High radial nerve palsy

Systematic review of humeral shaft fracture (OTA/AO 12) complicated with iatrogenic radial nerve injury

OBJECTIVES

To compare the iatrogenic radial nerve injury (iRNI) rate of different implant (plate vs. intramedullary nail) and surgical approaches during humeral shaft fracture surgery.

METHODS

The online PubMed database was used to search for articles describing iRNI after humeral fracture with a publication date from Jan 2000 to October 2023. The following types of articles were selected: (1) case series associating with adult humeral shaft fracture, preoperative radial nerve continuity, non-pathological fracture and non-periprosthetic fracture; (2) involving humeral shaft (OTA/AO 12) fractures. Articles where we were unable to judge surgical approach or fracture pattern (OTA/AO 12) were excluded. The data were analyzed by SPSS 27.0 and Chi-square test was performed to identify incidence of iRNI associated with different implant and surgical approaches.

RESULTS

Fifty-four articles with 5063 cases were included, with 3510 cases of the plate, 830 cases of intramedullary nail and 723 cases of uncertain internal fixation. The incidences of iRNI with plate and intramedullary nail were 5.95% (209/3510) and 2.77% (23/830) (p < 0.05). And iRNI incidences of different surgical approaches were 3.7% (3/82) for deltopectoral approach, 5.74% (76/1323) for anterolateral approach, 13.54% (26/192) for lateral approach and 6.68% (50/749) for posterior approach. The iRNI rates were 0.00% (0/33) for anteromedial MIPO, 2.67% (10/374) for anterolateral MIPO and 5.40% (2/37) for posterior MIPO (p > 0.05). The iRNI rates were 2.87% (21/732) for anterograde intramedullary nail and 2.04% (2/98) for retrograde intramedullary nail (p > 0.05). In humeral bone nonunion surgery, the rate of iRNI was 15.00% (9/60) for anterolateral approach, 16.7% (2/12) for lateral approach and 18.2% (6/33) for posterior approach (p  > 0.05).

CONCLUSION

Intramedullary nailing is the preferred method of internal fixation for humeral shaft fractures that has the lowest rate of iRNI. Compared with anterolateral and posterior approaches, the lateral surgical approach had a higher incidence of iRNI. The rate of iRNI in MIPO was lower than that in open reduction and internal fixation.

LEVEL OF EVIDENCE

Level IV.

Primary Radial Nerve Lesions in Humerus Shaft Fractures-Revision or Wait and See

Background: This study investigates the surgical state-of-the-art procedure for humeral shaft fractures with primary radial nerve palsy based on its own case series in relation to the current and established literature. Methods: Retrospective review of treated cases between January 2018 and December 2022 describing radial nerve palsy after humerus shaft fractures, radiological fracture classification, intraoperative findings, surgical procedure, patient follow-up and functional outcome. Results: A total of 804 patients (463 women and 341 men) with humerus shaft fractures were identified. A total of 33 patients showed symptomatic lesions of the radial nerve (4.1%). The primary lesion was identified in 17 patients (2.1%). A broad and inhomogeneous distribution of fractures according to the AO classification was found. According to the operative reports, the distraction of the radial nerve was found eleven times, bony interposed three times and soft tissue constricted/compressed three times. In every case the radial nerve was surgically explored, there was no case of complete traumatic nerve transection. Four intramedullary nails and thirteen locking plates were used for osteosynthesis. Complete recovery of nerve function was seen in 12 cases within 1 to 36 months. Three patients still showed mild hypesthesia in the thumb area after 18 months. Two patients were lost during follow-up. Conclusions: With this study, we support the strategy of early nerve exploration and plate osteosynthesis in humeral fractures with primary radial nerve palsy when there is a clear indication for surgical fracture stabilisation. In addition, early exploration appears sensible in the case of palsies in open fractures and secondary palsy following surgery without nerve exposure as well as in the case of diagnostically recognisable nerve damage. Late nerve exploration is recommended if there are no definite signs of recovery after 6 months. An initial wait-and-see strategy with clinical observation seems reasonable for primary radial nerve palsies without indication for surgical fracture stabilisation.

Comparison of nerve versus tendon transfer for radial nerve palsy

OBJECTIVE

This study aims to investigate the choice of intervention time and operation mode between nerve and tendon transfer for the treatment of radial nerve palsy (RNP).

METHODS

46 RNP patients underwent nerve transfer (n = 22) and tendon transfer (n = 24). The intraoperative blood loss, main incision length, operation duration, and length of hospital stay and follow-up period of patients in these two groups were recorded and compared. The range of motion (ROM) of the elbow, wrist, fingers, and thumb, the hand grip and pinch strength, the Disabilities of Arm, Shoulder, and Hand (DASH) and the 36-Item Short Form Health Survey (SF-36) scores were measured and compared preoperatively and postoperatively between the two groups.

RESULTS

The ROM of thumb and the hand grip strength of patients in the nerve transfer group were greater than that in the tendon transfer (P < 0.05). Both of the two groups indicated significant improvements in the ROM of elbow, wrist, finger, thumb and the hand grip and pinch strength (P < 0.05) postoperatively. The DASH scores decreased significantly at 6 months (P < 0.05) and 12 months (P < 0.05) after surgery in both groups, while the postoperative SF-36 scores significantly increased (P < 0.05). There was no significant difference in postoperative DASH and SF-36 scores between the two groups (P > 0.05).

CONCLUSION

In summary, both nerve and tendon transfer techniques are effective treatments for RNP. Nerve transfer is particularly advantageous for early RNP, while tendon transfer is suitable for patients with radial nerve injury more than one year.

Recovery and functional outcome after radial nerve palsy in adults with a humeral shaft fracture: a multicenter prospective case series

Background

The consequences of radial nerve palsy associated with a humeral shaft fracture are unclear. The aim of this study was to examine the functional recovery of radial nerve palsy, at presentation or postoperatively, in patients with a humeral shaft fracture.

Methods

Data from patients who participated in the HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER) study, a multicenter prospective cohort study including adults with a closed humeral shaft fracture Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 12A or 12B, and had radial nerve palsy at presentation or postoperatively, were extracted from the HUMMER database. The primary outcome measure was clinically assessed recovery of motor function of the radial nerve. Secondary outcomes consisted of treatment, functional outcome (Disabilities of the Arm, Shoulder, and Hand and Constant-Murley Score), pain level, quality of life (Short Form-36 and EuroQoL-5D-3L), activity resumption, and range of motion of the shoulder and elbow joint at 12 months after trauma.

Results

Three of the 145 nonoperatively treated patients had radial nerve palsy at presentation. One recovered spontaneously and 1 after osteosynthesis. Despite multiple surgical interventions, the third patient had no recovery after entrapment between fracture fragments. Thirteen of the 245 operatively treated patients had radial nerve palsy at presentation; all recovered. Nine other patients had postoperative radial nerve palsy; 8 recovered. One had ongoing recovery at the last follow-up, after nerve release and suture repair due to entrapment under the plate. At 12 months, the functional outcome scores of all patients suggested full recovery regarding functional outcome, pain, quality of life, activity resumption, and range of motion.

Conclusion

Radial nerve palsy in patients with a humeral shaft fracture at presentation or postoperatively functionally recovers in 94% and 89%, respectively.

Radial nerve compression: anatomical perspective and clinical consequences

The radial nerve is the biggest branch of the posterior cord of the brachial plexus and one of its five terminal branches. Entrapment of the radial nerve at the elbow is the third most common compressive neuropathy of the upper limb after carpal tunnel and cubital tunnel syndromes. Because the incidence is relatively low and many agents can compress it along its whole course, entrapment of the radial nerve or its branches can pose a considerable clinical challenge. Several of these agents are related to normal or variant anatomy. The most common of the compressive neuropathies related to the radial nerve is the posterior interosseus nerve syndrome. Appropriate treatment requires familiarity with the anatomical traits influencing the presenting symptoms and the related prognoses. The aim of this study is to describe the compressive neuropathies of the radial nerve, emphasizing the anatomical perspective and highlighting the traps awaiting physicians evaluating these entrapments.

Nerve merging repair in the replantation of a severed limb with defects in multiple nerves: five cases and long-term follow-up

Background

Repairing all nerves is challenging in cases of upper arm avulsion combined with defects in multiple nerves because the donor area for autogenous nerve transplantation is limited and the outcomes of long-segment allogeneic nerve transplantation are poor. Based on the principle of magnified nerve regeneration, we present a method called nerve merging repair, the feasibility of which needs to be confirmed in clinical practice.

Methods

The nerve merging repair method relies on the use of fewer proximal nerves to innervate more distal nerves and depends mainly on whether the radial nerve (RN) can repair itself. In the case of defects in multiple nerves precluding RN self-repair, median-(median + radial) (M-(M + R)) repair is performed. If the RN can undergo self-repair, median-(median + ulnar) (M-(M + U)) or ulnar-(ulnar + median) (U-(U + M)) is used to repair the three nerves. Five cases were included in the study and involved the analysis of joint motor function, muscle strength and sensory recovery of the affected limb.

Results

The replanted limb survived in all 5 cases. Follow-up visits were conducted with the patients for 51–80 months, during which they experienced satisfactory recovery of skin sensation, elbow flexion and extension and partial recovery of hand muscle strength.

Conclusions

To a certain extent, treatment with the nerve merging repair method improved the sensory and motor function of the affected limb and limited the loss of function of the donor nerve area. This intervention provides a new approach for repairing long-segment defects in multiple nerves caused by avulsion amputation of the upper limb.

Ultrasound of the Radial Nerve: A Pictorial Review

This pictorial review focuses on the ultrasound (US) appearance of the normal and pathological radial nerve (RN) and its branches and provides tips with which to locate them and avoid misinterpretation of normal findings. A wide range of our pathological cases are reviewed and presented to help in familiarizing the reader with common and uncommon clinical scenarios that affect the RN and its main branches.

Presentation and Management Outcome of High Radial Nerve Palsy with Tendon Transfers

BACKGROUND

This randomized clinical trial was carried out to document the clinical presentation of isolated high radial nerve palsy (high RNP) and compare the outcome of triple tendon transfers.

METHODS

The study included patients of all genders and ages who presented with isolated high RNP. Half of them were randomly assigned to the flexor carpi radialis set (FCR-set) of tendon transfers (group A) and a half to the flexor carpi ulnaris (FCU-set) of tendon transfers (group B).

RESULTS

Out of 44 patients, 38 were males, and 6 were females. The age ranged from 7 years to 55 years. 26(59.09%) patients had primary RNP in association with fractures of the humerus. The postoperative mean disability of arm, shoulder, and hand score (Quick DASH-11 score) for the patients in the FCR-set of transfers was 34.54%% versus 41.81% for the FCU-set of transfers. 11 patients (25%) developed radial deviation deformity.

CONCLUSION

RNP was predominantly found among males of the young age group, and the majority of the cases resulted from preventable causes. The triple tendon transfers among patients of the two groups robustly restored the lost extension of the wrist and digits in a matching way. The patients also subjectively reported remarkable improvement in terms of the favorable Quick-DASH-11 scores. Radial deviation deformity occurred among half of the patients who underwent the FCU set of tendon transfers.

Tendon transfers for radial nerve palsy with extensor carpi ulnaris revival: Technique and results

BACKGROUND

Nerve repair is the gold standard for treatment of radial palsy. In case of failure or contraindication, palliative techniques using tendon transfers provide good results. However, wrist extension frequently shows radial deviation, impairing grip strength.

HYPOTHESIS

Associating extensor carpi ulnaris (ECU) revival avoids radial deviation.

STUDY DESIGN

Single-center retrospective study.

MATERIAL AND METHODS

The inclusion criterion was radial nerve palsy treated by tendon transfers involving revival of the ECU. Nine patients, with a mean age of 33 years [15-60] were included. Four palsies were trauma-induced, 3 tumor-induced and 2 idiopathic. The mean time to treatment was 32 months [4.6-120].

RESULTS

Mean follow-up was 51 months [3-160.7]. Eight patients could be assessed. Wrist extension was balanced in 6 cases, in ulnar deviation in 1 and in radial deviation in the other. Wrist motion was 54° [30°-80°] in extension, 46° [20°-70°] in flexion, with an active motion in the frontal plane of 21° [0°-35°]. Finger extension was possible with the wrist in extension in 6 cases. Thumb abduction was subnormal in 3 cases, incomplete but functional in 4 and barely functional in 1. Fist closure was always complete. Mean QuickDASH score was 41/100 [14-63].

CONCLUSION

This technique is reliable and reproducible, giving good functional results and avoiding the radial deviation of the wrist in extension observed with traditional techniques.

LEVEL OF EVIDENCE

IV.