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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 52  |  Issue : 4  |  Page : 139-142

Late-onset radial nerve palsy associated with conservatively managed humeral shaft fracture


Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Date of Submission04-Dec-2018
Date of Decision14-Feb-2019
Date of Acceptance26-Mar-2019
Date of Web Publication27-Aug-2019

Correspondence Address:
Wahyu Widodo
MD, No. 71, Salemba, Jalan Pangeran Diponegoro, Kenari, RW.5, Kenari, Senen, Kota Jakarta Pusat, Daerah Khusus Ibukota Jakarta 10430
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_129_18

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  Abstract 


Radial nerve palsy commonly associated with humeral shaft fracture, at the time of injury (primary), after manipulation (secondary), or late onset (not related to injury or manipulation). For the latter, there are still few documented cases regarding late-onset radial nerve palsy. In this case report, we present a case of late-onset radial nerve palsy associated with humeral shaft fracture treated with coaptation splint, which became evident 5 weeks after treatment. Surgical exploration revealed that the radial nerve had become stretched and encapsulated in callus and fibrous tissue. Neurolysis was performed with subsequent recovery of the radial nerve 12 weeks after the surgery.

Keywords: Delayed, humeral shaft fracture, late-onset, neurolysis, radial nerve palsy


How to cite this article:
Widodo W, Asril E, Wisnubaroto R. Late-onset radial nerve palsy associated with conservatively managed humeral shaft fracture. Formos J Surg 2019;52:139-42

How to cite this URL:
Widodo W, Asril E, Wisnubaroto R. Late-onset radial nerve palsy associated with conservatively managed humeral shaft fracture. Formos J Surg [serial online] 2019 [cited 2019 Nov 19];52:139-42. Available from: http://www.e-fjs.org/text.asp?2019/52/4/139/265488




  Introduction Top


Radial nerve palsy is a loss of radial nerve function due to injury. It creates significant disability due to loss of active wrist extension that provides grasp and grip strength.[1] This injury is commonly associated with humeral shaft fracture, in which the documented incident is 2%–17%.[2] In the United States, more than 237,000 cases of humeral shaft fracture have been documented each year, which have bimodal distribution in the incidence: the first peak consists of young adults and the second peak consists of older women.[3]

The radial nerve itself is the largest nerve in the upper limb, which is a branch of the brachial plexus arising from the posterior cord, originating from C5 through T1 roots. This nerve courses on the posterior wall of the axilla and then gives three branches: posterior cutaneous nerve of the arm, branch to the long head of the triceps, and branch to the medial head of the triceps. At the level of radiohumeral joint, it divides to form two terminal branches: superficial sensory branch and posterior interosseous nerve.[4]

Nerve injury can cause the form of neuropraxia which can appear as a minor contusion, axonotmesis – where the damage extends to the axons and accompany distal  Wallerian degeneration More Details, or neurotmesis – a complete anatomical discontinuation of the nerve.[5] Based on the anatomical location, radial injury can be classified into high (complete radial nerve injuries) and low (posterior interosseous radial nerve injuries). Functional deficits associated with high radial nerve palsy include a loss of wrist extension, digital extension, and thumb extension/abduction, whereas, in low radial nerve palsy, wrist extension is spared. The diagnostic of radial nerve injury is mainly based on the clinical examination, nevertheless electrodiagnostic and radiological studies can help identify the exact location of the injury and the degree of damage.[4]

The radial nerve palsy can also be classified into three categories based on the time of the injury: primary (at the time of injury), secondary (at the time of reduction), and late onset/delayed (related to neither injury nor reduction).[6] Although this classification is not used widely so far, it helps record this injury in order. Moreover, there are still very few documentations about late-onset or delayed radial nerve palsy, so it is important to report this type of injury, especially in English literature. We present a case of delayed radial nerve palsy occurring 5 weeks following conservative treatment with coaptation splint in a 34-year-old male.


  Case Report Top


A 34-year-old male had a right humeral shaft fracture from a road accident. He hit a utility pole when he was driving motorcycle. After admission to the emergency department, he was diagnosed with mild head injury, broken jaw, and broken right humeral bone. He was initially treated conservatively with coaptation splint and later discharged. Three weeks after discharged, he began to complain of progressive weakness on his right wrist and fingers. Two weeks later, the ability to extend his wrist and fingers of the right hand completely diminished.

On evaluation of the arm, there was obvious right upper arm angulation, hypesthesia on the dorsum of the lateral side of the right palm, and inability to extend the wrist or thumb on the right hand. From the clinical examination, we believed that the patient had suffered from radial nerve injury. The radiograph of the patient showed humeral shaft fracture with the clinical union and mild angulation [Figure 1].
Figure 1: Radiograph of the patient

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After obtaining consent, we started preparing for surgical exploration. Later, the radial nerve was explored and was found stretched and wrapped in highly vascularized tissue, callus, and fibrotic tissue [Figure 2]. The callus was excised, and the nerve was released; in addition, we also performed neurolysis [Figure 3]. Postoperatively, the patient was treated with plaster of Paris splint and evaluated with Disabilities of the Arm, Shoulder, and Hand (DASH) score.[7]
Figure 2: Nerve exploration

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Figure 3: Neurolysis

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The patient was later discharged and followed up weekly [Table 1]. His radial nerve function began to return after 4 weeks and regained full recovery in 12 weeks. The DASH score was also recalculated on week 12 [Figure 4] and [Table 2].
Table 1: Weekly follow-up of the right hand function

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Figure 4: (a) Thumb extension before surgery, (b) thumb extension 12 weeks after surgery, (c) wrist extension before surgery, (d) wrist extension 12 weeks after surgery, (e) thumb opposition before surgery, (f) thumb opposition 12 weeks after surgery, (g) handgrip function before surgery, (h) handgrip function 12 weeks after surgery

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Table 2: Comparison of shoulder score before and after 12 weeks of surgery

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  Discussion Top


Humeral shaft fracture is commonly associated with radial nerve palsy, in which the incident is 2%–17%. It can be classified into primary or secondary, depends on what happened before or after treatment regarding humeral shaft fracture. Another uncommon variation is late-onset radial nerve palsy, which is slightly different from the previously mentioned two.[6]

Edward and Kurth[8] reported a radial nerve palsy developed 6 weeks after open reduction internal fixation treatment of humeral shaft fracture, on which during the exploration, the nerve was found to transected and encased in the callus. Another case was described by Chesser and Leslie,[9] that happened 3 months after conservatively managed humeral fracture, in which the nerve was found entrapped by the lateral intermuscular septum. We believed that our case was similar with Chesser's, from the point that nerve injury began to appear after 5 weeks of conservatively treated humeral shaft fracture.

The surgical treatment regarding radial nerve palsy which associated with humeral shaft fracture can be classified into three procedures: neurolysis, nerve repair, or functional procedure, for example, tendon or muscle transfer. For timing of the surgery, it can be done early or late. Early surgery is reserved for the case with open fracture, vascular injury, gunshot injury, or severe soft-tissue injury. Often the radial nerve palsy can be managed without immediate surgical exploration. In one of studies, the functional recovery rate was 87.3% functional recovery.[10] Conventionally, the treatment of radial nerve palsy is often only observation, with late exploration in cases without spontaneous recovery within 3–6 months.

However, in this case, the patient underwent early exploration even though he did not meet the previously described criteria for this treatment. The rationale behind this treatment is that the surgeon feared for the progressive injury of the nerve as described from previous studies.[8],[9] The damage to the nerve was thought to be chronic in nature due to continuous traction of the nerve occurred because of callus formation.

After the surgery, the patient was followed up closely to ensure the continuous injury of the nerve halted and ultimately began to heal. During follow-up, the motor strength and sensory function began to recover after 4 weeks and returned to functional level after 12 weeks.


  Conclusion Top


Delayed radial nerve palsy is a rare complication of humeral shaft fracture. The mechanism of injury appeared to be related to the normal healing of the bone or an ongoing traction at the injury. An immediate surgical exploration may be indicated to relieve the radial nerve from its entrapment. In our case, an excellent recovery was able to be obtained using this method. Surgeons must be aware and recognize this rare complication in patients with distal humeral shaft fractures treated conservatively in the outpatient clinic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bumbasirevic M, Palibrk T, Lesic A, Atkinson H. Radial nerve palsy. EFORT Open Rev 2016;1:286-94.  Back to cited text no. 1
    
2.
Niver GE, Ilyas AM. Management of radial nerve palsy following fractures of the humerus. Orthop Clin North Am 2013;44:419-24, x.  Back to cited text no. 2
    
3.
Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br 1998;80:249-53.  Back to cited text no. 3
    
4.
Abrams RA, Ziets RJ, Lieber RL, Botte MJ. Anatomy of the radial nerve motor branches in the forearm. J Hand Surg Am 1997;22:232-7.  Back to cited text no. 4
    
5.
Noble J, Munro CA, Prasad VS, Midha R. Analysis of upper and lower extremity peripheral nerve injuries in a population of patients with multiple injuries. J Trauma 1998;45:116-22.  Back to cited text no. 5
    
6.
Abdelgawad AA, Wassef A, Ebraheim NA. Late-onset radial nerve palsy associated with conservatively managed humeral fracture. A case report and suggested classification system. HSS J 2010;6:49-51.  Back to cited text no. 6
    
7.
Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected]. The upper extremity collaborative group (UECG) Am J Ind Med 1996;29:602-8.  Back to cited text no. 7
    
8.
Edwards P, Kurth L. Postoperative radial nerve paralysis caused by fracture callus. J Orthop Trauma 1992;6:234-6.  Back to cited text no. 8
    
9.
Chesser TJ, Leslie IJ. Radial nerve entrapment by the lateral intermuscular septum after trauma. J Orthop Trauma 2000;14:65-6.  Back to cited text no. 9
    
10.
Vural M, Arslantaş A. Delayed radial nerve palsy due to entrapment of the nerve in the callus of a distal third humerus fracture. Turk Neurosurg 2008;18:194-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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