Humeral Shaft Fractures and Radial Nerve Palsy: To Explore or Not to Explore … That is the Question

Author(s): Heckler MW and Bamberger H

Source: Am J Orthop 37(8): 1-05, 2008.

Summary:

Humeral shaft fracture with radial nerve palsy has been the subject of debate since this entity was originally described by Holstein and Lewis in 1963.  To clarify how physicians are actually treating these patients, the authors surveyed practice tendencies on treatment of the radial nerve.  In addition, the authors integrated the survey results with the current literature to propose an algorithm directing treatment of these individuals.

The authors surveyed physicians in 3 groups:  1) American Society of Surgery of the Hand (ASSH), 2)  Orthopaedic Trauma Association (OTA), and 3) a group of orthopedic surgery residents.  Each group was asked a series of questions pertaining to the treatment of humeral shaft fracture with associated radial nerve palsy.

Overall, 558 surgeons responded.  For an adult patient without palsy, the 3 groups agreed that the plate and screws are the implant of choice when fixation is indicated in a closed neurovascularly intact midshaft humerus fracture.  Similarly, the groups agreed that open humeral shaft fractures with radial nerve palsy should be explored.  Regarding the closed “Holstein-Lewis fracture,” 40% of respondents remained neutral.  Yet, 60% of physicians and all organizations agreed that this fracture is not a primary indication for exploration.  Overall, 65% of respondents agreed with initial exploration for secondary palsies, but the percentage was much higher for ASSH members (70%) than for OTA members (47%) and residents (41%).

Some take home points from this paper are the fact that there is a trend towards plate fixation over intramedullary nails for neurovascularly intact midshaft humerus fractures.  Secondarily, open fractures with radial nerve palsy should be explored.  The real question relates with what to do with secondary palsies?  Unfortunately, this paper does not give us a concrete answer.  One benefit is that t either form of intervention (i.e. exploration or observation) is acceptable.  Thus, the ambiguity persists leading us to the need for further studies.