: 04/17/2022] [Indexed: 02/01/2023] Open
Abstract
PURPOSE The purpose of this study was to evaluate and compare the risk of iatrogenic radial nerve injury between arm positionings of 45° and 60° abduction in anterolateral humeral plating using a 4.5-mm narrow dynamic compression plate. METHODS Fifty-six humeri of cadavers in the supine position with 45° of arm abduction were exposed through the anterolateral approach. A hypothetical fracture line was marked at the middle of the humerus, and a precontoured ten-hole 4.5-mm narrow dynamic compression plate was applied and fixed to the anterolateral surface. After the fixation, the radial nerve was exposed through a triceps-splitting approach. Screws in contact with or which had penetrated the radial nerve were deemed to be injuries. Then, the screws and plate were removed, the arm changed to the 60° arm abduction position, and the steps of applying the plate and inserting the screws were followed as in the 45° arm abduction step. RESULTS The screws which could potentially injure the radial nerve were those of the second to sixth screw holes in both the 45° and 60° of arm abduction positions. The incidences of iatrogenic radial nerve injury of the second to sixth screw holes in the 45° position were 5.36%, 39.29%, 80.36%, 60.71%, and 10.71%, respectively, and at the 60° position were 5.36%, 53.57%, 83.93%, 60.71%, and 7.14%, respectively. There were no statistically significant differences in risk of injury between the two positions in all screw holes (all P-values > 0.05). DISCUSSION In anterolateral humeral shaft fixation, arm abduction position did not affect the risk of iatrogenic radial nerve injury, with the main risk from certain screw holes. The surgeon should be careful in screw insertion, especially at the fourth and fifth screw holes. LEVEL OF EVIDENCE IV; cadaveric study.
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Fox HM, Hsue LJ, Thompson AR, Ramsey DC, Hadden RW, Mirarchi AJ, Nazir OF. Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management. J Shoulder Elbow Surg 2022; 31:1969-1981. [PMID: 35398163 DOI: 10.1016/j.jse.2022.02.033] [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: 09/27/2021] [Revised: 02/12/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated. METHODS A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated. RESULTS Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses. CONCLUSIONS Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.
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Affiliation(s)
- Henry M Fox
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Lauren J Hsue
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Austin R Thompson
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Duncan C Ramsey
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Ryan W Hadden
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Adam J Mirarchi
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Omar F Nazir
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA.
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19
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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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20
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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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21
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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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22
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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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23
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Abstract
Humeral shaft fractures are relatively common, representing approximately 1% to 5% of all fractures. Conservative management is the treatment of choice for most humeral shaft fractures and offers functional results and union rates that are not inferior to surgical management. Age and oblique fractures of the proximal third are risk factors for nonunion. Surgical indication threshold should be lower in patients older than 55 years presenting with this type of fracture. Functional outcomes and union rates after plating and intramedullary nailing are comparable, but the likelihood of shoulder complications is higher with intramedullary nailing. There is no advantage to early exploration of the radial nerve even in secondary radial nerve palsy.
Cite this article: EFORT Open Rev 2021;6:24-34. DOI: 10.1302/2058-5241.6.200033
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Affiliation(s)
- Nicolas Gallusser
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Bardia Barimani
- Division of Orthopedic Surgery, McGill University, Montreal, Canada
| | - Frédéric Vauclair
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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24
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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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From Bench to Bedside: Patience is a Virtue-A Time to Reflect and Reevaluate Surgical Indications. Clin Orthop Relat Res 2020; 478:1981-1983. [PMID: 32452932 PMCID: PMC7431258 DOI: 10.1097/corr.0000000000001328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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