Mateusz Gładysz FESSH prep

FESSH prep Compressive neuropathies Traumatic radial nerve injury

Radial nerve palsy following humeral shaft fractures

Last reviewed v1.0

FESSH-011Compressive neuropathies●●○ intermediate

Regarding radial nerve palsy following fractures of the humeral shaft.

  1. 1.The Holstein–Lewis fracture — a spiral fracture of the distal third of the humeral shaft — has a higher rate of associated radial nerve palsy than other humeral-shaft fracture patterns.

  2. 2.In closed fractures, neuropraxia is the most common nerve injury; in open fractures, neurotmesis is more common.

  3. 3.Iatrogenic radial nerve palsy occurs more commonly after posterior than anterolateral approach for humeral-shaft open reduction and internal fixation.

  4. 4.Spontaneous recovery of nerve function is often observed around 7 weeks, with full recovery by approximately 6 months.

  5. 5.Surgical exploration is indicated in open fractures and in closed fractures that do not show improvement within 4–6 months.

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Question ID
FESSH-011
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. The Holstein–Lewis fracture — a spiral fracture of the distal third of the humeral shaft — has a higher rate of associated radial nerve palsy than other humeral-shaft fracture patterns.

    True

    Holstein and Lewis described this distal-third spiral pattern in 1963 in a series of 341 distal humeral fractures, in which five of six radial nerve palsies in the cohort had this configuration. Ekholm and colleagues' subsequent epidemiological series reported a substantially higher rate of radial nerve palsy in Holstein–Lewis fractures than in other humeral-shaft fracture patterns. The mechanism is entrapment or laceration of the radial nerve at the lateral intermuscular septum by the displaced proximal fragment.

    • Holstein A, Lewis GB. Fractures of the humerus with radial-nerve paralysis. J Bone Joint Surg Am. 1963;45(7):1382-1388. PMID 14069777
    • Ekholm R, Ponzer S, Törnkvist H, Adami J, Tidermark J. The Holstein-Lewis humeral shaft fracture: aspects of radial nerve injury, primary treatment, and outcome. J Orthop Trauma. 2008;22(10):693-697. PMID 18978544

  2. 2. In closed fractures, neuropraxia is the most common nerve injury; in open fractures, neurotmesis is more common.

    True

    Closed humeral-shaft fractures most often produce neuropraxia, with high rates of spontaneous recovery. In Bishop and Ring's high-energy series all six patients with complete radial-nerve transection had open fractures, five of which were part of complex upper-extremity injuries. Subsequent systematic reviews report a similar pattern: complete transection occurs almost exclusively in open fractures, while closed injuries are dominated by neuropraxia and axonotmesis.

    • Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am. 2004;29(1):144-147. PMID 14751118
    • Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87(12):1647-1652. PMID 16326879

  3. 3. Iatrogenic radial nerve palsy occurs more commonly after posterior than anterolateral approach for humeral-shaft open reduction and internal fixation.

    True

    Smolle and colleagues' systematic review and meta-analysis of 43 studies found that the posterior approach carried a significantly higher risk of iatrogenic radial nerve palsy than the anterior or anterolateral approach (relative risk 2.68, 95% CI 1.34–5.36; I² = 0%). Claessen's multicentre series similarly reported iatrogenic palsy in 17.9% of triceps-sparing posterior approaches, 11.7% of triceps-splitting posterior approaches, and 7.1% of anterolateral approaches.

    • Smolle MA, Bösmüller S, Puchwein P, Ornig M, Leithner A, Seibert FJ. Complications in humeral shaft fractures - non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis. EFORT Open Rev. 2022;7(1):95-108. PMID 35073516
    • Streufert BD, Eaford I, Sellers TR, Christensen JT, Maxson B, Infante A, et al.. Iatrogenic nerve palsy occurs with anterior and posterior approaches for humeral shaft fixation. J Orthop Trauma. 2020;34(3):163-168. PMID 31842186

  4. 4. Spontaneous recovery of nerve function is often observed around 7 weeks, with full recovery by approximately 6 months.

    True

    In Bishop and Ring's series of 24 high-energy diaphyseal humeral fractures with complete radial nerve palsy, the average time to initial signs of recovery was 7 weeks (range 1–25 weeks) and the average time to full recovery was 6 months (range 1–21 months). Recovery timing is consistently faster in low-energy fractures and in cases without nerve transection; Shao's systematic review reported a mean time to recovery of 6.1 months across pooled cohorts.

    • Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am. 2004;29(1):144-147. PMID 14751118
    • Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87(12):1647-1652. PMID 16326879

  5. 5. Surgical exploration is indicated in open fractures and in closed fractures that do not show improvement within 4–6 months.

    True

    Open humeral-shaft fractures with radial nerve palsy are typically explored at the time of fracture fixation. For closed fractures, observation for 3–4 months is supported by Shao's systematic review, which found no difference in long-term outcome between expectantly managed and early-explored cohorts. Ilyas's updated systematic review reported a recovery rate of 89.8% with surgical exploration within three weeks of injury versus 68.1% for explorations performed beyond eight weeks; exploration is therefore considered if no clinical or electrodiagnostic signs of recovery have appeared within an agreed observation window.

    • Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87(12):1647-1652. PMID 16326879
    • Ilyas AM, Mangan JJ, Graham J. Radial nerve palsy recovery with fractures of the humerus: an updated systematic review. J Am Acad Orthop Surg. 2020;28(6):e263-e269. PMID 31714418