International Orthopaedics (SICOT) DOI 10.1007/s00264-015-2745-3
ORIGINAL PAPER
Plate osteosynthesis of humeral diaphyseal fractures associated with radial palsy: twenty cases Regis Pailhé 1 & Virginie Mesquida 1,2 & Brice Rubens-Duval 1 & Dominique Saragaglia 1
Received: 7 December 2014 / Accepted: 7 March 2015 # SICOT aisbl 2015
Abstract Background Surgical management of humeral fractures associated with radial nerve palsy remains controversial. Some advocate surgical treatment in emergency while others recommend nonoperative treatment. Purpose The aim of the study was to assess nerve recovery in a series of patients treated with open reduction and internal fixation (ORIF) with plate for humeral fracture associated with radial nerve palsy. We hypothesised that surgical treatment with ORIF in emergency allows good nerve recovery. Methods We conducted a retrospective study on 20 patients out of 225 humeral shaft fractures operated between 1995 and 2012. There were 11 women and nine men, with a mean age of 51 ± 22 years (23–93). The fractures were located in mid third of the shaft in15 cases (75 %), distal third in four (20 %) and superior third in one (5 %). Mean delay for surgical treatment was three days (zero to 15). The plate was positioned at the medial face in 16 cases (80 %) and posterior face in four (20 %). In six cases, the radial nerve was not seen (30 %). In the 14 cases where it was seen (70 %), it was continuous. Neurolysis was performed in seven cases (35 %). * Regis Pailhé [email protected] Virginie Mesquida [email protected] Brice Rubens-Duval [email protected] Dominique Saragaglia [email protected] 1
Department of Orthopaedic Surgery and Sport Traumatology, Grenoble South Teaching Hospital, Avenue de Kimberley, 38130 Échirolles, France
2
Hand and plastic Unit, Grenoble North Teaching Hospital, 38700 La Tronche, France
Results Fifteen patients (75 %) had a good nerve palsy recovery, with a mean delay of ten months (six to 12). Statistically significant correlation was observed between delay of surgical treatment and delay of radial recovery (p=0.0166; Rho=− 0.53). Early osteosynthesis was correlated with better nerve recovery. One patient required complementary nerve surgery and another tendon transfer. Bone healing was obtained in all cases. Concerning functional outcomes, mean QuickDASH, a shortened version of the Disabilities of the Arm, Shoulder and Hand (DASH) score, was 9 ± 17 (0–59), and 85 % of patients were able to recover their previous physical activities. Conclusion ORIF by plate of humeral shaft fracture with radial nerve palsy in emergency allows good palsy recovery (75 %) with a short delay (about three days). Level of evidence Level IV, retrospective study.
Keywords Humerus . Fracture . Palsy . Radial nerve . Osteosynthesis . Plate
Introduction Radial nerve palsy is the most common nerve complication after humeral shaft fracture [1, 2]. Its incidence is estimated to be around 2–17 % [1, 3, 4]. In most cases, the radial nerve is intact, and a prognosis of complete recovery is high [4–8]. Management of humeral fracture associated with radial nerve palsy remains controversial: some authors advocate surgical treatment in emergency; others recommend nonoperative treatment [2, 7, 9, 10]. However, in 6–20 % of cases, lack of recovery is explained by nerve entrapment in the fracture site [1]. Osteosynthesis (ORIF) by plate enables control of radial nerve entrapment and humeral anatomy restoration, and thus a decrease in potential stress on the nerve [11]. The aim of the study was to
International Orthopaedics (SICOT)
assess nerve recovery in a series of patients treated with open reduction and internal fixation (ORIF) with plate for humeral fracture associated with radial nerve palsy. We hypothesised that surgical treatment with ORIF in emergency allows good nerve recovery.
Materials and methods Population We conducted a retrospective study of patients treated by ORIF with plate for closed humeral shaft fracture following a delay of 15 days. We collected from our database 225 fractures operated between 1995 to 2012. Among them, 20 patients (8.9 %) presented preoperative radial nerve palsy; 11 women and nine men. Mean age was 51 ± 22 years (23–93); 17 were right handed and three left handed. In eight cases, fracture concerned the right side and in 12 the left, being on the dominant side in ten. In 14 cases (70 %), the fracture happened during a high-energy trauma: four road traffic accidents, seven skiing accidents, two deltaplane accidents and one horse-riding accident. Fractures involved the mid third of the shaft in 15 cases (75 %), distal third in four (20 %) and proximal third in one (5 %). Fractures were transverse in eight cases (40 %), spiroid in seven (35 %) and comminuted with a third fragment in five (25 %). Mean delay of surgical treatment was three days (zero to 15). In three cases, surgical treatment was secondary to a previous treatment: nonoperative in two cases (one haematoma under anticoagulant therapy, and one secondary displacement) and after a failed centromedullary nail effort at a tertiary hospital. Surgical technique An anterolateral approach was used in midshaft fractures (75 %), posterior approach in distal-third fractures (20 %) and extended deltopectoral approach in one case of proximal shaft fracture (5 %). The radial nerve was not systematically explored unless a posterior approach was used. Nonetheless, with other approaches, the surgeon always checked that the radial nerve was not entrapped in the fracture site. Thus, in six cases, the radial nerve was not seen (30 %). In the 14 cases where it was seen, it was continuous. It was contused in five cases (25 %) and entrapped in six (30 %). Neurolysis was performed in seven cases (35 %), four of which corresponded to a posterior approach. The plate was positioned on the medial face of the humeral shaft in 16 cases (80 %) and the posterior face in four (20 %) (Fig. 1). In eight cases, fracture was fixed using a small number of screws in order to maintain reduction before placing the
Fig. 1 a Distal third humeral shaft fracture with associated radial nerve palsy. b. Osteosynthesis with three screws and Lambda® plate. Note the posterior position of the plate. The radial nerve shows neurolysis and crosses the plate above the proximal-third screw
neutralisation plate. In ten cases (50 %), a narrow unlocking locking compression plate (LCP), Arbeitsgemeinschaft für Osteosynthesefragen (AO), was used; in three cases (15 %), a dynamic compression plate (DCP), AO, in two (10 %), a Lambda® plate [12] and in one (5 %), an acetabular reconstruction plate (⦸ 4.5 mm).
Outcome measures Medical files of all patients were reviewed, and all patients were seen in clinics by an independent observer for the last follow-up assessment. Two patients were dead at the last follow-up; cause of death was unrelated to the fracture. Parameters assessed were bone healing and delay, nerve palsy recovery and delay and second surgery for neurolysis or tendon transfer. Nerve recovery was clinically assessed by strength testing of muscles innervated by the radial nerve. Rating was determined according to the recommendations of the Medical Research Council [13]. Recovery was assessed according to the Alnot Classification [4], which established a score according to muscular response. Functional recovery was assessed by range of mobility measurement of elbow and shoulder. Objective functional evaluation was obtained using the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score of 100 point. Return to normal and professional activities was systematically recorded.
International Orthopaedics (SICOT)
Statistical analysis All statistical analysis was carried out by an independent statistician using EXCEL® (Microsoft Inc, Redmond, WA, USA) and SPSS software® (SPSS Inc, Chicago, IL, USA). Descriptive data analysis was performed using Student’st test. Comparative analysis used the Fisher–Student tests for parametric data and Mann–Whitney Wilcoxon test and correlation with Spearman test. Significance was determined to be p
ORIGINAL PAPER
Plate osteosynthesis of humeral diaphyseal fractures associated with radial palsy: twenty cases Regis Pailhé 1 & Virginie Mesquida 1,2 & Brice Rubens-Duval 1 & Dominique Saragaglia 1
Received: 7 December 2014 / Accepted: 7 March 2015 # SICOT aisbl 2015
Abstract Background Surgical management of humeral fractures associated with radial nerve palsy remains controversial. Some advocate surgical treatment in emergency while others recommend nonoperative treatment. Purpose The aim of the study was to assess nerve recovery in a series of patients treated with open reduction and internal fixation (ORIF) with plate for humeral fracture associated with radial nerve palsy. We hypothesised that surgical treatment with ORIF in emergency allows good nerve recovery. Methods We conducted a retrospective study on 20 patients out of 225 humeral shaft fractures operated between 1995 and 2012. There were 11 women and nine men, with a mean age of 51 ± 22 years (23–93). The fractures were located in mid third of the shaft in15 cases (75 %), distal third in four (20 %) and superior third in one (5 %). Mean delay for surgical treatment was three days (zero to 15). The plate was positioned at the medial face in 16 cases (80 %) and posterior face in four (20 %). In six cases, the radial nerve was not seen (30 %). In the 14 cases where it was seen (70 %), it was continuous. Neurolysis was performed in seven cases (35 %). * Regis Pailhé [email protected] Virginie Mesquida [email protected] Brice Rubens-Duval [email protected] Dominique Saragaglia [email protected] 1
Department of Orthopaedic Surgery and Sport Traumatology, Grenoble South Teaching Hospital, Avenue de Kimberley, 38130 Échirolles, France
2
Hand and plastic Unit, Grenoble North Teaching Hospital, 38700 La Tronche, France
Results Fifteen patients (75 %) had a good nerve palsy recovery, with a mean delay of ten months (six to 12). Statistically significant correlation was observed between delay of surgical treatment and delay of radial recovery (p=0.0166; Rho=− 0.53). Early osteosynthesis was correlated with better nerve recovery. One patient required complementary nerve surgery and another tendon transfer. Bone healing was obtained in all cases. Concerning functional outcomes, mean QuickDASH, a shortened version of the Disabilities of the Arm, Shoulder and Hand (DASH) score, was 9 ± 17 (0–59), and 85 % of patients were able to recover their previous physical activities. Conclusion ORIF by plate of humeral shaft fracture with radial nerve palsy in emergency allows good palsy recovery (75 %) with a short delay (about three days). Level of evidence Level IV, retrospective study.
Keywords Humerus . Fracture . Palsy . Radial nerve . Osteosynthesis . Plate
Introduction Radial nerve palsy is the most common nerve complication after humeral shaft fracture [1, 2]. Its incidence is estimated to be around 2–17 % [1, 3, 4]. In most cases, the radial nerve is intact, and a prognosis of complete recovery is high [4–8]. Management of humeral fracture associated with radial nerve palsy remains controversial: some authors advocate surgical treatment in emergency; others recommend nonoperative treatment [2, 7, 9, 10]. However, in 6–20 % of cases, lack of recovery is explained by nerve entrapment in the fracture site [1]. Osteosynthesis (ORIF) by plate enables control of radial nerve entrapment and humeral anatomy restoration, and thus a decrease in potential stress on the nerve [11]. The aim of the study was to
International Orthopaedics (SICOT)
assess nerve recovery in a series of patients treated with open reduction and internal fixation (ORIF) with plate for humeral fracture associated with radial nerve palsy. We hypothesised that surgical treatment with ORIF in emergency allows good nerve recovery.
Materials and methods Population We conducted a retrospective study of patients treated by ORIF with plate for closed humeral shaft fracture following a delay of 15 days. We collected from our database 225 fractures operated between 1995 to 2012. Among them, 20 patients (8.9 %) presented preoperative radial nerve palsy; 11 women and nine men. Mean age was 51 ± 22 years (23–93); 17 were right handed and three left handed. In eight cases, fracture concerned the right side and in 12 the left, being on the dominant side in ten. In 14 cases (70 %), the fracture happened during a high-energy trauma: four road traffic accidents, seven skiing accidents, two deltaplane accidents and one horse-riding accident. Fractures involved the mid third of the shaft in 15 cases (75 %), distal third in four (20 %) and proximal third in one (5 %). Fractures were transverse in eight cases (40 %), spiroid in seven (35 %) and comminuted with a third fragment in five (25 %). Mean delay of surgical treatment was three days (zero to 15). In three cases, surgical treatment was secondary to a previous treatment: nonoperative in two cases (one haematoma under anticoagulant therapy, and one secondary displacement) and after a failed centromedullary nail effort at a tertiary hospital. Surgical technique An anterolateral approach was used in midshaft fractures (75 %), posterior approach in distal-third fractures (20 %) and extended deltopectoral approach in one case of proximal shaft fracture (5 %). The radial nerve was not systematically explored unless a posterior approach was used. Nonetheless, with other approaches, the surgeon always checked that the radial nerve was not entrapped in the fracture site. Thus, in six cases, the radial nerve was not seen (30 %). In the 14 cases where it was seen, it was continuous. It was contused in five cases (25 %) and entrapped in six (30 %). Neurolysis was performed in seven cases (35 %), four of which corresponded to a posterior approach. The plate was positioned on the medial face of the humeral shaft in 16 cases (80 %) and the posterior face in four (20 %) (Fig. 1). In eight cases, fracture was fixed using a small number of screws in order to maintain reduction before placing the
Fig. 1 a Distal third humeral shaft fracture with associated radial nerve palsy. b. Osteosynthesis with three screws and Lambda® plate. Note the posterior position of the plate. The radial nerve shows neurolysis and crosses the plate above the proximal-third screw
neutralisation plate. In ten cases (50 %), a narrow unlocking locking compression plate (LCP), Arbeitsgemeinschaft für Osteosynthesefragen (AO), was used; in three cases (15 %), a dynamic compression plate (DCP), AO, in two (10 %), a Lambda® plate [12] and in one (5 %), an acetabular reconstruction plate (⦸ 4.5 mm).
Outcome measures Medical files of all patients were reviewed, and all patients were seen in clinics by an independent observer for the last follow-up assessment. Two patients were dead at the last follow-up; cause of death was unrelated to the fracture. Parameters assessed were bone healing and delay, nerve palsy recovery and delay and second surgery for neurolysis or tendon transfer. Nerve recovery was clinically assessed by strength testing of muscles innervated by the radial nerve. Rating was determined according to the recommendations of the Medical Research Council [13]. Recovery was assessed according to the Alnot Classification [4], which established a score according to muscular response. Functional recovery was assessed by range of mobility measurement of elbow and shoulder. Objective functional evaluation was obtained using the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score of 100 point. Return to normal and professional activities was systematically recorded.
International Orthopaedics (SICOT)
Statistical analysis All statistical analysis was carried out by an independent statistician using EXCEL® (Microsoft Inc, Redmond, WA, USA) and SPSS software® (SPSS Inc, Chicago, IL, USA). Descriptive data analysis was performed using Student’st test. Comparative analysis used the Fisher–Student tests for parametric data and Mann–Whitney Wilcoxon test and correlation with Spearman test. Significance was determined to be p
