Radial nerve injuries in fractures of the shaft of the humerus

Radial

Nerve Injuries in Fractures Shaft of the Humerus

ALEXANDER GARCIA, JR., M.D. AND BENJAMIN H. MAECK,

From tbe Department of Ortbopaedic Surgery, College of Physicians and Surgeons, Columbia University, and tbe Fracture Service, New York Ortbopaedic Hospital, Columbia-Presbyterian Medical Center, New York, New York.

ONFUSION exists among surgeons on management of immediate nerve palsies complicating fractures of the shaft of the humerus. The treatment of such patients by operation and cIosed methods at the Fracture Service of the Columbia-Presbyterian MedicaI Center focused our interest on this problem and prompted the present study. The records of over 500 patients with fractures of the shaft of the humerus treated since 1929 have been reviewed. Excluding fractures of the surgica1 neck and supracondyIar and pathologica fractures, there remained 226 fractures of the shaft in aduIts of which twentyseven (I 1.7 per cent) were compIicated by immediate nerve paIsies. In addition there were four chiIdren with radial nerve palsies, making a total of thirty-one patients with immediate injuries in this series. Twenty-four additiona patients had radial nerve paIsies after open reduction for fracture making a tota of fifty-five patients with radia1 nerve injuries compIicating fractures of the humeral shaft.

C

M.D.,

of the

New York, New York

TweIve of twenty-one patients with compIete paraIysis had complete Ioss of sensation, whiIe nine others had some radia1 nerve sensation. (TabIe II.) In ten patients with incomplete motor loss, the sensory deficit was incomplete, with one instance of no sensory 10s~. Treatment. Of the thirty-one patients with immediate nerve paIsies, twenty-three underwent surgery on or shortIy after admission, eight were treated expectantjy. Eighteen of the twenty-three who were operated upon made a compIete recovery. Three had residua1 deficits and two were Iost to foIIow-up. Of the eight patients treated conservatively two were Iost to follow up, three made a com-

IMMEDIATE RADIAL NERVE PALSIES Patients with immediate radia1 nerve palsies ranged from a newborn to a nonagenarian. There was a sIightIy higher incidence in women, but no predominance of either arm. As might be anticipated, in twenty-seven or two-thirds of the patients paIsy was associated with fractures of the middIe shaft. (Fig. I.) The spira1 obhque fracture with a butterffy fragment accounted for the majority of nerve injuries at a11 IeveIs. (TabIe I.)

L

.

._-

_

_

-1

FIG. I. LeveI of fracture in immediate radiaI nerve paky.

625

American

Journal

of Surgery,

Volume

99,

May,

1960

Garcia TABLE

and

Maeck

I

TABLE II FINDINGS

INITIAL NEUROLOGICAL

LeveI

Total No.

I

Spira’

4

0

I

21

3

3

6

Third Fragment

Complete

TABLE IV RATE OF RETURN

PathoIogy

Severed.

I

Severed.

I

Immediate

2

I

5

5

2 7

2

NormaI............ Not recorded.......

3 3

7 2 2

Complete

8 mo.

1* 2

Bruised Stretched. Interposed. NormaI.

Incomplete

InitiaI

Radial Nerve Palsy Treated Surgically (Twenty Patients)

I mpaIed

(after suture) Impaled.. Bruised. Stretched.. Interposed..

No.

Immediate

TABLE III RECOVERY AFTER IMMEDIATE SURGERY (TWENTY-THREE PATIENTS)

CompIete

None

I

Recovery. In genera1 the operative findings correIated with the recovery. In patients with bruised, stretched and interposed nerves recovery was compIete; in those with one of two nerves impated by fragments motor recovery was incompIete. In one patient with a nerve described as normal recovery was incompIete. (TabIe III.) There is no constant relationship between operative findings and rate of return of sensation and motor power. In patients with nerves that were impaIed, bruised, interposed or stretched return of function commenced within one week to four months after surgery. (TabIe IV.) In one patient with an apparentIy norma nerve there was no sign of recovery for six weeks and return was not compIete for eight months. It is cIear that visibIe evidence of nerve

pIete recovery and two had residua1 deficit. Surgery was advised but refused by one patient who stiII had not recovered after four years. The other patient was operated upon three and a haIf months later; the nerve was found to be severed and encased in caIIus. It was freed, resected and sutured. The suture Iine was enveIoped with millipore. Not until nine months Iater was there partia1 return of nerve function. In the majority of cases the nerve was mereIy examined or extricated from the site of the fracture, and the fracture stabilized usuaIIy by plating. When there was bruising of the nerve saline was injected beneath the nerve sheath. Primary suturing was carried out in one instance, with compIete recovery. A ffap of muscIe frequentIy was interposed to protect the nerve against the forming caIIus. of the Operative Findings. The condition nerve was recorded at operation in twenty It was interposed between the instances. fracture fragments in seven patients, bruised in five, stretched in two, impaIed in two, severed in one and normal in three.

No.

Incomplete

I

-

PathoIogy

Sensory Loss

3 I5 4

2

0

CASES)

Total No

Motor Loss

Transverse

Upper third. Middle third. Lower third..

I !

Type of Fracture

(THIRTY-ONE

I I I I I

5 2 7 3

wk.-? wk.-335 mo. wk.-? wk.-4 mo. wk.-6 wk.

4 6 4 10 6

yr. mo.-I6 mo. mo.-I6 mo. mo.-? wk.-g mo.

2 mo.-8 mo.

Radial Nerve Palsy Treated Conservatively (Eight Patients)

I

Unknown.. * Sutured. t Two patients Iost to folIow up.

I

I

626

I

3t

I

I wk.-335 mo.

had no return;

7 wk.-I2 mo.

three patients

were

RadiaI Nerve

Injuries

in Fractures

of Humerus

TABLE VI POSTOPERATIVE RADIAL NERVE PALSIES

TABLE V PathoIogy

No.

I

ResiduaI

I Radial

Years* Complete Motor Loss (Twenty-One

Severed............................ ImpaIed... Bruised............................ Interposed........................ Stretched............ .._......... NormaI.. Not recorded or operated on..

Patients) 2 2 5 z I 4

1929-1939 1940-1949 *95’=‘959

I 1 0 0 0 0 I

Nerve

PaIsy

(No.)

56 24 22

____ Total

‘7 7 _

____~___

102

* In which operation

0 24

was performed.

Incomplete Motor Loss (Ten Patients) POSTOPERATIVE NormaI., Stretched.......................... Interposed....... Not operated on. Unknown..

2

0

I

0

I 3 3

0 0 0

It is the policy of the Fracture Service at CoIumbia-Presbyterian MedicaI Center to operate upon patients with fractures of the shaft of the humerus when they present with definite evidence of radial nerve injury. ConsequentIy this series has too few patients treated expectantly to permit statistica comparison of the two methods. Since it is impossibIe to determine the condition of the radia1 nerve cIinicaIIy, the conclusion may be drawn from this study that patients with compIete nerve injuries shouId undergo surgery as soon after injury as possibIe, this being the onIy procedure which permits treatment when it is necessary. On the other hand incomplete palsy means that the fibers are intact and such patients should be treated expectantIy. However, surgery shouId be performed at the first sign of progression of the paraIysis. In addition patients who show no signs of improvement after four months shouId have the radia1 nerve expIored. ObviousIy many patients who undergo surgery require no treatment. Many do, however, and with good surgical technic the rewards of earIy operation justify the risks.

No.

.

.

PALSY

CONCLUSIONS

TABLE VII RESIDUALS OF POSTOPERATIVE PALSY (TWENTY-FOUR PATIENTS)

CompIete recovery. . ResiduaI motor deficit.. ResiduaI sensory deficit. . Sensory and motor deficit. Inadequate follow up.

NERVE

One hundred two patients with fractures of the shaft of the humerus with intact radial nerves were operated upon. In twenty-four of these postoperative radial nerve palsies developed. (TabIe VI.) One year after surgery eIeven of these patients had some residual deficit. (TabIe VII.) However, during the past decade there have been no postoperative radial nerve injuries.

damage bears no constant relation to the rate of return of nerve function; it is equaIIy clear that early initiaI return does not justify anticipation of earIy complete recovery. The rate of recovery of patients undergoing surgery is comparable to that of patients treated ConservativeIy; namely, there was initial return of nerve function within four months. (TabIe IV.) The compIeteness of immediate radia1 nerve Ioss of function recorded at the time of injury has been correlated with the findings at operation and the residua1 deficit at foIIow-up. (TabIe v.) It is apparent that in patients with complete motor loss, the majority showed some visibIe sign of injury to the nerve at operation. In patients with incomplete loss of motor function at initial examination, 0nIy two showed visible signs of injury at surgery.

Result

RADIAL

11

. 2 2

z 627