Date: Saturday, March 25, 2000 12:37 AM
From: Samir Chhabra
Subject: Humeral Shaft Fx + Radial Nerve Palsy
I'd value an opinion in this case. A 19 year old male, driver travelling at 50-60 miles per hour, hit a wall. Only injury being a comminuted middle-third, lower third fracture of the humerus whichis grade I Gustilo open with a radial nerve palsy identified at presentation.
My query is: Is exploration of the nerve essential at this (one day) stage. Wound has been debrided though the nerve not formally exposed. My intention was to treat this conservatively. Explore the nerve only if recovery doesn't occur at three-four months.
Thank you, Samir Chhabra
Date: Sat, 25 Mar 2000 14:12:15 -0500
From: bruce meinhard
Since the fracture was open and formal debridement was appropriate, I would have inspected the nerve and fixed the humerus with a plate initially. My reasons for so doing are:
Of course this could also early or late require humeral shortening for end to end repair.
Date: March 25, 2000 17:38:37 -0600
From: Adam Starr
I would've plated the bone at the time of the initial debridement. The easiest time to find and examine the nerve, fix it if necessary, and plate the bone, is within the first few days.
So, at this point, I think I would vote for repeat I & D, nerve exploration and plate fixation.
Adam Starr, Dallas
Date: Sat, 25 Mar 2000 23:19:09 -0600
From: Gregory J Schmeling
I will enter in a third opinion. I would irrigate & debride wound at the time of ORIF of the fracture on the date of injury and not explore the nerve. The vast majority of these nerve injuries from blunt trauma are not lacerations but neuropraxia. Exploring the nerve may risk its blood supply resulting in delayed recovery or no recovery. Also neither the open wound nor the surgical exposure for ORIF are optimum for nerve exploration. Thus a second or third wound is needed to explore the nerve adequately further placing at risk the blood supply of the fracture and the nerve. At 3-5 wks post injury I would get an EMG/NCV to determine the continuity of the nerve. If this shows that the nerve is lacerated, exploration with primary repair or nerve grafting is done. The results of primary repair or graft at 6 wks are no worse than on the day of injury.
Gregory J Schmeling
Date: Sun, 26 Mar 2000 14:31:27 -0600
From: Andrew H. Schmidt
Greg is right regarding the difficulty associated with exploration of the nerve acutely, as well as the excellent results with delayed nerve repair. However, a paper out of Seattle showed that in cases of radial nerve palsy with open humeral fractures, 64% of the cases either had a lacerated nerve or the nerve was found directly within the fracture where it would have been bound up by callus had it not been explored acutely.
Therefore, it has been my policy to explore the nerve acutely in cases of open fractures with radial nerve palsy, and then to proceed with plate fixation.
Foster RJ; Swiontkowski MF; Bach AW; Sack JT. Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg [Am] (United States), Jan 1993, 18(1) p121-4
ABSTRACT: Although radial nerve palsy associated with a closed humeral shaft fracture may be managed by observation, it is our experience that an open humeral shaft fracture with radial nerve palsy requires exploration of the nerve. In a series of 14 patients with radial nerve palsy caused by an open humeral shaft fracture, 9 (64%) of the 14 patients had a radial nerve that was either lacerated or interposed between the fracture fragments. There was an equal incidence of radial nerve lacerations or entrapments in types I, II, and III open humeral shaft fractures. Epineural radial nerve repair, done primarily or secondarily, provided a satisfactory return of radial nerve function. Rigid fixation of the associated fracture is the recommended treatment.
Andrew H. Schmidt, M.D., Hennepin County Medical Center, University of Minnesota
Date: Sun, 26 Mar 2000 19:12:24 +0600
From: Alexander Chelnokov
Sunday, March 26, 2000, 11:19:09 AM, you wrote:
GJS> I will enter in a third opinion. I would irrigate & debride wound at the time of ORIF of the fracture on the date of injury
Closed nailing and ex-fix are good options too, and may be even better than plating for the case - plating itself can be a good source of the nerve lesion. Functional brace may also be in the list - the nerve contusion was happened at the moment of initial injury and hardly ever can be worse in brace.
GJS> from blunt trauma are not lacerations but neuropraxia. Exploring the nerve may risks its blood supply resulting in delayed
Recent years we haven't exposed radial nerve in similar cases - all proceed to healing. Revision is needed only for cases of excessive wound over the nerve where we find the nerve ruptured/cut. A couple of years ago I reviewed a clinical guideline prepared in Kurgan Center - they also directly stated that such a revision is unnecessary.
Best regards, Alexander N. Chelnokov, Ural Scientific Institute of Traumatology and Orthopaedics, str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 27 Mar 2000 07:40:35 -0700
From: John Ruth
I have found the nerve entrapped in the fracture site with this type of fracture. I would recommend exploring it and doing and ORIF with plate and screws. The radial nerve has a good chance of recovering.
Date: Mon, 27 Mar 2000 010:45
From: Bill Burman
>I would recommend exploring it and doing an ORIF with plate and screws
While the consensus appears to be nerve exploration and plate ORIF for this Grade I open humerus fx associated with radial nerve palsy, a 1981 JBJS paper by Pollock et al has been cited by Richard Gelberman at the Maine Orthopaedic Review as the basis for his opinion that the isolated humerus shaft fracture (including the Holstein variant) associated with a radial nerve palsy should be treated conservatively for at least 5 months waiting for either clinical or EMG signs of neurologic recovery. That series of 24 cases included 3 open fractures.
I do not have the full text of that article readily available to me but as far as I know, no specific or different conclusions were drawn for the management of open fractures in that series.
Date: Mon, 27 Mar 2000 19:23:51 +0100
From: samir chhabra
I have operated on the humerus fracture today. The radial nerve was indeed trapped between the fracture fragments and was in continuity but bruised. I stabilised the fracture using a DCP and interfragmentory screws. Thank you.