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Li Y, Luo Y, Peng J, Fan J, Long XT. Clinical effect of operative vs nonoperative treatment on humeral shaft fractures: Systematic review and meta-analysis of clinical trials. World J Orthop 2024; 15:783-795. [PMID: 39165869 PMCID: PMC11331324 DOI: 10.5312/wjo.v15.i8.783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 06/05/2024] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND Whether operation is superior to non-operation for humeral shaft fracture remains debatable. We hypothesized that operation could decrease the nonunion and reintervention rates and increase the functional outcomes. AIM To compare the clinical efficacy between operative and nonoperative approaches for humeral shaft fractures. METHODS We searched the PubMed, Web of Science, ScienceDirect, and Cochrane databases from 1990 to December 2023 for clinical trials and cohort studies comparing the effects of operative and conservative methods on humeral shaft fractures. Two investigators independently extracted data from the eligible studies, and the other two assessed the methodological quality of each study. The quality of the included studies was assessed using the Cochrane risk bias or Newcastle-Ottawa Scale. The nonunion, reintervention and the overall complications and functional scores were pooled and analyzed using Review Manager software (version 5.3). RESULTS A total of four randomized control trials and 13 cohort studies were included, with 1285 and 1346 patients in the operative and nonoperative groups, respectively. Patients in the operative group were treated with a plate or nail, whereas those in the conservative group were managed with splint or functional bracing. Four studies were assessed as having a high risk of bias, and the other 13 were of a low risk of bias according to the Newcastle-Ottawa Scale or Cochrane risk bias tool. The operative group had a significantly decreased rate of nonunion [odds ratio (OR) 0.30; 95%CI: 0.23 to 0.40), reintervention (OR: 0.33; 95%CI: 0.24 to 0.47), and overall complications (OR: 0.62; 95%CI: 0.49 to 0.78)]. The pooled effect of the Disabilities of Arm, Shoulder, and Hand score showed a significant difference at 3 [mean difference (MD) -8.26; 95%CI: -13.60 to -2.92], 6 (MD: -6.72; 95%CI: -11.34 to -2.10), and 12 months (MD: -2.55; 95%CI: -4.36 to -0.74). The pooled effect of Visual Analog Scale scores and the Constant-Murley score did not significantly differ between the two groups. CONCLUSION This systematic review and meta-analysis revealed a trend of rapid functional recovery and decreased rates of nonunion and reintervention after operation for humeral shaft fracture compared to conservative treatment.
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Affiliation(s)
- Yang Li
- Department of Traumatic Orthopedics, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Yi Luo
- Department of Orthopedics, Bishan Hospital of Chongqing, Chongqing 402760, China
| | - Jing Peng
- Department of Traumatic Orthopedics, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Jun Fan
- Department of Traumatic Orthopedics, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Xiao-Tao Long
- Department of Traumatic Orthopedics, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
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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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Ha C, Choi I, Lee JK, Oh J, Ahn W, Han SH. Anterolateral Dual Plate Fixation for Distal Metaphyseal-Diaphyseal Junction Fractures of the Humerus: Biomechanical Finite Element Analysis with Clinical Results. Clin Orthop Surg 2024; 16:493-505. [PMID: 38827752 PMCID: PMC11130622 DOI: 10.4055/cios23376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 06/04/2024] Open
Abstract
Background Distal metaphyseal-diaphyseal junction fractures of the humerus are a subset of injuries between humeral shaft fractures and distal intra-articular humerus fractures. A lack of space for distal fixation and the unique anatomy of concave curvature create difficulties during operative treatment. The closely lying radial nerve is another major concern. The aim of this study was to determine whether anterolateral dual plate fixation could be effective for a distal junctional fracture of the humerus both biomechanically and clinically. Methods A right humerus 3-dimensional (3D) model was obtained based on plain radiographs and computed tomography data of patients. Two fractures, a spiral type and a spiral wedge type, were constructed. Three-dimensional models of locking compression plates and screws were constructed using materials provided by the manufacturer. The experiment was conducted by using COMSOL Multiphysics, a finite element analysis, solver, and simulation software package. For the clinical study, from July 2008 to March 2021, a total of 72 patients were included. Their medical records were retrospectively reviewed to obtain patient demographics, elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, Mayo Elbow Performance Scores (MEPS), and hand grip strength. Results No fracture fixation construct completely restored stiffness comparable to the intact model in torsion or compression. Combinations of the 7-hole and 5-hole plates and the 8-hole and 6-hole plates showed superior structural stiffness and stress than those with single lateral plates. At least 3 screws (6 cortices) should be inserted into the lateral plate to reduce the load effectively. For the anterior plate, it was sufficient to purchase only the near cortex. Regarding clinical results of the surgery, the range of motion showed satisfactory results in elbow flexion, elbow extension, and forearm rotation. The average DASH score was 4.3 and the average MEPS was 88.2. Conclusions Anterolateral dual plate fixation was biomechanically superior to the single-plate method in the finite element analysis of a distal junctional fracture of the humerus model. Anterolateral dual plate fixation was also clinically effective in a large cohort of patients with distal junctional fractures of the humerus.
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Affiliation(s)
- Cheungsoo Ha
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Inrak Choi
- Intuitive Surgical Inc., Sunnyvale, CA, USA
| | - Jun-Ku Lee
- Department of Orthopaedic Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jongbeom Oh
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Wooyeol Ahn
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Soo-Hong Han
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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Łukasz W, Ryszard T, Maria D. Radial Nerve Palsy Associated with Humeral Shaft Fractures in Children. BIOMED RESEARCH INTERNATIONAL 2023; 2023:3974604. [PMID: 38075371 PMCID: PMC10708953 DOI: 10.1155/2023/3974604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 01/02/2023] [Accepted: 01/20/2023] [Indexed: 12/18/2023]
Abstract
Background This is the first systematic review of the relationship between humeral shaft fractures and radial nerve palsy in children. The present comprehensive review is aimed at identifying important clinical findings between humeral diaphysis fractures and radial nerve injuries and assessing the effects of treatment. Methods We searched electronic bibliographic databases, including PubMed, the Cochrane Library, Scopus, and Web of Knowledge, until March 2022. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the patients, interventions, comparisons, outcomes guidelines. Results We identified 23 original papers, of which 10 were eligible for further analysis. Cases of 32 young patients with radial nerve palsy were identified and analyzed. The prevalence of radial nerve palsy was 4.34% (eight cases out of 184 patients with humeral shaft fractures). The radial nerve was most often associated with a simple transverse fracture (12A3, 17 cases (65.4%)). Conclusions Radial nerve injury in humeral shaft fractures in children is rare, with a frequency of 4.34%. We highly recommend early surgical nerve exploration with transverse fractures in the distal third segment combined with primary radial palsy. Furthermore, we recommend making thoughtful decisions regarding early nerve exploration in the Holstein-Lewis fractures. In addition, consideration of early surgical nerve exploration in fractures resulting from high-energy trauma and open fractures despite their morphology is recommended.
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Affiliation(s)
- Wiktor Łukasz
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children's Health Centre, Katowice, Poland
- Department of Trauma and Orthopedic Surgery, ZSM Hospital, Chorzów, Poland
| | - Tomaszewski Ryszard
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children's Health Centre, Katowice, Poland
- Faculty of Science and Technology, Institute of Biomedical Engineering, University of Silesia in Katowice, Katowice, Poland
| | - Damps Maria
- Department of Anaesthesiology and Intensive Care, Upper Silesian Child Health Centre, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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Zavras AG, Monahan KT, Winek NC, Pan T, Altman GT, Altman DT, Westrick ER. Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis. J Bone Joint Surg Am 2023; 105:1112-1122. [PMID: 37224234 DOI: 10.2106/jbjs.22.01374] [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: 05/26/2023]
Abstract
BACKGROUND Historically, humeral shaft fractures have been successfully treated with nonoperative management and functional bracing; however, various surgical options are also available. In the present study, we compared the outcomes of nonoperative versus operative interventions for the treatment of extra-articular humeral shaft fractures. METHODS This study was a network meta-analysis of prospective randomized controlled trials (RCTs) in which functional bracing was compared with surgical techniques (including open reduction and internal fixation [ORIF], minimally invasive plate osteosynthesis [MIPO], and intramedullary nailing in both antegrade [aIMN] and retrograde [rIMN] directions) for the treatment of humeral shaft fractures. The outcomes that were assessed included time to union and the rates of nonunion, malunion, delayed union, secondary surgical intervention, iatrogenic radial nerve palsy, and infection. Mean differences and log odds ratios (ORs) were used to analyze continuous and categorical data, respectively. RESULTS Twenty-one RCTs evaluating the outcomes for 1,203 patients who had been treated with functional bracing (n = 190), ORIF (n = 479), MIPO (n = 177), aIMN (n = 312), or rIMN (n = 45) were included. Functional bracing yielded significantly higher odds of nonunion and significantly longer time to union than ORIF, MIPO, and aIMN (p < 0.05). Comparison of surgical fixation techniques demonstrated significantly faster time to union with MIPO than with ORIF (p = 0.043). Significantly higher odds of malunion were observed with functional bracing than with ORIF (p = 0.047). Significantly higher odds of delayed union were observed with aIMN than with ORIF (p = 0.036). Significantly higher odds of secondary surgical intervention were observed with functional bracing than with ORIF (p = 0.001), MIPO (p = 0.007), and aIMN (p = 0.004). However, ORIF was associated with significantly higher odds of iatrogenic radial nerve injury and superficial infection than both functional bracing and MIPO (p < 0.05). CONCLUSIONS Compared with functional bracing, most operative interventions demonstrated lower rates of reoperation. MIPO demonstrated significantly faster time to union while limiting periosteal stripping, whereas ORIF was associated with significantly higher rates of radial nerve palsy. Nonoperative management with functional bracing demonstrated higher nonunion rates than most surgical techniques, often requiring conversion to surgical fixation. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Athan G Zavras
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Van Bergen SH, Van Lieshout EM, Verhofstad MH, Den Hartog D. Recovery and functional outcome after radial nerve palsy in adults with a humeral shaft fracture: a multicenter prospective case series. JSES Int 2023; 7:516-522. [PMID: 37266182 PMCID: PMC10229417 DOI: 10.1016/j.jseint.2023.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Background The consequences of radial nerve palsy associated with a humeral shaft fracture are unclear. The aim of this study was to examine the functional recovery of radial nerve palsy, at presentation or postoperatively, in patients with a humeral shaft fracture. Methods Data from patients who participated in the HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER) study, a multicenter prospective cohort study including adults with a closed humeral shaft fracture Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 12A or 12B, and had radial nerve palsy at presentation or postoperatively, were extracted from the HUMMER database. The primary outcome measure was clinically assessed recovery of motor function of the radial nerve. Secondary outcomes consisted of treatment, functional outcome (Disabilities of the Arm, Shoulder, and Hand and Constant-Murley Score), pain level, quality of life (Short Form-36 and EuroQoL-5D-3L), activity resumption, and range of motion of the shoulder and elbow joint at 12 months after trauma. Results Three of the 145 nonoperatively treated patients had radial nerve palsy at presentation. One recovered spontaneously and 1 after osteosynthesis. Despite multiple surgical interventions, the third patient had no recovery after entrapment between fracture fragments. Thirteen of the 245 operatively treated patients had radial nerve palsy at presentation; all recovered. Nine other patients had postoperative radial nerve palsy; 8 recovered. One had ongoing recovery at the last follow-up, after nerve release and suture repair due to entrapment under the plate. At 12 months, the functional outcome scores of all patients suggested full recovery regarding functional outcome, pain, quality of life, activity resumption, and range of motion. Conclusion Radial nerve palsy in patients with a humeral shaft fracture at presentation or postoperatively functionally recovers in 94% and 89%, respectively.
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Affiliation(s)
- Saskia H. Van Bergen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Esther M.M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michael H.J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Van Bergen SH, Mahabier KC, Van Lieshout EMM, Van der Torre T, Notenboom CAW, Jawahier PA, Verhofstad MHJ, Den Hartog D. Humeral shaft fracture: systematic review of non-operative and operative treatment. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04836-8. [PMID: 37093269 PMCID: PMC10374687 DOI: 10.1007/s00402-023-04836-8] [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: 10/20/2022] [Accepted: 03/01/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome. METHODS Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc. RESULTS A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group. CONCLUSION This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.
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Affiliation(s)
- Saskia H Van Bergen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Kiran C Mahabier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Tim Van der Torre
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Cornelia A W Notenboom
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Priscilla A Jawahier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Tian J, Leng M, Wang K, Huang Q. Pronator teres nerve branch transfer to the extensor carpi radialis brevis nerve branch for wrist extension reconstruction in proximal radial nerve injury following humeral shaft fractures. BMC Musculoskelet Disord 2022; 23:980. [DOI: 10.1186/s12891-022-05950-1] [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: 08/06/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Tendon and nerve transfers are used for functional reconstruction in cases of proximal radial nerve injury complicated by humeral fractures in patients who do not show functional recovery after primary nerve repair. The effectiveness of pronator teres (PT) nerve branch transfer to the extensor carpi radialis brevis (ERCB) nerve branch for wrist extension reconstruction was investigated and compared to the results of tendon transfer.
Methods
This study included 10 patients with proximal radial nerve injury, who did not show functional recovery after primary nerve repair at our hospital between April 2016 and May 2019. The nerve transfer procedure included PT nerve branch transfer to the ECRB nerve branch to restore wrist extension and the flexor carpi radialis (FCR) nerve branch to the posterior interosseous nerve (PIN) to restore thumb and finger extension. Tendon transfer procedures included PT transfer to the ECRB for wrist extension, FCR transfer to the extensor digitorum communis (EDC) for finger extension and palmaris longus (PL) transfer to the extensor pollicis longus (EPL) for thumb extension.
Results
Five patients recovered Medical Research Council grade M4 muscle strength in the ECRB and EPL in both tendon and nerve groups. Two patients recovered grade M3 strength and three patients recovered grade M4 strength in the EDC in the tendon transfer group, and all five patients recovered grade M4 strength in the EDC in the nerve transfer group. Limited wrist flexion was observed only in one patient in the tendon transfer group.
Conclusion
PT nerve branch transfer to the ECRB nerve branch combined with FCR nerve branch transfer to PIN is a useful strategy for wrist and fingers extension reconstruction in patients with proximal radial nerve injuries.
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Singh V, Hayes HV, Kazemi N, Dey S, Parikh SN. The Holstein-Lewis humerus shaft fracture in children: are they different from adults? J Pediatr Orthop B 2022; 31:274-280. [PMID: 34028376 DOI: 10.1097/bpb.0000000000000863] [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: 11/26/2022]
Abstract
Spiral fractures in the distal third humerus shaft (Holstein-Lewis fracture pattern) have been associated with high risk of radial nerve palsy in adults and surgical treatment is recommended as the treatment of choice to remove the entrapped nerve from the fracture site. But this association and treatment approach has not been evaluated in pediatric humerus shaft fractures. In a retrospective study, 38 pediatric patients with Holstein-Lewis fracture configuration were identified after a review of radiographs of 1609 patients with humerus shaft fracture. Age at initial presentation, sex, mechanism of injury, side involved, presence of any associated injuries, neurovascular status, radial nerve status, fracture management, and any complications were noted. Thiry-three (86.8%) patients with mean age 10.1 ± 3.7 years were successfully treated by closed methods. Five patients (13.2%) with mean age 15.2 ± 2.6 years underwent surgical treatment. Contrary to adults, no children/adolescents had radial nerve palsy at presentation. Radiographic healing was acceptable in all cases at latest follow-up. Holstein-Lewis fracture behaves differently in children with no increased risk of radial nerve palsy. Majority can be treated conservatively. The thick periosteum in children may offer protection to the radial nerve and may be responsible for the success of closed treatment.
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Affiliation(s)
- Vivek Singh
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center
| | - Hannah V Hayes
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Namdar Kazemi
- Department of Orthopaedics, Washington Orthopaedic Center, Olympia, Washington, USA
| | - Sukalyan Dey
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center
| | - Shital N Parikh
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center
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Abstract
Radial nerve injury with humeral shaft fracture is common. Treatment options include expectant management, early exploration and repair, delayed reconstruction, nerve transfers, and tendon transfers. Knowledge of the appropriate application of these treatments will assist orthopedic surgeons and nerve surgeons in coordinating care for these patients.
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Affiliation(s)
- Michael Daly
- Department of Orthopaedic Traumatology, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Chris Langhammer
- Department of Orthopaedic Traumatology, University of Maryland, 22 South Greene Street, Baltimore, MD 21201, USA.
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Li W, Li H, Wang H, Wang S. Ultrasound-guided preoperative localization of radial nerve in the treatment of extra-articular distal humeral shaft fractures. BMC Musculoskelet Disord 2022; 23:1. [PMID: 34980067 PMCID: PMC8725401 DOI: 10.1186/s12891-021-04954-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/08/2021] [Indexed: 01/13/2023] Open
Abstract
Background The aim of this study was to discuss the treatment of extra-articular distal humeral shaft fractures using ultrasound-guided preoperative localization of radial nerve. Methods Between May 2010 and December 2019, 56 patients with extra-articular distal humeral shaft fractures were retrospectively reviewed. Twenty eight patients were received examination by using preoperative localization of radial nerve guided by ultrasound-guided preoperative localization (group A) and 28 control patients without ultrasound-guided (group B). All patients were treated surgically for distal humeral shaft fractures by posterior approach techniques. Operative time, radial nerve exposure time, intraoperative bleeding volume, union time and iatrogenic radial nerve palsy rate were compared between the two groups. Elbow function was also evaluated using the Mayo Elbow Performance Score (MEPS). Results A significant difference was observed between the two groups, Operative time (113.25 min vs 135.86 min) (P < 0.001), radial nerve exposure time (20.82 min vs 32.53 min) (P < 0.001), intraoperative bleeding volume (246.80 ml vs 335.52 ml) (P < 0.001). However, iatrogenic radial nerve palsy rate (3.6% vs 7.1%) (P = 0.129), the fracture union time (13.52 months vs 12.96 months) (P = 0.796) and the MEPS score (87.56 vs 86.38) (P = 0.594) were no significantly different in both groups. Conclusions The study demonstrates that ultrasound-guided preoperative localization is an effective approach in the treatment of extra-articular distal humeral shaft fracture by revealing radial nerve, which may help reduce the operative time, radial nerve exposure time and the intraoperative bleeding volume.
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Affiliation(s)
- Weifeng Li
- Department of Orthopaedic Surgery, Baoding No 1 Central Hospital, No. 320, Changcheng Street, Baoding, 071000, Hebei, People's Republic of China
| | - Hui Li
- Department of Orthopaedic Surgery, Baoding No 1 Central Hospital, No. 320, Changcheng Street, Baoding, 071000, Hebei, People's Republic of China
| | - Haiying Wang
- Department of Orthopaedic Surgery, Baoding No 1 Central Hospital, No. 320, Changcheng Street, Baoding, 071000, Hebei, People's Republic of China
| | - Shunyi Wang
- Department of Orthopaedic Surgery, Baoding No 1 Central Hospital, No. 320, Changcheng Street, Baoding, 071000, Hebei, People's Republic of China.
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Mohanty K, Agarwal R. Trauma. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1007/978-3-030-78529-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Entezari V, Olson JJ, Vallier HA. Predictors of traumatic nerve injury and nerve recovery following humeral shaft fracture. J Shoulder Elbow Surg 2021; 30:2711-2719. [PMID: 33964428 DOI: 10.1016/j.jse.2021.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 04/06/2021] [Accepted: 04/18/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Nerve palsy is common after humeral shaft fracture, with the radial nerve being the most commonly injured nerve. Isolated nerve injuries usually recover spontaneously, and operative intervention is rarely indicated. Our goal was to study the predictors of traumatic nerve injury and recovery in a large cohort of patients with humeral shaft fractures. METHODS A total of 376 patients with humeral shaft fracture, including 96 patients with documented traumatic nerve palsy and 280 with intact neurovascular examination on presentation, were retrospectively included in the study. The primary outcome was incidence of a traumatic nerve palsy, and the secondary outcome was nerve recovery. RESULTS Nerve palsy was present in 96 patients (25.5%) at the time of injury. Radial nerve was the most commonly injured nerve (93.6%), followed by the ulnar (5.1%) and axillary (1.2%) nerves. Seventeen patients (17.7%) had multiple nerves palsies. A multivariable regression analysis revealed that the concomitant vascular injury (odds ratio [OR] 52, 95% confidence interval [CI] 5.6-480.6), distal one-third fractures (OR 6.3, 95% CI 2.7-14.7), and middle one-third (OR 2.8, 95% CI 1.2-6.5) vs. proximal fractures, open fracture (OR 2.1, 95% CI 1.1-4.4), and high-energy trauma (OR 1.7, 95% CI 1.1-2.9) were independent predictors of nerve palsy. Iatrogenic nerve injury was detected in 7 patients (4.6%), all affecting the radial nerve. Spontaneous recovery of traumatic nerve injuries was detected in 87 patients (91%), with 19% partial and 72% complete recovery. The initial sign of recovery was observed at median times of 7 and 9 weeks for those managed conservatively or fracture fixation. Operative treatment of the fracture had no effect on the outcome of nerve recovery (88.5% vs. 100%, P = .14). Ten patients (14.1%) had transected nerves at the time of exploration and open fractures (22.7% vs. 6.8%, P = .04), and concomitant vascular injury (33.3% vs. 7.3%, P = .02) were associated with nerve transection, portending a worse prognosis for nerve recovery compared with nerves in continuity (40% vs. 95.3%, P = .004). DISCUSSION The incidence of nerve injury after humeral shaft fracture was 25%, reflecting an abundance of high-energy and open injuries in this cohort. Ninety-one percent of patients experienced improvement in their nerve function with a median time to recovery of 7-9 weeks. Operative treatment of the fracture did not change the rate of nerve recovery. Patients with multiple nerve palsies and concurrent vascular insult had worse nerve recovery. We recommend nerve studies if no sign of recovery is observed by 9 weeks.
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Affiliation(s)
- Vahid Entezari
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey J Olson
- Harvard Combined Orthopaedic Surgery Program, Boston, MA, USA
| | - Heather A Vallier
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA.
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Yeh KL, Liaw CK, Wu TY, Chen CP. Radial nerve recovery following closed nailing of humeral shaft fractures without radial nerve exploration: A retrospective study. World J Clin Cases 2021; 9:8044-8050. [PMID: 34621861 PMCID: PMC8462186 DOI: 10.12998/wjcc.v9.i27.8044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/08/2021] [Accepted: 08/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Radial nerve palsy due to humeral shaft fracture is the most common peripheral nerve injury associated with long bone fractures. An antegrade nailing surgical technique is becoming popular for the fixation of these fractures with minimal invasiveness. We analyzed nerve recovery in patients with humeral shaft fracture and radial nerve palsy treated with humeral nail fixation without nerve exploration.
AIM To assess the radial nerve recovery rate and time from humeral shaft fracture with surgical treatment using close nailing.
METHODS We retrospectively collected data of patients who underwent undergone surgical nail fixation for humeral shaft fractures between October 1, 2016, and March 31, 2020. Subsequently, we analyzed the primary or secondary radial nerve palsy recovery rate and radial nerve motor function recovery time.
RESULTS The study included 70 patients who underwent surgical treatment for closed- or Gustilo type I open humeral shaft fractures using a nail fixation technique without radial nerve exploration. The patients suffered from primary (n = 5) and secondary (n = 5) radial nerve palsy. A 100% radial nerve recovery rate was achieved. The mean recovery time was 4.3 mo.
CONCLUSION The study results indicate full recovery of radial nerve palsies from humeral shaft fracture using close nailing treatment. Surgeons need not be concerned about the occurrence of permanent nerve palsies.
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Affiliation(s)
- Kuei-Lin Yeh
- Department of Orthopedics, Shin Kong Wu-Ho Su Memorial Hospital, Taipei City 111, Taiwan
| | - Chen-Kun Liaw
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei City 11031, Taiwan
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Graduate Institute of Biomedical Optomechatronics, College of Biomedical Engineering; Research Center of Biomedical Device, Taipei Medical University, Taipei City 11301, Taiwan
| | - Tai-Yin Wu
- Department of Family Medicine, Zhongxing Branch, Taipei City Hospital, Taipei City 10341, Taiwan
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei City 10055, Taiwan
- National Taipei University of Nursing and Health Science, Taipei City 11219, Taiwan
| | - Chung-Pei Chen
- Department of Orthopedics, Cathay General Hospital, New Taipei City 221, Taiwan
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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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Moloney DP, Feeley I, Hughes AJ, Merghani K, Sheehan E, Kennedy M. Injuries associated with arm wrestling: A narrative review. J Clin Orthop Trauma 2021; 18:30-37. [PMID: 33996446 PMCID: PMC8091050 DOI: 10.1016/j.jcot.2021.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Arm wrestling is common sport amongst amateur enthusiasts. Multiple injuries are described as a result of the sport. The authors present a narrative review of the common injuries associated with the sport. DESIGN Systematic review with a critical appraisal of the literature and a narrative review of the injuries associated with arm wrestling. DATA SOURCES Seven electronic databases were systematically searched using medical subject headings (MeSH) terms as follows. Arm wrestling, Indian Wrestling, Fractures, Injury, Ligament Injury with Boolean search terms "AND". An extensive review of orthopaedic textbooks was also performed. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Inclusion criteria were publications which included patients who suffered bony or soft tissue injuries as a result of arm wrestling published in English language. RESULTS A total of 152 patients was seen across all studies. Spiral fractures of the distal third of the humerus are by far the most common injury reported in the setting of arm wrestling. The humerus fails due torsional and bending stresses. 23% were complicated by medial butterfly fragment and the incidence of radial nerve palsy was 23%. Fracture patterns differ in the skeletally immature arm wrestler, who show an increased incidence of medial humeral epicondyle fractures. We also report on the atypical fracture and soft tissue injury patterns that present.
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Affiliation(s)
- Darren Patrick Moloney
- University College Cork, College Road, Cork, Ireland,Department of Trauma and Orthopaedics, Cork University Hospital, Wilton Road, Cork, Ireland,Department of Trauma and Orthopaedics, Midland Regional Hospital Tullamore, Arden Road, Tullamore, Ireland,Corresponding author. Orthopaedic Office, Cork University Hospital, 1st Floor Wilton Road, Wilton Cork, T12 DC4A, Ireland.
| | - Iain Feeley
- Department of Trauma and Orthopaedics, Midland Regional Hospital Tullamore, Arden Road, Tullamore, Ireland
| | - Andrew J. Hughes
- Department of Trauma and Orthopaedics, Midland Regional Hospital Tullamore, Arden Road, Tullamore, Ireland
| | - Khalid Merghani
- Department of Trauma and Orthopaedics, Midland Regional Hospital Tullamore, Arden Road, Tullamore, Ireland
| | - Eoin Sheehan
- Department of Trauma and Orthopaedics, Midland Regional Hospital Tullamore, Arden Road, Tullamore, Ireland
| | - Muiris Kennedy
- Department of Trauma and Orthopaedics, Midland Regional Hospital Tullamore, Arden Road, Tullamore, Ireland
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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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18
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Hendrickx LAM, Hilgersom NFJ, Alkaduhimi H, Doornberg JN, van den Bekerom MPJ. Radial nerve palsy associated with closed humeral shaft fractures: a systematic review of 1758 patients. Arch Orthop Trauma Surg 2021; 141:561-568. [PMID: 32285189 PMCID: PMC7966639 DOI: 10.1007/s00402-020-03446-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Humeral shaft fractures are often associated with radial nerve palsy (RNP) (8-16%). The primary aim of this systematic review was to assess the incidence of primary and secondary RNP in closed humeral shaft fractures. The secondary aim was to compare the recovery rate of primary RNP and the incidence of secondary RNP between operative and non-operative treatment. METHODS A systematic literature search was performed in 'Trip Database', 'Embase' and 'PubMed' to identify original studies reporting on RNP in closed humeral shaft fractures. The Coleman Methodology Score was used to grade the quality of the studies. The incidence and recovery of RNP, fracture characteristics and treatment characteristics were extracted. Chi-square and Fisher exact tests were used to compare operative versus non-operative treatment. RESULTS Forty studies reporting on 1758 patients with closed humeral shaft fractures were included. The incidence of primary RNP was 10%. There was no difference in the recovery rate of primary RNP when comparing operative treatment with radial nerve exploration (98%) versus non-operative treatment (91%) (p = 0.29). The incidence of secondary RNP after operative and non-operative treatment was 4% and 0.4%, respectively (p < 0.01). INTERPRETATION One-in-ten patients with a closed humeral shaft fracture has an associated primary RNP, of which > 90% recovers without the need of (re-)intervention. No beneficial effect of early exploration on the recovery of primary RNP could be demonstrated when comparing patients managed non-operatively with those explored early. Patients managed operatively for closed humeral shaft fractures have a higher risk of developing secondary RNP. LEVEL OF EVIDENCE Level IV; Systematic Review.
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Affiliation(s)
- Laurent A. M. Hendrickx
- Department of Orthopaedic Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands ,Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, 5042 Australia
| | - Nick F. J. Hilgersom
- Department of Orthopaedic Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands ,Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, 1091 Amsterdam, The Netherlands
| | - Hassanin Alkaduhimi
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, 1091 Amsterdam, The Netherlands
| | - Job N. Doornberg
- Department of Orthopaedic Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands ,Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, 5042 Australia
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19
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Use of Magnetic Resonance Imaging for Orthopedic Trauma and Infection in the Emergency Department. Top Magn Reson Imaging 2020; 29:331-346. [PMID: 33264273 DOI: 10.1097/rmr.0000000000000256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Conditions affecting the musculoskeletal system constitute a significant portion of medical emergencies in the United States, with traumatic injury and infection being two of the most common etiologies. Although physical examination and plain radiographs are often sufficient to guide diagnosis and treatment, there are myriad traumatic and infectious pathologies that are commonly missed or simply not detectable on plain radiographs. Advanced imaging is subsequently warranted for additional workup.Magnetic resonance imaging (MRI) has become an increasingly used imaging modality for musculoskeletal complaints in the emergency department due to its superior visualization of soft tissues, focal edematous changes, and occult osseous insults often not visible on plain radiographs. Although multiple studies have evaluated its utility in the workup of emergency musculoskeletal complaints, there remains a dearth of literature examining the use of MRI for certain occult diagnoses.Radiologists, emergency clinicians, and orthopedic surgeons must be knowledgeable of the indications for MRI in the emergency setting, as delayed diagnosis may contribute to increased morbidity and possibly mortality. This review summarizes the use of MRI in diagnoses relating to trauma or infection among patients presenting to the emergency department with a musculoskeletal complaint.
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20
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van de Wall BJM, Ochen Y, Beeres FJP, Babst R, Link BC, Heng M, van der Velde D, Knobe M, Groenwold RHH, Houwert MR. Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. J Shoulder Elbow Surg 2020; 29:1493-1504. [PMID: 32249144 DOI: 10.1016/j.jse.2020.01.072] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/19/2019] [Accepted: 01/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND This meta-analysis aimed to compare conservative vs. operative treatment for humeral shaft fractures in terms of the nonunion rate, reintervention rate, permanent radial nerve palsy rate, and functional outcomes. Secondarily, effect estimates from observational studies were compared with estimates of randomized clinical trials (RCTs). METHODS The PubMed/Medline, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for both RCTs and observational studies comparing conservative with operative treatment for humeral shaft fractures. RESULTS A total of 2 RCTs (150 patients) and 10 observational studies (1262 patients) were included. The pooled nonunion rate of all studies was higher in patients treated conservatively (15.3%) vs. operatively (6.4%) (risk difference, 8%; odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.5; I2 = 0%). The reintervention rate was also higher for conservative treatment (14.3%) than for operative treatment (8.9%) (risk difference, 6%; OR, 1.9; 95% CI, 1.1-3.5; I2 = 30%). The higher reintervention rate was predominantly attributable to the higher nonunion rate in patients treated conservatively. The permanent radial nerve palsy rate was equal in both groups (OR, 0.6; 95% CI, 0.2-1.9; I2 = 18%). There appeared to be no difference in mean time to union and mean Disabilities of the Arm, Shoulder and Hand scores between the treatment groups. No difference was found between effect estimates form observational studies and RCTs. CONCLUSION This systematic review shows that satisfactory results can be achieved with both conservative and operative management; however, operative treatment reduces the risk of nonunion compared with conservative treatment, with comparable reintervention rates (for indications other than nonunion). Furthermore, operative treatment results in a similar permanent radial nerve palsy rate, despite its inherent additional surgery-related risks. No difference in mean time-to-union and short-term functional results was detected.
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Affiliation(s)
- Bryan J M van de Wall
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland; Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Yassine Ochen
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank J P Beeres
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Björn C Link
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Marilyn Heng
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital Boston, Boston, MA, USA
| | | | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marijn R Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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21
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Radial Nerve Palsy Recovery With Fractures of the Humerus: An Updated Systematic Review. J Am Acad Orthop Surg 2020; 28:e263-e269. [PMID: 31714418 DOI: 10.5435/jaaos-d-18-00142] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Radial nerve palsies with humeral shaft fractures have historically been treated with expectant management. A previous systematic review by Shao et al, based on studies published from 1964 to 2004, purported no difference in the rate of recovery between patients treated with early surgical intervention versus expectant treatment. However, the authors combined expectant treatment to include patients treated nonsurgically and those with delayed surgery. To better understand the effect of surgery and its timing on radial nerve recovery, an updated analysis was performed with stricter treatment definitions. METHODS An updated systematic review of the published literature was undertaken. An electronic database search was performed to identify publications that met specific inclusion criteria. A total of 23 articles published since 2000 met our eligibility requirements. Data were abstracted from these articles and analyzed in conjunction with the results of the systematic review by Shao et al. RESULTS:: The overall prevalence of radial nerve palsy was 12.3% (890/7,262). Patients with radial nerve palsy treated nonsurgically had a rate of spontaneous radial nerve recovery of 77.2%. Patients who failed nonsurgical management and underwent nerve exploration more than 8 weeks after their injury had a rate of recovery of 68.1%. Patients treated with early (within 3 weeks of the injury) surgical exploration and fracture repair had a rate of recovery of 89.8%. DISCUSSION From the published data from 1964 to 2017, patients who underwent surgical exploration within 3 weeks of injury had a significantly higher likelihood of regaining radial nerve function than patients who underwent nonsurgical management with or without late surgical exploration.
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Abstract
OBJECTIVE To determine if surgical approach impacts the rate of nerve palsy after plate fixation of humerus shaft fractures and whether or not iatrogenic nerve palsy recovers in similar ways to preoperative palsy. DESIGN Retrospective. SETTING Two trauma centers. PATIENTS Patients 18+ years of age with nonpathologic, extra-articular humerus shaft fractures (OTA/AO 12A/B/C and 13A2-3) treated with plate fixation. INTERVENTION Plate fixation of humerus shaft fractures, from 2008 to 2016. MAIN OUTCOME MEASUREMENT Rate of iatrogenic nerve palsy by a surgical approach and injury characteristics. RESULTS Two hundred sixty-one humeral shaft fractures were included. The rate of preoperative palsy was 19%. Radial nerve palsy (RNP) was present in 18%. Iatrogenic RNP occurred in 12.2% and iatrogenic ulnar palsy in 1.2%. Iatrogenic palsy occurred in 15.6% of middle and 15% of distal fractures, with fracture location significantly different in those developing RNP (P = 0.009). Iatrogenic RNP occurred in 7.1% of anterolateral, 11.7% of posterior triceps-splitting, and 17.9% of posterior triceps-sparing approaches (P = 0.11). Follow-up data were available for 139 patients at an average of 12 months. Preoperative RNP resolved less often than iatrogenic RNP, in 74% versus 95% (P = 0.06). Time to resolution was longer for preoperative RNP, at 5.5 versus 4.1 months (P = 0.91). Twenty-two percent with preoperative RNP underwent tendon transfer or wrist fusion, versus 0% after iatrogenic RNP (P = 0.006). CONCLUSION Iatrogenic RNP is not uncommon with humeral fracture fixation and occurs at similar rates in anterior and posterior approaches and with midshaft and distal fractures. Iatrogenic RNP had a high rate of recovery. Preoperative RNP more often requires surgery for unresolved palsy. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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23
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Day LM, Stroud SG, Shah NV, Pascal SC, Penny GS, Diebo BG, Illical EM. Radial Nerve Sensory Branch Anatomical Variant: A Case Report and Literature Review. JBJS Case Connect 2019; 9:e0489. [PMID: 31821200 DOI: 10.2106/jbjs.cc.18.00489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CASE Two patients sustained comminuted extra-articular distal humerus fractures. One patient was neurovascularly intact preoperatively. The other patient had a complete radial motor palsy with preserved sensation. Intraoperatively, both exhibited anatomic variants of the radial sensory nerve of the arm that pierced the triceps rather than branching from the distal third of the radial nerve proper, as is traditionally reported. CONCLUSIONS Although rare, variations in the radial nerve may exist about the distal humerus. Surgeons should be aware of these variations to avoid iatrogenic injury.
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Affiliation(s)
- Louis M Day
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Sarah G Stroud
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Scott C Pascal
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Gregory S Penny
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Bassel G Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Emmanuel M Illical
- Department of Orthopaedic Surgery, Kings County Hospital Center, Brooklyn, New York.,Department of Orthopaedic Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania
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Modified use of a proximal humeral internal locking system (PHILOS) plate in extra-articular distal-third diaphyseal humeral fractures. Injury 2019; 50:1300-1305. [PMID: 31178147 DOI: 10.1016/j.injury.2019.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgical treatment of extra-articular distal-third diaphyseal humeral fractures is controversial in terms of surgical approach and position of implant. The aim of this study is to evaluate the clinical and radiological outcomes of a modified application of the proximal humeral internal locking system (PHILOS) plate in extra-articular distal-third diaphyseal humeral fractures. MATERIALS AND METHODS A total of 23 patients with extra-articular distal humerus fractures were treated using either open plating or the minimally invasive plate osteosynthesis (MIPO) technique with upside down application of the PHILOS plate. Fracture configuration, number of screws in the distal fragment, and time to union were analysed. Elbow range of motion, Mayo Elbow Performance Score (MEPS), and complications were evaluated at the final follow-up. RESULTS Fracture union was obtained in all patients at a mean postoperative time of 20.8 ± 2.9 weeks. The mean shortest and longest cortical lengths were 50.7 ± 14.0 mm and 85.2 ± 12.4 mm, respectively. The average number of screws in the distal humeral fragment was 5.6 ± 0.7. No statistically significant correlation was observed between the shortest cortical length and number of screws in the distal fragment (p = 0.224) or between the longest cortical length and the number of screws in the distal humeral fragment (p = 0.956). The average MEPS was 97.6 (range, 75-100). No postoperative complications that required reoperation were occured. CONCLUSION A modified anterior application of the PHILOS plate in extra-articular distal-third diaphyseal humeral fracture showed satisfactory outcomes, so it is an alternative when considering the ability to increase plate-screw density with locking screw fixation in a distal humeral fragment. LEVEL OF EVIDENCE Therapeutic level IV, case series.
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25
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Martin AR, Gittings DJ, Levin LS, Donegan DJ, Gray BL. Acute Radial Nerve Repair with Humeral Shaft Shortening and Fixation Following a Closed Humeral Shaft Fracture: A Case Report. JBJS Case Connect 2018; 8:e109. [PMID: 30601279 DOI: 10.2106/jbjs.cc.18.00074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
CASE A 65-year-old woman sustained a closed segmental humeral shaft fracture with a complete radial nerve palsy. Radial nerve neurotmesis was found during acute surgical exploration and fixation. Treatment included a 2-cm shortening osteotomy of the humeral shaft and osteosynthesis in order to obtain a tension-free primary end-to-end repair of the radial nerve. CONCLUSION Tension-free primary nerve repair can be technically challenging with humeral shaft fractures. A shortening osteotomy of the humeral shaft and osteosynthesis are feasible to achieve tension-free neurorrhaphy without nerve-grafting.
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Affiliation(s)
- Anthony R Martin
- Department of Orthopaedics, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania
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26
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Abstract
There is still no gold standard for the treatment of humeral shaft fractures. This might be attributed to the fact that several commonly used treatment methods have shown good clinical results. A bimodal age distribution of humeral shaft fractures with frequency peaks between 20 and 30 years old and above 60 years old is reported. Decision making for conservative or operative treatment depends not only on the injury pattern but is also dependent on individual patient needs. Currently available operative techniques include antegrade and retrograde interlocking medullary nailing as well as the use of longer proximal humeral nails. Plate osteosynthesis can be performed as open reduction and internal fixation (ORIF) or as minimally invasive plate osteosynthesis (MIPO). There is currently insufficient evidence for a clear superiority of either of the methods. Radial nerve palsy is the most typical complication of humeral shaft fractures but an improved outcome is not achieved by an emergency revision of the nerve.
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Updegrove GF, Mourad W, Abboud JA. Humeral shaft fractures. J Shoulder Elbow Surg 2018; 27:e87-e97. [PMID: 29292035 DOI: 10.1016/j.jse.2017.10.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/09/2017] [Accepted: 10/18/2017] [Indexed: 02/01/2023]
Abstract
Fractures of the humeral shaft are common injuries with multiple management strategies. Many still regard nonoperative management as the standard of care; however, as the understanding of these injuries increases, treatment recommendations are also evolving. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. Operative management includes open reduction and internal fixation through a variety of exposures, intramedullary nail fixation, and external fixation. With increasing rates of shoulder arthroplasty, periprosthetic humeral shaft fractures also deserve special consideration.
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Affiliation(s)
| | - Wassim Mourad
- Division of Orthopedic Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Chen WA, Luo TD, Wigton MD, Li Z. Anatomical Factors Contributing to Radial Nerve Excursion at the Brachium: A Cadaveric Study. J Hand Surg Am 2018; 43:288.e1-288.e7. [PMID: 29122426 DOI: 10.1016/j.jhsa.2017.09.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/20/2017] [Accepted: 09/27/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE The radial nerve appears to be more vulnerable to injury in the brachium than the median and ulnar nerves. The underlying mechanism for this increased vulnerability is not well explained. We hypothesize that the radial nerve has less excursion than the median and ulnar nerves because it is anatomically tethered by the lateral intermuscular septum (LIS) and that elbow positioning and LIS release will improve its excursion. METHODS Eight paired fresh-frozen cadaveric upper extremity specimens were used. The radial, median, and ulnar nerves were transected at the level of the spiral groove. Nerve excursion was determined at a constant tension of 100 g from 0° to 90° of elbow flexion and repeated for the radial nerve after releasing the LIS. The cross-sectional areas of nervous and connective tissue were then determined histologically. RESULTS Radial and median nerve excursion correlated positively with increased elbow flexion, and ulnar nerve excursion correlated negatively with increased elbow flexion. Release of the LIS significantly improved radial nerve excursion at 0°, 60°, and 90° of elbow flexion. Release of the LIS with 90° of elbow flexion increased radial nerve excursion by approximately 3 times. Histological analysis demonstrated similar mean composition of nonnervous connective tissue among the 3 nerves. CONCLUSIONS The radial nerve is anatomically tethered in the brachium by the LIS and has limited excursion compared with the median and ulnar nerves. Radial nerve excursion improves with elbow flexion and LIS release. Flexing the elbow to 90° doubles radial nerve excursion. Releasing the LIS as well triples the excursion of the radial nerve. Histological composition was similar among the three nerves at the brachium. CLINICAL RELEVANCE Releasing the LIS and flexing the elbow improve radial nerve excursion. These steps may be useful during humeral fracture fixation.
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Affiliation(s)
- Wayne A Chen
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - T David Luo
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Michael D Wigton
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Zhongyu Li
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC.
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Ayoub MS, Tarkin IS. Best care paradigm to optimize functionality after extra-articular distal humeral fractures in the young patient. J Clin Orthop Trauma 2018; 9:S116-S122. [PMID: 29628712 PMCID: PMC5883908 DOI: 10.1016/j.jcot.2018.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 02/03/2018] [Indexed: 12/27/2022] Open
Abstract
For younger patients with extra-articular distal humerus fractures closed management is plagued with high rates of malunion, suboptimal functional outcomes, extended immobilization with loss of early motion, a delay in return to work, and a general period of lost productivity. Surgical management offers an appealing alternative. Maintaining respect for the triceps musculature and minimizing iatrogenic injury to the radial nerve are primary concerns with operative treatment. Accordingly, use of a triceps-sparing approach and single column plating may be the optimal treatment paradigm in the young patient presenting with an extra-articular distal humerus fracture.
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Affiliation(s)
- Mark S. Ayoub
- UCSF-Fresno, Department of Orthopaedic Surgery, 2823 Fresno Street, Fresno, CA 93721, United States,Corresponding author.
| | - Ivan S. Tarkin
- University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Kaufmann Medical Building, 3471 5th Avenue, Suite 1010, Pittsburgh, PA 15213, United States
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Latef TJ, Bilal M, Vetter M, Iwanaga J, Oskouian RJ, Tubbs RS. Injury of the Radial Nerve in the Arm: A Review. Cureus 2018; 10:e2199. [PMID: 29666777 PMCID: PMC5902095 DOI: 10.7759/cureus.2199] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Compression of the radial nerve is most commonly described at the supinator muscle (i.e., arcade of Frohse). However, radial nerve compression can occur in the arm. Therefore, the purpose of this article is to review both etiologies of radial nerve entrapment and the sites at which this can occur in the arm. The clinical presentation of radial nerve entrapment in the arm and how it differs from that of entrapment at other sites is reviewed and the conditions potentially predisposing to nerve entrapment are described. Particular attention is paid to the nerve’s course and potential variants of the anatomical structures in the arm. In each case, the recommended course of management for the neuropathy is described. Injury of the radial nerve can arise from a varied set of pathologies including trauma, tumors, anomalous muscles, and intramuscular injections. Physicians should have a good working knowledge of the anatomy and potential mechanisms for radial nerve injury.
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Affiliation(s)
| | - Muhammad Bilal
- Department of Medicine, Dow University of Health Sciences (DUHS), Karachi, Pakistan
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31
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Lee HM, Kim YS, Kang S, Lee MY, Kim JP. Modified anterolateral approach for internal fixation of Holstein-Lewis humeral shaft fractures. J Orthop Sci 2018; 23:137-143. [PMID: 29103824 DOI: 10.1016/j.jos.2017.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 08/08/2017] [Accepted: 10/12/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The authors modified the anterolateral approach for Holstein-Lewis humeral shaft fractures using a plating technique to achieve sufficient distal fixation by minimal splitting of the brachioradialis muscle to fix the most distal screws. The purpose of this retrospective study was to evaluate the efficacy of our modified anterolateral approach for Holstein-Lewis humeral fractures and document clinical and functional results. MATERIALS AND METHODS Between 2008 and 2014, 18 patients (mean age 35.4 years) with a Holstein-Lewis humeral shaft fracture who underwent open reduction and internal fixation with a plate and screws using the modified anterolateral approach and followed for a minimum of 12 months were included. Radiologic fracture configurations, number of distal cortical fixations, union rate, and time to union were analyzed. Clinical outcomes were evaluated using the Mayo elbow performance index system, range of elbow motion, and postoperative complications. RESULTS Mean fracture length was 60.2 ± 10.2 mm (range 49.2-77.2) and mean distal cortical length was 41.4 ± 7.04 mm (range 22.8-59.6). Distal fragments were fixed at a minimum of six cortical points (range 6-8) in all cases using the modified anterolateral approach. Average time to union was 10.5 weeks (range 8-12 weeks). All cases of radial nerve palsy completely recovered within 3 months. Mean elbow range of motion at final follow-up was 3.2 degrees of flexion contracture (range 0-10) and 135.4 degrees of further flexion (range 120-140), and the average Mayo elbow performance score was 96.3 points (range 90-100). There were no non-union or metal failures. CONCLUSIONS The results obtained indicate that the modified anterolateral approach is a safe and easy accessible method that provides sufficient distal osseous fixation for Holstein-Lewis humeral shaft fractures without serious complications. The modified anterolateral approach for plate osteosynthesis appears to be one of the most available options for the treatment of Holstein-Lewis humeral fractures. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Ho Min Lee
- Department of Orthopaedic Surgery, College of Medicine, Dongguk University, Gyeongju, Republic of Korea
| | - Young Sung Kim
- Department of Orthopaedic Surgery, College of Medicine, Dongguk University, Gyeongju, Republic of Korea
| | - Suk Kang
- Department of Orthopaedic Surgery, College of Medicine, Dongguk University, Gyeongju, Republic of Korea
| | - Min Young Lee
- Department of Orthopaedic Surgery, College of Medicine, Dongguk University, Gyeongju, Republic of Korea
| | - Jong Pil Kim
- Department of Orthopaedic Surgery, College of Medicine, Dongguk University, Gyeongju, Republic of Korea.
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32
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Delayed Radial Nerve Palsy after Closed Reduction of a Pediatric Humeral Shaft Fracture. Case Rep Orthop 2017; 2017:9723497. [PMID: 29445558 PMCID: PMC5763207 DOI: 10.1155/2017/9723497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 10/23/2017] [Indexed: 11/30/2022] Open
Abstract
Humeral shaft fractures are common in the United States and may be associated with radial nerve injuries due to their close anatomic relationship in the spiral groove. Most radial nerve palsies are found at presentation due to the initial trauma; however, they can present secondary to orthopaedic intervention following reduction. In this case report, we present a case of delayed radial nerve palsy in a pediatric patient that was identified four days after closed reduction and splinting which required open reduction, nerve exploration, and internal fixation. Fortunately, full motor and sensory recovery was observed at 6 weeks post-op. A unique aspect of this case is that immediate postreduction exam in the emergency department showed no signs of injury or entrapment of the radial nerve.
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Surgical treatment of extra-articular distal-third diaphyseal fractures of the humerus using a modified posterior approach and an extra-articular plate. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017. [DOI: 10.1016/j.recote.2017.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Páramo-Díaz P, Arroyo-Hernández M, Rodríguez Vega V, Aroca-Peinado M, León-Baltasar JL, Caba-Doussoux P. Surgical treatment of extra-articular distal-third diaphyseal fractures of the humerus using a modified posterior approach and an extra-articular plate. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 61:404-411. [PMID: 28890121 DOI: 10.1016/j.recot.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 06/17/2017] [Accepted: 07/03/2017] [Indexed: 11/15/2022] Open
Abstract
PURPOSE To evaluate the clinical and radiological outcomes of these fractures treated through a modified posterior approach with a distal humerus plate. MATERIAL AND METHODS Between 2013 and 2015 we performed a retrospective study of these fractures surgically treated in our centre. INCLUSION CRITERIA older than 18 years old, no pathological fractures, follow up 1 year at least. 23 patients underwent surgery, mean age 45 years old, with an average follow-up of 18 months. Patient characteristics, aetiology and type of fractures were recorded. The surgery was performed using Gerwin modified posterior approach with a posterolateral distal humerus plate. Clinical results were evaluated using Quick DASH, MEPS, VAS. Radiological results were also evaluated. Complications associated with treatment and radial nerve palsy incidence were recorded as well. RESULTS Type of fracture according AO/OTA: six 12-A, seven 12-B, ten 12-C. 23 patients progressed to union. After one year: QD 6.43, VAS 0.66, MEPS 88.88. No failure of internal fixation. Two superficial infections. 15 excellent results, 5 good, and 3 fair, with no poor results. CONCLUSION Surgical fixation of these fractures through a modified posterior approach with a posterolateral plate minimises iatrogenic nerve injury, provides better visualisation of the proximal humerus, provides stable fixation of these injuries and results in high union rates and overall excellent functional results.
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Affiliation(s)
- P Páramo-Díaz
- Unidad de Traumatología, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España.
| | - M Arroyo-Hernández
- Unidad de Traumatología, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - V Rodríguez Vega
- Unidad de Traumatología, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - M Aroca-Peinado
- Unidad de Traumatología, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - J L León-Baltasar
- Unidad de Traumatología, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - P Caba-Doussoux
- Unidad de Traumatología, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario 12 de Octubre, Madrid, España
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Nachef N, Bariatinsky V, Sulimovic S, Fontaine C, Chantelot C. Predictors of radial nerve palsy recovery in humeral shaft fractures: A retrospective review of 17 patients. Orthop Traumatol Surg Res 2017; 103:177-182. [PMID: 28065869 DOI: 10.1016/j.otsr.2016.10.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 09/12/2016] [Accepted: 10/20/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Radial nerve injury is common in humeral shaft fractures and fails to recover spontaneously in 30% of cases. Few studies have evaluated predictors of recovery. The objectives of this study were to identify predictors of radial nerve palsy recovery and to assess the usefulness of surgical radial nerve exploration in patients with preoperative radial nerve palsy. HYPOTHESIS Factors predicting the outcome of radial nerve palsy can be identified. METHODS Of 373 patients with humeral shaft fractures between 2005 and 2012, 43 had radial nerve palsy, including 23 who were lost to follow-up and 17 who were evaluated retrospectively at a mean of 26 months (range, 12-84 months) after internal fixation. The following were studied: age, smoking history, energy of the trauma, fracture type and displacement, skin integrity and intra-operative appearance of the radial nerve. RESULTS Of the 17 palsies, 13 were present preoperatively, including 10 that recovered (PreR group) and 3 that did not recover (PreNR group). Plate fixation and radial nerve exploration were performed in all patients. Of the 10 PreR patients, 6 had nerve contusion and 2-nerve entrapment. Of the 3 PreNR patients, 2 had gross nerve damage and 1 nerve contusion and a history of spinal muscular atrophy. Only age and presence of gross nerve damage differed significantly between the PreR and PreNR groups; trends towards significant differences were noted for skin breach and fracture displacement. Of the 4 postoperative radial nerve palsies, 2 recovered fully and 2 partially; mean age was higher in the 2 patients with partial recovery. DISCUSSION These findings are consistent with the few previous studies of outcome predictors in radial nerve palsy. Factors such as major fracture displacement and high-grade skin wounds probably promote the occurrence of gross nerve lesions. The high incidence of nerve entrapment and stretching supports routine nerve exploration during internal fixation in patients with preoperative radial nerve palsy. LEVEL OF EVIDENCE IV, retrospective study with no control group.
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Affiliation(s)
- N Nachef
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service d'orthopédie B, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France.
| | - V Bariatinsky
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service d'orthopédie B, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France
| | - S Sulimovic
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France
| | - C Fontaine
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service d'orthopédie B, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Laboratoire d'anatomie, faculté de médecine Henri-Warembourg, université de Lille 2, 59045 Lille cedex, France
| | - C Chantelot
- Université Lille-Nord-de-France, 2, avenue Oscar-Lambret, 59037 Lille, France; Service d'orthopédie B, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Service de traumatologie, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France
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Wong PKW, Hanna TN, Shuaib W, Sanders SM, Khosa F. What's in a name? Upper extremity fracture eponyms (Part 1). Int J Emerg Med 2015. [PMID: 26223984 PMCID: PMC4519440 DOI: 10.1186/s12245-015-0075-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Eponymous extremity fractures are commonly encountered in the emergency setting. Correct eponym usage allows rapid, succinct communication of complex injuries. We will review both common and less frequently encountered extremity fracture eponyms, focusing on imaging features to identify and differentiate these injuries. We focus on plain radiographic findings, with supporting computed tomography (CT) images. For each injury, important radiologic descriptors are discussed which may need to be communicated to consultants. Aspects of management and follow-up imaging recommendations are included. This is a two-part review: Part 1 focuses on fracture eponyms of the upper extremity, while Part 2 covers fracture eponyms of the lower extremity.
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Affiliation(s)
- Philip Kin-Wai Wong
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA, 30322, USA,
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Cadaveric investigation on radial nerve strain using different posterior surgical exposures for extraarticular distal humeral ORIF: merits of nerve decompression through a lateral paratricipital exposure. J Orthop Trauma 2015; 29:e43-5. [PMID: 25050751 DOI: 10.1097/bot.0000000000000204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether the type of posterior surgical approach for distal humeral fracture open reduction and internal fixation influenced radial nerve strain during simulated operative retraction in a cadaveric model. METHODS Three different posterior surgical exposures: triceps splitting, lateral paratricipital, and paratricipital with release of the lateral intermuscular septum were used. Radial nerve strain was measured using a microDVRT, while traction was applied with a digital force gauge at forces 0.1-0.3 kg. RESULTS The lateral paratricipital with nerve decompression was superior to both the triceps splitting approach (P < 0.048) and paratricipital method without decompression (P < 0.036). There was no significant difference between the triceps splitting method and paratricipital exposure without intermuscular septum release. CONCLUSIONS Radial nerve decompression through release of the lateral intermuscular septum through a lateral paratricipital exposure ideally decreases nerve strain during humeral open reduction and internal fixation in our cadaveric model.
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Abstract
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.
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Affiliation(s)
- Karin L Ljungquist
- Hand and Microsurgery, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
| | - Paul Martineau
- Hand and Microsurgery, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA
| | - Christopher Allan
- Hand and Microsurgery, Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA.
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40
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HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER): a multicenter comparative observational study. BMC Musculoskelet Disord 2014; 15:39. [PMID: 24517194 PMCID: PMC3922994 DOI: 10.1186/1471-2474-15-39] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 02/06/2014] [Indexed: 02/08/2023] Open
Abstract
Background Fractures of the humeral shaft are associated with a profound temporary (and in the elderly sometimes even permanent) impairment of independence and quality of life. These fractures can be treated operatively or non-operatively, but the optimal tailored treatment is an unresolved problem. As no high-quality comparative randomized or observational studies are available, a recent Cochrane review concluded there is no evidence of sufficient scientific quality available to inform the decision to operate or not. Since randomized controlled trials for this injury have shown feasibility issues, this study is designed to provide the best achievable evidence to answer this unresolved problem. The primary aim of this study is to evaluate functional recovery after operative versus non-operative treatment in adult patients who sustained a humeral shaft fracture. Secondary aims include the effect of treatment on pain, complications, generic health-related quality of life, time to resumption of activities of daily living and work, and cost-effectiveness. The main hypothesis is that operative treatment will result in faster recovery. Methods/design The design of the study will be a multicenter prospective observational study of 400 patients who have sustained a humeral shaft fracture, AO type 12A or 12B. Treatment decision (i.e., operative or non-operative) will be left to the discretion of the treating surgeon. Critical elements of treatment will be registered and outcome will be monitored at regular intervals over the subsequent 12 months. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcome measures are the Constant score, pain level at both sides, range of motion of the elbow and shoulder joint at both sides, radiographic healing, rate of complications and (secondary) interventions, health-related quality of life (Short-Form 36 and EuroQol-5D), time to resumption of ADL/work, and cost-effectiveness. Data will be analyzed using univariate and multivariable analyses (including mixed effects regression analysis). The cost-effectiveness analysis will be performed from a societal perspective. Discussion Successful completion of this trial will provide evidence on the effectiveness of operative versus non-operative treatment of patients with a humeral shaft fracture. Trial registration The trial is registered at the Netherlands Trial Register (NTR3617).
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Scolaro JA, Voleti P, Makani A, Namdari S, Mirza A, Mehta S. Surgical fixation of extra-articular distal humerus fractures with a posterolateral plate through a triceps-reflecting technique. J Shoulder Elbow Surg 2014; 23:251-7. [PMID: 24332951 DOI: 10.1016/j.jse.2013.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 09/19/2013] [Accepted: 09/26/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgical management of extra-articular distal humerus fractures results in predictable fracture alignment. Open reduction and internal fixation also decrease the soft tissue complications and frequent follow-up required with functional bracing. A triceps-reflecting posterior approach provides excellent exposure to the humerus and minimizes trauma to the triceps. An anatomically precontoured plate on the posterolateral surface of the humerus provides stable fixation of these injuries and is placed directly through the interval developed by the triceps-reflecting approach. METHODS We retrospectively reviewed the trauma databases at 2 level I academic trauma institutions during a 5-year period for all patients with an extra-articular distal humerus fracture treated with a triceps-reflecting approach and an anatomically precontoured posterolateral distal humerus plate. Patient and fracture characteristics were recorded, as were QuickDASH functional scores and visual analog scale scores for pain, function, and quality of life. RESULTS Forty patients were eligible for our study. Average follow-up was 88 weeks. Thirty-eight (95%) patients went on to union. Seven (20%) patients required a secondary procedure. The average QuickDASH score was 17.5 (range, 2.6-56.8). The average visual analog scale scores were 1.9 (range, 0-7) for pain, 2.3 (range, 0-8) for function, and 1.6 (range, 0-5) for quality of life. Thirty-five (87.5%) patients reported satisfaction with the outcome of their surgery. DISCUSSION Surgical fixation of extra-articular distal humerus fractures through a triceps-reflecting approach with an anatomically precontoured posterolateral distal humerus plate results in predictable osseous union and overall excellent functional results for patients with this injury.
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Affiliation(s)
| | | | - Amun Makani
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Amer Mirza
- Oregon Health and Science University, Portland, OR, USA
| | - Samir Mehta
- University of Pennsylvania, Philadelphia, PA, USA.
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Sabalic S, Kodvanj J, Pavic A. Comparative study of three models of extra-articular distal humerus fracture osteosynthesis using the finite element method on an osteoporotic computational model. Injury 2013; 44 Suppl 3:S56-61. [PMID: 24060021 DOI: 10.1016/s0020-1383(13)70200-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The biomechanical properties of extra-articular fractures of the distal humerus have not been researched sufficiently. The aim of the study was to examine three different models of osteosynthesis for extra-articular distal humerus fractures. Osteosynthesis with two parallel or perpendicular plates is a common method of osteosynthesis for those fractures. We wanted to examine the biomechanical performance of a newly designed Y plate, and compare it to the previously used osteosynthesis methods. MATERIALS AND METHODS On an osteoporotic computational model of the distal humerus, a 10 mm gap was made, 25 mm above the olecranon fossa, and osteosynthesis was performed with the newly designed Y-shaped plate and with 3.5 reconstruction plates in parallel and perpendicular configuration. The numerical simulations in axial compression, bending and varus loading were conducted using the finite element method. RESULTS On all models the largest displacements in the area of the fracture gap appear around the lower anterior edge. The parallel plate construct had the highest stiffness among the three plating techniques in axial compression. In bending and varus loading the construct with the newly designed plate had the highest stiffness, but in axial compression demonstrated the lowest. The parallel plate configurations had higher stiffness than the perpendicular ones in all three loading directions and the difference is most pronounced in axial compression. CONCLUSION The displacements that appeared in all three plating systems are minimal and within the limits that meet the requirements of sufficient biomechanical stability in the usual time for the healing of fractures in that region. The newly designed Y-shaped plate for extra-articular fractures of the distal humerus is a possible alternative to the usual method of osteosynthesis with two plates in the case of an extra-articular fracture of the distal humerus. Further biomechanical studies are needed for a decisive conclusion.
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Affiliation(s)
- Srecko Sabalic
- Trauma and General Surgeon, Sestre Milosrdnice University Hospital Center, University Hospital for Traumatology, Zagreb, Croatia.
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Eglseder WA. Distal humeral fractures: impact of lateral approach and fracture-specific plating on radial nerve palsies. Tech Hand Up Extrem Surg 2012; 16:127-131. [PMID: 22913991 DOI: 10.1097/bth.0b013e318256471f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We retrospectively reviewed supracondylar distal humeral fractures that had been treated with fracture-specific plating and definitive fixation through a lateral approach with a medial triceps mobilization technique. We determined the incidences of preoperative and postoperative radial nerve palsies (RNP) to evaluate the impact of the plating and fixation technique on RNP. Seventy-three patients treated at our institution from 2006 through 2009 were included in the study. The patients were assigned to 2 groups: 57 to the blunt injury group (motor vehicle collisions, falls, struck pedestrians, throwing) and 16 to the gunshot wound group. The incidence of known preoperative RNP in the blunt injury group was 27% (13 of 48 nonintubated patients); the incidence of known preoperative RNP in the gunshot wound group was 20% (2 of 10 nonintubated patients). The incidence of postoperative RNP for the combined groups of nonintubated patients who had intact radial nerve function preoperatively was 12% (5 of 43 patients). We found a high frequency of preoperative RNP, and we found postoperative RNP rates similar to those reported in the literature despite the use of the lateral approach medial triceps mobilization technique with a fracture-specific plate.
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Affiliation(s)
- W Andrew Eglseder
- Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, USA.
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Liu GY, Zhang CY, Wu HW. Comparison of initial nonoperative and operative management of radial nerve palsy associated with acute humeral shaft fractures. Orthopedics 2012; 35:702-8. [PMID: 22868596 DOI: 10.3928/01477447-20120725-10] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The optimal treatment approach for the initial management of radial nerve palsy associated with humeral shaft fractures has yet to be conclusively determined. The authors performed a systematic review of the literature to identify studies that compared the outcomes after initial nonoperative and operative management for radial nerve palsy associated with acute humeral shaft fractures. A meta-analysis of the data from these studies was also performed to determine whether recovery from radial nerve palsy was more favorable in one approach compared with the other. The primary outcome was recovery from radial nerve palsy and the secondary outcome was complaints after treatment. Nine articles (1 prospective observational and 8 retrospective) were included in the meta-analyses. Operative management showed no improved recovery from radial nerve palsy compared with nonoperative management. Nonoperative management was associated with a decreased risk of complaints relative to operative management. Recovery from radial nerve palsy associated with acute humeral shaft fractures is not influenced by the initial management approach.
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Affiliation(s)
- Geng-yan Liu
- Department of Orthopedics, The Third Xiangya Hospital of Central South University, China
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Oh CW, Byun YS, Oh JK, Kim JJ, Jeon IH, Lee JH, Park KH. Plating of humeral shaft fractures: comparison of standard conventional plating versus minimally invasive plating. Orthop Traumatol Surg Res 2012; 98:54-60. [PMID: 22204793 DOI: 10.1016/j.otsr.2011.09.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/17/2011] [Accepted: 09/13/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE This study compared clinical outcomes and complications in patients with humeral shaft fractures treated using two methods of fixation by plating. METHODS Minimally invasive plate osteosynthesis (MIPO, n=29) was prospectively performed from around the middle of the study period, while open reduction and plate osteosynthesis (ORPO, n=30) had been the original standard method. Locking compression plate was used in these two groups. Major characteristics of the two groups were similar in terms of fracture type, fracture location, age, associated injuries and numbers of open fractures. RESULTS Primary union was achieved in 28 of 29 in the MIPO and in 27 of 30 in the ORPO. Mean time to union was similar in the two groups. Mean operation time in the MIPO (110min) was shorter than in the ORPO (169min) (P<0.05). Bone grafting was performed in five patients of in the ORPO, but in no patient in the MIPO (P<0.0001). There was one case of deep infection in the ORPO. Functional outcome was satisfactory in both groups. CONCLUSIONS Minimally invasive plate osteosynthesis may achieve comparable results with the open plate osteosynthesis method in simple as well as complex fractures of humeral shaft. Although MIPO potentially has the radiation hazard, it may reduce the perioperative complications with a shortened operation time. LEVEL OF EVIDENCE Level III. Case-control study.
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Affiliation(s)
- C-W Oh
- Kyungpook National University Hospital, Daegu, Republic of Korea.
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Hey HW, Tan TC, Lahiri A, Wilder-Smith EP, Kumar VP, Kagda FH, Lim AYT. Deep peroneal nerve entrapment by a spiral fibular fracture: a case report. J Bone Joint Surg Am 2011; 93:e113(1-5). [PMID: 22005874 DOI: 10.2106/jbjs.j.00842] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Hwee Weng Hey
- Department of Orthopaedic Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore.
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Cox C, Riherd D, Tubbs R, Bradley E, Lee D. Predicting radial nerve location using palpable landmarks. Clin Anat 2010; 23:420-6. [DOI: 10.1002/ca.20951] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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