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Management of clinical radial nerve palsy with closed fracture shaft of humerus — A postal questionnaire survey
ORIGINAL ARTICLE D. G. Shivarathre S. K. Dheerendra A. Bari B. N. Muddu
Tameside General Hospital, Ashton Under Lyne Correspondence to: Mr BN Muddu, Tameside General Hospital, Fountain Street, Ashton Under Lyne Tel: +44 (0)161 3316285 Fax: +44 (0)161 3316300 E-mail: bnmuddu@hotmail. com
MANAGEMENT OF CLINICAL RADIAL NERVE PALSY WITH CLOSED FRACTURE SHAFT OF HUMERUS – A POSTAL QUESTIONNAIRE SURVEY The management of radial nerve palsy associated with fracture shaft of humerus is still a matter of debate. Various studies based on surgical and conservative management of this clinical problem have shown good results. After a recent systematic review by Shao et al. we felt that it was timely to survey the current practice among trauma and orthopaedic surgeons in England. Postal questionnaires were sent to orthopaedic surgeons in the north of England. The response rate was 64%. The survey showed that surgeons still differ in the ways of management of radial nerve palsy associated with fracture shaft of humerus, with a slightly higher percentage of surgeons preferring conservative treatment. The study also reveals the current practice of immobilisation, investigations and the duration of expectant treatment before surgical exploration among surgeons in the north of England. keywords: radial nerve palsy, questionnaire, england Surgeon, 1 April 2008 76-78
INTRODUCTION Radial nerve palsy in fractures of the shaft of humerus is a well recognised injury.14,9 Significant differences and diverse treatment options exist while managing the nerve injury in an otherwise conservatively manageable, isolated, closed fracture of the humeral shaft. The best treatment remains unclear and a universal protocol is not followed. Many authors in the past have claimed radial nerve palsy in such fractures is merely neuropraxia, which resolves completely and does not require any acute surgical intervention.1,10,12,17,18 However, there is another equally strong school of thought suggesting that early exploration decreases the chances of nerve entrapment in the fracture ends and surgical stabilisation of the fracture will prevent further damage to the nerve.9,3,8,11,15 Considerable variations in the choice of further investigation and method of immobilisation exist. Although there have been a handful of published papers, lack of large prospective randomised trials contributes to the ambiguity of the evidence regarding acute management of fractures with radial nerve injury. However, Shao et al. published a systematic review 76
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the royal colleges of surgeons of edinburgh and ireland
of all previous clinical studies.13 The aim of this survey was to ascertain the preferred management for these injuries amongst orthopaedic surgeons in the north of England. METHODS Four hundred and three consultants who had agreed to participate in research and educational activities in the north of England were sent questionnaires to their hospital work addresses, obtained from the British Orthopaedic Association. The two-page tick box questionnaire focused on the management of fractures of the junction of the middle-third and distal-third of humerus in the first page and a similar set of questions focusing on the management of fractures of the mid-shaft the second page. The questions related to options of conservative/surgical management and the preferred investigation to diagnose nerve injury, and if the preferred treatment was conservative, the length of expectant period before surgical exploration and mode of immobilising the arm. The replies were analysed. © 2008 Surgeon 6; 2: 76-78
Table 1. Consultant response to questionnaire on management of closed fracture shaft of humerus with radial nerve palsy Middle 1/3 - distal 1/3 junction
Mid-shaft
How would you treat a closed fracture shaft of humerus with radial nerve palsy in the acute stage? Conservative management and observe
111(42.7)
128(49.2)
MUA/sedation without exploration of the nerve
2(0.8)
2(0.8)
MUA + surgical exploration of nerve
24(9.2)
14(5.4)
ORIF + exploration of radial nerve
123(47.3)
116(44.6)
None
156(60)
166(63.8)
Nerve conduction studies
100(38.5)
90(34.6)
MR scan
4(1.5)
4(1.5)
Would you request any special tests?
If conservative management, how long would you wait before exploration of the radial nerve? < 2 weeks
0(0)
0(0)
2 weeks to 1 month
10(9.0)
11(8.6)
1–3 months
49(44.1)
55(42.9)
3–6 months
40(36.0)
49(38.3)
>6 months
5(4.5)
5(3.9)
Referral to specialist centre
5(4.5)
5(3.9)
Discuss with patient and proceed
2(1.9)
2(1.6)
U-slab
53(47.8)
55(42.9)
Functional brace
25(22.7)
32(25.0)
Hanging cast
15(13.7)
20(15.6)
Cuff and collar sling
9(7.9)
9(7.3)
Any other
9(7.9)
12(9.4)
If conservative management, what would you use?
Figures in brackets represents the percentage RESULTS A total of 290 replies were received. Thirty questionnaires, that were incomplete and ambiguous were excluded. Two hundred and sixty questionnaires (64.5%) from practising orthopaedic consultants were analysed. The results have been tabulated in Table 1.
would continue with the expectant policy for 1–3 months and 36% would wait 3–6 months before any surgical exploration. The preferred method of immobilisation of the arm was U-slab (47.8%), functional brace (22.7%), hanging cast (13.7%) and cuff and collar sling (7.9%).
Management of fractures of the junction of middle-third and distal-third shaft Of the 260 participants, 111 (42.7%) surgeons would manage fracture associated with nerve injury conservatively and would observe for a certain period of time before surgical exploration. Manipulation and surgical exploration of the nerve was advocated by 24 (9.2%). However, the majority of the surgeons (47.3%) opted for surgical exploration of the nerve and stabilisation of the fracture with either plates and screws or intramedullary nail fixation. Sixty per cent of the surgeons would not request any special tests, while 38.5% of them opted for nerve conduction studies and 0.75% suggested magnetic resonance imaging and ultrasound to aid in the diagnosis of nerve injury. Of the 111 surgeons who would manage conservatively, 44.1%
Management of fractures of the junction of mid-shaft Of the 260 participants, 128 (49.4%) surgeons advocated expectant treatment and 44.6% advocated the surgical exploration and fracture stabilisation. A small percentage of the surgeons (5.4%) opted for manipulation of the fracture and surgical exploration of the nerve. The majority of the surgeons (63.8%) requested no special investigations, 34.6% opted for nerve conduction studies and 0.75% suggested that magnetic resonance imaging and ultrasound would benefit in diagnosis of the injury. Of the 128 surgeons who would want to manage the fracture conservatively, 42.9% and 38.3% of the surgeons would wait 1-3 months and 3-6 months respectively. The preferred immobilisation was U-slab (42.9%), functional brace (25%), hanging cast (15.6%) and cuff and collar sling (7.3%).
© 2008 Surgeon 6; 2: 76-78
the royal colleges of surgeons of edinburgh and ireland |
77
DISCUSSION There could be three clinical scenarios causing radial nerve palsy in fracture shaft of humerus. (A) Neuropraxia, where the radial nerve would recover with time following conservative management. (B) Complete transection of the nerve, where a surgical repair might result in nerve recovery. However, it has been noted that there was no significant difference in the prognosis of the nerve that was repaired following a period of expectant treatment.13 Also, it can be argued that radial nerve repair which might need humeral shortening is best done in the acute stage.9,11 (C) Entrapment of the nerve in the fracture fragments, where an immediate surgical exploration will release the nerve and prevent it from being engulfed in the fracture callus. Also, stabilisation of the fracture might protect any further damage to the nerve by rubbing against the sharp bony fracture ends.3,9,11 However, the best diagnostic tool to identify the nerve’s condition is surgical exploration. In our survey, the majority of the surgeons advocated surgical exploration and fracture stabilisation (47.3% in fracture middle-distal third junction and 44.6% in fracture mid-shaft). The slightly increased tendency among surgeons to operate on distal humeral fractures associated with radial nerve palsy can be related to the increased incidence of nerve injury in fractures in that region (Holstein–Lewis fracture). Various methods of immobilisation have been reported with good outcomes. Functional humeral brace would reduce the complications of elbow stiffness as compared to U-slab.4,5 U-slab is more cost-effective and has similar outcomes in terms of healing time and fracture alignment.5 There has been no study on the methods of immobilisation in cases where humeral fracture was associated with radial nerve palsy. Most of the respondents in our survey preferred U-slab or functional humeral brace. There is no standard evidence regarding the maximum time period of expectant treatment. However, based on a nerve regeneration rate of 1mm per day, the number of days required for nerve recovery could be calculated from the distance between the fracture site and the nerve insertion into the brachioradialis (2cm above lateral epicondyle).16,7 In our survey, we found that 44.1% (fracture middle-distal third junction) and 42.9% (mid-shaft fractures) would continue with the expectant policy for 1–3 months. Thirty-six percent (fracture middledistal third junction) and 38.3% (mid-shaft fractures) of the surgeons would wait 3–6 months before any surgical exploration. Serial nerve conduction studies have been the gold standard investigation.17 Recently, ultrasound has been used to identify nerve damage and regeneration in humeral shaft fractures with reasonable accuracy. Although non-invasive and cost-effective, it needs an experienced radiologist and high quality machines to delineate the soft tissue structures.2 The majority of the respondents in our study did not feel the need for any investigation to proceed with further management of the fracture. However, 34.6% and 38.5% of the surgeons requested nerve conduction studies and less than 1% thought that an MR scan or ultrasound would be helpful. There have not been any surveys like this in the British literature which reflects the current practice among orthopaedic surgeons. However, it has to be accepted that postal surveys over a limited geographical area has their own limitations. Evidence of variation shown in this survey may be used to identify areas of uncertainty for future research.
REFERENCES 1. Ammilo S, Barrios RH, Martinéz-Peric R, Losada Jl. Surgical treatment of the radial nerve lesions associated with fractures of the humerus. J Orthop Trauma 1993; 7: 211-15 2. Bodner G, Buchberger W, Schocke M et al. Radial nerve palsy associated with humeral shaft fracture: evaluation with US-initial experience. Radiology 2001; 219: 811-16 3. Dabezies EJ, Banta CJ 2nd, Murphy CP, d’Ambrosia RD. Plate xation of the humeral shaft for acute fractures, with and without radial nerve injuries. J Orthop 1992; 6(1): 10-13 4. Camden P, Nade S. Fracture bracing the humerus. Injury 1992; 23(4): 245-48 5. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000; 82(4): 478-86 6. Pehlivan O. Functional treatment of the distal third humeral shaft fractures. Arch Orthop Trauma Surg 2002; 122(7): 390-95. Epub 2002 Apr 26 7. Green DP, Hotchkiss RN, Pederson WC. Green’s Operative Hand Surgery. VoI. 2 4th ed. New York: Churchill Livingstone, 1999: 1492 8. Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures: the Basel experience. J Trauma 1993: 35: 226-32 9. Holstein A, Lewis GM. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg [Am] 1963; 45-A: 1382-88 10. Larsen LB, Barfred T. Radial nerve palsy after simple fracture of the humerus. Scand J Plast Reconstr Surg Hand Surg 2000: 34: 363-66 11. Packer JW, Foster RR, Garcia A, Grantham SA. The humeral fracture with radial nerve palsy: is exploration warranted? Clin Orthop 1972; 88: 34-8 12. Pollock FH, Drake D, Bovill EG, Day L, Trafton PG. Treatment of radial neuropathy associated with fractures of the humérus. J Bone Joint Surg Am 1981; 63-A: 239-43 13. Shao YC, Harwood P, Grotz MRW, 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): 1647-52 14. Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD. Rockwood and Green’s Fracture in adults. 4th ed. Philadelphia: Lippincott-Raven, 1996: 1043-5 15. Samardzic M, Grujicic D, Milinkovic ZB. Radial nerve lesions associated with fractures of the humeral shaft. Injury 1990; 21: 220-22 16. Seddon HJ. Nerve grafting. J Bone Joint Surg Br 1963; 45-B: 447-61 17. Shah JJ, Bhatti NA. Radial nerve paralysis associated with fractures of the humerus: a review of 62 cases. Clin Orthop Relat Res 1983; 172: 171-76 18. Sonneveld GJ, Patka P, van Mourik JC, Broere G. Treatment of fractures of the shaft of the humerus accompanied by paralysis of the radial nerve. Injury 1987; 18: 404-6
Copyright © 30 July 2007 78
|
the royal colleges of surgeons of edinburgh and ireland
© 2008 Surgeon 6; 2: 76-78
Tameside General Hospital, Ashton Under Lyne Correspondence to: Mr BN Muddu, Tameside General Hospital, Fountain Street, Ashton Under Lyne Tel: +44 (0)161 3316285 Fax: +44 (0)161 3316300 E-mail: bnmuddu@hotmail. com
MANAGEMENT OF CLINICAL RADIAL NERVE PALSY WITH CLOSED FRACTURE SHAFT OF HUMERUS – A POSTAL QUESTIONNAIRE SURVEY The management of radial nerve palsy associated with fracture shaft of humerus is still a matter of debate. Various studies based on surgical and conservative management of this clinical problem have shown good results. After a recent systematic review by Shao et al. we felt that it was timely to survey the current practice among trauma and orthopaedic surgeons in England. Postal questionnaires were sent to orthopaedic surgeons in the north of England. The response rate was 64%. The survey showed that surgeons still differ in the ways of management of radial nerve palsy associated with fracture shaft of humerus, with a slightly higher percentage of surgeons preferring conservative treatment. The study also reveals the current practice of immobilisation, investigations and the duration of expectant treatment before surgical exploration among surgeons in the north of England. keywords: radial nerve palsy, questionnaire, england Surgeon, 1 April 2008 76-78
INTRODUCTION Radial nerve palsy in fractures of the shaft of humerus is a well recognised injury.14,9 Significant differences and diverse treatment options exist while managing the nerve injury in an otherwise conservatively manageable, isolated, closed fracture of the humeral shaft. The best treatment remains unclear and a universal protocol is not followed. Many authors in the past have claimed radial nerve palsy in such fractures is merely neuropraxia, which resolves completely and does not require any acute surgical intervention.1,10,12,17,18 However, there is another equally strong school of thought suggesting that early exploration decreases the chances of nerve entrapment in the fracture ends and surgical stabilisation of the fracture will prevent further damage to the nerve.9,3,8,11,15 Considerable variations in the choice of further investigation and method of immobilisation exist. Although there have been a handful of published papers, lack of large prospective randomised trials contributes to the ambiguity of the evidence regarding acute management of fractures with radial nerve injury. However, Shao et al. published a systematic review 76
|
the royal colleges of surgeons of edinburgh and ireland
of all previous clinical studies.13 The aim of this survey was to ascertain the preferred management for these injuries amongst orthopaedic surgeons in the north of England. METHODS Four hundred and three consultants who had agreed to participate in research and educational activities in the north of England were sent questionnaires to their hospital work addresses, obtained from the British Orthopaedic Association. The two-page tick box questionnaire focused on the management of fractures of the junction of the middle-third and distal-third of humerus in the first page and a similar set of questions focusing on the management of fractures of the mid-shaft the second page. The questions related to options of conservative/surgical management and the preferred investigation to diagnose nerve injury, and if the preferred treatment was conservative, the length of expectant period before surgical exploration and mode of immobilising the arm. The replies were analysed. © 2008 Surgeon 6; 2: 76-78
Table 1. Consultant response to questionnaire on management of closed fracture shaft of humerus with radial nerve palsy Middle 1/3 - distal 1/3 junction
Mid-shaft
How would you treat a closed fracture shaft of humerus with radial nerve palsy in the acute stage? Conservative management and observe
111(42.7)
128(49.2)
MUA/sedation without exploration of the nerve
2(0.8)
2(0.8)
MUA + surgical exploration of nerve
24(9.2)
14(5.4)
ORIF + exploration of radial nerve
123(47.3)
116(44.6)
None
156(60)
166(63.8)
Nerve conduction studies
100(38.5)
90(34.6)
MR scan
4(1.5)
4(1.5)
Would you request any special tests?
If conservative management, how long would you wait before exploration of the radial nerve? < 2 weeks
0(0)
0(0)
2 weeks to 1 month
10(9.0)
11(8.6)
1–3 months
49(44.1)
55(42.9)
3–6 months
40(36.0)
49(38.3)
>6 months
5(4.5)
5(3.9)
Referral to specialist centre
5(4.5)
5(3.9)
Discuss with patient and proceed
2(1.9)
2(1.6)
U-slab
53(47.8)
55(42.9)
Functional brace
25(22.7)
32(25.0)
Hanging cast
15(13.7)
20(15.6)
Cuff and collar sling
9(7.9)
9(7.3)
Any other
9(7.9)
12(9.4)
If conservative management, what would you use?
Figures in brackets represents the percentage RESULTS A total of 290 replies were received. Thirty questionnaires, that were incomplete and ambiguous were excluded. Two hundred and sixty questionnaires (64.5%) from practising orthopaedic consultants were analysed. The results have been tabulated in Table 1.
would continue with the expectant policy for 1–3 months and 36% would wait 3–6 months before any surgical exploration. The preferred method of immobilisation of the arm was U-slab (47.8%), functional brace (22.7%), hanging cast (13.7%) and cuff and collar sling (7.9%).
Management of fractures of the junction of middle-third and distal-third shaft Of the 260 participants, 111 (42.7%) surgeons would manage fracture associated with nerve injury conservatively and would observe for a certain period of time before surgical exploration. Manipulation and surgical exploration of the nerve was advocated by 24 (9.2%). However, the majority of the surgeons (47.3%) opted for surgical exploration of the nerve and stabilisation of the fracture with either plates and screws or intramedullary nail fixation. Sixty per cent of the surgeons would not request any special tests, while 38.5% of them opted for nerve conduction studies and 0.75% suggested magnetic resonance imaging and ultrasound to aid in the diagnosis of nerve injury. Of the 111 surgeons who would manage conservatively, 44.1%
Management of fractures of the junction of mid-shaft Of the 260 participants, 128 (49.4%) surgeons advocated expectant treatment and 44.6% advocated the surgical exploration and fracture stabilisation. A small percentage of the surgeons (5.4%) opted for manipulation of the fracture and surgical exploration of the nerve. The majority of the surgeons (63.8%) requested no special investigations, 34.6% opted for nerve conduction studies and 0.75% suggested that magnetic resonance imaging and ultrasound would benefit in diagnosis of the injury. Of the 128 surgeons who would want to manage the fracture conservatively, 42.9% and 38.3% of the surgeons would wait 1-3 months and 3-6 months respectively. The preferred immobilisation was U-slab (42.9%), functional brace (25%), hanging cast (15.6%) and cuff and collar sling (7.3%).
© 2008 Surgeon 6; 2: 76-78
the royal colleges of surgeons of edinburgh and ireland |
77
DISCUSSION There could be three clinical scenarios causing radial nerve palsy in fracture shaft of humerus. (A) Neuropraxia, where the radial nerve would recover with time following conservative management. (B) Complete transection of the nerve, where a surgical repair might result in nerve recovery. However, it has been noted that there was no significant difference in the prognosis of the nerve that was repaired following a period of expectant treatment.13 Also, it can be argued that radial nerve repair which might need humeral shortening is best done in the acute stage.9,11 (C) Entrapment of the nerve in the fracture fragments, where an immediate surgical exploration will release the nerve and prevent it from being engulfed in the fracture callus. Also, stabilisation of the fracture might protect any further damage to the nerve by rubbing against the sharp bony fracture ends.3,9,11 However, the best diagnostic tool to identify the nerve’s condition is surgical exploration. In our survey, the majority of the surgeons advocated surgical exploration and fracture stabilisation (47.3% in fracture middle-distal third junction and 44.6% in fracture mid-shaft). The slightly increased tendency among surgeons to operate on distal humeral fractures associated with radial nerve palsy can be related to the increased incidence of nerve injury in fractures in that region (Holstein–Lewis fracture). Various methods of immobilisation have been reported with good outcomes. Functional humeral brace would reduce the complications of elbow stiffness as compared to U-slab.4,5 U-slab is more cost-effective and has similar outcomes in terms of healing time and fracture alignment.5 There has been no study on the methods of immobilisation in cases where humeral fracture was associated with radial nerve palsy. Most of the respondents in our survey preferred U-slab or functional humeral brace. There is no standard evidence regarding the maximum time period of expectant treatment. However, based on a nerve regeneration rate of 1mm per day, the number of days required for nerve recovery could be calculated from the distance between the fracture site and the nerve insertion into the brachioradialis (2cm above lateral epicondyle).16,7 In our survey, we found that 44.1% (fracture middle-distal third junction) and 42.9% (mid-shaft fractures) would continue with the expectant policy for 1–3 months. Thirty-six percent (fracture middledistal third junction) and 38.3% (mid-shaft fractures) of the surgeons would wait 3–6 months before any surgical exploration. Serial nerve conduction studies have been the gold standard investigation.17 Recently, ultrasound has been used to identify nerve damage and regeneration in humeral shaft fractures with reasonable accuracy. Although non-invasive and cost-effective, it needs an experienced radiologist and high quality machines to delineate the soft tissue structures.2 The majority of the respondents in our study did not feel the need for any investigation to proceed with further management of the fracture. However, 34.6% and 38.5% of the surgeons requested nerve conduction studies and less than 1% thought that an MR scan or ultrasound would be helpful. There have not been any surveys like this in the British literature which reflects the current practice among orthopaedic surgeons. However, it has to be accepted that postal surveys over a limited geographical area has their own limitations. Evidence of variation shown in this survey may be used to identify areas of uncertainty for future research.
REFERENCES 1. Ammilo S, Barrios RH, Martinéz-Peric R, Losada Jl. Surgical treatment of the radial nerve lesions associated with fractures of the humerus. J Orthop Trauma 1993; 7: 211-15 2. Bodner G, Buchberger W, Schocke M et al. Radial nerve palsy associated with humeral shaft fracture: evaluation with US-initial experience. Radiology 2001; 219: 811-16 3. Dabezies EJ, Banta CJ 2nd, Murphy CP, d’Ambrosia RD. Plate xation of the humeral shaft for acute fractures, with and without radial nerve injuries. J Orthop 1992; 6(1): 10-13 4. Camden P, Nade S. Fracture bracing the humerus. Injury 1992; 23(4): 245-48 5. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000; 82(4): 478-86 6. Pehlivan O. Functional treatment of the distal third humeral shaft fractures. Arch Orthop Trauma Surg 2002; 122(7): 390-95. Epub 2002 Apr 26 7. Green DP, Hotchkiss RN, Pederson WC. Green’s Operative Hand Surgery. VoI. 2 4th ed. New York: Churchill Livingstone, 1999: 1492 8. Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures: the Basel experience. J Trauma 1993: 35: 226-32 9. Holstein A, Lewis GM. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg [Am] 1963; 45-A: 1382-88 10. Larsen LB, Barfred T. Radial nerve palsy after simple fracture of the humerus. Scand J Plast Reconstr Surg Hand Surg 2000: 34: 363-66 11. Packer JW, Foster RR, Garcia A, Grantham SA. The humeral fracture with radial nerve palsy: is exploration warranted? Clin Orthop 1972; 88: 34-8 12. Pollock FH, Drake D, Bovill EG, Day L, Trafton PG. Treatment of radial neuropathy associated with fractures of the humérus. J Bone Joint Surg Am 1981; 63-A: 239-43 13. Shao YC, Harwood P, Grotz MRW, 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): 1647-52 14. Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD. Rockwood and Green’s Fracture in adults. 4th ed. Philadelphia: Lippincott-Raven, 1996: 1043-5 15. Samardzic M, Grujicic D, Milinkovic ZB. Radial nerve lesions associated with fractures of the humeral shaft. Injury 1990; 21: 220-22 16. Seddon HJ. Nerve grafting. J Bone Joint Surg Br 1963; 45-B: 447-61 17. Shah JJ, Bhatti NA. Radial nerve paralysis associated with fractures of the humerus: a review of 62 cases. Clin Orthop Relat Res 1983; 172: 171-76 18. Sonneveld GJ, Patka P, van Mourik JC, Broere G. Treatment of fractures of the shaft of the humerus accompanied by paralysis of the radial nerve. Injury 1987; 18: 404-6
Copyright © 30 July 2007 78
|
the royal colleges of surgeons of edinburgh and ireland
© 2008 Surgeon 6; 2: 76-78