Complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to assess risk for iatrogenic radial nerve palsy (iRNP), non-union, and post-operative infection in humeral shaft fractures. A PubMed search including original articles comparing different treatments for humeral shaft fractures published since January 2000 was performed. Random effect models with relative risks (RR) and 95% CIs were calculated for treatment groups and outcomes. Of the 841 results, 43 studies were included in the meta-analysis (11 level II, 5 level III, 27 level IV). Twenty-seven compared intramedullary nailing (IM) with ORIF, nine conservative with operative treatment, four ORIF with minimally invasive plate osteosynthesis (MIPO), and three anterior/anterolateral with posterior approach. iRNP risk was higher for ORIF vs IM (18 studies; RR: 1.80; P = 0.047), ORIF vs MIPO (4 studies; RR: 5.60; P = 0.011), and posterior vs anterior/anterolateral approach (3 studies; RR: 2.68; P = 0.005). Non-union risk was lower for operative vs conservative therapy (six studies; RR: 0.37; P < 0.001), but not significantly different between ORIF and IM (21 studies; RR: 1.00; P = 0.997), or approaches (two studies; RR: 0.36; P = 0.369). Post-operative infection risk was higher for ORIF vs IM (14 studies; RR: 1.84; P = 0.004) but not different between approaches (2 studies; RR: 0.95; P = 0.960). Surgery appears to be the method of choice when aiming to secure bony union, albeit risk for iRNP has to be considered, particularly in case of ORIF vs IM or MIPO, and posterior approach. Due to the limited number of randomised studies, evidence on the best treatment option remains moderate, though.

Distal 3rd Diaphysial Fracture of Humerus Fixed with Dynamic Compression Plate Using Posterior Approach- The Assessment of the Outcome

Objectives: The effectiveness of open reduction and Dynamic Compression Plate (DCP) fixation with or without autogenous bone grafting using the posterior midline approach in the treatment of distal third diaphyseal humeral fractures was assessed. Methods: For humeral nonunion, comminuted fractures, or early failure of conservative therapies, 33 patients (24 men, 9 women; mean age 37 years; range 20 to 60 years) were operated on. The study was carried out at Dhaka Medical College Hospital (DMCH), Dhaka from July 2005 to December 2006. Results: After an average of 17 weeks, all of the patients had union (range 14 to 26 weeks).There was no deep infection, nonunion, malunion, implant failure, or nerve injury in any of the patients. In two cases, transient radial nerve palsy occurred. Minor infections were seen in four of the individuals. All of the patients were pain-free after surgery.The functional outcome was outstanding in all instances and good in 16 patients, yielding 87 % satisfying results. Functional outcomes increased considerably postoperatively compared to preoperatively (p<0.001). In 20 individuals, the range of motion of the shoulders was great. The range of motion at the elbow was considerable in 21 patients and moderate in seven others. More than three-quarters of the patients (75.8%) experienced no problems. Four patients (12.1%) were infected, and two patients (6.1%) developed iatrogenic radial nerve palsy as a result of the surgery. One patient (3%) had a loose screw, while another (3%) needed blood transfusions owing to extensive bleeding at the donor graft site. Conclusion: In distal third humeral fractures, open reduction and posterior DCP fixing, with or without autogenous bone grafting, is a safe and effective treatment option, especially when there is no infection or bony or neurovascular damage. Very few study conducted on distal 3rd diaphysial fracture of humerus fixed with DCP using posterior approach, therefore this study conducted to know the assessment of the outcome.

Humeral shaft fracture associated with radial nerve palsy -a case report

Radial nerve palsy was induced by radial nerve compression, which was often caused by humerus bone fracture. This leads to pain, weakness, or loss of function mostly in the wrist, hand, and fingers. We reported a case of a 24-year-old male patient with complaints of swelling of the right-hand wrist joint and pain during extension and flexion while moving. He had a three-month history of mild displaced humeral shaft fracture from a traffic accident and an intramedullary Ender nailing was performed. He now has been admitted with swelling in his right wrist joint and pain while moving his hand. The case was diagnosed as Radial nerve palsy. Surgery was performed, the proximal and distal ends of the radial nerve were separated at the humeral bone's surface. The radial nerve stumps were enough long to be sutured. Our one-month follow-up shows no complications. The majority cases of radial nerve palsy will resolve within a few weeks after surgery, as our patient did, and the most prominent is patient education.

Secondary radial neuropathy after closed intramedullary nailing of humeral shaft fractures. Results over a 10-year period

Background. Retrospective study to examine secondary radial nerve palsy after humeral shaft fixation with closed locked intramedullary nailing. Materials and methods. Patients were identified from the hospitals’ registration systems for humeral shaft fractures, nerve lesions, plating, nailing and external fixation during a 10-year period from January 2007 to December 2016. All radial nerve lesions were registered and followed-up in patient files. Results. 89 patients with locked intramedullary nailing were available for an outpatient follow-up. Mean age was 67 years at the time of injury. 72 fractures were non-pathological. Of these, 31 were nonunions. 28, 61 and zero were identified in the proximal, middle and distal thirds of the humeral shaft respectively. 76 procedures were closed and 13 were with open reduction. Six radial nerves had nerve exploration. Eight patients developed immediate postoperative radial nerve palsies. Of these, six developed after closed surgery, two after nerve exploration. Of seven available patients with a radial nerve palsy, six of these remitted. Two patients were later surgically explored. One patient out of 89 sustained a verifiable permanent radial nerve paralysis. Conclusions. In this study, the risk of a radial nerve palsy was 7.9 % with closed locked intramedullary nailing. This study suggests that exploration of the radial nerve is not necessary routinely in order to prevent radial nerve lesions when performing closed intramedullary nailing for humeral shaft fractures in adults with a preoperative normal radial nerve function. Level of Evidence : Level IV.

Ultrasound-guided Preoperative Localization of Radial Nerve in the Treatment of Extra-articular Distal Humeral Shaft Fractures

Background: The aim of this study was to discuss the treatment of extra-articular distal humeral shaft fractures using ultrasound-guided preoperative localization of radial nerve.Methods: Between May 2014 and December 2019, 56 patients with extra-articular distal humeral shaft fractures were retrospectively reviewed. 28 patients were received examination by using preoperative localization of radial nerve guided by ultrasound-guided preoperative localization (group A) and 28 control patients without ultrasound-guided (group B). All patients were treated surgically for distal humeral shaft fractures by posterior approach techniques. Operative time, radial nerve exposure time, intraoperative bleeding volume, union time and iatrogenic radial nerve palsy rate were compared between the two groups. Elbow function was also evaluated using the Mayo Elbow Performance Score (MEPS). Results: A significant difference was observed between the two groups, Operative time (113.25 min vs 135.86 min) (p < 0.001), radial nerve exposure time (20.82 min vs 32.53 min) (p < 0.001), intraoperative bleeding volume (246.80 ml vs 335.52 ml) (p < 0.001) and iatrogenic radial nerve palsy rate (0 vs 10.7% ) (p< 0.001). However, the fracture union time (13.52 months vs 12.96 months) (p = 0.796) and the MEPS sscore (87.56 vs 86.38) (p = 0.594) were no significantly different in both groups. Conclusion: The study demonstrates that ultrasound-guided preoperative localization is an effective approach in the treatment of extra-articular distal humeral shaft fracture by revealing radial nerve, which may help reduce the incidence of iatrogenic radial nerve injury and the intraoperative bleeding volume. In addition, it has the advantages of operability, safety, efficiency and repeatability.

FUNCTIONAL OUTCOME BY EVALUATION OF DASH SCORE ON DROP HAND PATIENT TREATED WITH JONES’ TENDON TRANSFER: A RETROSPECTIVE STUDY

Background: Drop hands due to radial nerve injuries cause functional and structural disabilities. Tendon transfer became the last option when nerve repair could not give patients restoration. The most popular method was Jones' Tendon transfer to restore wrist dorsiflexion, extending the thumb and the fingers. The Disabilities of Arm, Shoulder, and Hand (DASH) score measures functional outcomes in patients with upper extremities injuries. This study was to acknowledge the functional outcome and evaluate the DASH score in drop hand patients who undergone surgery by Jones’ Tendon Transfer in Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta from January 2014 to June 2016.Methods: The collected data from the medical record was evaluated based on functional outcome and DASH score. Eleven patients were included, ten male patients (90.9%) and one female patient (9.1%). The mean age of patients was 27.4 years old, with the most frequently injured arm was the right arm, counted to be eight patients (72.7%), and the left arm was three patients (27.3%).Results: The result from the evaluation of the DASH score indicated ten patients (90.9%) were minimal disability, and one patient (9.1%) was moderate disability. The average score was 12.48, which means that most patients could cope with most daily living activities post-operatively.Conclusions: In conclusion, surgery for drop hand due to radial nerve palsy by Jones’ Tendon Transfer gave a satisfactory functional outcome based on the DASH score.

EVALUATION OF RESULTS OF NON OPERATIVE TREATMENT OF FRACTURE SHAFT OF THE HUMERUS WITH A FUNCTIONAL BRACE

Introduction: Fractures of the humeral shaft account for roughly 3% of all fractures due to fall on the outstretched hand, motor vehicle accidents and direct loads to the arm. The brace effectively compresses the bulky biceps and triceps muscle allowing early shoulder, elbow, wrist and hand motion with nonunion and radial nerve palsy in a signicant percentage of humeral shaft fractures. This study intends to assess the results of non-operative treatment of fracture shaft of the humerus with a functional brace. Materials and Methods: Prospective observational study was conducted in NMCTH, Birgunj among 50 patients from 16 years onwards of age who presented with fracture of humerus shaft. The patients with open fracture, oating elbow, bilateral humeral fracture, polytrauma, pathological fracture, additional injury of the extremities and patients with neurologic and psychiatric disorders were excluded from the study. The patients were treated with close reduction and immobilization in functional humeral cast brace and were followed up in outpatient department basis once a week for the rst four weeks and every four weeks subsequently till fracture united. After removal of brace functional evaluation of results of upper limb was done according to Hunter's criteria. RESULTS: Six patients out of 50 lost to follow up and was removed from nal analysis . Out of 44 cases, mean age of patient was 34.77 year. Most of them 28(64%) were male. RTA was most common mode of injury 24(54%). Most of the patient 26(59%) had rd fracture on non dominant side. Majority of the fractures 24(55%) were in the middle 1/3 . Thirty two cases (72%) attended the hospital within 24 hours of injury. Union was achieved in 41(93%) patients within a mean time of 11.48 weeks. One transverse and two comminuted fractures in middle and distal third of diaphysis did not unite and were treated surgically. According to Hunter's criteria of evaluation of results, 31(75.6%) of united fractures had excellent (G5) and 10(24.4%) had good (G4) results. Restriction of few degrees of terminal range of movements of shoulder abduction and external rotation present initially improved subsequently after physiotherapy. Mean varus angulation in 39 patients at the time of removal of brace was 7.05° and mean valgus angulation in four patients was 6.00°. Mean anterior angulation of 6.85° was present in 21 patients and mean posterior angulation of 7.11° was present in 20 patients at the time of removal of brace. Mean shortening of 6.5 mm was present in 36 patients. The various angulation deformities and shortening at the end of union did not cause functional and cosmetic effect. Conclusion: Fracture shaft of humerus treated by close reduction and functional bracing has good functional outcomes.