The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy.

BACKGROUND: The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively. METHODS: Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure. RESULTS: Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury. CONCLUSIONS: Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6-24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs. LEVEL OF EVIDENCE: Level III.

Postoperative radial nerve palsy in humeral shaft nonunion reconstruction: Can the lateral paratricipital approach prevent this common complication?

BACKGROUND: Postoperative radial nerve palsy (RNP) is a well-known complication of nonunion reconstruction of the humerus. The purpose of the current study is to determine if the surgical approach for nonunion reconstruction of the humerus influences the rate of postoperative radial nerve palsy. METHODS: A retrospective case-control study of all humeral shaft and extraarticular distal humerus nonunion reconstructions performed between January 1, 2004, and August 31, 2021, was conducted. Patients included were over 18 years of age, had a non-pathologic humerus fracture nonunion and had intact radial nerve function prior to nonunion reconstruction. Exclusion criteria consisted of nonunions involving the proximal humerus, intraarticular fractures, and reconstructive treatment procedures with either intramedullary nail or external fixation methods. Perioperative variables were recorded and analyzed in regard to the development of postoperative RNP. A subgroup analysis was performed to assess the interaction of significant variables on the development of postoperative RNP. RESULTS: The overall rate of postoperative RNP in this series was 6/53 (11%). However, no cases of postoperative radial nerve palsy were observed in patients who underwent nonunion reconstruction with a lateral paratricipital approach. A new RNP was seen in 4/9 (44%) of those patients who underwent a triceps splitting approach, which was significantly higher than those utilizing either an anterolateral approach (2/28, 7%) or a lateral paratricipital approach (0/16, 0%, p = 0.007). DISCUSSION AND CONCLUSION: Our data suggests that the lateral paratricipital exposure decreases the risk of radial nerve injury with nonunion reconstruction of the humerus. The lateral paratricipital exposure offers the benefit of radial nerve exploration, decompression, neurolysis and protection prior to fracture manipulation and instrumentation. This study shows conventional approaches may predispose patients to a high rate of postoperative RNP, similar to that in the literature.

Radial Nerve Sensory Branch Anatomical Variant: A Case Report and Literature Review.

CASE: Two patients sustained comminuted extra-articular distal humerus fractures. One patient was neurovascularly intact preoperatively. The other patient had a complete radial motor palsy with preserved sensation. Intraoperatively, both exhibited anatomic variants of the radial sensory nerve of the arm that pierced the triceps rather than branching from the distal third of the radial nerve proper, as is traditionally reported. CONCLUSIONS: Although rare, variations in the radial nerve may exist about the distal humerus. Surgeons should be aware of these variations to avoid iatrogenic injury.

Anterior humeral approach with nerve stimulator.

INTRODUCTION: The prevalence of radial nerve injury during surgery is as high as the prevalence of radial nerve injury due to trauma. The aim of this study is to minimize the risk of iatrogenic injury of radial nerve. MATERIALS AND METHODS: Fifty patients with middle or distal diaphysis fractures of humerus and 18 patients with pseudoarthrosis at the same localizations were treated with surgery. Plate-screw fixation was performed with anterior approach in 43 patients. Eleven patients had minimally invasive plate osteosynthesis, and 14 patients had intramedullary nailing. The localization of the radial nerve was determined with nerve stimulator at the area of dissection. RESULTS: Iatrogenic radial nerve injury did not occur in patients treated with open reduction or minimally invasive approach. DISCUSSION: Nerve stimulator may be a method that decreases radial nerve injury, an iatrogenic complication. This method may be used in anterior approach and minimally invasive procedures.

Avoiding radial nerve palsy in proximal radius shaft plating - a cadaver study.

BACKGROUND: Opinions vary concerning the position of forearm rotation during detachment of the supinator in radial nerve palsy Henry's and Thompson's approaches. PURPOSE: To define the optimal forearm position for a safe detachment of the supinator during these approaches and to clarify their close relationship to the posterior interosseous nerve (PIN). METHODS: The study sample comprised 90 upper extremities of 45 human adult cadavers, embalmed using Thiel's method. After detection of the radial nerve in the interval between the brachialis and brachioradialis, its pathway was traced to the Arcade of Frohse (AF). Measurements involved the distance between the AFand the radial border of the distal biceps tendon (DBT) in pronation and supination, the interval between the AF and the radiocapitellar joint space (RCJS) in supination and the radial length (RL). RESULTS: Distances between the DBT and the AF were significantly shorter during pronation (right side: 14.1 ± 3.4mm; left side: 13.5 ± 3.2mm) compared with supination (right side: 20.5 ± 3.6mm; left side: 19.8 ± 3.5mm) for both right and left extremities. The mean interval between the AF and the centre of the RCJS was 25.2 ± 5.9mm for the right side and 24.7 ± 5.6mm for the left side, which correlated positively with the RL. CONCLUSION: These results indicate a safe detachment of the supinator from the radius with the forearm placed in supination during both Henry's and Thompson's approaches.

Is locked compressive intramedullary nailing for adult humerus shaft fractures advantageous?

OBJECTIVES: This study aims to evaluate the radiological and functional outcomes of locked compressive intramedullary nailing (IMN) cases in adult humerus shaft fractures. PATIENTS AND METHODS: A total of 24 patients (12 males, 12 females; mean age 42 years; range 23 to 55 years) with humerus fractures were treated with locked compressive IMN at the Orthopedics and Traumatology Clinic, Antalya Training and Research Hospital between December 2009 and March 2015. Fluoroscopy was used only to check fracture reduction before the reaming procedure. Of the patients, closed IMN was performed in 21, while open reduction was performed in three. Lock screws were locked without fluoroscopy in all patients. Of the patients in whom open reduction was performed, radial nerve lesion developed in one. Anteroposterior and lateral graphs of all patients were taken postoperatively. Fracture union was assessed according to existence of the fracture line and the callus tissue in the anteroposterior and lateral graphs. The Constant-Murley scoring system was used for functional evaluation. The mean follow-up period was 24 months (range 12 to 72 months). Finite element analysis was performed for the stress distribution on fracture site. RESULTS: Radiological fracture union was achieved in all patients at mean 14.8 weeks (range 12 to 17 weeks). The Constant-Murley score was mean 90 (range 72 to 100). There was a statistically significant, negative and strong correlation between union period and the Constant-Murley score (r=-0.78, p<0.001). In one patient who developed postoperative radial nerve symptoms, all functions were regained in fourth month. No infection occurred in any patient. In two patients, tip of the nail remained high. Of these patients, one developed impingement findings, and the other patient had no problems. CONCLUSION: Treatment of humerus shaft fractures with locked compressive IMN provides sufficient fixation and early movement opportunity in the shoulder and elbow joints, and gives satisfactory radiological and functional results.

Radial nerve palsy in surgical revision of total elbow arthroplasties: A study of 4 cases and anatomical study, possible aetiologies and prevention.

BACKGROUND: Damage to the radial nerve in the arm during revision of total elbow arthroplasty is a serious complication; which is still not well documented. The aim of this study was to define a way on how to avoid this complication and to prevent it. PATIENTS AND METHODS: Four patients underwent radial palsy after revision of total elbow arthroplasty. An anatomical study on 20 upper limbs was performed to define landmarks for the radial nerve in the arm and elbow. RESULTS: Radial nerve damage occurred near the proximal tip of the stem in all four patients, due to cement seepage caused by cortical effraction in two patients, and to damage caused by the retractors in the two other patients. The anatomical study made it possible to specify landmarks for the radial nerve in relation to the humerus. A high-risk area located 14cm away from the tip of the olecranon fossa, and 15.5cm from the medial epicondyle, was identified. CONCLUSION: A high-risk area for the radial nerve was defined and suggested targeted landmarks with a posterior proximal counter-incision situated at about 14cm above the olecranon fossa. LEVEL OF EVIDENCE: IV.

Management of Humeral Shaft Fractures With Intramedullary Interlocking Nail Versus Locking Compression Plate.

Surgical fixation of humeral shaft fractures generally involves plating or nailing. It is unclear whether one method is more effective than the other. The aim of this study was to compare the results of the intramedullary nail and locking compression plate for the treatment of humeral shaft fractures. A total of 60 patients with humeral shaft fractures were randomized to undergo surgery with an intramedullary interlocking nail (n=30) or locking compression plate (n=30). The outcome was assessed in terms of intraoperative blood loss, operative time, hospital stay, union time, union rate, functional outcome, and incidence of complications. Functional outcome was assessed using the Constant score and the American Shoulder and Elbow Surgeons (ASES) score. Intraoperative blood loss, operative time, and hospital stay in group A (intramedullary interlocking nail) were significantly lower than those in group B (locking compression plate). No statistically significant difference was found regarding the union rate, mean Constant score, and mean ASES score between the groups. The average union time was found to be significantly lower for the intramedullary interlocking nail compared with the locking compression plate. The incidence of complications such as radial nerve palsy was found to be higher with the locking compression plate compared with the intramedullary interlocking nail. The intramedullary interlocking nail can be considered a better surgical option for the management of humeral shaft fractures because it offers decreased intraoperative blood loss; shorter operative times, hospital stays, and union times; and a lower incidence of serious complications such as radial nerve palsy.

Radial nerve location at the posterior aspect of the humerus: an anatomic study of 100 specimens.

PURPOSE: Radial neuropathy represents a devastating complication in a posterior approach to the distal humerus. This study aimed to propose "safe zones" regarding the radial nerve (RN) location at the posterior aspect of the humerus to minimize the risk of iatrogenic injury. METHODS: In 100 embalmed specimens, the distances of the proximal edge of the olecranon fossa (OF) to the radial nerve at the medial edge (R1), at the center (R2) and at the lateral edge (R3) of the posterior aspect of humeral shaft were measured. Humeral length (HL) and transcondylar width (TW) were evaluated and correlated to R1, R2 and R3. RESULTS: R1 was 15.0 (±2.1; 10.6-19.5) cm, R2 averaged 12.7 (±1.6; 8.9-15.7) cm, R3 was 10.6 (±1.3; 7.6-13.7) cm. HL was 30.8 (±1.9) cm. TW averaged 6.3 (±0.6) cm. TW and HL correlate with R1, R2, R3 (r = 0.451-0.565 [95% CI 0.279-0.685]). The mean ratio was 2.3 (±0.18) for HL/R1, 2.6 (±0.23) for HL/R2 and 3.1 (±0.31) for HL/R3. The ratio averaged 2.2 (±0.20) for R1/TW, 1.9 (±0.18) for R2/TW and 1.6 (±0.15) for R3/TW. CONCLUSIONS: We present the OF as an osseous landmark to reduce the risk of iatrogenic radial neuropathy. HL and TW can be reliably used to estimate the RN location. The consistent "safe zones" of the RN in relation to the OF are 10.5 cm at the medial edge, 9 cm at the center and 7.5 cm at the lateral edge of the posterior aspect of the humeral shaft.

Distal humeral fractures: impact of lateral approach and fracture-specific plating on radial nerve palsies.

We retrospectively reviewed supracondylar distal humeral fractures that had been treated with fracture-specific plating and definitive fixation through a lateral approach with a medial triceps mobilization technique. We determined the incidences of preoperative and postoperative radial nerve palsies (RNP) to evaluate the impact of the plating and fixation technique on RNP. Seventy-three patients treated at our institution from 2006 through 2009 were included in the study. The patients were assigned to 2 groups: 57 to the blunt injury group (motor vehicle collisions, falls, struck pedestrians, throwing) and 16 to the gunshot wound group. The incidence of known preoperative RNP in the blunt injury group was 27% (13 of 48 nonintubated patients); the incidence of known preoperative RNP in the gunshot wound group was 20% (2 of 10 nonintubated patients). The incidence of postoperative RNP for the combined groups of nonintubated patients who had intact radial nerve function preoperatively was 12% (5 of 43 patients). We found a high frequency of preoperative RNP, and we found postoperative RNP rates similar to those reported in the literature despite the use of the lateral approach medial triceps mobilization technique with a fracture-specific plate.

Avoiding iatrogenic radial nerve injury during humeral fracture surgery: a modified approach to the distal humerus.

OBJECTIVE: Our aim was to assess the results of posterior retraction technique to prevent iatrogenic radial nerve injury during humeral fracture surgery. METHODS: Seventy-two patients who underwent surgery for a distal humerus fracture between 1996 and 2002 were reviewed. These 72 patients comprised Group 1. Following a cadaveric study on the vascularization of the radial nerve, a modified surgical approach was undertaken starting in 2002. Sixty-one patients who underwent this new surgical approach were included in Group 2. The rates of radial nerve deficit of the groups were compared using the Pearson chi-square test. RESULTS: In Group 1, 19 iatrogenic nerve deficits occurred. After defining the blood circulation of the nerve, the lateral approach was modified. The anterolateral side of the nerve was released and the nerve was left attached to the triceps muscle. In Group 2, one patient developed postoperative transient nerve deficit. CONCLUSION: The radial nerve is supplied by the branches of the deep brachial artery in close relation with the triceps muscle. Anterior dissection and posterior retraction of the radial nerve during lateral approach may preserve its blood supply and reduces the risk of iatrogenic injury.

A method to localize the radial nerve using the 'apex of triceps aponeurosis' as a landmark.

BACKGROUND: The relationship of the radial nerve is described with various osseous landmarks, but such relationships may be disturbed in the setting of humerus shaft fractures. Alternative landmarks would be helpful to more consistently and reliably allow the surgeon to locate the radial nerve during the posterior approach to the arm. QUESTIONS/PURPOSES: We investigated the relationship of the radial nerve with the apex of triceps aponeurosis, and describe a technique to locate the nerve. MATERIALS AND METHODS: We performed dissections of 10 cadavers and gathered surgical details of 60 patients (30 patients and 30 control patients) during the posterior approach of the humerus. We measured the distance of the radial nerve from the apex of the triceps aponeurosis along the long axis of the humerus in cadaveric dissections and patients. This distance was correlated with the height and arm length. For all patients, we recorded time until first observation of the radial nerve, blood loss, and postoperative radial nerve function. RESULTS: The mean distance of the radial nerve from the apex of the triceps aponeurosis was 2.5 cm, which correlated with the patients' height and arm length. The mean time until the first observation of the radial nerve from beginning the skin incision was 6 minutes, as compared with 16 minutes in the control group. Mean blood loss was 188 mL and 237 mL, respectively. With the numbers available, we observed no difference in the incidence of patients with postoperative nerve palsy: none in the study group and three in the control group. CONCLUSION: The apex of the triceps aponeurosis appears to be a useful anatomic landmark for localization of the radial nerve during the posterior approach to the humerus.

Reliable techniques to avoid damaging the superficial radial nerve due to percutaneous Kirschner wire fixation of the distal radius fracture through the radial styloid process.

PURPOSE: The use of percutaneous Kirschner wires for fixation of unstable fractures of the distal radius has been widely accepted as the least invasive procedure. However, the injury to the superficial branch of the radial nerve (SBRN) is common. Our purpose in this study was to develop a reliable technique to avoid damaging the SBRN. METHODS: Twenty cadaver forearms were dissected to identify the SBRN distribution, and 18 forearms were used to undergo placement of three Kirschner wires (KW-A, KW-B, and KW-C). The KW-A, KW-B, and KW-C were driven in the frontal plane into the distal radius, and KW-A and KW-C through the tip of radial styloid process at different angles. The SBRN distribution and its relationship with the KW insertion were identified. Fifty-three patients with unstable distal radius fractures were fixed with external fixator and augmented with 1-3 KW, and the injury rates of SBRN were evaluated. RESULTS: We found a blind region of the SBRN bound by its first bifurcations into radial and ulnar branches and the line crossing the tip of the styloid process. The mean distance of the three wires (KW-A, KW-C, and KW-B) to the closest nerve branch was 4.5, 4.4, and 3.4 mm, respectively. The injury of SBRN occurred in two of 53 patients. CONCLUSION: The injury rate of the SBRN can be effectively reduced when the Kirschner wire is placed along the curve AB and as in proximity to the TRSP as possible under fluoroscopic guidance. Our pinning technique is therefore reliable and practical.

[Positioning of the patient for surgery]. / Lagerung des Patienten zur Operation.

The success of an operation does not only depend on a perfect surgical technique, an appropriate anesthesia, convenient surgical instruments and functional technical equipment, but also on a proper operative positioning. Meeting the requirements of the surgeon, the positioning has also to be in accordance with the patient's individual needs. Seemingly trivial in "simple" positions, there must be paid attention to details, as they can have serious harm to the patient if done incorrectly. The surgeon is in charge for the positioning, but the performance is done in a horizontal division of work between surgeon and anesthesiologist. This article describes standard positions, demonstrates their realization and special damages, and points out juristic aspects as well as technical items like operating table and positioning facilities.

The functional impact of the Freehand System on tetraplegic hand function. Clinical Results.

STUDY DESIGN: A B design with subjects acting as their own control when the device is turned off. OBJECTIVE: Evaluation of the efficacy of the NeuroControl Freehand System. SETTING: A supra regional spinal unit in the UK. METHODS: The Freehand system is an implanted Functional Electrical Stimulation (FES) device for restoration of lateral and palmar grasps following C5 or C6 tetraplegia. Its use was assessed using the Grasp Relies Test (GRT), Activities of Daily Living (ADL), Grip strength and two-point discrimination. RESULTS: Seven out of nine subjects are currently daily users of the device. There were statistically significant increases in the number of types of task achieved and the number of repetitions of those tasks in the Grasp Release Test. The system produced a functionally strong grasp where no grip strength at all was possible prior to implantation. Three of the four subjects who had sensory ability prior to implant showed improvements in two-point discrimination. Most of the selected tasks were achieved in the ADL assessment indicating a significant improvement in independence. CONCLUSION: The Freehand system can significantly improve the functional ability of C5 and C6 lesion tetraplegics. SPONSORSHIP: This study was funded by the charity INSPIRE.

[Radial neuropathy after peripheral venous puncture]. / Neuropathie radiale après ponction veineuse périphérique.

We report a case of left radial neuropathy from a venipuncture, in a 59-year-old woman. She had a history of amputation of the four last fingers of the right hand, when she was 27-year-old. One year before, she had a difficult venipuncture of the left radial vein, for a preanaesthetic assessment for cataract surgery. The puncture elicited an excruciating pain, associated with hypoaesthesia in the area of the radial nerve, at forearm and the wrist. Conventional therapeutic means had only a minor efficiency. The concept of nervous system sensitizing is discussed. Prevention is essential.