Treatment of radial nerve palsyfollowing humerus shaft fractures

still a controversy?

Dr Uday Kumar MS(Orth) DNB(Orth)

Sagar HospitalsSindhi HospitalChinmaya Hospital

Bangalore

24th May 2014RATS

• Incidence 11.8% of shaft fractures

(532 palsies in 4517 fractures).

• Primary - occurs @ injury

• Secondary - occurs later during

closed or open management

• Mangement controversial

Radial nerve palsy

Jbjs 2005

• Transverse fractures of middle 1/3 most

commonly associated with neuropraxia

• Spiral fractures of distal 1/3 (Holstein-Lewis

fracture)-- higher risk of laceration or

entrapment of the radial nerve

--a wrist drop splint is given

--static or dynamic splint

--exercises

Radial nerve palsy foll # humerusManagement

• Spontaneous recovery of nerve function is

found in >70% of cases

• Even secondary palsies, those associated

with fracture manipulation, have a high rate

of spontaneous recovery

• 90% will resolve in 3 to 4 months

Management

Controversies

---To explore or not to explore

---When to explore---Early---Late

EXPLORE RADIAL NERVE

--ORIF HUMERUS---EXPLORE NERVE AND FIX

--OPEN FRACTURE HUMERUS

--RADIAL NERVE PALSY FOLLOWING CLOSED REDUCTION

--HOLSTEIN-LEWIS FRACTURE

The American Journal of Orthopedics®M. W. Heckler et al--2009

Proponents of early exploration

-technically easier and safer

-clarifies diagnosis and extent of lesion

-OR reduces further nerve damage

-early means within 3 weeks

Proponents of late exploration(wait for 4 months then explore)

-High rate of spontaneous recovery90% recover by 3 months

-avoid unnecessary nerve dissection as majority are neuropraxias

-easier to treat nerve injury after fracture has healed

• Precise evaluation of a nerve lesion is

possible

• The associated fracture will(may) have

united

• The results of secondary repair are as good

as those of primary repair

• Exploration for palsy in an open fracture is the

only indication that is not associated with

conflicting data

• For secondary palsies, it is not clearly

established that surgery will improve the

ultimate recovery rate compared to nonsurgical

management

Jbjs 2005

• Review of 714 primary and 130 secondary palsies all

observed initially,

no difference noted in recovery rates (88.6% and

93.1%, respectively) after closed treatment

Hak D, Orthopedics 32:111 (2009)

• Early exploration may risk additional injury to nerve

if it is only contused

Electro diagnostic studies

--done after 3-6 weeks after injury

--useful only after the process of walleriandegeneration has set in

--not able to distinguishbetween a severed nerve andunrecovered intact nerve

Results from electrical studies parallel clinical findings.

Electrical signs of recovery occur no more than a month before recovery becomes apparent clinically

Ultrasound exam of radial nerve

-done about 3 weeks after injury

-should be done by an experienced radiologist

-differentiates between a severed and intact nerve

-drawbacks: observer dependent

How long to wait before exploration?

Shao et al-- the mean time to the onset of spontaneous recovery was 7.3 weeks-- minimum waiting time before exploration

- The optimal time of observation before intervention has been debated, but no clear answer is universally supported

- About 4 -6 months

Nerve exploration, neurolysis and nerve grafting

most appropriatein patients who can tolerate

--- a wrist brace--- long recovery periods and --- an uncertain outcome

--- reserved for patients 6 to 12 months from injury with no signs of recovery.

Tendon transfers

Indications

-persistent palsy after an extended recovery period

-persistent palsy after neurolysis or nerve grafting

-patients who want rapid return of nerve function

-timing---usually at least a year from injuryto allow for possible recovery

ConclusionsRadial nerve palsy following # shaft humerus

-Recovery occurs in 90% cases in 3-4 months

-Early exploration is indicated in ORIF, open fractures-Exploration for secondary nerve palsy and

Holstein-Lewis # remains equivocal

-Electrodiagnostic studies do not differentiatebetween a severed nerve and an unrecovered intact nerve

-Tendon transfers should be done if there ispersistent palsy after 1 year after injury