International Journal of Research in Orthopaedics

Aslam M et al. Int J Res Orthop. 2022 Nov;8(6):728-730

http://www.ijoro.org

Case Series

DOI: https://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20222714

Exploration of radial nerve in patients with humerus shaft fracture with radial nerve palsy, is it necessary?

Marouf Aslam*, Asif Sultan

Department of Orthopaedics, GMC Srinagar, Jammu and Kashmir, India

Received: 08 September 2022

Revised: 01 October 2022

Accepted: 03 October 2022

*Correspondence:

Dr. Marouf Aslam,

E-mail: maroufaslam3@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Fractures in the distal third of the humerus shaft usually are associated with complete or incomplete radial nerve lesions which may be caused due to traction, entrapment or compression between bony fragments. We managed these patients by bridge plating using minimally invasive percutaneous plate osteosynthesis. A total of 5 patients were operated on and all showed full functional recovery of radial nerve. Fracture united in all cases and no patient developed any complication.

Keywords: Humerus, MIPO, Radial nerve

INTRODUCTION

Minimally invasive percutaneous plate osteosynthesis (MIPPO) has been used with good success for the treatment of diaphyseal humerus fractures without radial nerve palsy.1-3 Fractures in the distal third of the humerus shaft may be associated with radial nerve palsy due to contusion, laceration or entrapment of radial nerve at the fracture site.4

CASE SERIES

Operative technique: Procedure was done in supine position with the fractured arm resting on a side arm rest which was attached to the operating table. Initially distal incision about 2-3 cm in length was given. After retracting the biceps towards the medial side musculo-cutaneous nerve was visible. Access to the humerus was gained by splitting the brachialis muscle. Musculo-cutaneous nerve was retracted along the medial half of brachialis and radial nerve along the lateral half. For proximal incision, interval between lateral border of the proximal part of the biceps and the medial border of the deltoid were palpated. A 2-3 cm proximal incision was made approximately 5 cm distal to the anterior part of the acromion process and the dissection was carried down to the humerus. A sub muscular tunnel was created from the distal to the proximal incision using a tunneling instrument. Plate was attached to tunneling instrument at the proximal site and drawn from proximal to distal incision. The forearm was positioned in supination, pronation brings the radial nerve closer to plate.5 Reduction of the fracture was achieved by manual manipulation. Traction was used to restore the length and to correct angulation. Finally, the fixation was completed with at least two screws in each fragment.

Table 1: Clinical details of five patients.
Table reproduced from source PDF page 1
Figure 1: Pre operative radiograph of fracture.
Figure 1: Pre operative radiograph of fracture.
Figure 2: Immediate post operative radiograph.
Figure 2: Immediate post operative radiograph.
Figure 3: Final radiograph at 3 months.
Figure 3: Final radiograph at 3 months.

In this case series, five patients were operated and all showed full functional recovery. No exploration of radial nerve was done in any of our patients. Fracture healing occurred at a mean of 3.4 months and complete neurological recovery occurred at a mean of 3 months. Normal range of motion in shoulder and elbow was seen in all patients at final follow up. No patient developed any post operative complication.

Table 2: Details of results in the five patients.
Table reproduced from source PDF page 2

DISCUSSION

Increasing traffic accidents and sports activities resulted in the increased incidence of humeral fractures, about 30%-50% of which are humeral shaft fractures.6 In the distal third spiral and oblique fractures are common and in middle third transverse fracture morphology is mostly seen.7 In about 1.8% to 18% of cases with a mean of 11% radial nerve palsy occur following humerus fracture.3,4,7 The function usually recovers spontaneously in 80% of cases after conservative treatment that is why some recommend conservative treatment of these fractures.8 However, some authors recommend urgent exploration of nerve with open reduction and plating of these fractures. Lesions of radial nerve in middle third of humerus are due to Neuropraxia and resolve spontaneously.9The nerve is fixed by lateral intermuscular septum in the distal third of humerus. Lesion of radial nerve at this area are due to entrapment or contusion of the nerve. Oblique or spiral fractures have an increased tendency towards causing this type of nerve lesion, making spontaneous reclamation unpredictable.4,7,9,10 In patients with partial lesions of nerve the rate of recovery of nerve is greater than in those patients with both motor and sensory loss.

CONCLUSION

We concluded that most of the nerve palsies associated with humerus shaft fractures are due to Neuropraxia and resolve spontaneously without the need for exploration of radial nerve.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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