Iatrogenic radial nerve palsy in the surgical treatment of humerus shaft fracture -anterolateral versus posterior approach: A systematic review and meta-analysis.

BACKGROUND: Although many studies have investigated iatrogenic radial nerve palsy (RNP) in humerus shaft fracture, there is inconsistent evidence on which approach leads to iatrogenic RNP. Moreover, no meta-analysis has directly compared the anterolateral and posterior approaches regarding iatrogenic RNP. METHODS: In this systematic review and meta-analysis, the MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before March 30, 2021. We included studies that (1) assessed the RNP in the surgical treatment of humerus shaft fracture and (2) directly compared the anterolateral and posterior approaches regarding the RNP. We performed synthetic analyses of the incidence of iatrogenic RNP and the recovery rate of iatrogenic RNP in humerus shaft fracture between the anterolateral and posterior approaches. RESULTS: Our study enrolled nine studies, representing 1303 patients who underwent surgery for humerus shaft fracture. After exclusion of traumatic RNP, iatrogenic RNP was reported in 35 out of 678 patients in the anterolateral approach and in 69 out of 497 patients in the posterior approach. Pooled analysis revealed that the incidence of iatrogenic RNP was significantly higher in the posterior approach than in the anterolateral approach (OR = 2.72; 95% confidence interval (CI), 1.70-4.35; P < 0.0001, I2 = 0%), but there was no significant difference in the recovery rates of iatrogenic RNP between the two approaches (OR = 1.55; 95% CI, 0.26-9.18; P = 0.63, I2 = 0%). CONCLUSION: In this meta-analysis, the posterior approach showed a higher incidence of iatrogenic RNP than the anterolateral approach in the surgical treatment of humerus shaft fracture. With limited studies, it is difficult to anticipate if any particular approach favors the recovery of iatrogenic RNP.

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.

Radial Nerve Palsy in Paediatric Humeral Shaft Fractures: Incidence and Management.

BACKGROUND: Humeral shaft fractures are relatively rare in the paediatric population. The purpose of our study was to retrospectively evaluate all humeral shaft fractures treated at a children's trauma centre and assess cases involving radial nerve injury. MATERIAL AND METHODS: We retrospectively evaluated a group of 5 skeletally immature patients with radial nerve palsy out of a total of 104 patients with humeral shaft fractures treated in our hospital between January 2011 and December 2021. RESULTS: The study group consisted of four boys and one girl aged 8.6 to 17.2 years (average age 13.6). Mean follow-up duration was 18.4 months. We diagnosed two open and three closed fractures. There were two cases of neurotmesis, two cases of nerve entrapment within the fracture site and one case of neuropraxia. Bone union and functional recovery was achieved in all five patients. CONCLUSIONS: 1. Humeral shaft fractures complicated with radial nerve palsy are a challenging medical problem; 2. The incidence of radial nerve injury in the paediatric population is significantly lower than in adults; in our study, it accounted for 4.8% of all humeral shaft fractures; 3. Expectant observation without nerve exploration is reasonable in fractures caused by a low-energy trauma; 4. Early surgical nerve exploration combined with fracture stabilisation is highly recommended in fractures due to a high-energy trauma.

Secondary radial neuropathy after closed intramedullary nailing of humeral shaft fractures. Results over a 10-year period.

BACKGROUND: Retrospective study to examine secondary radial nerve palsy after humeral shaft fixation with closed locked intramedullary nailing. MATERIALS AND METHODS: Patients were identified from the hospitals' registration systems for humeral shaft fractures, nerve lesions, plating, nailing and external fixation during a 10-year period from January 2007 to December 2016. All radial nerve lesions were registered and followed-up in patient files. RESULTS: 89 patients with locked intramedullary nailing were available for an outpatient follow-up. Mean age was 67 years at the time of injury. 72 fractures were non-pathological. Of these, 31 were nonunions. 28, 61 and zero were identified in the proximal, middle and distal thirds of the humeral shaft respectively. 76 procedures were closed and 13 were with open reduction. Six radial nerves had nerve exploration. Eight patients developed immediate postoperative radial nerve palsies. Of these, six developed after closed surgery, two after nerve exploration. Of seven available patients with a radial nerve palsy, six of these remitted. Two patients were later surgically explored. One patient out of 89 sustained a verifiable permanent radial nerve paralysis. CONCLUSIONS: In this study, the risk of a radial nerve palsy was 7.9 % with closed locked intramedullary nailing. This study suggests that exploration of the radial nerve is not necessary routinely in order to prevent radial nerve lesions when performing closed intramedullary nailing for humeral shaft fractures in adults with a preoperative normal radial nerve function. LEVEL OF EVIDENCE: Level IV.

Primary radial nerve palsy associated with humeral shaft fractures according to injury mechanism: is early exploration needed?

BACKGROUND: Radial nerve palsy is a common complication associated with humeral shaft fractures. The purposes of this study were (1) to evaluate the status of primary radial nerve palsy in patients with humeral shaft fracture according to injury mechanism, (2) to estimate the risk factors of primary RNP, and (3) to evaluate whether early exploration is helpful for radial nerve recovery. METHODS: This study analyzed 162 patients with humeral shaft fractures from January 2014 to December 2019. All patients were surgically treated in our hospital. Of these, 109 high-energy injuries were identified and compared with 53 low-energy injuries. The risk factors of radial nerve palsy were analyzed, and the prevalence of radial nerve palsy and status of radial nerve exploration according to injury mechanism were evaluated. Nerve recovery rate according to early nerve exploration was investigated. RESULTS: There were 31 cases of radial nerve palsy among 162 patients: 27 in the high-energy humeral shaft fracture group and 4 in the low-energy humeral shaft fracture group. Logistic regression analysis for risk factors showed that the injury mechanism was significantly associated with primary radial nerve palsy. Among 31 radial nerve palsy patients, 21 radial nerves were explored and 19 radial nerves recovered completely (80.6%). In the high-energy humeral shaft fracture group, 18 radial nerves were explored during surgery among 27 radial nerve palsy cases, and 16 cases recovered (88.9%). The other 9 radial nerves were not explored, and only 5 cases recovered (55.6%). CONCLUSIONS: This study confirmed that the incidence of radial nerve paralysis was higher in high-energy humeral shaft fractures than in low-energy fractures. The more common fracture patterns were oblique, transverse, wedge, and comminuted in high-energy humeral shaft fracture. This study suggests that these patterns are not directly associated with radial nerve palsy, but that high-energy injury is associated with a specific fracture pattern. Early nerve exploration during surgical treatment in patients with radial nerve palsy associated with humeral shaft fracture was helpful especially after high-energy injury.

Relationship between incidence of postoperative radial nerve palsy and surgical experience in the treatment of humeral shaft fractures through a posterior triceps splitting approach: A retrospective study.

OBJECTIVE: The aim of this study was to investigate the incidence of postoperative radial nerve palsy (PORNP) after the surgical treatment of humeral shaft fractures through a posterior triceps splitting approach by a single surgeon's experience in a consecutive case series from a single trauma center. METHODS: In this retrospective study, a total of 118 patients (82male, 36 female;mean age = 48 years, age range = 16 - 80 years)who underwent open reduction and plate fixation through posterior triceps splitting approach due to humeral shaft fractures at a level I trauma center were included. Level of the fractures was categorized as the proximal third, middle third, and distal third of the diaphysis, and then all the fractures were classified according to the AO/OTA classification system. The trend of incidence of PORNP was investigated. All the operations were performed by a single surgeon. The recovery time of PORNP was also recorded. RESULTS: There were 13 cases of proximal third, 67 cases of middle third, and 38 cases of distal third fracture. Based on AO/OTA classification, there were 29 cases of A1-type, 23 cases of A2-type, 42 cases of A3-type, 17 cases of B2-type, 3 cases of B3-type, and 4 cases of C2-type fracture. The overall incidence of PORNP was 11% (13 cases). All the PORNP cases fully recovered within 10.3 ± 10.4 weeks (range = 1 - 44) with conservative treatment. Incidence of PORNP significantly decreased with increase in surgical experience (P = 0.009). The incidence of radial nerve palsy was not significantly related to the level of the fracture (P = 0.199). The incidence of radial nerve palsy was not significantly related with the fracture pattern according to AO/OTA classification (P = 0.659). CONCLUSION: Evidence from this study has shown that the incidence of PORNP following the posterior triceps splitting approach for the treatment of humeral shaft fractures is significantly associated with the surgeon's experience. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Predictors of traumatic nerve injury and nerve recovery following humeral shaft fracture.

INTRODUCTION: Nerve palsy is common after humeral shaft fracture, with the radial nerve being the most commonly injured nerve. Isolated nerve injuries usually recover spontaneously, and operative intervention is rarely indicated. Our goal was to study the predictors of traumatic nerve injury and recovery in a large cohort of patients with humeral shaft fractures. METHODS: A total of 376 patients with humeral shaft fracture, including 96 patients with documented traumatic nerve palsy and 280 with intact neurovascular examination on presentation, were retrospectively included in the study. The primary outcome was incidence of a traumatic nerve palsy, and the secondary outcome was nerve recovery. RESULTS: Nerve palsy was present in 96 patients (25.5%) at the time of injury. Radial nerve was the most commonly injured nerve (93.6%), followed by the ulnar (5.1%) and axillary (1.2%) nerves. Seventeen patients (17.7%) had multiple nerves palsies. A multivariable regression analysis revealed that the concomitant vascular injury (odds ratio [OR] 52, 95% confidence interval [CI] 5.6-480.6), distal one-third fractures (OR 6.3, 95% CI 2.7-14.7), and middle one-third (OR 2.8, 95% CI 1.2-6.5) vs. proximal fractures, open fracture (OR 2.1, 95% CI 1.1-4.4), and high-energy trauma (OR 1.7, 95% CI 1.1-2.9) were independent predictors of nerve palsy. Iatrogenic nerve injury was detected in 7 patients (4.6%), all affecting the radial nerve. Spontaneous recovery of traumatic nerve injuries was detected in 87 patients (91%), with 19% partial and 72% complete recovery. The initial sign of recovery was observed at median times of 7 and 9 weeks for those managed conservatively or fracture fixation. Operative treatment of the fracture had no effect on the outcome of nerve recovery (88.5% vs. 100%, P = .14). Ten patients (14.1%) had transected nerves at the time of exploration and open fractures (22.7% vs. 6.8%, P = .04), and concomitant vascular injury (33.3% vs. 7.3%, P = .02) were associated with nerve transection, portending a worse prognosis for nerve recovery compared with nerves in continuity (40% vs. 95.3%, P = .004). DISCUSSION: The incidence of nerve injury after humeral shaft fracture was 25%, reflecting an abundance of high-energy and open injuries in this cohort. Ninety-one percent of patients experienced improvement in their nerve function with a median time to recovery of 7-9 weeks. Operative treatment of the fracture did not change the rate of nerve recovery. Patients with multiple nerve palsies and concurrent vascular insult had worse nerve recovery. We recommend nerve studies if no sign of recovery is observed by 9 weeks.

Humeral shaft fracture and radial nerve palsy in Korean soldiers: focus on arm wrestling related injury.

INTRODUCTION: Humeral shaft fractures can lead to radial nerve injury and may require surgery and rehabilitation. We determined the causative events of humeral fracture, including arm wrestling, in young Korean soldiers and examined whether humeral fracture is related to demographic characteristics and the presence of radial nerve palsy. METHODS: We reviewed 7.5 years (July 2012 to June 2019) of medical records covering patients who had experienced a humeral shaft fracture after entering military service and had received surgery for open reduction and internal fixation. Data were obtained on basic demographics, initial event provoking the fracture, presence of radial nerve palsy, initial and follow-up severity of the weakness, and any discharge from military service because of prolonged radial nerve palsy. RESULTS: Of 123 cases, arm wrestling was the leading cause (52.8%). A high energy injury, such as falling from a height (11.4%), and sports related slips (10.6%) were other causes. All humeral shaft fractures caused by forceful contraction were spiral, while 40% of the fractures caused by external force related events were of a transverse type. The percentage of left-sided fractures was significantly higher for fractures arising from an external force than in those caused by forceful contraction related events. Radial nerve palsy was found in 34 patients (27.6%), and 16 were discharged from the military because of prolonged radial nerve palsy 6 months after the fracture. The causative events and other factors did not affect the presence of radial nerve palsy. CONCLUSION: Arm wrestling was the leading cause of humeral fracture in young Korean soldiers but the chance of developing comorbid radial nerve palsy did not differ from that of other causes. These epidemiologic findings in this young active group may help in understanding the causes of humeral shaft fracture in soldiers and in the wider young population.

Radial nerve palsy associated with closed humeral shaft fractures: a systematic review of 1758 patients.

BACKGROUND AND PURPOSE: Humeral shaft fractures are often associated with radial nerve palsy (RNP) (8-16%). The primary aim of this systematic review was to assess the incidence of primary and secondary RNP in closed humeral shaft fractures. The secondary aim was to compare the recovery rate of primary RNP and the incidence of secondary RNP between operative and non-operative treatment. METHODS: A systematic literature search was performed in 'Trip Database', 'Embase' and 'PubMed' to identify original studies reporting on RNP in closed humeral shaft fractures. The Coleman Methodology Score was used to grade the quality of the studies. The incidence and recovery of RNP, fracture characteristics and treatment characteristics were extracted. Chi-square and Fisher exact tests were used to compare operative versus non-operative treatment. RESULTS: Forty studies reporting on 1758 patients with closed humeral shaft fractures were included. The incidence of primary RNP was 10%. There was no difference in the recovery rate of primary RNP when comparing operative treatment with radial nerve exploration (98%) versus non-operative treatment (91%) (p = 0.29). The incidence of secondary RNP after operative and non-operative treatment was 4% and 0.4%, respectively (p < 0.01). INTERPRETATION: One-in-ten patients with a closed humeral shaft fracture has an associated primary RNP, of which > 90% recovers without the need of (re-)intervention. No beneficial effect of early exploration on the recovery of primary RNP could be demonstrated when comparing patients managed non-operatively with those explored early. Patients managed operatively for closed humeral shaft fractures have a higher risk of developing secondary RNP. LEVEL OF EVIDENCE: Level IV; Systematic Review.

What is the Real Rate of Radial Nerve Injury After Humeral Nonunion Surgery?

OBJECTIVES: To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. DESIGN: Consecutive retrospective cohort review. SETTING: Eighteen academic orthopedic trauma centers. PATIENTS/PARTICIPANTS: Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. INTERVENTION: Humeral shaft nonunion repair and assessment of postoperative radial nerve function. MAIN OUTCOME: Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. RESULTS: Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. CONCLUSION: In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparing iatrogenic radial nerve lesions in humeral shaft fractures treated with helical or straight PHILOS plates: a 10-year retrospective cohort study of 62 cases.

BACKGROUND: Humerus shaft fractures are common and often treated surgically with a proximal humerus internal locking system like the long PHILOS® plate. Due to its close anatomical proximity to the humerus, the radial nerve is particularly susceptible to traumatic and iatrogenic damage. The iatrogenic radial nerve damage associated with internal locking systems is described in about 7% of the cases. In order to avoid this lesion, helical plates have been suggested since 1999. This technique continues to not being used as standard as there is still a clear lack of evidence. This study aimed to understand if twisting a long PHILOS plate can reduce the rate of iatrogenic radial nerve damage in humerus shaft fractures. METHODS: In this 10-year retrospective comparative study, patients with primary traumatic proximal humerus shaft fracture treated with a straight or twisted helical PHILOS® plate were analyzed and compared. Among the 62 patients meeting the inclusion criteria between 2008 and 2018, 33 received a conventional straight plate, while 29 were treated with a helical plate. The primary endpoint was iatrogenic radial nerve damage immediately after surgery with a follow-up of at least 3 months. RESULTS: No case of radial nerve damage was reported in the helical group. In the control group, iatrogenic radial nerve damage occurred in two cases (6%), which was not statistically significant when comparing both groups (p = 0.18). CONCLUSION: Manually twisting long PHILOS® plates is a safe procedure to avoid radial nerve lesion in humerus shaft fractures. Even though the group size did not allow a statistically relevant difference, we underline that only the helical group showed no iatrogenic radial lesion. This technique deserves further attention. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.

Incidence and operations of median, ulnar and radial entrapment neuropathies in Finland: a nationwide register study.

The aim of this study was to investigate the incidence rates and operations for carpal tunnel syndrome and ulnar and radial neuropathies in specialist care in Finland. Patients diagnosed with entrapment neuropathies of the upper extremity were identified from the Care Register for Health Care, 2007-2016. There were 81,911 cases in 54,095,070 person-years. The total crude incidence rates per 100,000 person-years among women and men were 197 and 105 for carpal tunnel syndrome, 26 and 36 for ulnar neuropathies, and 5.7 and 8.5 for radial neuropathies, respectively. Of these, carpal tunnel syndrome was operated on in 63% of women and 61% of men, ulnar neuropathy in 43% of women and 47% of men, and radial neuropathy in 11% of women and 8% of men. Incidence of carpal tunnel syndrome and ulnar neuropathies increased up to late middle age, while radial neuropathies were less common. Level of evidence: III.

Clinical outcomes of dual 3.5-mm locking compression plate fixation for humeral shaft fractures: Comparison with single 4.5-mm locking compression plate fixation.

BACKGROUND: Recently, several in vitro biomechanical studies that used dual small locking plate fixation for humeral shaft fractures have investigated. However, in vivo studies about dual plate fixation for humeral shaft fractures are limited. The purpose of our study was to report the outcomes of dual small plating for humeral shaft fractures in comparison with those of single large fragment plating. METHODS: Sixty consecutive patients who underwent an open reduction internal fixation for humeral shaft fractures at our institution from September 2014 to December 2017 were included. Single 4.5-mm locking compression plate (LCP) fixation was used in the first 40 cases, and dual 3.5-mm LCP fixation was used in the final 20 consecutive cases. Data were collected to define patient characteristics, injury mechanism, clinical outcomes, time to surgery, operative time, estimated blood loss, and complications. Using simple radiography during the follow-up period (6, 12, 24, and 52 weeks after surgery), the shoulder and elbow joint ranges of motion (ROM) were also evaluated. RESULTS: Demographic data, time to surgery, surgical time, and estimated blood loss had no significant differences between the two groups. No significant differences were observed in nonunion rate and union rate 3 months after surgery. However, two patients (5%) in the single 4.5-mm LCP fixation group showed metal failure and breakage. No significant differences were found in postoperative shoulder and elbow ROM. Three patients (7.5%) in the single plating group and one patient (5%) in the dual plating group developed radial nerve palsy after surgery. No vascular injury and deep infection were observed in either group. CONCLUSION: For diaphyseal humeral fractures, dual 3.5-mm LCP fixation to the humerus is a possible treatment choice. This method showed satisfactory union rate, ROM, and complication rate, without increasing surgical time, in comparison with the conventional single 4.5-mm LCP fixation. Level of evidence: III.

Occupational biomechanical risk factors for radial nerve entrapment in a 13-year prospective study among male construction workers.

OBJECTIVES: The aim was to assess the association between occupational biomechanical exposure and the occurrence of radial nerve entrapment (RNE) in construction workers over a 13-year follow-up period. METHODS: A cohort of 229 707 male construction workers who participated in a national occupational health surveillance programme (1971-1993) was examined prospectively (2001-2013) for RNE. Height, weight, age, smoking status and job title (construction trade) were obtained on health examination. RNE case status was defined by surgical release of RNE, with data from the Swedish national registry for out-patient surgery records. A job exposure matrix was developed, and biomechanical exposure estimates were assigned according to job title. Highly correlated exposures were summed into biomechanical exposure scores. Negative binomial models were used to estimate the relative risks (RR) (incidence rate ratios) of RNE surgical release for the biomechanical factors and exposure sum scores. Predicted incidence was assessed for each exposure score modelled as a continuous variable to assess exposure-response relationships. RESULTS: The total incidence rate of surgically treated RNE over the 13-year observation period was 3.53 cases per 100 000 person-years. There were 92 cases with occupational information. Increased risk for RNE was seen in workers with elevated hand-grip forces (RR=1.79, 95% CI 0.97 to 3.28) and exposure to hand-arm vibration (RR=1.47, 95% CI 1.08 to 2.00). CONCLUSIONS: Occupational exposure to forceful handgrip work and vibration increased the risk for surgical treatment of RNE.

[Treatment of humerus diaphyseal fractures using Hackethal's retrograde centro-medullary bundle nailing: about 54 cases]. / Traitement des fractures de la diaphyse humérale par l'embrochage centro-médullaire rétrograde de Hackethal: à propos de 54 cas.

We here report 54 cases of humerus diaphyseal fractures treated via Hackethal's bundle nailing. We observed 3 cases of radial nerve palsy. Therapeutic abstention associated with monitoring was the applied attitude toward these patients on presentation to the Emergency Department. It resulted in recovery. Hackethal's bundle nailing technique is relatively easy but it requires rigorous surgical procedure performed by an experienced surgeon. A rate of 7.84% of pseudarthrosis is reported. Hackethal's bundle nailing is a very safe, improved orthopedic treatment with modest cost.

Posterior interosseous nerve entrapments: review of the literature. Is the entrapment distal to the arcade of Frohse a really rare condition?

INTRODUCTION: Spontaneous posterior interosseous nerve palsy is a rare condition. Entrapment is mostly at level of the arcade of Frohse, and a few cases of distal entrapment have been described. METHODS: A case of entrapment distal to the arcade of Frohse is described here. Cases of distal entrapment have been reviewed from the published literature in order to evaluate the frequency of atraumatic mechanical palsy. RESULTS: Seven cases of distal entrapment have been identified. Lesion is the cause of palsy in 58.7% of the cases and entrapment in 20.65%. The pathology is at the elbow in 33.7% of the cases, at the arcade of Frohse in 28.26%, and at the supinator canal in 10.33%. Entrapment is at the arcade of Frohse in 64.45%, proximal in 20%, and distal in 15.55%. CONCLUSION: Posterior interosseous nerve distal entrapment is a rare condition; therefore, further investigation is needed when radiological images at the arcade of Frohse do not show any entrapment.

Humerus shaft fracture associated with traumatic radial nerve palsy: An international survey among orthopedic trauma surgeons from Latin America and Asia/Pacific.

PURPOSE: The purpose of this article is to explore the real-life practice of clinical management of humeral shaft fracture associated with traumatic radial nerve palsy among orthopedic trauma surgeons. METHODS: Two hundred seventy-nine orthopedic surgeons worldwide reviewed 10 real cases of a humeral shaft fracture associated with traumatic radial nerve palsy answering two questions: (1) What treatment would you choose/recommend: nonoperative or operative? (2) What are the reasons for your decision-making? The survey was developed in an online survey tool. All participants were active members from AOTrauma International. RESULTS: Two hundred sixty-six (95.3%) participants were from Latin America and Asia/Pacific. One hundred sixty-two participants (58.1%) had more than 10 years in practice and 178 (63.8%) of them did trauma as the main area of interest. One hundred fifty-one (54.1%) participants treated less than three humeral shaft fractures a month. Traumatic radial nerve palsy was the main reason (88.4%) for surgeons to recommend surgical treatment. Open reduction and internal fixation (ORIF) or percutaneous fixation of the fracture associated with acutely explore of radial nerve was the first option in 62.0% of the cases. A combination of morphology and level of the fracture and the presence of the radial nerve palsy was the most suggested reason to surgically treat the humerus fracture. The main isolated factor was the morphology of the fracture. CONCLUSION: Our survey highlight the tendency for a more aggressive management of any humeral shaft fracture associated with a traumatic radial nerve palsy, with surgeons preferring to use ORIF with acute exploration of the radial nerve. Nonsurgical management was the less chosen option among the 279 respondents. Fracture morphology, level of the fracture, and the presence of the radial nerve palsy were most influential for guiding their treatment.

Time From Injury to Surgical Fixation of Diaphyseal Humerus Fractures Is Not Associated With an Increased Risk of Iatrogenic Radial Nerve Palsy.

OBJECTIVES: To determine whether time from injury to fixation of diaphyseal humeral fractures and nonunions is associated with the risk of iatrogenic radial nerve palsy. DESIGN: Retrospective review. SETTING: Two Level 1 trauma centers. PATIENTS/PARTICIPANTS: Between 2001 and 2015, 325 patients who had documented intact radial nerve function preoperatively were treated with fixation of a humerus fracture or humerus nonunion. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Development of an iatrogenic radial nerve injury. Those with an injury were followed to either resolution of the nerve palsy or definitive treatment. RESULTS: The risk of iatrogenic radial nerve palsy was 7.7% (25/325). Time to surgery was not significantly associated with iatrogenic radial nerve palsy. In a multiple variable analysis, when comparing patients treated within 4 weeks to those treated 4-8 weeks (P = 0.41), 8-12 weeks (P = 0.94), and over 12 weeks (0.20), there were no significant associations. Independent risk factors for iatrogenic radial nerve palsy included distal location of fracture (P = 0.04, odds ratio 3.71) and previous fixation (P = 0.03, odds ratio 3.80). Of the 25 iatrogenic nerve injuries, 22 recovered fully with expectant management, 1 was lost to follow-up, and 2 required either nerve graft or tendon transfers. CONCLUSIONS: Time from injury to surgery does not seem to be a risk factor for developing an iatrogenic radial nerve palsy when treating diaphyseal humerus fractures. Patients with distal fractures, and those with previous fracture implants, are at increased risk of iatrogenic radial nerve palsy. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Incidence and predictors of radial nerve palsy with the anterolateral brachialis splitting approach to the humeral shaft.

PURPOSE: Fractures of the humeral shaft are common and account for 3%-5% of all orthopedic injuries. This study aims to estimate the incidence of radial nerve palsy and its outcome when the anterior approach is employed and to analyze the predictive factors. METHODS: The study was performed in the department of orthopaedics unit of a tertiary care trauma referral center. Patients who underwent surgery for acute fractures and nonunions of humerus shaft through an anterior approach from January 2007 to December 2012 were included. We retrospectively analyzed medical records, including radiographs and discharge summaries, demographic data, surgical procedures prior to our index surgery, AO fracture type and level of fracture or nonunion, experience of the operating surgeon, time of the day when surgery was performed, and radial nerve palsy with its recovery condition. The level of humerus shaft fracture or nonunion was divided into upper third, middle third and lower third. Irrespective of prior surgeries done elsewhere, the first surgery done in our institute through an anterior approach was considered as the index surgery and subsequent surgical exposures were considered as secondary procedures. RESULTS: Of 85 patients included, 19 had preoperative radial nerve palsy. Eleven (16%) patients developed radial nerve palsy after our index procedure. Surgeons who have two or less than two years of surgical experience were 9.2 times more likely to induce radial nerve palsy (p=0.002). Patients who had surgery between 8 p.m. and 8 a.m. were about 8 times more likely to have palsy (p=0.004). The rest risk factor is AO type A fractures, whose incidence of radial nerve palsy was 1.3 times as compared with type B fractures (p =0.338). For all the 11 patients, one was lost to follow-up and the others recovered within 6 months. CONCLUSION: Contrary to our expectations, secondary procedures and prior multiple surgeries with failed implants and poor soft tissue were not predictive factors of postoperative deficit. From our study, we also conclude that radial nerve recovery can be reasonably expected in all patients with a postoperative palsy following the anterolateral approach.

Iatrogenic Radial Nerve Palsy After Humeral Shaft Nonunion Repair: More Common Than You Think.

OBJECTIVES: To determine the rate of iatrogenic radial nerve palsy (RNP) after surgical repair of established humeral shaft nonunion (HSNU). DESIGN: Retrospective chart review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Fifty-four patients with HSNU, 10 (18.5%) of whom developed an iatrogenic RNP after nonunion repair. INTERVENTION: HSNU repair with compression plate stabilization with or without autogenous bone graft. MAIN OUTCOME MEASUREMENTS: Postoperative iatrogenic RNP. RESULTS: Ten (18.5%) patients developed iatrogenic radial nerve palsies: 8 experienced complete resolution (mean, 2.5 months) and 2 experienced partial resolution. There were no statistically significant differences between patients who developed nerve palsy and those who did not in regard to age, gender, tobacco use, diabetic status, previous RNP, initial management (operative vs. nonoperative), surgical approach, presence of infected nonunion, number of previous surgeries, or operative time (P > 0.05). CONCLUSIONS: The occurrence of iatrogenic RNP for patients undergoing surgical repair of an HSNU was 18.5%. According to historical data, this rate is nearly 3 times higher than for those undergoing open reduction and internal fixation of either acute humeral shaft fractures or HSNUs. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of Levels of Evidence.