Primary exploration for radial nerve palsy associated with unstable closed humeral shaft fracture

BACKGROUND: The treatment of radial nerve palsy caused by closed humeral shaft fracture is a matter of debate. The purpose of this study is to evaluate the outcome of early surgical management of radial nerve palsy in patients with unstable closed humeral shaft fractures and to determine whether patients with this injury should be surgically explored.
METHODS: Medical records of 15 consecutive patients who had undergone open reduction and internal fixation for unstable closed humeral shaft fractures were reviewed. Injury mechanisms, radiographs, intraoperative findings of the injured nerve, and clinical improvement were analyzed. Of the 15 patients, two were injured during simple falls, two during baseball pitching, one by a fall from a height, one during skiing, and one by direct machine impaction during work. Fracture locations were middle humerus in six patients, middle-distal in eight patients, and middle-proximal in one patient. Fracture patterns were transverse fracture in six patients, butterfly segment fracture in four patients, oblique segment fracture in three patients, and spiral fracture in two patients.
RESULTS: Eleven patients showed macroscopically intact nerves, and four had total nerve transection. All four patients with total nerve transection were injured in traffic accident. Of these four patients, one showed comminuted fracture with butterfly fragment on the middle-distal shaft and the other three showed displaced transverse fracture on the middle to middle-distal shaft area. Transected nerves were directly repaired in two patients. In the other two patients, humerus shortening and nerve grafting were performed because of mangled nerve endings. All patients who had intact nerves showed fully recovered function at the last follow-up.
CONCLUSION: For radial nerve palsy accompanied by unstable humeral shaft fracture, primary exploration of the radial nerve and open reduction and plate fixation of the fracture should be considered as a treatment of choice. High-energy trauma, fracture location at the middle-distal humerus, and simple transverse fracture or comminuted fracture with butterfly fragment seems to be risk factors for radial nerve transection.

Kararlý olmayan kapalý humerus cismi kýrýðý ile iliþkili radiyal sinir felcinin primer eksplorasyonu

AMAÇ: Kapalý humerus cismi kýrýðýnýn neden olduðu radyal sinir felcinin tedavisi tartýþmalýdýr. Bu çalýþmanýn amacý, kararlý olmayan kapalý humerus cismi kýrýklarý olan hastalarda radiyal sinir felcinin erken evrede tedavisinin sonlanýmýný deðerlendirmek ve bu tip yaralanmasý olan hastalarýn cerrahi yolla eksplore edilip edilmemesi gerektiðini belirlemektir.
GEREÇ VE YÖNTEM: Kararlý olmayan kapalý humerus cismi kýrýklarýnýn tedavisi için açýk redüksiyon ve internal fiksasyon geçirmiþ 15 ardýþýk hastanýn týbbi kayýtlarý gözden geçirildi. Yaralanma mekanizmalarý, radyogramlar, zedelenmiþ sinirin intraoperatif bulgularý ve klinik iyileþmeler irdelendi. On beþ hastanýn ikisi basit düþme, ikisi beyzbol oynarken, biri kayak yaparken biri de iþ sýrasýnda makineye kaptýrmýþtý. Kýrýklar 6 hastada humerusun ortasýnda 8 hastada orta-distalinde ve bir hastada orta-proksimalinde bulunuyordu. Kýrýklar 6 hastada transvers kýrýk, 4 hastada kelebek fragmanlý parçalý kýrýk, 3 hastada oblik segmentli kýrýk ve 2 hastada spiral kýrýk þeklindeydi.
BULGULAR: On bir hastada makroskopik olarak sinirler saðlamdý ve dördünde sinir tamamen enine kesilmiþti. Total sinir kesisi olan dört hasta trafik kazasý geçirmiþti. Bu dört hastanýn birinde humerus cisminin orta-distal kýsmýnda kelebek fragmanlý parçalý kýrýk, diðer üçünde ise yine humerus cisminin orta-distalinde deplase transvers kýrýk mevcuttu. Ýki olguda enine kesili sinirler primer onarýldý. Diðer iki olguda sinir uçlarý ezilmiþ olduðu için humerus boyu kýsaltýldý ve sinir grefti kondu. Saðlam sinirli hastalarýn tümü son izlemde tamamen fonksiyonlarýna kavuþmuþtu.
TARTIÞMA: Kararlý olmayan humerus cismi kýrýðýnýn eþlik ettiði radiyal sinir felcinin tedavisi için tercihen radiyal sinirin primer eksplorasyonu, açýk redüksiyon, kýrýðýn plakayla tespiti düþünülmelidir. Yüksek enerjili travma, orta-distal humerusta lokalize kýrýk ve basit transvers kýrýk veya kelebek fragmanlý parçalý kýrýðýn radiyal sinir transeksiyonu için risk faktörleri olduðu görünmektedir.