Radial Nerve Palsy in Fracture Shaft of Humerus

A radial nerve injury associated with a humeral shaft fracture is an important injury pattern among trauma patients.This study is to find out the incidence of radial nerve palsy and to analyze results of treatment of fracture shaft of Humerus associated with radial nerve injury to improve outcome and avoid long-term morbidity.A total of eighty patients of fractures were analyzed with twenty immediate and five with secondary radial nerve palsy. Out of 25 patients, 20 presented with primary radial nerve palsy. 18 patients recovered completely.The outcome of radial nerve palsy was not found to be related to age group, sex, side, mechanism of injury, geometry of fracture, intraoperative condition of nerve, method of treatment of fracture and time of exploration of radial nerve.Our study recommends a conservative management and a complete recovery of the nerve can be quite delayed, patience is merited before considering tendon transfers. Introduction: A radial nerve injury associated with a humeral shaft fracture is an important injury pattern among trauma patients. It is the most common peripheral nerve injury associated with this fracture. Injuries to the radial nerve can result in significant motor impairment of the arm and the wrist with the loss of wrist extension, the ability to grasp is significantly reduced leading to a serious handicap. The radial nerve may be injured by the force that fractures the humeral shaft directly with contusion or laceration by a spur or by traction when the bone ends are forcibly separated during closed reduction. The risk results from the anatomic position of the radial nerve which turns around the distal portion of the humeral shaft and separated from it by a layer of triceps fibres. When the radial nerve pierces the lateral intermuscular septum to enter the anterior compartment of the arm, it is relatively more fixed and susceptible to injury. As a rule, radial palsy regresses spontaneously, but in a few cases surgery may be required to achieve neurological recovery. Strong convictions for and against either line of treatment conservative or operative can be drawn from the literature. Opinion also differs regarding the time of operative intervention whether to go for early or delayed repair. The newer imaging modalitiesultrasound and MRI have added a new dimension to the study of this problem. The management of radial nerve palsy associated with fractures of the shaft of the Humerus is a controversial subject among upper-extremity surgeons and poses a challenge to treating surgeon. This study is attempted to find out the incidence of radial nerve palsy and to analyze results of various modalities of treatment of fracture shaft of Humerus associated with radial nerve injury to improve outcome and avoid longterm morbidity. Materials and methods: This is a prospective study of eighty patients with closed and open diaphyseal fracture of Humerus twenty with complete primary radial nerve palsy and five with secondary nerve palsy treated at teaching hospitals, during the period from January 2004 to September 2006.The inclusion criteria in this prospective study were diaphyseal fracture of the Humerus with radial nerve palsy developing before and after the treatment. Exclusion criteria included fractures in children, fractures of either ends of Humerus and pathological fractures. All patients with radial nerve palsy with fracture of the humerus were evaluated for various parameters mode of injury, time since injury, primary or secondary, details of any treatment received and history of any increase in the symptoms or recovery of the palsy. Local examination of the arm and fractured area to rule out any compounding and treat associated bruises and soft tissue injuries. Detailed neurological examination was performed. Antero-posterior and lateral view X-rays done in order to document level and type of fracture. The fracture was managed initially by a U slab under sedation. Antero-posterior view and lateral views were taken to check the reduction. All the patients associated with radial nerve palsy underwent open reduction and internal fixation with exploration of radial nerve.The associated wrist drop was managed by a static cock-up splint and regular physiotherapy. A wrist dorsiflexion splint dramatically improves grip strength and function. All the patients were advice passive range of motion exercise and monitored for developing contraction. The patients were followed up at 1, 3, 6 and 12 months. At each follow up clinical sign of nerve recovery were assessed. Results: A total of eighty patients of fracture shaft of humerus were analyzed in this study with twenty immediate and five with secondary radial nerve palsy. The youngest patient was 20 years and the oldest was 70 years old. Majority of the patient were in 21 to 40 years of age.Out of 25 patients with radial nerve palsy 16 were males and 9 were females.The most common mode of injury was fall followed by road traffic accident.Primary nerve palsy was found to be more common in our series. Out of 25 patients, 20 presented with primary radial nerve palsy.The middle third and distal third region of Humerus shaft was involved in 96 % of patients.Oblique fracture of the humerus was found to be more commonly associated with radial nerve palsy in our series.All the cases showed the nerve to be in anatomical continuity. We studied the relationship between recovery and age group, sex, side, mechanism of injury, geometry of fracture, intraoperative condition of nerve, method of treatment of fracture and time of exploration of radial nerve and found it to be statistically insignificant. Only one patient recovered within 6 weeks and he belongs to the 30 to 50 age group.We found that majority of the patients in either sex took more than 18 weeks for recovery.We studied the relationship between recovery vs level of fracture and found it to be statistically significant suggesting that upper third fracture with radial nerve palsy recover faster. One patient who sustained upper third fracture showed complete recovery in 6 weeks.In our series, 18 patients recovered completely.