|Year : 2017 | Volume
| Issue : 1 | Page : 1-9
Prognostic factors for radial nerve palsy associated with humeral shaft fracture
Yen-Yi Hoa, Lee-Wei Chen, Kao-Chang Yang, Kuei Chang Hsu, Wen-Chung Liu, Cheng-Ta Lin
Department of Surgery, Division of Plastic Surgery, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
|Date of Web Publication||28-Feb-2017|
Department of Surgery, Kaohsiung Veterans General Hospital, 386, Ta-Chung 1st Road, Kaohsiung 81362
Source of Support: None, Conflict of Interest: None
Background: Radial nerve palsy (RNP) associated with humeral shaft fracture is a common injury pattern in trauma patients. The management of RNP associated with humeral fractures in high-energy trauma is controversial and poses a challenge to surgeons treating it.
Purpose: Based on a review of our experience over the past 15 years, we determined the prognostic factors of radial nerve recovery after humeral fractures, evaluated the diagnostic role of nerve conduction studies and electromyography (EMG), and compared the outcomes of different treatment strategies.
Materials and Methods: The data of 26 patients having RNP associated with humeral shaft fractures over a 15-year period were collected for a retrospective review. For statistical analysis, the patients were divided into groups on the basis of their recovery from RNP and the treatment strategies used.
Results: The incidence of RNP associated with humeral fractures was 2.05%. In total, 91.3% of patients with primary RNP in this series experienced high-energy trauma. Spontaneous recovery was observed in 9 of 26 patients (34.6%). Radial nerve lesions were found in 7 of 8 patients with high-energy trauma. The severity of humeral shaft fractures was found to be a significant prognostic factor for spontaneous recovery from RNP. The rate of spontaneous recovery was significantly higher in the AO Foundation and Orthopaedic Trauma Association Type A humeral shaft fractures (P = 0.028) and lower in Type C fractures (P = 0.055). The median time to detect initial radial nerve recovery using EMG was 34 and 75 days after injury (P = 0.033). In high-energy trauma, tendon transfers were associated with more predictable outcomes than nerve reconstruction (favorable functional recovery: 100% for tendon transfers vs. 25% for nerve reconstruction, P = 0.007). Moreover, tendon transfers were associated with a shorter overall treatment duration (median treatment duration: 190 days for tendon transfers vs. 422 days for nerve reconstruction, P = 0.007).
Conclusion: The prognosis of RNP associated with humeral shaft fractures in high-energy trauma is less favorable, with a low rate of spontaneous recovery. EMG is helpful for the early detection of initial nerve recovery. The outcomes of tendon transfers in high-energy trauma are predictable and the treatment duration is shorter. First-intention tendon transfer is a reasonable treatment strategy in patients with difficult nerve exploration, lower requirement for functional recovery, and lower compliance with treatment.
Keywords: Electromyography, nerve conduction studies, nerve reconstruction, nerve recovery, tendon transfer
|How to cite this article:|
Hoa YY, Chen LW, Yang KC, Hsu KC, Liu WC, Lin CT. Prognostic factors for radial nerve palsy associated with humeral shaft fracture. Formos J Surg 2017;50:1-9
|How to cite this URL:|
Hoa YY, Chen LW, Yang KC, Hsu KC, Liu WC, Lin CT. Prognostic factors for radial nerve palsy associated with humeral shaft fracture. Formos J Surg [serial online] 2017 [cited 2020 Sep 24];50:1-9. Available from: http://www.e-fjs.org/text.asp?2017/50/1/1/201182
| Introduction|| |
Radial nerve palsy (RNP) associated with humeral shaft fractures is a common injury pattern in trauma patients. The reported incidence of RNP ranges from 1.8% to 22% in all humeral shaft fracture cases., RNP may occur in open or closed humeral shaft fracture cases, with diversity in the mechanisms and severity of nerve injuries. The prognosis of RNP is favorable in most closed fracture cases with presumed intact nerves., Initial signs of spontaneous nerve recovery usually appear within 3 months. Iatrogenic RNP following fracture reduction surgeries has also been reported in the literature and results from operative interventions in 4.2% to 20% for RNP in humeral shaft fracture cases.,
Less favorable prognosis has been reported for RNP in humeral shaft fracture cases resulting from high-energy injuries, with a high rate of nerve transection and a high failure rate of nerve repair., Falls from a standing position are defined as low-energy trauma, whereas motor vehicle accidents, falls from a height, and crushing injuries are defined as high-energy trauma. Open humeral shaft fractures are associated with a low rate of spontaneous recovery in the literature. Early exploration of the radial nerve has been recommended for open humeral fractures and high-energy trauma with associated soft-tissue damage. In closed humeral shaft fractures, the necessity and timing of initial nerve exploration and the subsequent treatment options for delayed nerve recovery remain undetermined.,,
Despite their usefulness in the evaluation of peripheral nerve injuries, nerve conduction studies and electromyography (EMG) have not yet been used routinely in patients having RNP associated with humeral shaft fractures. EMG can aid in localizing the level of nerve injury and differentiating between conduction block (neuropraxia) and axonal degeneration, and EMG may predict the prognosis of injury for guiding patient's management., The diagnostic role of EMG in RNP associated with humeral shaft fractures remains poorly defined.
The purposes of this study are to evaluate the prognostic factors of persistent RNP after humeral fractures, to determine the diagnostic role of EMG, and to evaluate the outcomes of treatment strategies for patients with persistent RNP after high-energy humeral fractures.
| Materials And Methods|| |
The data of patients having RNP associated with humeral shaft fractures over the period from January 1995 to December 2009 were retrieved from our medical records by searching for the registered International Classification of Diseases-9 codes for humeral shaft fractures and radial nerve palsies (812 and 955.3, respectively). Patient's demographics including age (at the time of injury), sex, mechanism of injury, other associated upper extremity injuries, type of fractures, date and number of operative procedures associated with humeral fractures and RNP (i.e., fracture reduction surgeries, nerve explorations, nerve reconstructions, and tendon transfers), and complications other than iatrogenic RNP following fracture reduction surgeries were collected. Patients were excluded if the injury level or mechanisms of radial nerve injuries were not compatible with the injury level of humeral fractures. Patients were also excluded if they had concomitant injuries in the spinal cord and ulnar or median nerves or if they were lost to follow-up after fracture-reduction surgeries.
The radiographic images of the humerus (standard anteroposterior and lateral views) at the time of injury were reviewed by radiologists. According to the AO Foundation and Orthopaedic Trauma Association (AO/OTA) Classification, the humeral shaft fractures were classified into Type A (simple fractures with 2 bony segments), B (wedge fractures), and C (complex or comminuted fractures) with increasing severity.
The outcomes of functional recovery from RNP after nerve or tendon reconstruction mainly focused on motor recovery according to the Medical Research Council (MRC) neurological scales from Grade 0 (complete paralysis) to 5 (normal power). In this study, the recovery of motor function was rated as “favorable recovery,” “partial recovery,” “poor recovery,” and “no recovery” according to different MRC grades for wrist and finger/thumb extensions [Table 1].
|Table 1: Motor recovery rated according to Medical Research Council scale|
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When MRC scale evaluations were unavailable from chart records (for some patients who did not receive nerve or tendon reconstructions), the signs of nerve recovery were judged based on subjective descriptions (for example, “favorable recovery,” “improved motor function,” “weakness on the wrist extensors,” and “no improvement”). EMG data, imaging studies, and photographic and video records were collected as adjuncts to outcome evaluations, if available.
The patients were divided into two groups on the basis of their recovery from RNP. The spontaneous recovery group comprised patients who recovered from RNP without any interventions for the radial nerve. The persistent RNP group comprised patients without EMG data and clinical signs of improved radial nerve function within 3 months and those with disrupted radial nerves noted during nerve exploration. Demographic data, location, severity, types of fractures, and complications of fracture-reduction surgery were compared between the two groups to determine the prognostic factors of persistent RNP after humeral fractures.
In the spontaneous recovery group, the diagnostic value of EMG for the early detection of nerve recovery was evaluated. In the persistent RNP group, the outcomes (functional recovery) of different treatment strategies were evaluated. In patients exhibiting favorable recovery after nerve or tendon reconstruction, the recovery time (from first surgical intervention to recovery) and the overall treatment duration (from injury to recovery) were recorded and compared to evaluate the efficacy of treatment strategies. For calculating the recovery time and overall treatment duration, the date of recovery was defined as the date on which functional recovery was favorable (MRC ≥3 for both wrist and finger/thumb extensions) on chart records, and no additional nerve or tendon interventions were required.
Statistical analyses were conducted using SPSS version 16 (SPSS, Chicago, IL, USA). The Mann–Whitney U-test was used to analyze continuous variables between different two groups. Fisher's exact test on a 2 × 2 contingency table was used to compare categorical data in a small sample size. A P < 0.05 was considered statistically significant.
| Results|| |
In total, 1646 patients who had received humeral fracture reduction surgeries were registered in our database from January 1995 to December 2009. Thirty patients developed RNP associated with humeral shaft fractures. The incidence of RNP associated with humeral shaft fractures was 2.05%. This study excluded four patients who were lost to follow-up after fracture reduction surgeries. [Table 2] summarizes the mechanisms of injury in 26 patients. The most common cause of RNP associated with humeral shaft fractures was traffic accidents in 18 patients (69.2%). Three patients developed iatrogenic RNP following fracture reduction surgeries [Figure 1]. The incidence of iatrogenic RNP was 3.8% in all RNP cases and 0.2% in all fracture reduction surgery cases.
|Table 2: Mechanisms of radial nerve injury associated with humeral fracture|
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Among patients with primary RNP, 21 of 23 patients (91.3%) experienced high-energy trauma (comprising 18 with traffic accidents, 2 who fell from a height of >2 m, and 1 with crushing injury). [Table 3] lists the location and severity of humeral shaft fractures and the type of injuries in 26 patients. The median age of 26 patients was 36 years (range, 7–83 years), with a male predominance (male: female ratio, 6.67:1). The median follow-up period was 75 days (range, 44–114 days) for the spontaneous recovery group and 340 days (range, 113–2485 days) for the persistent RNP group.
|Table 3: Demographic data of patients with or without spontaneous recovery|
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Spontaneous recovery from RNP occurred in 9 of 26 patients (34.6%). The median duration from injury to signs of physically detectable spontaneous recovery (according to chart records) was 75 days (range, 44–114 days). Two of nine patients exhibiting spontaneous recovery from RNP showed signs of nerve reinnervation on EMG 34 days after injury. Compared with physical examination, EMG tests enabled earlier detection of radial nerve reinnervation (median, 34 days with EMG tests vs. 75 days with physical examination, P = 0.03). These same two patients demonstrated reinnervation of the radial nerve on the wrist, thumb, and finger extensors on EMG studies without voluntary movement of these muscles on physical examination. Patients with no clinical signs of nerve recovery at the end of follow-up exhibited no EMG evidence of nerve recovery.
Comparison between patients with and without spontaneous recovery from RNP revealed no statistical difference in age, gender distribution, or location of the injury. The severity of humeral shaft fractures according to AO/OTA classification was related to the prognosis of RNP. The rate of spontaneous recovery was significantly higher (P = 0.028) in AO/OTA Type A (simple) humeral shaft fractures. Although not statistically significant (P = 0.055), AO/OTA Type C (complex or comminuted) humeral shaft fractures showed a trend toward the development of persistent RNP, and all five patients with AO/OTA Type C fractures had persistent RNP in this study.
The type of injury did not significantly influence the occurrence of spontaneous recovery. However, all three patients with iatrogenic RNP and all four patients with complicated fracture reduction surgeries exhibited no signs of spontaneous recovery from RNP at the end of follow-up.
Early (i.e., along with open reduction of humeral fracture) or delayed nerve exploration was conducted in nine patients, comprising 8 with high- and 1 with low-energy injuries. [Table 4] summarizes the timing of nerve exploration, interventions, and outcomes. Radial nerve avulsion was noted in the patient with low-energy trauma; favorable functional recovery was achieved after nerve graft repair. Nerve exploration in 7 of the 8 patients with high-energy injuries revealed nerve lesions, including transection, avulsion, nerve defects, nerve entrapment with perineural fibrosis, and neuroma. Only 2 of the 7 patients exhibited favorable recovery after nerve interventions. Patients with direct nerve repair and neurolysis for perineural fibrosis failed to recover from RNP. Nerve grafts were required for repair in 5 patients; nerve recovery was favorable in 1 patient (neuroma), partial in 2 patients, and poor in 2 remaining patients. Three patients received additional tendon transfers. One of these three patients exhibited a limited range of motion due to adhesion after tendon transfers and received another surgery for tenolysis. Eventually, all three patients with tendon transfers exhibited favorable functional recovery.
For treatment of persistent RNP, five patients received first-intention tendon transfers without nerve explorations. All five patients exhibited favorable functional recovery and efficiently adapted to their daily activities [Table 5]. Difficulties of nerve exploration and patient preference were the main reasons for not performing radial nerve exploration. In Case 1, the patient had old distal humeral shaft fractures complicated with osteomyelitis, followed by five surgeries on the right upper arm. Peri-implant fractures occurred after an accidental fall, and iatrogenic RNP developed after the last fracture reduction surgery. In Case 2, the patient had multileveled comminuted fractures at the right middle humeral shaft and humeral head. Performing nerve exploration would be difficult for the aforementioned two patients because of repeated trauma around the fracture site and long trauma zone. Cases 3–5 involved elderly patients (<65 years) who required useful but not delicate functional recovery from RNP, and these patients preferred a shorter treatment duration for RNP.
Tendon transfers were associated with a more predictable functional recovery than nerve reconstruction (favorable recovery in all 8 patients after tendon transfers vs. 2 of 8 patients after nerve reconstruction, P = 0.007). For the restoration of useful functional recovery (MRC ≥3 for wrist, finger, and thumb extensions), first-intention tendon transfers reduced the overall treatment duration, following RNP associated with humeral shaft fractures (median treatment duration: 190 days for tendon transfers vs. 422 days for nerve reconstructions, P = 0.009).
A 27-year-old man with depression fell from the fifth floor and suffered multiple fractures. He received surgery with open reduction, internal fixation, and bone graft for a left humeral shaft fracture [Figure 2]a. However, left RNP with drop wrist was noted postoperatively [Figure 2]b. Nerve conduction velocity and EMG showed left RNP with no recovery. Therefore, the patient received surgery with tendon transfer over the left forearm 4 months after the trauma [Figure 2]c. Recovery of useful function of extension of the left wrist and fingers was noted after follow-up [Figure 2]d.
|Figure 2: (a) A 27-year-old man with depression fell from the fifth floor and suffered multiple fractures. He received surgery with open reduction, internal fixation, and bone graft for left humeral shaft fracture, (b) left radial nerve palsy with drop wrist was noted postoperatively, (c) nerve conduction velocity and electromyography showed left radial nerve palsy with no recovery 4 months after trauma. Therefore, he received surgery with the tendon transfer of pronator teres to extensor carpi radialis brevis and extensor carpi radialis longus, flexor carpi radialis to abductor pollicis longus and extensor pollicis brevis, third flexor digitorum superficialis to extensor digitorum communis, and fourth flexor digitorum superficialis to extensor indicis proprius and extensor pollicis longus tendon, (d) recovery of the useful function of the extension of left wrist and fingers was noted after follow-up. Nerve conduction velocity; electromyography|
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| Discussion|| |
The radial nerve is the most frequently injured major nerve in the upper extremity. The reported incidence of RNP ranges from 1.8% to 22% in all humeral shaft fracture cases,, with an average prevalence of 11.8% according to a meta-analysis of 4517 fractures reported in 21 studies. The incidence of RNP associated with humeral shaft fractures in our series was 2.05%, with only three iatrogenic RNP cases in 1646 fracture reduction surgeries (0.2%), which is lower than the incidence of 4.2%–20% for iatrogenic RNP reported in the literature.,
A favorable prognosis has been described for RNP associated with humeral shaft fractures in the literature, with a spontaneous recovery rate of >70% in closed or open humeral fractures cases., In studies reporting a high spontaneous recovery rate for RNP associated with humeral shaft fractures, the explored radial nerves were slightly injured in most of the cases., The radial nerves were found to be in continuity in 93% of the explored nerves in a study by Sonneveld et al. and 85% by Böstman et al., with an overall spontaneous recovery rate of 78%.
By contrast, the spontaneous recovery rate in our series was relatively low (9 of 26 patients, 34.6%). In our series, 21 of 23 (91.3%) patients with primary RNP experienced from high-energy humeral fractures (comprising 18 with traffic accidents, 2 who fell from a height of >2 m, and 1 with crushing injury). Radial nerve lesions were found in 7 of 8 patients with high-energy injuries, including avulsion, entrapment, and transections with or without nerve defects of radial nerves. High-energy trauma often leads to more severe bone and soft tissue injuries, which may explain the higher rate of nerve lesions and lower rate of spontaneous recovery from RNP in our series. Venouziou et al. reported similar results, in which all patients with low-energy trauma had an intact or entrapped radial nerve and recovered completely, whereas complete nerve recovery was achieved only in 5 of 13 patients with high-energy trauma.
Open humeral fractures are associated with a low rate of spontaneous recovery from RNP as demonstrated in a systemic review by Shao et al. The rate of spontaneous radial nerve recovery between open and closed fractures was not significantly different in our series. However, we found that the severity of humeral shaft fracture according to AO/OTA classification influenced the prognosis of RNP. Type A humeral shaft fractures (simple fractures with two bony segments) were associated with spontaneous recovery from RNP (P = 0.028). By contrast, Type C (complex, comminuted) fractures were associated with the development of persistent RNP (P = 0.055). In general, open and comminuted fractures more often result in the development of severe injuries, which may be related to a higher likelihood for and a higher extent of radial nerve severance in high-energy trauma. Other factors, including age and gender distribution, location of fractures, associated forearm fractures, iatrogenic RNP, and complicated fracture reduction surgeries, exerted no significant effect on the spontaneous recovery from RNP in our series.
Two studies have reported complete functional recovery in all cases of iatrogenic RNP., Shah and Bhatti reported intact nerves in all eight patients with iatrogenic RNP. Most cases of postoperative radial nerve paralysis result from traction during exposure. However, all three patients with iatrogenic RNP in our series failed to recover during a mean follow-up period of 320 (190–486) days. They all exhibited nonunion or loss of reduction of the fracture site that required multiple surgeries for the management of humeral fractures. Nerve exploration was not performed because of scarring and chronic inflammation of the upper arm. However, the complicated clinical courses of these patients implied more severe nerve injuries than merely nerve tractions reported in other studies.
The average duration from injury to signs of physically detectable spontaneous recovery from primary RNP in our series was approximately 10 weeks (74 days; range, 44–114). Shao et al. reported that the mean time to the onset of recovery was 7.3 weeks (2 weeks to 6.6 months), and the mean time to complete recovery was 6.1 months (3.4–12 months). Venouziou et al. noted a significantly prolonged recovery time for RNP in high-energy trauma patients, with 12 (3–23) weeks to initial recovery and 26 (11–35) weeks to complete recovery.
EMG can aid not only in localizing the site of the lesion but also in quantifying the extent of axonal loss and demyelination when distinguishing neuropraxia from more severe axonotmesis or neurotmesis., EMG findings may precede clinical indications of reinnervation by up to 4 weeks., In our series, EMG showed signs of nerve reinnervation before signs of physically detectable recovery from RNP (P = 0.03). EMG showed muscle recovery before muscle contraction could be observed. In this study, the absence of nerve reinnervation on EMG also corresponded to the absence of nerve recovery clinically at the end of follow-up. Similarly, Ring et al. reported that the EMG findings of seven patients corresponded to their clinical findings. Bumbasirevic et al. also reported that six patients failed to recover from RNP; correspondingly, no signs of nerve recovery were detected on EMG at 12 weeks. Bumbasirevic et al. suggested that nerve exploration should be conducted without further delay if no signs of clinical or EMG recovery are detected at 10–12 weeks. Difficulties in performing nerve exploration may occur when the type of the nerve lesion is the mixed type with both conduction block and axonal loss or when severe muscular contusion resembles denervation. Interpretation should therefore always be based on the combined results of electrodiagnostic studies and clinical information.,
Nerve reconstruction for RNP associated with humeral shaft fractures yields favorable results in 70%–90% of the cases., However, the outcomes of 8 nerve reconstructions were poor in our study, with favorable recovery in 2, partial recovery in 2, poor recovery in 2, and no recovery in 2 patients, who underwent primary repair of the transected radial nerve and neurolysis for entrapment and perineural fibrosis. This result is comparable with poorer outcomes of nerve reconstruction in high-energy trauma reported in the literature., Ring et al. reported that 5 of 6 high-energy injury patients with primary repair of radial nerves failed to recover motor function, which is likely because of the extensive zone of injury. Venouziou et al. found no recovery for four microsurgically reconstructed nerves. Another four patients in their series had tendon transfers rather than nerve reconstruction because of severely injured nerves.
Many reports have described the treatment of RNP caused by humeral shaft fracture. To maintain wrist extension at 15°–30°, the dense fibrotic fascia of the pronator teres muscle is transferred to the extensor carpi radialis longus and extensor carpi radialis brevis, which are initially used as an internal splint to preserve partial hand function. This is followed by a waiting period for the spontaneous reinnervation of the radial nerve and recovery of extensor muscle group function after RNP. If the extension function does not return, then extension of the wrist will shorten the flexor tendons of the fingers, making semi-flexion of the fingers associated with normal existing interosseous muscles function the gold standard procedure. Furthermore, arthrodesis for the first metatarsophalangeal joint and interphalangeal joint is useful to preserve thumb abduction. Five of our patients with persistent RNP received first-intention tendon transfers, and three patients received tendon transfers for the salvage of failed nerve recovery after nerve reconstruction. One patient exhibited marked stiffness due to adhesions after tendon transfers, which required another surgery for tenolysis. All patients who received tendon transfers eventually attained useful functional recovery (MRC ≥3 for wrist, finger, and thumb extension).
Difficult nerve exploration was the reason for first-intention tendon transfers in 2 of 5 patients, who had extensive scarring from multiple previous surgeries and long trauma zone in multileveled humeral fractures. Nerve exploration in such situations may result in excessive trauma to the radial nerve, and outcomes of nerve reconstruction are worse in patients with high-energy trauma than in those with low-energy trauma., Patient preference, expectations, and perspectives also influenced the decision of first-intention therapy. The decisions of first-intention tendon transfers in 3 of 5 patients were based on patient preference; 3 elderly patients expected useful but not delicate motor recovery and shorter treatment durations postoperatively. Tendon transfers were associated with more predictable outcomes than nerve reconstruction (favorable recovery in all 8 first-intention or salvage tendon transfers and in 2 of 8 nerve reconstructions, P = 0.007). Moreover, tendon transfers reduced overall treatment duration (median treatment durations: 190 days for tendon transfers vs. 422 days for nerve reconstructions, P = 0.009) in our series. This result is comparable with that of Bevin.
Although adhesion, stiffness, lack of dexterity, radial deviation, and decreased muscle power are common complications and limitations following tendon transfers,, patients still efficiently adapted to daily activities both in our series and in reports from the literature. Kruft et al. reported that 38 of 43 patients ultimately returned to their original jobs after tendon transfers. Skoll et al. reported that almost all patients coped efficiently with daily activities; 13 of 17 previously employed patients and 1 of 7 heavy manual laborers could work after tendon transfers, even in patients with limited rehabilitation. Considering the predictable functional recovery and short recovery time of tendon transfers, first-intention tendon transfers are a reasonable choice in patients with lower requirements for functional recovery or lower compliance with treatment and in those who expect a shorter treatment duration.
| Conclusion|| |
Our study showed that the prognosis of RNP associated with humeral shaft fractures is worse in patients who experienced high-energy trauma, with low rates of spontaneous nerve recovery and successful nerve reconstructions. The severity of humeral fractures according to the AO/OTA classification is a significant prognostic factor for spontaneous recovery from RNP. EMG studies are helpful in the early detection of radial nerve recovery; the findings of EMG are comparable with the findings of subsequent physical examinations. Compared with nerve reconstruction in high-energy injuries, tendon transfers are associated with more predictable outcomes and shorter treatment duration. Because of lower requirements for functional recovery, lower compliance with treatment, and shorter desired treatment duration, first-intention tendon transfers are a reasonable choice of treatment for persistent RNP, following humeral shaft fractures in patients with difficult nerve exploration.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]