Radial nerve palsy in mid/distal humeral fractures: is early exploration effective?

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Excerpt

Radial nerve palsy is a well‐documented complication of humeral fractures, particularly displaced fractures involving the mid‐shaft or distal humerus. Many surgeons currently manage this type of injury conservatively, with investigation of the radial nerve following a failed period of non‐operative management. Evidence to support conservative management versus early exploration is limited.
We hypothesize that early exploration and decompression of the radial nerve can give the surgeon, and hence the patient, an indication of the damage sustained by the radial nerve and a likely prognosis for recovery. Furthermore, early exploration and decompression provides an opportunity to extricate an entrapped nerve from between fracture fragments and stabilization of the skeleton then provides a rigid, firm base to allow for optimum nerve recovery. As discussed by Niver and Ilyas,1 early repair of a nerve results in quicker nerve recovery with less atrophy, less degradation of the motor endplate, and a reduced delay in return to function.
Current conservative management is supported by a systematic review of 21 articles by Shao et al.2 found an incidence of 11.8% of radial nerve palsy in humeral fractures, and of these, 88.1% recover. They found that early exploration had no impact compared with those treated conservatively. Thus, they found that 11.9% of patients did not recover. Venouziou et al. (2011) suggest that the mechanism of injury may determine the need for exploration, with low‐energy injuries recovering without exploration but that high‐energy closed injuries may benefit from early exploration.3
There have also been a number of studies that explore the outcomes of radial nerve palsies managed operatively after the failure of initial conservative management, which also generally suggest a positive outcome.4 In these situations, however, the patient is left uncertain as to the eventual outcome of their palsy. The study by Korompilias et al.7 found that at delayed exploration of 12 closed injuries with radial nerve palsy, two had complete transection of the nerve, two were entrapped in the fracture and two were adhesed (and underwent neurolysis), and that all intact nerves recovered 20–24 weeks post injury.
There are, however, only a limited number of studies that examine the outcomes of early operative exploration in patients with a recognized radial nerve palsy. Ring et al.8 demonstrated that early operative exploration may be of benefit in assessing the state of the radial nerve which can assist in prognosticating the likely functional outcome for the patient. A meta‐analysis by Li et al.9 advocated a conservative approach in low‐energy, closed fractures however early surgical exploration in high‐energy or open fractures.
This case series examines 10 consecutive patients who all demonstrated a new‐onset radial nerve palsy following displaced mid‐shaft and distal humeral fractures, and who subsequently underwent early exploration and mobilization of the nerve.
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