DOI: 10.1016/j.jcot.2018.11.002
Abstract
The management of secondary radial nerve injury that commonly occurs with humerus shaft fracture has long been a topic of contention among orthopedic professionals. Recent research has aimed to provide clarity and evidence-based direction for dealing with such nerve injuries post-operatively or after closed reduction. In light of the current evidence, the consensus appears to lean away from the practice of early intervention, suggesting that if no instrumentation errors or macroscopic nerve lacerations are evident, a conservative approach might be just as effective.
Introduction
The radial nerve, anatomically predisposed to injury due to its position in the arm, is frequently associated with humerus shaft fractures. The resultant nerve palsy can either occur at the moment of injury—defined as primary or may develop secondarily as a complication of treatment. Diverse therapeutic approaches have been discussed in literature, swinging from conservative management to arguments for early surgical exploration.
Study Review Findings
A study review, drawing from databases such as PubMed, Science Direct, Scopus, and Google Scholar, culled over a decade of scholarly articles to closely examine outcomes related to both secondary and primary radial nerve injuries in the aftermath of humerus fractures. A total of 114 articles were sifted through with only seven meeting the stringent criteria for inclusion in the review.
Three out of these seven meticulously studied reports focused exclusively on secondary radial nerve injuries. Four of the studies suggested conservative management, advising surgical exploration only if nerve recovery hadn’t commenced within three to five months post-injury. Contrarily, three other studies put forth recommendations for early nerve exploration, within the fortnight following the injury.
The data analyzed underscored a pivotal conclusion: the trajectory and timeline of nerve recovery post-secondary injury were akin to that observed in cases of primary radial nerve palsy. In essence, there wasn’t a substantial benefit to immediate surgical exploration.
Detailed Discussion
Reports by esteemed researchers like Wang JP, Reichert P, and others, spanning years of clinical observations, offer a window into the nuanced debate over treating radial nerve injuries associated with humeral shaft fractures. These documents discredit the necessity for early nerve exploration in the absence of clear indications like misplaced hardware or visible nerve damage. Furthermore, they advocate for a discretionary period of watchful waiting, believing that the nerve often mirrors the natural healing process seen in primary nerve injuries.
This approach is bolstered by various studies, including those by Noaman H and Gouse M, which highlight that the primary difference is the evolution of nerve damage during treatment rather than from the initial trauma. Evidence suggests that secondary radial nerve injuries typically fend well under conservative management with outcomes comparable to early surgical interventions.
Clinical Implications
For orthopedic surgeons treating humeral shaft fractures complicated by radial nerve palsy, the review provides a strong rationale for tempering an aggressive surgical stance. The data directs them towards a more patient, observation-led strategy, reserving nerve exploration for occasions where healing fails to commence within a reasonable timeframe or if surgical complications necessitate immediate correction.
References
1. Abdelgawad A.A., Wassef A., Ebraheim N.A. (2010). Late-onset radial nerve palsy associated with conservatively managed humeral fracture: A case report and suggested classification system. [HSS J. 6, 49–51.](https://doi.org/10.1007/s11420-009-9130-8)
2. Bishop J., Ring D. (2009). Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model. [J Hand Surg Am. 34A, 991–996.](https://doi.org/10.1016/j.jhsa.2009.03.007)
3. Shah A., Jebson P.J. (2008). Current treatment of radial nerve palsy following fracture of the humeral shaft. [J Hand Surg Am. 33, 1433–1434.](https://doi.org/10.1016/j.jhsa.2008.05.019)
4. Shao Y.C., Harwood P., Grotz M.R., Limb D., Giannoudis P.V. (2005). Radial nerve palsy associated with fractures of the shaft of the humerus. [J Bone Joint Surg. 87B, 1647–1652.](https://doi.org/10.1302/0301-620X.87B12.16333)
5. Wang J.P., Shen W.J., et al. (2009). Iatrogenic radial nerve palsy after operative management of humeral shaft fractures. [J Trauma. 66, 800–803.](https://doi.org/10.1097/TA.0b013e3181886d12)
Keywords
1. Secondary Radial Nerve Injury
2. Humerus Shaft Fracture Treatment
3. Radial Nerve Palsy Surgery
4. Conservative Management of Radial Nerve
5. Orthopaedic Nerve Injury Recovery
Conclusion
The reviewed literature conjures a compelling argument for a measured approach to secondary radial nerve injury in the context of humerus shaft fractures. The emphasized takeaway for clinicians is to gauge the injury on the merits of clinical and radiographic findings, leaning towards conservation, and reserving exploration for cases where conservative methods fail or complications clearly mandate intervention. This evidence-based approach aligns with the healing tendencies of the radial nerve, suggesting that patience and prudence may be as valuable as the surgeon’s scalpel in the management of this common orthopedic dilemma.