Session II - Upper Extremity

Radial Nerve Palsy Associated with Humeral Fractures Roy Sanders, MD; Jeff Yach, MD, FRCSC; Thomas DiPasquale, DO; Dolfi Herscovici, DO, Florida Orthopaedic Institute, Tampa, FL

Purpose: Treatment guidelines for the management of radial nerve palsy associated with fracture of the humerus have not been definitively reported in the orthopaedic literature. The purpose of this study was to evaluate patients with radial nerve palsies associated with humeral fractures to determine prognostic factors and develop a treatment algorithm.

Method: The Orthopaedic Trauma Association (OTA) database was used to identify patients presenting with humeral fractures over a 10-year period between 1989 and 1999. A subset of patients who were diagnosed with diaphyseal and/or distal humeral fractures associated with radial nerve palsy was derived from this group. A retrospective analysis was performed on the resultant subject group using chart reviews, patient questionnaires and telephone interviews. Data were collected on patient demographics, fracture type, extent of radial nerve dysfunction, treatment, intraoperative findings, recovery, complications and need for subsequent procedures.

Results: A total of 232 patients with humeral fractures were identified >from the OTA database. Of these, 46 patients were found to have diaphyseal and/or distal humeral fractures with an associated radial nerve palsy. Thirty patients sustained closed fractures with adequate follow-up on 22 patients (average = 9 months). There were 16 open fractures, 12 were available for follow-up (average = 13 months). Fifty percent of patients with closed fractures underwent nerve exploration in conjunction with their treatment; there were no cases of radial neuronotmesis. By contrast, 69% of patients with open fractures underwent radial nerve exploration; 55% of these injuries were associated with at least a partial disruption of the radial nerve. Follow-up revealed a significant difference in the incidence of satisfactory recovery of radial nerve function. Patients with closed fractures experienced satisfactory recovery in 86% of cases as compared to only 33% of patients with open fractures (P= 0.0005).

Discussion: Radial nerve palsy associated with closed humeral fractures is generally secondary to neuropraxia and the majority will resolve spontaneously. However, the outcome is not uniformly favorable, and some patients do experience no or incomplete recovery. These results would support the practice of expectantly managing closed radial nerve injuries acutely. If recovery fails to occur within 3 to 4 months, then nerve conduction studies and exploration should be performed. The outcome of radial nerve injuries with open humeral fractures is significantly worse. The high incidence of nerve laceration and incomplete recovery suggests that more immediate surgical management is appropriate.

Conclusions: The outcome of radial nerve injury associated with humeral fractures is directly related to the degree of bone and soft tissue injury. To improve outcome, high-energy and open injuries should be managed aggressively with surgical exploration secondary to the increased incidence of a correctable lesion.