Early surgical exploration of radial nerve injury associated with fracture shaft humerus

The series included 36 patients, predominantly male, mean age 30.3 years. The most common cause of injury was motor car accident in 20 patients. Postreduction radial nerve injury occurred in nine cases. Open fracture humerus with radial nerve injury in seven cases. The fractures were situated in the middle or distal third of the humeral shaft. Most were transverse fractures. Twelve patients had surgery on the day of injury and the other 24 at a mean of 8 days later (3-14). Narrow dynamic compression plate was generally used for fixation. Exploration of the radial nerve demonstrated compression at the lateral intermuscular septum in 19 cases, entrapment in the fracture site in nine cases, and loss of its continuity in eight cases. Neurolysis was required in 20 cases, epineurorrhaphy in nine cases, interfascicular nerve grafts in five, and first-intention tendon transfer in two. Results of nerve surgery were assessed with the MRC (Medical Research Council) at a mean follow-up of 8.2 years. Outcome was rated good to excellent in 28 patients, fair in 1, and poor (failure) in 3. First-intention tendon transfers were performed in 2 patients and 2 patients were lost to follow-up. Mean delay to recovery was 7 months after neurolysis and nerve repair and 15 months after nerve grafts. The fracture was united in all cases. The mean time of union was 5 months.     

桡神经内移在肱骨干骨折固定中的应用

目的:总结桡神经内移在肱骨干骨折固定中应用的结果。方法:2005年1月至2009年12月,对16例肱骨干骨折患者,在行前外侧钢板固定中应用桡神经内移方法治疗。其中,男12例,女4例;年龄26～49岁,平均36岁。左侧9例,右侧7例。根据AO骨折分类:6例为A3.2型,5例为A2.2型,2例为A1.2型,3例为B2.2型。应用美国骨科医师协会提出的DASH量表进行疗效评定,0表示上肢功能正常,1～100表示上肢功能有不同程度的损伤。结果:16例患者术后没有发生与手术相关的并发症,无神经损伤与伤口感染。术后随访20～46个月,平均29个月。上肢功能按DASH上肢功能量表评定,均达到了正常数值(数值为0),取得了满意的临床效果。结论:桡神经内移是一种安全的操作方法,不会引起医源性神经损伤,不影响对骨折的处理。在对肱骨干骨折行开放复位以及前外侧钢板固定中,该手术方法可防止桡神经受损伤。     

微创旋入钉内固定技术治疗伴桡神经麻痹的肱骨干中下段骨折

目的：总结微创旋入钉内固定技术在治疗伴桡神经麻痹的肱骨干中、下段骨折的应用效果。方法：自2004年1月至2008年1月,收治36倒伴桡神经麻痹的肱骨干中、下段骨折患者。其中男28例,女8例;年龄20～58岁,平均36．5岁。致伤原因：机械伤18例,交通伤8例,意外伤10例,均为闭合性骨折。根据AO分型：A1型5例,A2型7例,B1型8例,B2型7例,B3型5例,C3型4例。于骨折部位外侧做小切口,探查桡神经后,复位骨折。经肩峰外侧做小切口,分开三角肌,于大结节后侧开槽,顺行用髓腔钻扩髓,挑选合适旋入钉旋入髓腔远端,沿槽口打入锁片完成固定。记录术后并发症、骨折愈合时间、桡神经功能恢复时间、肩关节和肘关节屈伸范围。采用ASES肩关节和HSS肘关节评分标准评价疗效.结果：36例患者切口均Ⅰ期愈合。获随访9-36周,平均18．5周。骨折愈合时间12～16周,平均为15．6周。桡神经功能术后12～36周完全恢复,平均17．8周。肩关节外展150°～170°,平均160°;肘关节活动范围130°～140°,平均135°。肩关节功能根据ASES评分标准,由术前的（43．85±8．90）分上升至术后的（91．27±7．66）分,差异有统计学意义（t=24．238,P=0．000）,其中优20例,良12例,可4例;肘关节根据HSS评分标准,由术前的（39．97±16．06）分上升至术后的（96．22±3．59）分,差异有统计学意义（t=20．512,P=0．000）,36例均为优。结论：采用微创旋入钉内固定技术治疗伴桡神经麻痹的肱骨干中、下段骨折可获得良好效果。     

Treatment of un-united fractures of the shaft of the humerus with bent nail

The results of operative treatment of 78 cases of un-united fractures of the humeral diaphysis are reported. The operation consisted of medullary nail fixation, the nail being bent at the fracture site in order to engage the cortex above and below the fracture, and was followed by plaster splintage. Forty-nine cases showed evidence of union within 20 weeks and 21 united between 20 and 30 weeks. Of the remaining cases, two had broken nails and five were lost to follow-up.     

Secondary radial nerve palsy after internal fixation of humeral shaft fractures

Objective and background

There was no agreement with regard to the treatment for secondary radial nerve palsy. This study aimed to investigate at what point should exploration of the nerve be considered.

Methods

One hundred and twenty-five patients with fracture of the diaphyseal humerus treated with internal fixation at our hospital from February 2000 to February 2010 were reviewed retrospectively. There were six cases of secondary radial nerve palsy occurred soon after humeral internal fixation. No recognized intraoperative injuries to the radial nerve were recorded. Initial conservative observation was carried out in all six cases.

Results

Follow-up period averaged 28 months (range 24–37 months). In four cases, the beginning of electromyography recovery averaged 3.5 months (range 1–5 months), the meantime of onset of clinical recovery was 4.8 months (range 1–6 months), and the average time to full recovery of wrist and finger extension was 8.5 months (range 3–12 months). In other two cases, nerve exploration was made when there was no nerve recovery 3 months after internal fixation of humeral fracture at the request of patients. There were no macroscopic lesions of the radial nerve. At 2-year follow-up, extension of wrist and finger recovered to nearly normal in these two cases.

Conclusions

For treatment for secondary radial nerve palsy, it seems reasonable to consider watchful waiting for about 5 months before nerve exploration if the decision as to the period of waiting was based on the clinical recovery onset time.     

桡神经内移加钢板固定治疗肱骨中下1/3骨折

肱骨干骨折多见，其中肱骨中下1／3骨折常并发桡神经损伤，既往此类骨折均采用切开复位内固定术治疗。为了避免二次手术取出钢板时损伤桡神经，我们从2001年1月～2004年12月间对14例肱骨中下1／3骨折患者采用将桡神经由外侧移到内侧加钢板固定的新方法，收到良好的效果，现报告如下。     

Early functional treatment of humerus shaft fractures by the Sarmiento method

The functional treatment of humerus shaft fractures with a brace according to Sarmiento is described. Reported are the results of the functional treatment of 47 humerus shaft fractures. Every humerus shaft fracture normally treated conservatively, including the humerus shaft fractures in polytraumatised patients and those patients with a primary radial nerve injury, can be treated in this way. The functional treatment of humerus shaft fractures results in a quick and uneventful healing of the fracture with a good function and cosmetic aspect.     

Trans-fracture transposition of the radial nerve during the open approach of humeral shaft fractures

The radial nerve constitutes a major problem in humeral shaft fractures; it may be injured immediately or during closed reduction or open reduction and internal fixation with plate and screws. After fixation, the nerve always runs directly over the plate without any interposed structure. If a revision surgery is indicated, the nerve is at high risk as it is usually difficult to dissect from surrounding fibrotic scar tissue or callus formation. To avoid these complications, some authors reported transposition of the radial nerve through the fracture line. We present herein the surgical technique of the trans-fracture transposition of the radial nerve during open reduction and internal fixation of humeral shaft fractures, along with our preliminary results in 6 cases and a review of the literature.     

Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review

The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol. The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p < 0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors.     

桡骨干骨折的治疗进展

桡骨干在前臂的功能活动中有重要作用,其发生骨折时多因直接暴力、间接暴力及扭转暴力所致,且往往伴有下尺桡关节脱位及尺骨损伤.对于此类骨折,主要的治疗目的是保持轴向稳定性、旋转稳定性以及保持骨长[1-2].虽然这些治疗目标是不变的,但是在选择骨折治疗方式时涉及多种骨折特异性和患者自身的具体因素[3],这就需要临床工作者根据...     

Postoperative radial nerve paralysis caused by fracture callus.

This is a case of late-onset (6 weeks) radial nerve paralysis following open reduction and internal fixation of a comminuted distal humerus fracture. A transected radial nerve within the callus was found at reoperation. The mechanism of transection was thought to be repetitive motion of the nerve across an edge of new bone. The nerve was repaired and tendon transfers done subsequently with less than full functional recovery at 16 months. No such case has been previously reported.     

Proximal humerus and humeral shaft fractures in children

Proximal humerus fractures and fractures of the humeral shaft are relatively rare in children. The incidence of the former is about 1 to 3 cases/1000 population per year, comprising fewer than 3% of all pediatric fractures. Fractures of the humeral shaft represent fewer than 10% of all humerus fractures in children. Both types of fractures in babies and young children can be treated nonsurgically, because of the joint's ability to remodel. Simple swaddling with a sling or swaddling cloth can be the solution. For older children, splints and braces may be necessary for short periods of time. Fractures can sometimes be a sign of parental child abuse, so suspicion should remain high when evaluating children with these injuries.     

Nonunited humerus shaft fractures treated by external fixator augmented by intramedullary rod

Background:

Nonunion of humeral shaft fractures after previously failed surgical treatment presents a challenging therapeutic problem especially in the presence of osteoporosis, bone defect, and joint stiffness. It would be beneficial to combine the use of external fixation technique and intramedullary rod in the treatment of such cases. The present study evaluates the results of using external fixator augmented by intramedullary rod and autogenous iliac crest bone grafting (ICBG) for the treatment of humerus shaft nonunion following previously failed surgical treatment.

Materials and Methods:

Eighteen patients with atrophic nonunion of the humeral shaft following previous implant surgery with no active infection were included in the present study. The procedure included exploration of the nonunion, insertion of intramedullary rod (IM rod), autogenous ICBG and application of external fixator for compression. Ilizarov fixator was used in eight cases and monolateral fixator in ten cases. The monolateral fixator was preferred for females and obese patients to avoid abutment against the breast or chest wall following the use of Ilizarov fixator. The fixator was removed after clinical and radiological healing of the nonunion, but the IM rod was left indefinitely. The evaluation of results included both bone results (union rate, angular deformity and limb shortening) and functional outcome using the University of California, Los Angeles (UCLA) rating scale.

Results:

The mean follow-up was 35 months (range 24 to 52 months). Bone union was obtained in all cases. The functional outcome was satisfactory in 15 cases (83%) and unsatisfactory in 3 cases (17%) due to joint stiffness. The time to bone healing averaged 4.2 months (range 3 to 7 months). The external fixator time averaged 4.5 months (range 3.2 to 8 months). Superficial pin tract infection occurred in 39% (28/72) of the pins. No cases of nerve palsy, refracture, or deep infection were encountered.

Conclusion:

The proposed technique is effective in treating humeral nonunion especially in the presence of osteoporosis and short bone segments. The inclusion of intramedullary rod as internal splint improves stability of fixation and prevents refracture after fixator removal.