RadialNerve Fractures

A
BY JOSEPH REVIEW

Paralysis of the
OF FORTY-FIVE HARILAOS

Associated Humerus
CASES

with

*t
M.D.f,

L. SHAW,

M.D4, BOSTON,

AND

SAKELLAHIDES,

ItIASSACHUSETTS

Radial-nerve
conimoni peripheral

paralysis
nerve

associated
lesion

with

fracture
fractures

of

the
.

complicating

humerus However, has failed

is the most appropriate The pressing to show any help exploration

to an cx-

treatment question signs

and prognosis still remains,

remain somewhat controversial When do you explore a nerve studies and injured
always

1,2,3,5,6,7,8,9,10

which are

of recovery? Nerve-conduction the

these

electromyography nerve
available

of considerable riced
to

in
.

evaluating
However,

status
tools

of an
are not

and

the
arid

possible
are difficult

for

apply

tremity data

immobilized

in plaster.

Therefore,

it may

be necessary

to rely for

on

clinical exthat

alone to determine The purpose of this can usually of injury, considerably,

humeral

the appropriate time for nerve exploration. study is to show that the appropriate time from the clinical data and time for depending
arid its

nerve out

plorationi

be determined

to point

the mechanism paralysis vary

respect to the

exploration, on when
subsequent and of

arid prognosis for radial-nerve the nerve injury occurred with

treatment.

fracture

Clinical
This study includes forty-five

Material
cases

Data
paralysis associated with

radial-nerve

hunieral The data examinration follow-up additional up data. The years, and mcii nine arid The

fractures were

seen obtained

at the

Massachusetts of the hospital

General records

Hospital

from

1934
by

to

1964.

by review

of all patients,

personal arid by Fifteen follow-

of fourteen patients, questioniriaires, filled cases were evaluated age distribution of the cent) were wonienr. fractures at forty-five the

seven of whom we had personally treated, out by the remaining thirty-one patients. but were eliminated because of insufficient time patients of fracture years by falls
by

ranged were of age. from

falls

from under There

six were

to

sevenity-onre years of age twenty-eight in sixteen

arid by

thirty-two (20 per seventeen humeral

(75 per cent)

forty

under were

thirteen caused

a standing
from a height

positionr
iii seveti,

patients, by automobile miscellaneous injuries lortv-two of the

of most
angulation,

accidenrts in nine. forty-five

the cases there had of

in thirteen,

fractures
paralysis

were

located
at

in the the

middle
time

or lower However, displacenienrt, were open, of treatnrenrt in the

Surgeons, Avensue,

third
there
iti

the

humerus.

In patients

occurring

of accident,

were

about
of these

equal

numbers

of spiral,
also

oblique,
been

arid

transverse
injury

a severe

with

fractures. marked

none the

was l)atienits
4

or comminution of the caused by a penetrating with

at the

fracture. wound. riot vary

Americans to: 1)r.

Eight of these fractures The findings arid results significantly

Acadeniy Jose1)h L. Shaw,

but in

open
Animal

fractures
Meetinsg

did
of The

from
of Orthopaedic 2475

those

pat ienrts
Chicago Sans Frau-

1ead

Illiniois,

January 23, 1966. t Please address requests for reprints cisco, Califorisia 94115. Presbyterian Medical Censter, Clay #{182} I)epartmeirt of Orthopaedic Surgery, Ma.ssachuset ts 02114.
VOL. 49-A, NO. 5, JULY 1967

Pa-ific

and Webster Massachusetts

Streets, Sarr Franscisco, Genseral hospital,

Californsia. Fruit Street,

Bostoni,

899

900

.r.

L.

SHAW

AND

HARILAOS

SAKELLARIDES

with
ciated function

closed
with was

fractures.
more longer distal

In this series,
(supracondylar) children in the

the radial-nerve
fractures, than in the adults.

paralyses
yet the

in children

time

required

were assoto regain

Results Radial-Nerve Paralysis Occurring at the Time of Accident

In thirty-one
was fractured. The of the occurred eight

of the
paralysis

forty-five
was

patients,
partial

paralysis
in six Onset for full and

occurred
complete

when

the

humerus
Five usually days to fully

in twenty-five. recovery from three who recovered

was

partial paralyses by two weeks. months, the average

recovered fully. The time required being four

of spontaneous recovery varied Three patients but

by

months.

had open reduction and internal fixation in only one. In this patient, the nerve neurolysis delayed
function was

of the fracture, was compressed patient failed paralysis,

was noted

the nerve the fracture

explored fragments; despite full

to

not

necessary. and

The

sixth

to regain fifteen
at from

function regained
two weeks

exploration Of the twenty-five

spontaneously.

neurolysis. patients with

Onset of

complete Full

nerve
four

recovery

months, two

the

average

being

five

weeks.

recovery

required

from

three

months

to

arid one-half years, or an average of ten months. Fifteen of the patients with complete paralysis underwent nerve. The explorations were performed within six months (an one-half explorations finrdinrgs division nerves
between

exploration of the average of two arid excessively The Of the with delayed operative partial divided

months included of the

after four nerve,

injury) one and four divided

except one-half, nerves, neuromas,

in three and two and large

patients three five years, neuromas

who

had

at one,

respectively.
in continuity

contused

nerves.

two were anastomosed arid two were not, because it was felt that the gap the nerve ends could riot be bridged. Both large nreuromas in continuity were excised arid neurorrhaphy was performed ; the four neuromas were treated by nieurolysis, arid the five contused nerves required no repair. The quired
Only

results rio repair of the in one 1930s,

of surgery recovered. four year. and

were discouraging. The five contused nerves which No functional recovery followed the four neurorrhaphies. resulted five of with function who failed Immediately in improved these eight were excessively complete at an sustained to regain after nerve procedures delayed. function, were

re-

one the

recovery during

neurolyses However, three patients full patient,

with full performed

explorations

Of the remaining ten exploration, nine recovered fracture, while the tenth humerus Radial-Nerve Five fracture fracture, anrgulationr twenrt\-four found patients to secondary Paralysis

paralysis who did not undergo average of twelve months after a pathological fracture of the any Fracture radial-nerve Manipulation of the type of lateral at from arid was
In

to fibrosarcoma, Occurring

function.

of the forty-five paralyses occurred immediately after manripulatioir and were complete. Four of the five were associated with a specific a spiral or oblique fracture in the distal third of the humerus with and overriding hours to three be intact but of the weeks compressed fragments. The after manipulation between the radial nerve of these was explored four fractures fragmenrts. stabilized Recovery of nine child with began months. with recovery

fracture

all

four

the nerve was freed, the fracture was reduced and fixation, and return of radial-nerve function was complete. four weeks after operation and was complete at an average The conidylar
complete

internal two to a suprawas

remaining fracture.
by

patient Exploration months.

in this
was

group not

was

a seven-year-old Radial-nerve

performed.

nine

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

RADIAL-NERVE

PARALYSIS

901
of Humeral Fractures fixatiorr of extensive patients associated arid

Radial-Nerve

Paralysis

Resulting

from

Open

Reduction

the the

Nine of the forty-five fracture. Five of these and fixation note with operative specifically

paralyses followed nine fractures were multiple stated screws that the

open reduction in the mid-shaft or a plate reductions The radial arid were

and internal and required screws. difficult was nerve In three arid

exposure

with heavy retraction retracted free of the The treated nerve

difficult.

on the radial nerve. field in all five cases.

identified

remaining four by open reduction was riot identified this over-all group,

fractures were intercondylar and internal fixation with in any of these procedures their, there were Seven open six

or supracondylar and were one or more screws. The radial and reduction was generally arid three partial nerve sponifor full

In paralyses, taneously

complete nine

all of which recovered fully. within two months after the months two

of the reduction.

began to recover The average time

recovers was three ysis. The remaining begun of the with

for partial paralysis radial nerves were

arid eight months explored because

for complete paralrecovery had not

there was a fracture

by three arid four months, respectively. In both patienits mid-shaft of the humerus, and the nerve was surrounded requiring nieurolysis. Onset of recovery was rioted within three

by denise scar tissue, weeks of neurolysis,

full

recovers

occurring

within

three

months

in each

patient.

Treatment The paralysis this studs. patients reduction complete Radial-Nerve Partial reduced within justifies
which

genenally associated Iull

optimistic attitude concerning with fracture of the humerus recovery of radial-nerve in whom
By contrast

the prognosis is supported occurred after

recovery no

by

for radial-nerve the findings cent

cent of

in the

function paralysis
there was

in 75 per manipulation
in 40 per

arid in all patients of the fracttnre. paralyses Paralysis paralysis have a good which

occurred time of the of Humeral fractures of spontaneous

or open
of the

occurred
OCCurring

at the

accident. Fracture have series recovery with the recovery. arid an been at closed fracture satisfactorily began months fractures should of two in this recovery

at the Time with Since eviderrce closed

associated prognosis. of any

which

in all patients

two months, lack explorations. In cases of coml)lete have been satisfactorily and the

radial-nerve reduced observed to patient

paralysis
by

associated manipulation, of nerve weeks, exploration (1)

gentle for onset

be immobilized recovery treatment

operation

If evidence appropriate unnecessary

is riot rioted of the nerve of the

within seven is indicated. nerve at seven

eight to eight

Exploration

weeks

avoids

in most patients ins whom spontaneous nerve recovery will occur; (2) does riot. interfere with fracture healing arid consequently does riot increase the danger of liOns-uniOn or delayed union ; (3) allows the neuroma to become well delineated and henrce to be adequately resected ; and (4) does not impair satisfactory neurorrhaphy
sinrce nerve However, 01 complete retraction immediate should not be excessive by this time.

operative

exploration

of the

nerve

is indicated

for partial or (2) a closed of exploration or resection of the ends nreurorr-

radial-nerve fracture which requires If the nerve is found aird recovery is not nieuroma and should merely
von..
49-A. NO. 5,

paralysis associated with (1) an open fracture open reduction and internal fixation. to be intact but severely crushed at the time after seven to eight weeks, neurolysis

evident

neurorrhaphy be approximated
JULY

should be performed. If the nerve is divided, and delayed resection of the neuroma and

1967

902 haphy assume be performed the success Paralysis of the five

fracture

J.

L.

SHAW

AND

HARILAOS

SAKELLARIDES

subsequenrtly, of a primary after

unless neurorrhaphy.

the

surgeon

is sufficiently

experienced

to

Radial-Nerve Four
spiral

Fracture

Manipulation injuries in this group

humerus

radial-nerve
in the distal

were
with

associated
lateral
.

with
angulation

or oblique

third

of the

and overriding of fragments as operative exploration is indicated nierve coming on after manipulation third
of this

described by Holstein and Lewis for complete or progressive paralysis of a fracture, particularly one during manipulative reduction

Immediate of the radial in the lower of fractures

of the
type

humerus.
is clearly

Extreme
indicated.

caution

Radial-Nerve
In this

Paralysis
group by of

Follouing
nerve

Open

Reduction
associated

of Humeral
with mid-shaft

Fractures
or supraconrdylar

injuries,

fractures which fails explored.

treated

open

reduction,

the

prognosis within

is excellent. two months

However, should

any probably

nerve be

to show

evidence

of recovery

Conclusion
1.

The

mechanism

of injury,

treatment, vary to the injuries

and

prognosis

of paralysis its

of the on

radial

nerve nerve
treatment..

complicating humeral inrjury occurred with 2. It is helpful to consider accident,

fractures respect these

considerably, depending humeral fracture and in three following of the accident if no with categories: manipulation nerve appear

when the subsequent occurfracture,

(a) paralysis of the

ring and

at the (c)
3.

time

of the

(b) paralysis

ParalYsis following open reduction. The clinical indications for exploration paralysis exploration weeks. occurs at the time of the of the nerve is indicated If the paralysis is associated

to be as follows: with a closed within seven or a closed

(a) When fracture, to eight

arid is associated recovery is noted an open fracture

fracture which requires open reduction, or if the paralysis is progressive, immediate explorations is indicated. (b) Paralysis following manipulation of a fracture in the lower third of the humerus with lateral angulation arid displacement of the fragmerrts requires early explorationr. (c) If paralysis occurs after anr open reduction in which should the nerve was riot seen or the status of the be explored if no recovery is rioted by eight References
to Nerves mr Limbs. Philadelphia, W. B. Saunders, Co., 1962. GARCIA, ALEXANDER, JR., and MAECK, B. H. : Radial Nerve Injuries in Fractures of the Shaft of the Humerus. Am. J. Surg., 99: 625-627, 1960. :3. HOLsTEIN, AiITHuIS, and LEwIs, G. B. : Fractures of the Humerus and Radial-Nerve Paralysis. J. Bonre aird Joint Surg., 45-A : 1382-1388, Oct. 1963. 4. LEwIs, I)EAN, and MILLER, E. M. : Peripheral Nerve Injuries Associated with Fractures. Ants. Surg., 76: 528-538, 1922. 5. MARBLE, H. C.; HAMLIN, EDWARD, JR.; arid WATKINS, A. L.: Hegeireratioir ins the Ulnar, Medians, and Hadial Nerves. Am. J. Surg., 55 : 274-294, 1942. 6. MEDICAL I)EPARTMENT, UNITED STATES ARMY: Surgery in World War II. Vol. 6. Orthopedic Surgery mr the European Theater of Operations, p. 104. Edited by Mather Clevelansd. Washington, D. C., Office of the Surgeon General, 1956. 7. POLLOCK, L. J., anrd DAVIS, LOYAL: The Radial Nerve. In Peripheral Nerve Injuries. Am. J. Surg., 16 : 566, 1932. 8. ScIENrnFnc 1IESEARCH COMMIVFEE, PENNSYLVANIA ORTHOPEDIC SOCIETY: Fresh Midshaft Fractures of the Humerus in Adulth. Pennsylvanria Med. J., 62 : 848-850, 1959. 9. SE000N, H. J. lEditorl: Peripheral Nerve Injuries. Special Report Series No. 282. London, Her Majestys Stationery Office, 1954. 10. WATSON JONES, H.: Primary Nerve Lesions in Injuries of the Elbow anrd Wrist. J. Boise ansd Joint Surg., 12 : 121-140, Jans. 1930.
BATEMAN, THE JOURNAL OF BONE AND JOINT SURGERY

nerve weeks.

was

in doubt,

the

nerve

1. 2.

J. E.:

Trauma