humero fx holstein lewis -data journals jbjs 445 1382

7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382

1/8

INTER

MUSCULAR

SEPTUM

RAD IA L NE

RAD IUS

4

R t. A nt.V ie w

F ractu res o f the H um erus w ith R ad ia l-N e rv e

1382 T H F : JO U R N A l. o il. B O N E A N I) J( iIN I S U R G E R Y

Paralys i s

*

B Y A R T H U R H O L S T E IN , M .I).f, A N I) G \\IL iM B . L E W IS , M .D .t, B F :ItK E L E Y , C A L IF O R N IA

In our experience w hen p araly sis o f th e rad ia l ne rve com p lica tes frac tu res of

the shaft. o f th e hun ie rus , a spec ific s itu a tion usua .lly ex is ts . T he frac tu re

is

in the

d is ta l th ird of th e hum erus , it. is sp ira l in ty pe , the ( lis ta l bone frag n iem it is a lw ay s

d isp la (ed prox im ally w ith its p rox im al end d ev iated rad ialw am d , th e

ra d ial ne rve

is cau gh t in the frac tu re s ite , and , if th ere is a con im inu ted fragm ent, it is th e ob l ique

surface I f

the d ista l en d

of the prox im al fragm en t th at dam ages the nerve . \V hen

fr;uetules i n t .h is a re a occur and the in itia l trau m a does no t. Pm o (lu (e g ro ss d isp l;tce -

n ien t

I f

the type desc ribed , theu m i ad i al - mi e rv e p a ra l ys i s m ay not occur (Fig. I ).

F in . I

I

)r a w in g sh o w in g re la tio n sh ip o f n er v e to fr a t t tir t.

I ie lo re (le ft ) am id al ter dis l )ha oe mlle l i t ( r igh t

W ith rad ial d isph atem ent an d overridimig of til( dis ta l lragm eii t

t

li e m iervo , fixe d

to ) t

h o l ir ox ir na l

ilagniomlt.

l)y t.h t

ilit(lI iitiSttllaI s(pt tin ), is

tlapl)ttl h)o t

th o fm a ct t ilt su lfa tes .

T o u nderstand the m echam ii(s o f th is f ractu re sy nd i(Im e , the fo llow iiig ana tom i-

ca l fac to rs a re pertinen t.

A s W hitsou i ( Ien iou istra ted , con tra ry

to tli(

deser ip t iomms iii

stand ard ana tom ica l

tex tbooks 1,2, the rad ia l ne rve

does

iiot tr av el a lon g

the so-called sp ira l

groove of the

* He a ( l at

t i i o

Amimiuah M eeting o il Tlit A n i e n i o a i i A oado n iy o il (lit

hi o l )a e t l i o

Siimgeoimis, Chicago ,

I lh in o iis, J anu ary 28 , 1 96 2 .

t

:30 11 T ele gra ph A v enu e, B e rke lt

5,

Califo rn ia .


2/8

F in . 2

F 1 I A C T U R E S OF TH H U M E R U S

1383

V o l.. 4 5 -A , N O . 7 , O C T O B E R 1 9 6 3

humerus ; in s tead , a lo m ig InoIst o f its co urse , it is sepa la te (l f rom ii the hum erus b y from

on e to fiv e cen t.in iete rs o f n iu sc le , the a \e Iage th iick m iess o f the m usc le b e iiig 3 .4

cen tim e te rs . T he ne rve lie s clo se to the in fe rio r lip o f th e sp ira l

gra ov e, i)u t no t

in the

gro ove . lo r (lilly a sho rt d is t.m tm ice near th e la te ra l supraco ndy la r ridg e is th e nerve

iii d irec t con tac t w ith th e hu m erus, and it is in th is au ea tha t the nerve p ie rces the

la te ra l in t.e rm u scu lau sep tum befo re pass im ig On

to th e

su rface of the brach ia lis

n iu sc le . F ron i o ur ana t(In iical d issections , the nerve has leas t n i(Ib ih ity a t th is po in t,

am id , in our op in io n , it is th is lack of n ioh ility tha t is a p rim e fac to r con trihu itiu ig to

the n erve im iju uy in f rac tu res o f the hun ie ru s a t th is lev el.

T h e fo llow in g case reports a re

reco rded to ca ll a ttem itio n to the

im por tance of

ueco gn iz im m g th is fractu re sy ndron ie tax i th e m ieed

fo r o pen reduc tion to avo id fu rthe r

r lmin i ige

to th e nerv e .

C a se 1 . Lateral 9 .1 1 (1 a m it( m t )p o ste r io r ro em ltg e m m o g r a n ls s lm o t p ita l lrao t tire . N ote th ia rao to ris tic

fea tu res: its lo cat .iou i in th e d ista l o m i(-t .h ird , its sp ira l

to ilto u r , a n ( t iio rad ia l (lev ia tio in o il th e

1 )ro x im na l e li(1 o f the (lis ta l lrag nem it .

S ev eu i typ ica l frac tu res ve i co llec ted , four tu e ;u ted by us and th ree seeu i in

consu lta t.iou i fo r the U uiited S ta tes N av y (A .Il.) . I ii an

eflolrt to

de te rm u itie the

freq uency of th is particu lar sy ndrom e, 34 1

co iis ecu iti\e f ractu re s o f

th e shaft. (If th e

hu n ierus a t one priva te h osp ita l w eue a lso rev iew ed . ( )f th ese , 1 93 w em e in

the p rox i-

m al th ird o f the sha ft o f the hu m erus, six ty -th ree

iii

th e n iid -p ort ion of th e hum erus ,

a iid e igh ty - fiv e iii

the d istal

portion of the h um uerus . O f

th is ho le g rou p , six had

assoc iated rad ia l-im erve illvo lvem em lt, m m in cidem ice o f 1 .8 per (em it. F ive of th e si x

e re d isp laced fract tire s (If th e type we are desc rib ing . T h e o ther as a frac tu re iii

the n iidd le th ird o f th e hu m erus. T h is case is p resen ted h ere m ere ly to i l lu st rate

how th is frac tu re d if fers fron i the sy m id rom e w e are desc rib ing (C ase 8). The low

inc idence o f rad ia l-ne rve invo lven ien t in th is se r ies is o f in te res t in v iew of th e receu it

s tudy by t.he P ennsy lvam iia O rthoped ic S oc ie ty , iii w hich rad ia l-ne rve im ivo lhvem em m t.


3/8

Fw . 3

1384 AIIrHITR HOLSTEIN AN1) G. B. LEWIS

T H F :

J O U R N A L

O F B 0 N F : A N I) J O IN T S U R G E R Y

w as fou nd iii 12 1e1 ccitt. o f a la rg e ser ie s o f m id -sha ft hu tuera l fiac t.u res.

C ase P rese nta tio ns

CASE 1 . A . P ., a w om an fi fty ye ars o ld , w as th now m i aga ins t the side o f the c an i m i a n au tomobi le

accidemit an d expeniellced su(Ideli severe pain in the n igh t arm . O n ad m is sio m i, a

dia gnosis

o f f ra ct ur e

th e h um erus

with

n ad ia l-u ie nv e p ara ly sis

w as

m a d e .

At

operation, tue d is tal fnagm euit

o f th e hu m e rus had im pale d the ra d ia l

m ien ve om i it . s

sh iarp

ti p at th e 1)o in t . w h ere the

ne r v e

passes from th e

I)o stcn io r co m n pa n tm e m it ., th ro u g h th e in te r m u scu la r

sep tum , in to th e an ten ion c om pa rtm ent (F ig . 2 ). T he ne rve w as fre ed f rom the b)o ne frag m e nt

an d

disp laced

laterally

to th is d is ta l lnagm eu it.. T he frac tu re w as red uc ed and fixed w ith tw o screw s

p laced tra nsv ersely across the frac tu re l ine . A palm -to-a x il la plaster cast

wa s

app l ied . Alter dis-

charge

from th ie hosp ital, t.he

pa tien t tran sfe rred to ano the r area fo r

fo l low -up cane.

N o fu rth e r

imifonniation is ava i lab le .

( t st 2 . F ai lu ro

t. ti

ach ieve l)ro P(r aligm im uen t m u u i ( o m it .a t t. (if the f rao t.u m o surf ;u es liv O l(ist d

m l i; Lm ii l) tl la t.i O) mi s ug go s t

5 iu it .en l)os it.ion o il the lao lia l n orv ( nu t m o .la t .ed soft .

t

issomos.

C. E

2. (

;

\\. ,

a m i it il i, t hi rt y- si x y ears o ld , \ 5

i n jur o (1

w lam i h is o ar str tick a tree .

lit

l lad

i1 llI lie( ii t( 1 )tt im i iii Ins le ft. arm

a bove

th e

elbo w , n ian ked paim i in th ie le ft p ant

o f h is ch est am id b )ac k ,

i1 0 0 l 1 )a l ill

th it righ t sh io iu i(le r are a .

Ihi(

a tlm nit tim ig d ia gm io ao es

Ope l i

oollimllinut(( lraoture of

th e

d ista l t m id o f t .h io lo f t litllllerus w it h n di al -m ie rv e l)ares is ; lra ct.u rts o f th e s( to n(I th iro ug h tu e e igh th

rib s o tt t .ii( . righ t. ; a m i d ( O Il if lh il lu te ( f ra ot ur es o f

th e t.h ir(l th rough e ig h th ribs 0 )1 1 the le ft w ith a

I li ti l o h es t.

al i ( l

I L l n ao tu m eo r igh t

s( apu la .

Im iit.ia liy , the re as o i ily sl igh t re str ic tion o f ex ten sio n

0)1 the finge rs at the

m fl ( ta ( a r po phl a l a m i -

goal jo)ilit . s am itl o il the w rist. o n th e left w ith (liffuse hy pes the sia to ligh t . touc h thro ug hou t. the le ft

ha miol ,

espec ially o n its

( lonsona dia l

aspect .

S inc e

th e chest in ju ry took l)reo (d enco, at firs t om ily

o l# {2 3 3} li ni tl em e m it . 0 )1 the w oun d in

th e

arm w a s d one

with im m lio l)iliz atio li o f th e

h itim era l fra cture im i a

iialmii-t.o-axilla

plaster

tas t.

R e(h lec k of the fin ge n-w nis t m ov em ents les s th ian tw e uity -fo un ho lun s

after injury showed complete loss of do )rsiflex ion o f 1)0 th th e wrist and the fingers .

At operationi filt4eii day s after the in ju ry the p rox im al

p o r tio n o f

th e rad ial nerve wa s freed and

t raced (arolullv

int.oI

th e dista l pant o f th io arm. Th e mitrve w as

c om p lete ly en m eshie ti in

th e

f i br o us

t

issu e a r o u nd

th e frac tu re . T he ne rvo w as in co m itin u itv :

a m i o i ,

alter

hi t i m l g

disset.ttoi fre e f rom its

f i h ro u i s tissue 1)0 01 ,

it.

w as d isp lated la tera lly a ual the fra ctu re of th e h ium orus w as re du ced an d

fix ed b y

m e ans o f a pla te a nd fo ur sc rew s.


4/8

F R A C T U R E S O F T H E H U M E R U S 1385

O n e of the fac tons to no te h ere wa s the fa ilu re to o b ta in appo sition of the fragm ents af ter initial

d #{23 3}b n id em en t an d im m ob iliz ation in a p laster c ast

(F ig . 3 ). T h is shou ld have sugg es ted th at the

ne r v e

wa s in terposed b e tw een th e frag m ents as wa s a lso the s itua tion in C ase 5 . T hree m onths

a fte r opera tio n ac tiv ity o f the ex tenso r ca rp i re tu rned and five m on th s afte r op era tion fu ll finger

ex ten sio n w as noted . F u ll re tu rn o f p o w e rfu l fin ge r an d w ris t m otion w as no ted a t eigh t m onths .

T he o n ly residuu m at on e year w as sligh t hypes th esia in the ana tom ica l snuff box .

C A S E 3 . M .W ., a w om an , f ifty yea rs o ld , fe ll in h en b ath tub , lan d in g o n h en left arm . S h e

reported im m edia te pa in and gro ss defo rm ity of the le ft a rm , bu t rem ain ed a t hom e for tw en ty -

fou r h ours. A t th at tim e exam ina tion revea led a sp iral f ractu re o f the sh af t o f th e d is ta l pa rt o f

th e h u m e ru s w ith c om p le te p a ralysis of m otor an d sen sor y com p on en ts of th e r ad ia l n e rve . A t

opera tion fo rty -e igh t h ours af te r the in ju ry , the d ista l hum era l frag m en t wa s im media tely v isib le

in th e p r oxim a l en d o f th e w o u n d .

T h e tip of

th is fragm ent had p ie rced th e m u scle an d com e ou t

th rou g h a r en t in the fasc ia in to the subcu taneous tissue . Im m edia te ly in ev idence , just m ed ia l

to the d ista l fragm ent and la te ra l to the prox im al frag m en t, wa s the rad ial ne rve . A defin ite con-

tu sion of the nerve a t the leve l o f th e frac tu re lin e

wa s

v is ib le . T he n erve w as resting be tw een the

tw o frag m en ts o f bo ne a t the po in t w here it w ou ld no rm ally have p ie rced the la teral sep tum .

T he nerv e

w as

re m o v ed fr o m its p osition be tw een the tw o ends of the frac tu re and

w as

d isp laced

to th e rad ial side of the d ista l frag m ent. T he frac tu re

wa s th en r ed u ced an d

he ld by tw o screw s .

T h e re w as r etu r n o f m u scle fu n c tion in th e fin g er s an d w r ist five m on th s after su r ger y , w ith

persisten t hy pes the sia in the an ato m ical snu ff box and a tin g ling se nsa tio n in the sam e a rea .

C A S E

4 . L W ., a m an , th irty -th ree years o ld , wa s w or k in g o n a sc affo ld o n a b rid g e w h en

he fe ll tw en ty fee t, sus tain ing an op en com m inu ted frac tu re o f the le ft hum eru s w ith com ple te

r a di a l -ne r v e

paralysis. H e a lso fra ctu re d hi s n ig ht cla vicle. In itia lly the w ound wa s debrided and

a

ligh t p laste r cas t w as app lied . T he w ou nd becam e in fec ted and dra ined . E xp lo ra tion of the

fr actu r e s ite w a s d ela yed for th r ee m on th s .

A t opera tion it w as fou nd tha t the n erve w as sev ered an d d isp laced to the m ed ia l s id e of

th e d is tal hum era l fragm ent, w here

it w as bou nd d ow n in m ark ed scar tissue . T he nerve en ds

w er e id en tified a n d r ep air ed b y e nd -t o- en d su ture a fter c u tting ba ck the nerv e en ds to satis fac to ry

nerve tissue. T h is rep air w as don e u nde r m od era te ten sio n .

T h e retu rn of som e d o rsiflex ion p o w e r of th e w rist an d se n sa tio n w as first n ot(( seve n m o n th s

fo llow in g the nerve

r e p air .

C A S E 5*# {149 }.G . (U .S .N .), a m an ,

tw en ty yea rs

o ld , b rok e h is le ft a rm

w hile p lm Ly ing foo tbal l.

T h e ex trem ity w as im m o bilized in a sp lin t and tw o days la ter h e

wa s tra nsferre d from a n av al

d isp en sary to a hosp ita l. O n adm is sio n the re w as ba rely de m o nstrab le w e akn ess o f w rist a nd

fin ge r e xten sion on th e

le ft s id e . T here w as hypes th es ia in the d is tribu tion

of th e rad ia l n er ve .

T he fractu re o f th e hum eru s w as m anipu la ted and he ld in a p laste r su gar -ton g sp lin t. l)u rin g th e

n ex t ten

d ays , w h ile the ar m w as im m ob il iz ed

in

th is sp lin t, th e ra d ia l-ne rve w e akn es s gradu ally

in cre ase d , an d n um bn ess in

the reg ion o f th e ana tom ica l snu ff b ox in the le ft han d deve loped .

At

opera tio n th e rad ia l n erve w as traced upw ard an d foun d , w ith

m u l)O rtio n of m usc le , to

r u m m i

righ t th ro ug h th e prox im a l p ort ion of the f rac tu re cle ft. T he nerve w m t.s

freed up

to

th e po in t

w he r e

it passed th rough the in term u scu lan se p tu m , then th e ho le th rou gh th is w as en larged to

let th e n e rve slid e fr ee . T he in ten l)o sed tis su e w as rem o ved from the frac tu re site , and the

fr a c tur e

w a s re du ced

ana tom ically and

h eld b y m ea ns of tw o scre w s an d a plaste r ca st.

C A S E

6 . C .K . (U .S .N .), a m an , tw en t. - th ree yea rs o ld , w h ile w o rk ing m tb oan d a tu g , stis -

tah ied a com minu ted fra ctu re of th e d ista l th ird of th e sh aft o f the hu m e rus w hen he fell in to th e

w a ter (F ig . 4 ). W rist-d ro p w as n oted on ad m is sio n to the h osp ita l on the d ay of th e acc ide n t.

A K irs ch ne n win e w as p laced th ro ugh the o lec ran on , and the arm w as th en p lac ed in b alan ced

t ra ctio n. E le ctro my og na ph ic

studies

d on e six d ays later sh ow ed n o activ ity in m o to r u n its su p -

p l ie d by th e rad ial ne rve .

O n th e n in th

da y afte r the in ju ry the fra ctu re in th e d is ta l p art o f the n igh t hu m e rus w a s

e xp lor ed an d th e rad ia l n e rve wa s foun d to be con tused over a d is tan ce of ab ou t on e an d on e-h a lf

in ch es at the le vel o f th e frac tu re s ite bu t to be g ros sly in tac t. In je cting sterile sal ine so lu tio n

i n to

th e n e rv e r ev eale d th e n e u n ilem m al sh ea th to b e in ta ct. A c cord in g ly the n erv e w as rem ove d

fr o m th e frac tu re site, an d th e fra ctu re w as re d u ce d an d held

with

tw o sc re w s. M u scle tissu e w as

p laced be tw een the rad ia l ne rve and the frac tu re s ite . A n ax illa -to -pa lm plas te r cast wa s ap p l ie d

a f te r w o und c lo su re.

C A S E 7 . W .B . (U .S .N .) , a b oy eigh tee n ye ars o ld , in a n a u to m o l)ile acc ide n t, sus ta in ed m m .

* N avy p erso nn el tran sfe r to the ir h om e are a an d w e are u na b le to o b ta in fo llow -up .

V O L . 4 5 -A , N O .

7,

O C T O B E R 1 9 6 3


5/8

1386

A R T h U R

HOLSTEIN ANI) G. B. L E W I S

T H I J O UR NA l. O F B O N E A N 1 ) J t) IN T S U R G E R Y

cOIiilliimitittt

lra tt tir ( o il th e shal t o f the r igh t hu ne rus in th e ( lista l tlii ro l w ith tom plete loss of

na i : t l -m i o r v o

lu m ictio m i, am i

o i n ( o m illf liliu t( ( I fr a ctu re

o f th io left tib ia , :011 (1 a clo sod fn acturo o f th e

nig h t litto ra l n ia llo o lus. In i tia l ly a p laster sI)h in t. w as use d for th e lra ttt ired hu m e rus . T h is w as

th ang to l to a h am ig im ig p la sto r cast. Hotmitgetiograms t h itn re vo alo d th at, t h it b on e c I l d S w or t m io it in

o o im i t ac t . T h o r o \ V I O 5 1 1 0 re tu nm i oil rad ial-m ie rve lun tt ion o l ur i m l g t h e f irs t lo iti r v oo ks afto r Ira ct tire .

.-

opo r a t ion twe ntv-n imie o lay s a lter illjtuv, th e

miorve

w a s foun d to l it

approxinlattly

90

iier ten t . stv o roo l at

t he

frao t u ro site w it h i om d a t h iin ten uou s I ia m id o o m ln e( ting the tw o en ds.

iho

n o m v e (m io ls

t.ra iip otI in t h o f ib ro u s callus at t h o f ractu re s ito . T he em itls of t h o miervo w o r e

lresh ionoo l

a mi ol a i i li ro xim n at o o

w it h i (1 000 00 si lk s tit u ros.

The fract tilt

\VIS

iI lilllo iliiliZ tO l im i

a

plaster

ca st . (

)ne m u o in th

la to m

t

lie

tia tiem it fell w it 11

ro ( un-

r e nt t o il pa in at t he l ra ct tm i o s it o , m it . m it i o h ia ng o

im i 1 io is ititill o f

th e

liaot. tire.

Cont. imiuod

i l l imo-

b il iz at io ii n es ul t( o l

in

b on o u mi it in .

W h e n

th e

patio n t w a s l :tst see n , t h ero b at. Ii ten m iti

r t tur n

oi l

nerve f tm n ctiom i. N oi fo llow -im p w a s p oss ih ilo .

F it; . 4 F in . 5 F it ;. (1

l i t i . 4 : ( tso 6 . (

O im liI liiillite (l fra ct u ro

w ith t l Ie

t

h iird lragm iit m it o isp la tt t n lo (iia llv a nd the (list m o l

frag nitm it ill t

lie t li:tm :tct .tristic lio is it .io in

it Ii o )v( rn i thn g a m id ra tlia l (1 ov iatio im l o il i ts tirox im a l end .

F ig . 5 : ( )l 34 1 frao t tire s of the h um noral shal t th is w a s th i t o im ily fra ctu re un it im i the d ista l om ie- tliind

vliioli

assooiatoo. l

i t h ia r s is o il

t

lie

ra d ial ne rve .

Fig .

6:

F ixa tion o il a sin i l)le sP in al lra otu rt w ith tw o i sorow s al to r r (n io iv al o il t he m iorv e fro m th e

l r ao tu r o s i to .

(

AS E

S . 1 . \Io L ., a ho t filteem i

o ld , s tis t :i .im iod a sp i la l fr:n t ou t in th e m nio ld lo o i ie-th ird

oil t h e h iu nio ru s \ t h i in j um y to t .h i( rad ial m io rv e cau sim ig los s of sem isatio m l

(iii

th e (lo rsum of the

h iamio betwt

Ii

t li t firs t and sec o ii( illt tac a .m lia ls l)u t no m tm st lo w eak mie ss (Fig. 5 ). A han gin g p las ter

cas t w as

applied.

( )m i t l it fo llo lw ing t av , it

\s . :ls mlote(

t h at t h io

patient

w as tim ia l ile to e x te m io l th ie

th iu m iib am id

t

hit fim ige rs fu lls a t th it m o ta oa r o ipha lam ig eal jo iin ts . ( ) m i the ten th d ay fo llo iw ing th e

in j u n , w ith m io i a o o itiona l trea tm em it

,

tho ro wa s

o v i o ( m i ( e

0)1 ro ttm rm i o f ra o ia l-m io rvo lu m a -tio n . T he

p at io n t con do a gain txtond t h o thun i l i an t f ingers , am se misa t io in ha m o t m rno t . 1 he re w as li ii

re t u rn o il rao ia l-nem v o lt im ittiom i o um in g im m iio b iliz a t lo in ill tilt

iilas t en

cast .

Ih is ease is m nem iti(Ined m ere ly to illu s tra te w ha t is ho t fliem tiit h W t.h ie syndro m e

lihi(I(

(0

)iisi(l(iltO u 1 . A li io ii g 34 1 h um uera l frac t tire s th is w as the o o il y ( ni e w it in the

d is tal o iie -th iird w hich

a s a sso ci: tt(o l

w ith im iju irv

tti

th ie rad ia l iie rve ,


6/8

F R A C T U R E S O F T F IE H U M E R U S

1 3 8 7

V O L . 4 5 -A , N t) . 7 , O ( TO B ER

1963

D is c us s ion

I ii th is frac tu re syndro n ie, the re a re ce rtain factors w h ich do i io t v ary . Ihe

fracti.ire is a lw ay s in the d ista l one-th ird of t.he hu m erus; it is spiral with rad ia l

m tiig u ia tio ii m it. th e fiacture si te and o verrid ing of th e d ista l fragm eiit; an d the re is

invo lvemen t ,

of the rad ial ne rv e, bo th senso ry and n io to r

co in ipom iem its . T he (lilly part

(If the sy m id rom ue th at v ar ies is the degree o f inv o lvem en t of the n erv e ; t.h is invo lve-

n ie iit va ries from co nt usi ol il to co lm pl et e s ev er an ce. Th e

degree

o f traum ua m u st. be

m e lu tive ly v io len t, and th ie re m u s t l)e d efin ite d isp lacem en t (.)f th e fragm en ts o f the

shaft . of the h um uerus as a re su lt o f the iiiju m y if m ierve d am ag e is to occur.

In a

n un li)e r of

these

f ractu res,

an in itia l c lo sed re (lu ctio m i was attempted

; iii

t .w o , mu n io re p rof i lun d rad ial-nerve paia ly sis resu lted . Iloen

t geno gram s , m ad e

af te r

Fm t;. 7

F ix a t io im i (if I t im a o t tilt t hi a p la to a m ioI lou tim s om tvs . H e m o t OI l in) imlut

io u m li: tt ( st tt irt str e w f ix a t io in

imiil)ti)sililt.

Iliu i i ip I i lmtt i ( )h i , revem tle (1 tha t th e frm tgm u en ts \v em e b eim ig he ld ap m im t ie5uf lim th )ly b y

iiiteipositioii

(If So ft tissue . A ll the frac tu res e re eve iitua lly trea ted surg ica lly ,

am id th e in ter l)ose (l so ft tis su ( w as im ivarim ib ly fou iid to im ich ide the ra (hm il nerve ,

sonietimues

to i th e ex ten t thm it the m ie rve

as su r rounded h) V early ca llus h )e tw ee ii the

bone (lid s.

O n the basis o f uur experience , we strong ly adv ise m tgm uim st at tem pte d clo sed

reduc t ion of fractures ouf the d ista l one-th ird (If the h un ie rus w ith (lem iiom is trab le

rad ia l-ne rve p :u esis . \V e reeon im iiem id p rim ary op en reduc tion th rou gh i m iii m uit ero -

lm ute ra l approach . T he m ie rve sho uld be loca ted , d issec ted free , m lii( l d isp lm tced lm it.erm illy

to the d is tm il frm ig n ien t. T he fractu re shou ld then be reduced ; and , because

of its

sp irm il eh m urm tc ter , it cm iii usu m ully be satisfactorily fixed by tw o screw s p lm uced acm s th e

frm .uc tu re . W hen there is sufhciemit coiiimiiinution to iuake s imple screw f ixm ut io n no t

satis fac tory , a

l igh t

btliie

p la te w ith four

sc r e w s

ca n

be use d .

A very ligh t,

p m u l m - t o -


7/8

1388 A R T H U R H O L S T E IN A N D G . B . L E W IS

ax illa han g ing p la ste r ca st is u sed fo r ex te rna l im m ob iliza tion (F igs . 6 and 7 ). T he

o p tim u m tim e fo r ne rv e repa ir , the best m e tho d fo r rep air ing the rad ial ne rve , and

the trea tm en t o f p erm anen t w eakness o f the w ris t an d fin ge r ex ten so rs a re no t the

con ce rn o f th is p ap e r. W e w ish o n ly to em ph as ize tha t the rm td ial ne rv e is freq uen tly

caugh t be tw een the frac tu re su rfaces in th is read ily recog n ized frac tu re m uiid hence

lik ely to be dam aged e ith er a t th e tim e of im iju ry or during trea tm en t.

S u m m a r y

T his pape r p re sen ts seven cases illu stra ting a hum era l-frac tu re synd ro m e corn -

p lica ted b y rad ia l-ne rv e para lysis . T he frac tu re occurs in th e d ista l one -th ird o f the

hum erus a t a po in t w here the rad ia l ne rve co m es th roug h the late ral in t.e rm uscu la r

sep tum and is in con tac t w ith the bon e. D ue to the fo rce of the in ju ry , the prox im al

fragm en t is d isp laced d ista lly , ca rry ing w ith it the in te rm uscu la r sep tu m and th e

rm udim tl ne rve con ta ined w ith in its fo ram en in th e sep tum . A t the sam e tim e th e ap ex

of the d istal frag m en t is m o ved prox im a lly and rad ia lly , la cera ting or trapp in g the

rad ia l ne rve be tw een

the bo ne frag m e n ts . P rim a ry op en red uc tio n is th e tre atm e n t

o f ch o ice fo r th is in ju ry . C losed m a iiipu latio n is con tra -in d icated w h en th e c rite r ia

o f th e syn drom e are p re sen t.

R e fe re nc e s

1. C U N N IN G H A M S T e xt-B oo k of A n a to m n v.

E d. 9 , p p . 253 , 490 , 10 81 . E d ited b y J. C . B rash , N ew

Y o r k ,

O x fo r d U n iv er sity P re ss ,

1951 .

2. M o R R I S

H u m a n

A na to m y . A C om p le te S yste m atic T r eatise. E d. 1 0 , lP 198 , 440 , 1 106 . E d ited

by J . P . Sch aeffen . P h ila de lph ia , T h e B lak isto n C o., 194 2 .

3. 1 E N N S Y L V A N IA O R T H O P E D IC S o C IE T Y , S C IE N T IF IC R E SE A R C H C O M M IT T E E :

F resh M id sha ft

F nm m .ct.u res o f the H um erus in A dults. E va lua tion o f T rea tm en t d uring 19 52 -19 56 . P en nsy lv an ia

M e d .

J. ,

62: 848 -850 , 1 959 .

4.

\ V H I T S o N ,

R . 0 . : R e la tion of the R ad ia l N erve to th e S haft o f the H um erus . J. B one am itl Jo in t

Su n g . ,

36-A : 85-8 8 , Jan . 1954 .

D I S C U S S I O N

l )mu.

B L A N D

W .

C A N N O N , M E M P H IS , T E N N E S S E E : D isc u ssio n of th is p re sen tation fro m a

n eu r olog ica l su rge on n ec essi ta te s th e assu m p tion th at th e m eth od o f tr ea tm en t of fra ctu re of th e

hume rus ,

w ith rad ia l-ne rv e im pa irm en t, depend s on the in teg rity o f the nerve . W e accep t th is

c om p lim e n t, for w e k n ow th at yo u , as o n th op ae d sts , are a w ar e of s in gu laritie s of th is n er ve

vh iich al low s m m .av ora b le resu lt u ltim ate ly , rega rd less of th e m etho d o f trea tm ent .

F or tun ate ly , the u sua l se qu elae of trm m .u m a tic ne urit is an d oth er p ain fu l syn dro m e s in n erv e

in ju ry are esem u peo l because of the ins ign ifican t senso ry com p onen t o f the rad ia l ne rve . R epa ir o f

th is lac erated o r d iv id ed ne rve usual ly y ield s retu nn i o f fun ctio n to all m usc les of its dom ain .

N ot in fre qu en tly , n ear norm a l ne uro log ica l sta tus is o b ta ined .

T he c ruc ial an ato m ical lo cation fo r ra d ial-ne rve in ju ry in fra ctu re of th e

h u m n e ru s is m is I ) n .

Holste in alld D r. L e w is h ave d es ign a te d . H ow ev er , th e d e cis ion to e ffe ct p r om p t o p em i r ed u ctiom i

sh ou ld n ot

be b ased on the ex istence of n er ve p ara lys is. If severance o f the nerv e h as occurred ,

the im m ed iate po st- in ju ry p erio d is no t the o p tim u m tim e for n erve repa ir. If con tus ion , w ithou t

lace ra tion , is found on inspec tio n of the nerv e, on ly lim ited constru c tive in fo rm ation has b een

g ain ed . A la pse of tim e is a lm ost n ece ssa ry in ev alu ating th e fu nct ion ing s ta tu s of th e n erv e. T h e

ap plicat ion of o ur neu ro phy sio log ica l on electrod iag nos tic aids , such a s elec tro m y ogn ap hy , is

usua l ly

im prac tical dur in g the

tw o w e eks

im m edia tely fo llo w ing th is typ e of traum atic n erve

para lys is. T he s ign ifican t ex cep tion to our adv ised de lay is illustra te d b y tw o of I )n . H o lste in

an d D r . L e w is cases, in w h ich a m o re pro fou nd paraly sis fo l low ed c losed re du ctio n .

If you p rod uce o r increase p ara lys is by m an ipu lat ion , p roc eed ing w ith surg ica l v isu alization

a nd d eco m p res sio n o f the ne rve is w ise .

O f the three ca ses de p ic tin g seve ran ce of the nerve, the lapse of

fifteen

d ays , tw en ty-n in e

d ay s, and three m onths, respe ctiv ely , before surg ica l a tta ck pro bab ly im p rov ed t .he c han ce of

success fu l ne rve rep air and neuro log ica l recovery .

A d e lay

in

ne r v e rep air o f

ap pro x im ate ly fifteen day s fm tcili ta te s

m t m o re a c cu r a te de te rmina-

tio n of the

are a of v iab le ne rve in th e con tused m ind dam ag ed pro x im al

an d d is ta l trun ks.

A l so ,

a su ita b le b ed for pro te ctio n of the su ture d nerve can b e

assured.

S u ch fa ctors are of pr im ary

impor tance

in o b ta in ing the b est resu lts. O therw ise , e v id enc e fav ors th e as sum ption tha t the

Co n tinued o n p aqe 148 4

T H E J O U R N A L O F B O N E A N D J O IN T S U R G E R Y


8/8

1484 H . S . U N G E R , L . H . S C H N E ID E R , A N D J O A N N A S H E R

2 . H IN E S , L . E .

: C o m press ion M yelitis S eco ndary to E c h ino c o c cu s D ise a se o f V er te b ra e an d

K i d n ey .

A rch . P a th o l. a n d L ab . M ed ., 1 : 1 80-181 , 19 26 .

3.

H O W O R T H , I. B .: E chino co cco sis o f B one . J. B one and Jo in t S im ng ., 27

:

4 01-41 1, July 1945.

4 . H UT CH IS O N, W . F .;

T H O M P S O N ,

W . B .; and D E R I A N , P . 5 .:

Osse ous

H yda tid (E ch ino coc cus )

I) isea se: R ep ort o f an Ind igen ous C a se. J . A m . M ed. A ssn ., 1 82 : 81-83 , 1 962 .

5.

M I L L S ,

T . J .: P a rap le gia D u e to H y d atid 1)ise ase. J. B one

an d

Jo in t S u rg. , 38 -B : 88 4-8 9 1 ,

Nov. 1 9 5 6 .

6 . R oB IN soN ,

R . G .:

H yd atid D isease of the S p ine and Its N euro log ical C om plicm otions . B ritish

J. Sung . , 47 : 301-3 06, 1 959 .

D I S C U S S I O N

F R A C T U R E S O F T H E

H U M E R U S

C on t inu ed from pa ge 138 8

de gre e m on d ra te o f m m en ve recov ery afte r su tun im u g is m oot in f lue moc e d by lem ig th of tim e b etw een

iiijilry

1 0 1 0 ( 1 o p e r a ti o n .

W e kno w of

n o cm ose o f fra ctu re o f th e h u m eru s im u w h u ich re a i)p n o xim a tion o f a sev ere d rad ia l

m u en ve c ou ld n o t b e effected , p rov id in g n o a vu lsion or tis su e lo ss oc cu rre d .

T hu s, a

neurosurg eo n m igh t su ggest pos tponem ent o f the chosen open reduc tion fo r a t

hem ost tha t pe riod o f t im e n ece ssa ry to cre ate a m ore d es ira b le a p p roa ch to c or rec tin g n e rve d ys -

fu l i c t i o l u .

R E F E R E N C E S

0 1 -1 -o S IT I0 N O F T H E T H U M B A N 1 ) IT S R E S T o R A T Io N

C on tinu ed fron t page 1396

9.

N IC U L A Y SE N , J O H A N :

T ram usp lan t:o tion des M . abd uc to r (jig . V . be i Feh iender ( )ppos i t io io Fbh ig -

k eit de s I)aum en s. l)e u ts che Z eit .sch n . f. C h in ., 16 8 : 1 33 -13 5 , 1 922 .

1 0. R O WN T RE E ,

T o M :

A no m alo us In nerva tion of the H and M usc les . J. B om ie tim id

Jo in t

Sun g., 31 -B :

505 -51 0 , N o v.

1949.

11 .

S A B A T I E R ,

R . B .: T rait#{2 33} d A n ato m ie. P ar is , 1764 .

12 . Sc Ho r r s T A E o T , E . I t.; L A R S E N ,

L . J .; a nd B O S T , F .

C .: C o m p lete M u sc le T r an sp o sitiom u . J .

B o ne a m id Jo in t S t ing ., 37-A : 89 7-919 , O ct. 19 55 .

13 . S U N D E R L A N D , S ., a nd H U G H E S , E . S . It. : M etrica l and N om u-M etn ica l F e to tunes o f the M usc u la r

B ranches of the U lnar N erve .

J.

C om np. N eu no l.,

85

: 1 1 3-123 , 194 6.

14 .

T H O M P S O N ,

T . C . : A Modif ied O p er atio li fo r O p p om oe n s P ara lys is. J. B om ie 9 11(1 Join t S u n g ., 24:

632 -64 0 , J u ly 19 42 .

R E F E R E N C E S

TH E Os O D O N T O I D U E M

C on t inuedfrom page 1471

13 .

P E N n E R G R A s S , E . P .;

S C H A E F F E R , J . P .;

an d H O D E S , P . J .: T h e H e ad a rid N e ck in

Roe n tge l i

l)iagm u osis . E d . 2 , p p . 1 529-1530 . Spn im u gfie ld , Illino is , C harles C . T h om as, 19 56 .

14. S Y M ON DS ,

C . P .;

M E A D O W S ,

S . P .; a nd

T A Y L O R ,

J. : C o m p res sio m o of the S p ina l C ord

in

th e

N eigh bo urh ood o f th e F o r a m e n

M a g n u m

w ith a N ote o n S u r gica l A p p ro ach . B r ain , 60 : 5 2-84 ,

1937 .

15. W A T S O N -JO N E S , R E G IN A L D : F rac tu re s a n d Jo im u t In ju rie s. E d . 4 , V o l. 2 , p . 980 . E d in b u rg h , E .

a n d S . L iv in g sto n e , 19 55 .

T H E J O U R N A L O F B O N E A N D J O IN T S U R G E R Y

humero fx holstein lewis -data journals jbjs 445 1382

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