radial nerve palsy associated with fracture of the … nerve palsy associated with fracture of the...
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Radial Nerve Palsy Associated with Fracture of the Humerus
Robert W. Wysocki, MD Division of Hand, Upper Extremity and
Microvascular Surgery Department of Orthopaedic Surgery
Rush University Medical Center
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Case Example
• 42 yo AAM MVC • Closed left humerus
fracture • T5 burst fracture • T6 compression fx • Multiple rib fxs • Sternal fx • Hemopneumothorax
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Physical Examination on Presentation to Emergency Room
• Left humerus with internal rotation and varus deformity – Radial nerve intact (firing, though pain limited quantification) – Median/ulnar nerves intact, palpable radial/ulnar pulses
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Emergency Room Management
Closed reduction – Distraction – Valgus stress – External rotation of distal
fracture fragment Coaptation splint
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Immediately Following Reduction
• Found to have 0/5 wrist extension, EPL
• Decreased sensibility to light touch in radial nerve sensory distribution
• Neurovascularly intact otherwise
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Humeral Shaft Fractures
• 1 to 3% of all fractures • Bi-modal distribution
demographically • Tolerance: -20 deg sagittal -30 deg coronal angulation -3 cm shortening
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Relevant Anatomy
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Radial Nerve Injury Incidence and Contributing Factors
• Incidence varies from 8-11% of shaft fractures
What about fracture location??
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Radial Nerve Injury Incidence and Contributing Factors
• Incidence varies from 8-11% of shaft fractures • Location: Proximal 2%, Middle 10%, Distal 20%
What about open vs. closed injury??
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Radial Nerve Injury Incidence and Contributing Factors
• Foster et al. – 14 open fractures with radial nerve palsy, 64% had surgically correctable radial nerve lesion
• Bishop et al. – Mixed case series, found only 40% chance of nerve recovery when open fracture observed
• Shao et al. – Meta-analysis, no significant relationship between recovery and open vs. closed
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Radial Nerve Injury Incidence and Contributing Factors
• Incidence varies from 8-11% of shaft fractures • Location: Proximal 2%, Middle 10%, Distal 20% • Open vs. closed - Controversial
What about secondary radial nerve palsy??
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Radial Nerve Injury Incidence and Contributing Factors
• Shaw et al. – 45 mixed cases, only 40% of primary palsies resolved, but 100% of secondary recovered
• Shao et al. – Meta-analysis, 88% primary resolved vs. 93% secondary
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Radial Nerve Injury Incidence and Contributing Factors
• Incidence varies from 8-11% of shaft fractures • Location: Proximal 2%, Middle 10%, Distal 20% • Open vs. closed – Controversial • Secondary palsy – No different or better recovery
than primary
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Diagnostic Testing??
• EMG/NCS -Baseline study at 3-6 weeks -Repeat study at 12+ weeks if no clinical improvement
• Ultrasound -Bodner et al. reported abrupt cutoff in a case of entrapment, and 11/11 recovery with nerves intact on ultrasound
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Radial Nerve Injury
Overall recovery rate of primary radial nerve palsy with closed fracture of the humerus is 70-90%
Why not just explore all of them??
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Radial Nerve Injury Why not just explore all of them??
1) Rate of recovery of intact radial nerve is WORSE if
explored versus if observed * Ring et al – 73% vs. 83% * Bostman et al – 73% vs. 87%
2) Final outcome no different if explored late versus early
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Radial Nerve Injury Delayed Nerve Grafting
1) Results of grafting superior if before 6 months
2) Graft length has no affect until >10 cm Shergill et al. 3) Expect overall recovery of >85% Nunley et al., Shergill et al.
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Radial Nerve Injury
What about the people who don’t get functional recovery??
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Radial Nerve Injury
• Radial Nerve Tendon Transfers 1) Wrist extension: PT to ECRB 2) Index through small finger extension: FCR to EDC 3) Thumb extension: PL to EPL
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Case Example
• 42 yo AAM MVC • Closed left humerus
fracture • T5 burst fracture • T6 compression fx • Multiple rib fxs • Sternal fx • Hemopneumothorax
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Physical Examination on Presentation to Emergency Room
• Left humerus with internal rotation and varus deformity – Radial nerve intact (firing, though pain limited quantification) – Median/ulnar nerves intact, palpable radial/ulnar pulses
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Emergency Room Management
Closed reduction – Distraction – Valgus stress – External rotation of distal
fracture fragment Coaptation splint
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Immediately Following Reduction
• Found to have 0/5 wrist extension, EPL
• Decreased sensibility to light touch in radial nerve sensory distribution
• Neurovascularly intact otherwise
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Algorithm
• Treat ALL expectantly EXCEPT open fracture • EMG at 3 weeks (consider ultrasound) • Repeat EMG at 12 weeks if no recovery • Ideal exploration time is 4 months • Sural nerve graft if < 10 cm if not in continuity • Radial nerve tendon transfers for >1 year, > 10 cm
defect, or for failed grafting
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Thank You!