Ahmedabad Call Girls CG Road 🔝9907093804 Short 1500 💋 Night 6000
Radial nerve palsy
1. Treatment of radial nerve palsy
following humerus shaft fractures
still a controversy?
Dr Uday Kumar
MS(Orth) DNB(Orth)
Sagar Hospitals
Sindhi Hospital
Chinmaya Hospital
Bangalore
24th May 2014
RATS
2. • Incidence 11.8% of shaft fractures
(532 palsies in 4517 fractures).
• Primary - occurs @ injury
• Secondary - occurs later during
closed or open management
• Mangement controversial
Radial nerve palsy
Jbjs 2005
3. • Transverse fractures of middle 1/3 most
commonly associated with neuropraxia
• Spiral fractures of distal 1/3 (Holstein-Lewis
fracture)-- higher risk of laceration or
entrapment of the radial nerve
4. --a wrist drop splint is given
--static or dynamic splint
--exercises
Radial nerve palsy foll # humerus
Management
5. • Spontaneous recovery of nerve function is
found in >70% of cases
• Even secondary palsies, those associated
with fracture manipulation, have a high rate
of spontaneous recovery
• 90% will resolve in 3 to 4 months
7. EXPLORE RADIAL NERVE
--ORIF HUMERUS---EXPLORE NERVE AND FIX
--OPEN FRACTURE HUMERUS
--RADIAL NERVE PALSY FOLLOWING CLOSED REDUCTION
--HOLSTEIN-LEWIS FRACTURE
The American Journal of Orthopedics®
M. W. Heckler et al--2009
8. Proponents of early exploration
-technically easier and safer
-clarifies diagnosis and extent of lesion
-OR reduces further nerve damage
-early means within 3 weeks
9. Proponents of late exploration
(wait for 4 months then explore)
-High rate of spontaneous recovery
90% recover by 3 months
-avoid unnecessary nerve dissection
as majority are neuropraxias
-easier to treat nerve injury after fracture has healed
10. • Precise evaluation of a nerve lesion is
possible
• The associated fracture will(may) have
united
• The results of secondary repair are as good
as those of primary repair
11.
12. • Exploration for palsy in an open fracture is the
only indication that is not associated with
conflicting data
• For secondary palsies, it is not clearly
established that surgery will improve the
ultimate recovery rate compared to nonsurgical
management
Jbjs 2005
13. • Review of 714 primary and 130 secondary palsies all
observed initially,
no difference noted in recovery rates (88.6% and
93.1%, respectively) after closed treatment
Hak D, Orthopedics 32:111 (2009)
• Early exploration may risk additional injury to nerve
if it is only contused
14. Electro diagnostic studies
--done after 3-6 weeks after injury
--useful only after the process of wallerian
degeneration has set in
--not able to distinguish
between a severed nerve and
unrecovered intact nerve
15. Results from electrical studies parallel clinical
findings.
Electrical signs of recovery occur no more than
a month before recovery becomes apparent
clinically
16. Ultrasound exam of radial nerve
-done about 3 weeks after injury
-should be done by an experienced radiologist
-differentiates between a severed and intact nerve
-drawbacks: observer dependent
17. How long to wait before exploration?
Shao et al-- the mean time to the onset of spontaneous recovery
was 7.3 weeks
-- minimum waiting time before exploration
- The optimal time of observation before intervention has been
debated, but no clear answer is universally supported
- About 4 -6 months
18. Nerve exploration, neurolysis and nerve grafting
most appropriate
in patients who can tolerate
--- a wrist brace
--- long recovery periods and
--- an uncertain outcome
--- reserved for patients 6 to 12 months
from injury with no signs of recovery.
22. Conclusions
Radial nerve palsy following # shaft humerus
-Recovery occurs in 90% cases in 3-4 months
-Early exploration is indicated in ORIF, open fractures
-Exploration for secondary nerve palsy and
Holstein-Lewis # remains equivocal
-Electrodiagnostic studies do not differentiate
between a severed nerve and an unrecovered intact nerve
-Tendon transfers should be done if there is
persistent palsy after 1 year after injury
