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.

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.

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.

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.

[Treatment of humerus diaphyseal fractures using Hackethal's retrograde centro-medullary bundle nailing: about 54 cases]

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.

Lateral pinning versus others procedures in the treatment of supracondylar humerus fractures in children

We compared results of lateral pinning procedure with crossed pinning, closed reduction, and open reduction in a retrospective review of 184 patients with displaced supracondylar humeral fractures. All patients had a minimum of 2 years follow-up (range 36-90 months). Patients were separated into 4 groups. Success was estimated by Flynn's criteria. We compared success of the lateral pinning to others procedures. Incidence of nerve palsy was recorded and compared. Esthetic effect of lateral pinning is significantly better than closed reduction (p=0.0007), but no significant difference was found comparing with cross pinning and open reduction. Elbow function was similar. Cross pinning procedure was followed with ulnar nerve palsy in ten patients (20.8%). There was 1 case (5%) of combined nerve palsy including ulnar, median and radial nerve after open reduction procedure. Lateral pinning is safe and effective method of therapy for Gartland type II and III supracondylar humeral fractures.

Long term results of radial tunnel release – the effect of co-existing tennis elbow, multiple compression syndromes and workers' compensation

SUMMARY

Surgical decompression of radial tunnel syndrome (RTS) remains controversial because the results are unpredictable. This study is a retrospective analysis of the long term outcomes of RTS release and a comparison of our findings with previous studies. Thirty-three extremities in 31 patients underwent decompression for radial tunnel syndrome between 1994 and 2003, of which 27 extremities in 25 patients were available for long term follow up after an average of 57 months (range 16 to 106 months). Outcomes were evaluated using the criteria of Ritts et al. (1987). For 16 patients (18 of 27 extremities), the outcome was rated as good (67%), for four patients (four extremities) as fair (15%), and for five patients (five extremities) as poor (18%). The outcome was better in patients with simple RTS (86% good results) compared with patients with additional nerve compression syndromes (57% good results), or patients with coexisting lateral epicondylitis (70% vs 43% good results), or patients who were receiving workers' compensation (73% vs 58% good results). One-third of patients still had moderate or severe disability which affected their ability to work, but 82% had relief of their pain. Surgical decompression is therefore beneficial for simple RTS, but may be less successful if there are co-existing additional nerve compression syndromes or lateral epicondylitis or if the patient is receiving workers'compensation.

Fractures of the shaft of the humerus

We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries.

Incidence of common compressive neuropathies in primary care

Apart from carpal tunnel syndrome, there are no population based studies of the epidemiology of compressive neuropathies. To provide this information, new presentations of compressive neuropathies among patients registered with 253 general practices in the UK General Practice Research Database with 1.83 million patient years at risk in 2000 were analysed. The study revealed that in 2000 the annual age standardised rates per 100 000 of new presentations in primary care were: carpal tunnel syndrome, men 87.8/women 192.8; Morton's metatarsalgia, men 50.2/women 87.5; ulnar neuropathy, men 25.2/women 18.9; meralgia paraesthetica, men 10.7/women 13.2; and radial neuropathy, men 2.97/women 1.42. New presentations were most frequent at ages 55-64 years except for carpal tunnel syndrome, which was most frequent in women aged 45-54 years, and radial nerve palsy, which was most frequent in men aged 75-84 years. In 2000, operative treatment was undertaken for 31% of new presentations of carpal tunnel syndrome, 3% of Morton's metatarsalgia, and 30% of ulnar neuropathy.

Long-term neurologic hand complications after radial artery harvesting using conventional cold and harmonic scalpel techniques

BACKGROUND

The purpose of this study was to determine the incidence of neurologic hand complications after radial artery harvesting and to compare the harmonic scalpel versus conventional cold scalpel technique.

METHODS

From 1995 to 2000, 786 radial arteries were harvested from 782 patients for coronary artery bypass grafting. From 1995 to 1997, the conventional cold scalpel technique was used (422 patients), and from 1998 to 2000, the harmonic scalpel was used (360 patients). Mean follow-up was 4.2 +/- 2.1 years and was 90% complete. Symptoms included thumb weakness or numbness, tingling, or pain in the hand.

RESULTS

The incidence of neurologic hand complications was similar with both techniques (11.2% +/- 3.5% cold, 11.0% +/- 3.6% harmonic, p > 0.95), and in 19% (13 of 67 with symptoms) there was complete resolution within 1 year. Symptoms persisted long-term in 9.0% +/- 3.2% cold scalpel and 9.0% +/- 3.3% harmonic scalpel patients (p > 0.81), but were considered a "constant and significant source of discomfort" in only 0.6% +/- 0.9% cold scalpel and 1.4% +/- 1.3% harmonic scalpel patients (p > 0.41).

CONCLUSIONS

The incidence of adverse neurologic outcomes causing significant long-term discomfort in the hand was low using either the cold scalpel or harmonic scalpel technique. However, a significant number of patients had neurologic hand symptoms in both groups, and this should be included when discussing operative risks with the patient.