Radial Nerve Injury Humerus Fractures

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1967;49:899-902.J Bone Joint Surg Am.JOSEPH L. SHAW and HARILAOS SAKELLARIDES

REVIEW OF FORTY-FIVE CASESRadial-Nerve Paralysis Associated with Fractures of the Humerus: A

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Radia lN erve P ara ly sis A sso c ia ted w ith

F rac tu res o f th e H um eru s

A R EV IE W O F FO R TY -FIVE C ASES * t

B Y JO S E P H L . S H A W , M .D 4, A N D H A R IL A O S S A K E L L A H ID E S , M .D . ,

B OS T O N, ItIA SS AC HU SE TT S

R ad ia l-ne rve p ara ly sis a ssoc ia ted w ith frac tu re o f the hu m eru s is the m ost

con im oni p erip hera l n erve lesion com plicating frac tu res H ow ever, app ro priate

trea tm en t an d progn osis rem ain som ew ha t con tro ve rsia l

1 2 3 5 6 7 8 9 10

T he p ressin g

q uestion still rem a ins, W hen d o y ou exp lo re a n erve w h ich has fa iled to sh ow any

sign s o f recov e ry?

N erve -co ndu ctio n stud ie s an d e lec trom y ography a re o f consid erab le he lp in

ev alu atin g the sta tu s o f an in ju red n erve an d th e p ossib le r iced fo r exp lo ra tion

H ow ever, these too ls a re no t alw ays ava ilab le a rid a re d ifficu lt to app ly to an cx-

trem ity im m ob ilized in p la ster . T he refo re, it m ay be n ecessa ry to re ly on c lin ica l

d a ta alo ne to de te rm ine the ap propria te tim e fo r ne rv e ex p lo ra tion .

T he pu rp ose o f th is stu dy is to sh ow th a t th e ap pro priate tim e fo r ne rve ex -

p lo ratio n i can usu ally be de te rm ined fro m the clin ica l da ta an d to p o in t o u t th a t

th e m echan ism o f in ju ry , tim e fo r exp lo ra tio n , a rid p ro gno sis fo r rad ial-ne rve

p a ra lysis va ry co nsid erab ly , depend in g o n w hen the ne rve in ju ry occu rred w ith

respec t to the hum era l frac tu re a rid its subseq uen t trea tm en t.

C lin ic al M ate ria l

an d Da ta

T his stud y inc ludes fo rty -five cases o f rad ia l-ne rve para lys is asso cia ted w ith

h un ie ral frac tu res seen at the M assachu setts G ene ra l H osp ital from 1 934 to 19 64 .

T he da ta w ere ob tain ed by rev iew of th e ho sp ita l reco rds o f a ll pa tien ts , by personal

ex am in ra tion of fou rteen pa tien ts , seven of w h om w e had pe rson ally trea ted , a r id by

fo llo w -up q uestion iria ire s , filled ou t by the rem a in ing th ir ty -one pa tien ts . F if teen

ad d itiona l ca ses w ere eva lua ted bu t w ere elim ina ted because o f insu ff ic ien t fo llow -

up d ata .

T he ag e d istr ibu tio n at the tim e o f frac tu re ran ged fro m s ix to sev en ity -on re

y ea rs , th irty -tw o o f th e fo rty -f ive p atien ts 7 5 pe r cen t) w ere un de r fo rty yea rs o f ag e

and n in e 20 pe r cen t) w ere u nde r th ir teen y ears o f ag e. T h ere w ere tw en ty -e igh t

m cii a r id seven teen w on ien r .

T he hum era l fractu re s w ere cau sed b y fa lls from a stan d ing p ositio n r in six teen

pa tien ts , by au tom ob ile accid en rts in th irteen , by falls from a he igh t iii seve ti, a rid b y

m isce llan eo us in ju rie s in n in e.

lo rtv -tw o o f th e fo rty -fiv e frac tu re s w ere loca ted in the m idd le o r low er th ird

o f the hum erus . In the cases o f para ly sis o ccurring at th e tim e o f acciden t, the re

w ere abou t eq ua l n um b ers o f sp ira l, o b liqu e, a rid transve rse frac tu res . H ow ev er , iti

m ost o f these pa tien ts the re had a lso b een a severe in ju ry w ith m arked d isp lacen ien rt,

angulat ion ,

or com m inu tion of th e frac tu re . E ig h t o f the se fractu re s w ere open , b u t

n one w as caused b y a p ene tra ting w oun d . T he fin d ing s a rid resu lts o f trea tn ren rt in

th e l)a tien its w ith op en fractu re s d id r io t v ary sign ifican tly from tho se in th e pa t ien rts

4 1ea d at th e A nim al M eetinsg of T he A m er ica ns A cad eniy of O rthop aed ic S u rge on s, C hic ago

Il lin io is , Jan uary 23 , 19 66 .

t

P lease add res s requ ests fo r rep rin ts to : 1 ) r. Jose1)h L . S ha w , 2 47 5 P a-ific A ven su e, S ans F rau -

cis co , C alifo ris ia 9 41 15 .

P resb y teria n M ed ica l C en ste r, C lay an d W eb ste r S treets, S ar r F ra nsc isc o , C alifo rn sia .

{182}

)e par tm e irt o f O rth op aed ic S u rg ery , M a ssa chu se tts G ensera l h osp ita l , F ru it S tree t, B oston i,

M a.s sac hu set ts 0 211 4 .

VO L . 49-A N O . 5 JUL Y 1 9 6 7 89 9


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90 0 .r . L . S H A W A N D H A R IL A O S S A K E L L A R ID E S

w ith c lo se d frac tu res . In th is se rie s , the ra d ia l-n erv e pa raly se s

in

ch ild ren w ere asso -

c ia ted w ith m ore d istal su p raco ndy lar) frac tu res , ye t the tim e req u ired to rega in

fu nc tion w as lon ge r in the ch ild ren than in the ad u lts .

Resu l ts

Radia l Nerve P ara lys is Occurring a t the Time o f cc ident

In th irty -on e o f the fo rty -five p atien ts , p ara ly sis o cc u rre d w he n the hu m e rus

w as fractu red . T he pa ra lys is w as p artia l in six and com ple te in tw en ty -fiv e. F iv e

o f the pa rtia l p a ra lyse s recov e red fu lly . O n se t o f spon tan eo us reco ve ry usu ally

o ccu rred by tw o w eek s. T he tim e req u ired fo r fu ll reco ve ry va ried from th ree days to

e igh t m on th s, the av erage be ing four m on ths. T h ree pa tien ts w ho recov ered fu lly

had open red uc tion and in te rna l f ixa tion of the fractu re , bu t th e n erve w as exp lo red

in o n ly on e. In th is pa tien t, the ne rv e w as co m pressed

by

the frac tu re fragm en ts;

neu ro lysis w as no t n ecessa ry . T he six th pa tien t fa iled to rega in fu nc tion desp ite

de lay ed exp lo ratio n and neuro lys is .

O f th e tw en ty -f ive pa tien ts w ith com p lete p ara lysis , f ifte en rega ined fu ll ne rv e

func tion sp on taneous ly . O n se t o f reco very w as no ted at from tw o w eek s to four

m onth s, th e av erage be ing five w eek s. F u ll recove ry req u ired from th ree m o n ths to

tw o a rid o ne -ha lf years , o r an ave rag e of ten m on th s.

F ifteen of the pa tien ts w ith co m ple te p ara lysis u nde rw en t exp lo ratio n of the

ne rv e. T h e exp lo ra tion s w ere pe rfo rm ed w ith in six m on ths an ave rag e o f tw o a rid

on e-ha lf m o n ths a f ter in ju ry ) excep t in th ree pa tien ts w h o had exces sive ly de lay ed

ex p lo ra tions a t on e, one and o ne -h a lf, and th ree yea rs , re spec tive ly . T he ope rativ e

f in rd in rgs inc lu ded fo ur d iv ided ne rv es , tw o la rg e neurom as in con tinu ity w ith p artia l

d iv is io n of the n erve , fou r n eu ro m as, and fiv e co n tused n erves. O f the d iv ided

ne rves tw o w ere anastom osed a rid tw o w ere no t, because it

w as

fe lt tha t the gap

be tw een the ne rve end s cou ld rio t be b rid ged . B o th la rg e n reu ro m as in con tin u ity

w ere exc ised a rid neuro rrh ap hy w as pe rfo rm ed ; the fo u r n eu ro m as w ere treated by

n ieu ro ly sis , ar id the f ive co n tused n erves requ ired

no

repair .

T he re su lts o f su rge ry w ere d isco urag ing . T h e five con tused ne rves w hich re -

qu ired rio repa ir reco ve red . N o fu nc tiona l recove ry fo llo w ed the fo u r n eu ro rrhaph ies.

O nly on e of th e fou r n eu ro lyse s re su lted in im pro ved n erve fu nc tion , w ith fu ll

recov e ry in on e yea r. H ow ev e r, fiv e o f these e igh t p rocedu re s w ere p erfo rm ed

du rin g the 193 0s , an d th ree exp lo ra tion s w ere exces sive ly d e lay ed .

O f the rem a in ing ten p a tien ts w ith com ple te pa raly sis w h o d id no t u nde rgo

exp lo ratio n , n ine recov ered fu ll fun ctio n at an av erage of tw e lv e m o n th s a f ter

frac tu re, w h ile the ten th pa tien t, w ho sus tain ed a p ath o log ical frac tu re o f the

h um erus seco nda ry to fib ro sarcom a , failed to rega in an y rad ia l-n erve func tion .

Radia l Nerve Paralysis Occurring Immediate ly a fter F racture Manipula tion

F ive of the fo rty -five pa raly se s occu rred im m ed ia te ly af te r m an rip u la tio ir o f the

fractu re and w ere com ple te. F o ur o f the f ive w ere as soc iated w ith a spec ific ty pe of

frac tu re , a sp ira l o r ob liq ue frac tu re in the d ista l th ird o f the hum erus w ith la te ra l

an rgu la tion r an d o ve rr id ing of the fragm en ts . T he rad ia l n erve w as exp lo red at fro m

tw en rt\ -fou r h ours to th ree w eeks a fter m an ipu la tion of these fo u r frac tu re s a r id w as

fo und to be in tact bu t co m pressed be tw een the frac tu re fragm en rts .

In

a ll fou r

pa tien ts the ne rv e w as freed , th e fractu re wa s red uced an d s tab ilized w ith in te rn al

f ixa t ion ,

and retu rn o f rad ia l-ne rve fu nc tion w as co m ple te . R eco ve ry beg an tw o to

fou r w eeks a fter ope ratio n and w as com p lete a t an ave rage of n in e m on ths.

T he rem ain ing pa tien t in th is g roup w as a seven -yea r-o ld ch ild w ith a sup ra -

co n idy lar frac tu re . E xp lo ra tion w as no t p erfo rm ed . R ad ial-ne rve recov ery w as

com plete b y

n ine m on th s.

T H E JO UR N A L O F B O N E A N D JO IN T SU R G E R Y


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R A D IA L -N E R V E P A R A L Y S IS

90 1

Radia l Nerve P ara lysis Resulting from Open Reduction of Humera l Fra ctures

N ine of th e fo rty -fiv e p ara lyse s fo llow ed open redu ctio n an d in te rna l f ixa tio rr o f

th e frac tu re. F iv e o f these n in e frac tu re s w ere in the m id -sha ft an d requ ired ex tensiv e

exp osu re and fixa tion w ith m u ltip le screw s or a p late ar id sc rew s. In th ree pa tien ts

th e op e ra tive no te specif ically s tated th a t th e redu c tio ns w ere d ifficu lt a rid as soc iated

w ith heavy re trac tion on the rad ia l ne rve . T he rad ia l ne rv e w as id en tified a rid

retracted free o f th e fie ld in all fiv e case s.

T h e rem a in ing fo ur frac tu re s w ere in te rcon dy la r o r sup raco ndy lar and w ere

treated by o pen reduc tion and in te rna l f ixa tion w ith on e or m ore screw s. T he rad ia l

ne rve w as rio t iden tif ied in any of these p ro cedu re s an d red uc tion w as g ene ra lly

difficult.

In th is o ve r-all g roup , the ir, the re w ere six com ple te a rid th ree pa rtia l n erve

pa raly se s, a ll o f w h ich recove red fu lly . S even o f th e n in e began to recov e r spon i-

taneou sly w ith in tw o m o nths af te r th e op en redu ctio n . T h e av e rage tim e fo r fu ll

recovers

wa s

th ree m on th s fo r p artia l p ara lysis a rid eig h t m o n ths fo r com p lete pa ra l-

ys is . T he rem a in ing tw o rad ia l ne rves w ere ex p lo red becau se recove ry h ad n o t

b eg u n by th ree a r id fo ur m onths , resp ec tive ly . In bo th pa tien its the re w as a frac tu re

of the m id -sha ft o f the hu m eru s, and the ne rve w as su rroun ded by den ise scar tis sue ,

requ ir ing n ieu ro ly sis . O n set o f reco ve ry w as rio ted w ith in th ree w eeks o f n eu ro lysis ,

w ith fu ll recov ers occu rr ing w ith in th ree m on ths in each pa tien t.

T r ea t m en t

T h e genena lly o p tim istic a ttitude con ce rn ing th e p rog nos is fo r rad ia l-ne rve

pa raly sis a sso c iated w ith frac tu re o f th e hum erus is supp orted by the fin d ing s in

th is s tuds . Iu ll recove ry o f rad ial-ne rve fu nc tion o ccu rred in 75 p er cen t

of

th e

pa tien ts a r id in a ll pa tien ts in w hom paraly sis o ccu rred afte r m an ipu la tion or open

red uc tion o f the frac ttn re.

B y con tras t the re w as n o recovery in 40 per cen t o f the

com ple te pa ra lyse s w h ich occurred at th e tim e o f th e acc iden t.

Radia l Nerve P ara lys is OCCurring at the Time o f Humeral Fra cture

P artia l pa ra lys is a ssoc ia ted w ith c losed frac tu re s w h ich have been sa tisfac to r ily

red uced have a g ood progn osis . S ince in all p atien ts in th is se rie s reco ve ry b eg an

w ith in tw o m o nths, lack o f an y ev ide rrce o f spo n taneous recov ery a t tw o m onth s

jus tifie s e xp lo ra tion s.

In case s o f com l)le te rad ia l-ne rve pa ra ly sis a ssoc ia ted w ith c losed frac tu re s

w hich h ave b een sa tisfacto rily redu ced by g en tle m an ipu latio n , the frac tu re sh ou ld

b e im m o b iliz ed and th e p atien t ob served fo r on se t o f n e rve recov ery . If ev idence of

recov e ry is rio t rio ted w ith in seven to e igh t w eeks , exp lo ratio n a rid app ro pria te

trea tm en t o f th e ne rv e is ind icated .

E x p lo ra tio n o f th e n erve a t seven to e igh t w eeks 1 ) avo id s an un necessary

opera t ion

in m ost pa tien ts in s w h om sp on taneou s n erve recove ry w ill o ccu r; 2 ) does

r io t. i nt er fe re

w ith fractu re hea ling a rid co nsequ en tly do es r io t inc rea se the dang er o f

l iOns-uniOn

or de layed un ion ; 3 ) a llow s the n eu ro m a to becom e w e ll de linea ted and

h en rce to b e ad eq ua tely re sected ; a nd 4 ) d oes no t im p air satis fac to ry neuro rrhaph y

s in rce nerve re trac tion sh ou ld no t be excess iv e b y th is tim e .

H o w ever, im m ed ia te

o pe ra tive ex p lo ra tion of th e ne rve

is

ind ica ted fo r p artia l

01 co m ple te rad ia l-n e rve p a ra lysis a ssoc ia ted w ith 1 an o pen frac tu re o r 2 ) a clo sed

fractu re w hich requ ire s op en red uc tion an d in terna l fix atio n .

If th e ne rv e is fo und to b e in tact bu t s ev ere ly c ru shed a t th e tim e of ex p lo ra tio n

a ird reco ve ry is no t ev iden t a f ter seven to e igh t w eeks, n eu ro lysis o r re sec tion o f

n ieu ro m a and n eu ro rrhaphy sh ou ld be p erfo rm ed . If the n erve is d iv ided , the end s

sho u ld m ere ly be app rox im a ted and de lay ed resec tion o f the n eu ro m a an d nreu ro rr-

von .. 49-A . N O . 5 , J U L Y

1967


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90 2 J. L . SH A W AN D

H A R IL A O S S A K E L L A R ID E S

h ap hy be p erfo rm ed subseq uenrtly , un less the su rgeon

is

su ffic ien tly exp erienced to

assum e the su ccess o f a p rim ary neuro rrhaph y .

Radia l-N erve P ara lys is a fte r F ra c ture M anipu la tion

F our o f the f ive rad ia l-n erve in ju r ies in th is g roup w ere asso cia ted w ith a

sp ira l o r ob lique frac tu re in the d ista l th ird of the hum erus w ith la te ra l ang u lation

and o ve rr id in g o f frag m en ts as desc rib ed b y H olste in and L ew is

I m m ed i a t e

o pe ra tive ex p lo ratio n is ind ica ted fo r co m ple te o r p ro g re ss ive pa raly sis o f the rad ial

n ie rve co m ing o n afte r m an ipu latio n of a frac tu re , p ar ticu la rly on e in the low er

th ird o f th e hum erus . E x trem e cau tio n d urin g m an ip u la tive redu ctio n of frac tu re s

of th is type is clea rly in d icated .

Radia l-N erve Pa ra lysis F ollou in g O pen Redu ctio n o f H um era l F ra c tures

In th is g ro up of nerve in ju ries , assoc ia ted w ith m id-shaft o r supraconrd y la r

fractu re s trea ted

by op en

red uc tion , the p rog no sis is exce llen t. H ow ev e r, any ne rv e

w h ich fails to show ev idence of recov ery w ith in tw o m o nths sh ou ld p robab ly be

exp lo red .

C onc lus ion

1.

T he m echan ism o f in ju ry , treatm en t, and progn osis o f pa raly sis o f the rad ial

ne rve co m plica ting h um eral frac tu re s va ry consid erab ly , depen d ing on w hen the

ne rve in rju ry o ccurred w ith re spec t to the hu m era l frac tu re an d its subseq uen t

t rea tmen t . .

2 . It is he lp fu l to co nside r the se in ju rie s in th ree ca tego rie s:

(a )

pa ra ly sis o ccu r-

r ing a t th e tim e o f the accid en t,

(b )

pa ra lys is fo llo w in g m an ipu latio n of th e fractu re ,

and c ) P ara lY sis fo llow ing o pen redu ctio n .

3. T he clin ica l in d icatio ns fo r ex p lo ra tion of the ne rve app ear to be as fo llow s:

(a )

W hen pa ra ly sis occu rs a t the tim e of th e acc iden t a r id is assoc iated w ith a c losed

frac tu re, exp lo ratio n of the ne rv e is ind ica ted if no recov ery is no ted w ith in seven

to e igh t w eeks . If th e p a ra lysis is a ssoc iated w ith an op en fractu re o r a c losed

frac tu re w h ich requ ire s o pen red uc tion , o r if the pa ra lysis

is

progre ssive , im med ia te

ex p lo ra tio ns is in d icated .

(b )

P araly sis fo llow ing m an ipu la tion of a frac tu re in the

low er th ird o f the hum erus w ith la tera l an gu la tion a rid d isp lacem en t o f the frag -

merr ts requ ire s ea rly ex p lo ratio n r .

(c )

If pa ra lysis occu rs a f ter an r open red uc tion in

w hich the ne rv e w as rio t s een or the sta tu s o f th e n erve w as in do ub t, the ne rv e

sh ou ld be exp lo red if no recove ry is r io ted b y e igh t w eek s.

References

1.

B AT E MAN

J. E .: T raum a to N erve s m r L im b s. Ph ilad elp h ia W . B . Saunder s Co. 1962.

2. G ARCI A AL E XANDE R JR . an d

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Radial Nerve Injury Humerus Fractures

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