Superficial thrombophlebitis in the forearm leading to entrapment of the radial nerve branch: a first case report and literature review.

This article reports a case of a female patient admitted with swelling and subcutaneous mass in the right forearm, initially suspected to be multiple nerve fibroma. However, through preoperative imaging and surgery, the final diagnosis confirmed superficial thrombophlebitis. This condition resulted in entrapment of the radial nerve branch, leading to noticeable nerve entrapment and radiating pain. The surgery involved the excision of inflammatory tissue and thrombus, ligation of the cephalic vein, and complete release of the radial nerve branch. Postoperative pathology confirmed the presence of Superficial Thrombophlebitis. Through this case, we emphasize the importance of comprehensive utilization of clinical, imaging, and surgical interventions for more accurate diagnosis and treatment. This is the first clinical report of radial nerve branch entrapment due to superficial thrombophlebitis.

Rare Variant of the Radial Artery Causing Compression of the Superficial Radial Nerve: A Case Report.

CASE: This case report describes a patient with paresthesia in the distribution of the superficial sensory branch of the radial nerve that was treated with surgery. Intraoperatively, there was a unique cause of internal compression by a rare superficial radial artery variant running adjacent to it. The nerve was mobilized from the artery with fascial releases. The patient had symptom resolution postoperatively. CONCLUSION: To our knowledge, this cause of compression has not been described before and should be considered in a differential diagnosis. In addition, clinicians should be aware of this anatomical variant during venipunctures and surgical approaches.

Radial Nerve Palsy in the Setting of Humeral Shaft Fracture.

The upper limb has a complex anatomy comprised of many nerve and vascular structures, making humeral shaft fractures extremely important. Injury to the humeral shaft commonly occurs due to trauma and affects younger male or older female patients. The radial nerve travels along the spiral groove of the humerus, placing it at an increased risk of damage in humeral shaft fractures. If injured, there are a variety of classifications of radial nerve injury, different indications for exploration, and treatment methods that orthopedic surgeons have available in treating these injuries. This review aims to discuss the etiology of humeral shaft fracture-associated radial nerve palsy, tools for diagnosis, and treatment.

A postoperative heterotopic ossification leading to radial palsy.

We report the case of a 58-year-old man who developed radial palsy three months after surgical reinsertion of the distal biceps brachii through a single anterior approach. Radiographs and ultrasound examinations revealed heterotopic ossification compressing the deep branch of the radial nerve. Surgical excision and neurolysis were performed. At the two-month follow-up, the patient was asymptomatic. Practitioners and orthopedic surgeons should be aware of the risk of heterotopic ossification after distal biceps reinsertion and its possible atypical clinical presentation.

Median to Radial Nerve Transfer: An 8-Year Experience From a Lower-Middle Income Country.

INTRODUCTION: With an incidence of 2-16%, radial nerve palsy is one of the common forms of nerve injuries globally. Radial nerve palsy causes debilitating effects including loss of elbow extension, wrist drop and loss of finger extension. Reparative surgical pathways range from primary repair and neurolysis, to nerve grafting, nerve transfers, and tendon transfers. Due to ease of performance and acceptability and reproducibility of outcomes, tendon transfers are considered the gold standard of radial nerve palsy repair. However, independent finger function cannot be achieved and as such may not give truly desirable results. In lower-middle income countries, the question of nerve transfer versus tendon transfer for patients who are keen to get back to work is key. While tendon transfer recovery is faster, the functional loss is often considered devastating for fine hand function due to loss of grip secondary to lack of wrist and finger extension. In this study, we present our experience of performing median nerve transfers for radial nerve palsy in Pakistan. METHODS: We performed a retrospective case-series of patients undergoing median to radial nerve transfer for radial nerve palsy over a period of 6 y, from 2012 to 2019. Patients with radial nerve palsy were diagnosed via electromyography and nerve conduction studies. The procedure involved coapting the branches of the flexor carpi radialis and flexor digitorum superficialis (long and ring finger) nerves to the posterior interosseous nerve and extensor carpi radialis brevis, respectively. Patients were assessed using the Medical Research Council scale for muscle strength of wrist, finger and thumb extension separately at 1 y time. Our results were then compared to results from similar nerve transfer studies. RESULTS: We operated on 10 right-hand dominant patients, eight males and two females with a median age of 33 y (6-63 y). four sustained injury to the right hand and six to the left. Causes of the injuries included road traffic accident (n = 3), firearm injury (n = 4), shrapnel (n = 1), iatrogenic injury (injection in deltoid region (n = 1) and fall (n = 1). Types of fracture included mid humerus fracture, fracture of the surgical neck of the humerus, and supracondylar fracture of the humerus. Median time to surgery since injury was 4 mo (1-8 mo). Independent wrist extension was M4+ in all patients and independent finger extension was M4+ in seven and M4-in two patients. However, a patient who presented late at 8 mo had poorer finger outcomes with extension at M2-. All patients had independent movement of fingers. CONCLUSIONS: Nerve transfer is a reliable method of post traumatic nerve repair and reinnervation, particularly in lower-middle income countries, even in cases where the nerve damage is severe and extensive and up to 6 mo may have elapsed between injury and presentation. Timely median to radial nerve transfer is a highly recommended option for radial nerve palsy, with regular follow-ups and physical therapy added to ensure positive outcomes.

Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis.

BACKGROUND: Historically, humeral shaft fractures have been successfully treated with nonoperative management and functional bracing; however, various surgical options are also available. In the present study, we compared the outcomes of nonoperative versus operative interventions for the treatment of extra-articular humeral shaft fractures. METHODS: This study was a network meta-analysis of prospective randomized controlled trials (RCTs) in which functional bracing was compared with surgical techniques (including open reduction and internal fixation [ORIF], minimally invasive plate osteosynthesis [MIPO], and intramedullary nailing in both antegrade [aIMN] and retrograde [rIMN] directions) for the treatment of humeral shaft fractures. The outcomes that were assessed included time to union and the rates of nonunion, malunion, delayed union, secondary surgical intervention, iatrogenic radial nerve palsy, and infection. Mean differences and log odds ratios (ORs) were used to analyze continuous and categorical data, respectively. RESULTS: Twenty-one RCTs evaluating the outcomes for 1,203 patients who had been treated with functional bracing (n = 190), ORIF (n = 479), MIPO (n = 177), aIMN (n = 312), or rIMN (n = 45) were included. Functional bracing yielded significantly higher odds of nonunion and significantly longer time to union than ORIF, MIPO, and aIMN (p < 0.05). Comparison of surgical fixation techniques demonstrated significantly faster time to union with MIPO than with ORIF (p = 0.043). Significantly higher odds of malunion were observed with functional bracing than with ORIF (p = 0.047). Significantly higher odds of delayed union were observed with aIMN than with ORIF (p = 0.036). Significantly higher odds of secondary surgical intervention were observed with functional bracing than with ORIF (p = 0.001), MIPO (p = 0.007), and aIMN (p = 0.004). However, ORIF was associated with significantly higher odds of iatrogenic radial nerve injury and superficial infection than both functional bracing and MIPO (p < 0.05). CONCLUSIONS: Compared with functional bracing, most operative interventions demonstrated lower rates of reoperation. MIPO demonstrated significantly faster time to union while limiting periosteal stripping, whereas ORIF was associated with significantly higher rates of radial nerve palsy. Nonoperative management with functional bracing demonstrated higher nonunion rates than most surgical techniques, often requiring conversion to surgical fixation. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Humeral shaft fracture: systematic review of non-operative and operative treatment.

INTRODUCTION: Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome. METHODS: Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc. RESULTS: A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group. CONCLUSION: This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.

Iatrogenic radial nerve palsy in the surgical treatment of humerus shaft fracture -anterolateral versus posterior approach: A systematic review and meta-analysis.

BACKGROUND: Although many studies have investigated iatrogenic radial nerve palsy (RNP) in humerus shaft fracture, there is inconsistent evidence on which approach leads to iatrogenic RNP. Moreover, no meta-analysis has directly compared the anterolateral and posterior approaches regarding iatrogenic RNP. METHODS: In this systematic review and meta-analysis, the MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before March 30, 2021. We included studies that (1) assessed the RNP in the surgical treatment of humerus shaft fracture and (2) directly compared the anterolateral and posterior approaches regarding the RNP. We performed synthetic analyses of the incidence of iatrogenic RNP and the recovery rate of iatrogenic RNP in humerus shaft fracture between the anterolateral and posterior approaches. RESULTS: Our study enrolled nine studies, representing 1303 patients who underwent surgery for humerus shaft fracture. After exclusion of traumatic RNP, iatrogenic RNP was reported in 35 out of 678 patients in the anterolateral approach and in 69 out of 497 patients in the posterior approach. Pooled analysis revealed that the incidence of iatrogenic RNP was significantly higher in the posterior approach than in the anterolateral approach (OR = 2.72; 95% confidence interval (CI), 1.70-4.35; P < 0.0001, I2 = 0%), but there was no significant difference in the recovery rates of iatrogenic RNP between the two approaches (OR = 1.55; 95% CI, 0.26-9.18; P = 0.63, I2 = 0%). CONCLUSION: In this meta-analysis, the posterior approach showed a higher incidence of iatrogenic RNP than the anterolateral approach in the surgical treatment of humerus shaft fracture. With limited studies, it is difficult to anticipate if any particular approach favors the recovery of iatrogenic RNP.

The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy.

BACKGROUND: The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively. METHODS: Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure. RESULTS: Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury. CONCLUSIONS: Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6-24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs. LEVEL OF EVIDENCE: Level III.

Distal locking technique affects the rate of iatrogenic radial nerve palsy in intramedullary nailing of humeral shaft fractures.

BACKGROUND: Intramedullary humeral nailing is a common and reliable procedure for the treatment of humeral shaft fractures. Radial nerve palsy is a common complication encountered in the treatment of this pathology. The radial nerve runs from posterior to anterior at the lateral aspect of the distal humerus. Hence, there is reason to believe that due to the anatomic vicinity of the radial nerve in this area, lateral-medial distal locking in intramedullary nailing of the humerus may be associated with a greater risk for iatrogenic radial nerve injury compared to anterior-posterior locking. QUESTIONS/PURPOSE: To assess whether the choice of distal locking (lateral-medial versus anterior-posterior distal locking) in intramedullary humeral nailing of humeral shaft fractures affects the risk for iatrogenic radial nerve injury. PATIENTS AND METHODS: Overall, 203 patients (116 females, mean age 64.3 ± 18.6 years), who underwent intramedullary nailing of the humerus between 2000 and 2020 at a single level-one trauma center, met the inclusion criteria and were analyzed in this retrospective case-control study. Patients were subdivided into two groups according to the distal locking technique. RESULTS: Anterior-posterior locking was performed in 176 patients versus lateral-medial locking in 27 patients. We observed four patients with iatrogenic radial nerve palsy in both groups. Risk for iatrogenic radial nerve palsy was almost 7.5 times higher for lateral-medial locking (OR 7.48, p = 0.006). There was no statistically significant difference regarding intraoperative complications, union rates or revision surgeries between both groups. CONCLUSIONS: Lateral-medial distal locking in intramedullary nailing of the humerus may be associated with a greater risk for iatrogenic radial nerve palsy than anterior-posterior locking. Hence, we advocate for anterior-posterior locking. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Radial nerve entrapment after fracture of the supracondylar humerus: a rare case of a 6-year-old.

Supracondylar fracture of the humerus is one of the most common fractures seen in children, and posteromedial displacement of the distal fragment in extension-type supracondylar humerus fractures can cause injury to the radial nerve. A 6-year old girl who presented with symptoms of radial nerve injury after a supracondylar fracture of the right humerus with complete posteromedial displacement of the distal fragment (Gartland type III) underwent surgery where closed reduction and percutaneous pinning was performed. The patient was routinely followed up and at 6 months postoperatively no neurological improvement was seen. Exploratory surgery revealed complete discontinuation of the radial nerve at the fracture site and entrapment of the nerve stumps in healed bone callus. A gap of 2 cm was observed between nerve stumps, and sural nerve cable grafting was performed with good results. If neurological symptoms do not improve over time, appropriate differential diagnosis and, if necessary, exploratory surgery should be considered. Despite limited reports and their conflicting outcomes, sural nerve cable grafting could be a useful option to bridge the gap of discontinued nerve injury. Level of Evidence: Level IV, Case Report.

What Are the Risks and Functional Outcomes Associated With Bilateral Humeral Lengthening Using a Monolateral External Fixator in Patients With Achondroplasia?

BACKGROUND: Many patients with achondroplasia experience functional impairments because of rhizomelic upper extremities (proximal limb shortening). Bilateral humeral lengthening may overcome these functional limitations, but it is associated with several risks, such as radial nerve palsy and insufficient bone regeneration. Only a few studies have reported on patient satisfaction and functional outcome after humeral lengthening in patients with achondroplasia. Furthermore, the reported numbers of adverse events associated with lengthening procedures using external fixators vary widely. QUESTIONS/PURPOSES: (1) Does bilateral humeral lengthening with a monolateral external fixator in patients with achondroplasia reliably improve patient function and autonomy, and what proportion of patients achieved at least 8 cm of humeral lengthening? (2) What adverse events occur after bilateral humeral lengthening with monolateral external fixators? METHODS: Between 2011 and 2019, 44 patients underwent humeral lengthening at our institution. Humeral lengthening was performed in patients with severe shortening of the upper extremities and functional impairments. In humeri in which intramedullary devices were not applicable, lengthening was performed with monolateral external fixators in 40 patients. Eight patients were excluded because they underwent unilateral lengthening for etiologies other than achondroplasia, and another four patients did not fulfill the minimum study follow-up period of 2 years, leaving 28 patients with bilateral humeral lengthening to treat achondroplasia available for analysis in this retrospective study. The patients had a median (interquartile range) age of 8 years (8 to 10), and 50% (14 of 28) were girls. The median follow-up time was 6 years (4 to 8). The median humeral lengthening was 9 cm (9 to 10) with a median elongation of 73% (67% to 78%) from an initial median length of 12 cm (11 to 13). To determine whether this treatment reliably improved patient function and autonomy, surgeons retrospectively evaluated patient charts. An unvalidated retrospective patient-reported outcome measure questionnaire consisting of nine items (with answers of "yes" or "no" or a 5-point Likert scale) was administered to assess the patient's functional improvement in activities of daily living, physical appearance, and overall satisfaction, such that 45 points was the highest possible score. The radiographic outcome was assessed on calibrated radiographs of the humerus. To ascertain the proportion of adverse events, study surgeons performed a chart review and telephone interviews. Major complications were defined as events that resulted in unplanned revision surgery, nerve injury (either temporary or permanent), refracture of the bone regenerate, or permanent functional sequelae. Minor complications were characterized as events that resolved without further surgical interventions. RESULTS: On our unvalidated assessment of patient function and independence, all patients reported improvement at their most recent follow-up compared with scores obtained before treatment (median [IQR] 24 [16 to 28] before surgery versus 44 [42 to 45] at latest follow-up, difference of medians 20 points, p < 0.001). A total of 89% (25 of 28) of patients achieved the desired 8 cm of lengthening in both arms. A total of 50% (14 of 28) of our patients experienced a major complication. Specifically, 39% (11 of 28) had an unplanned reoperation, 39% (11 of 28) had a radial nerve palsy, 18% (5 of 28) had a refracture of the regenerate, and 4% (1 of 28) concluded treatment with a severe limb length discrepancy. In addition, 82% (23 of 28) of our patients experienced minor complications that resolved without further surgery and did not involve radial nerve symptoms. Radial nerve palsy was observed immediately postoperatively in eight of 13 segments, and 1 to 7 days postoperatively in five of 13 segments. The treatment goal was not achieved because of radial nerve palsy in 5% (3 of 56) of lengthened segments, which occurred in 7% (2 of 28) of patients. Full functional recovery of the radial nerve was observed in all patients after a median (IQR) of 3 months (2 to 5). Refractures of bone regenerates were observed in 11% (6 of 56) of humeri in 18% (5 of 28) of patients. Of those refractures, 1 of 6 patients was treated nonsurgically with a hanging cast, while 5 of 6 patients underwent revision surgery with intramedullary rodding. CONCLUSION: Most patients with achondroplasia who underwent humeral lengthening achieved the treatment goal without permanent sequelae; nonetheless, complications of treatment were common, and the road to recovery was long and often complicated, with many patients experiencing problems that were either painful (such as refracture) or bothersome (such as temporary radial nerve palsy). However, using a subjective scale, patients seemed improved after treatment; nevertheless, robust outcomes tools are not available for this condition, and so we must interpret that finding with caution. Considering our discoveries, bilateral humeral lengthening with a monolateral external fixator should only be considered in patients with severe functional impairments because of rhizomelic shortening of the upper extremities. If feasible, internal lengthening devices might be preferable, as these are generally associated with higher patient comfort and decreased complication rates compared with external fixators. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Outcomes of Rerouting the Palmaris Longus to Extensor Pollicis Longus Tendon Transfer through the Second Extensor Compartment for Radial Nerve Palsy.

Background: A palmaris longus (PL) to extensor pollicis longus (EPL) is a standard tendon transfer used to restore thumb extension in patients with radial nerve palsy. This transfer is done by withdrawing the EPL from the third compartment and passing it subcutaneously to reach the PL. We modified this transfer by rerouting the EPL through the second extensor compartment to improve the retropulsion of the thumb. The aim of this study is to report the outcomes of this modified transfer. Methods: Four patients with traumatic radial nerve palsy underwent the modified PL to EPL transfer. They also underwent transfer of the pronator teres (PT) to extensor carpi radialis brevis (ECRB) and flexor carpi radialis (FCR) to extensor digitorum communis (EDC). Patients were followed up for at least 1 year after surgery. The data with regard to age, gender, cause of radial nerve palsy, duration between injury and surgery, and duration of follow-up was recorded. At final follow-up, the arc of motion at the interphalangeal joint (IPJ), metacarpophalangeal joint (MCPJ), palmar and radial abduction and retropulsion were measured for the reconstructed thumb and contralateral normal thumb. Results: All patients were male, with a mean age of 34.3 (range, 19-46) years. The mean duration between the injury and surgery was 15.9 (7-27) months, and the mean post-operative follow-up period was 16.8 (12-25) months. All patients recovered good thumb function. The mean arc of motion of the affected and contralateral thumb were IPJ flexion: 52°/80°; IPJ extension: 21°/14°; MCPJ flexion: 30°/33°; MCPJ extension:24°/31°; radial abduction: 70°/74°; palmar abduction: 68°/75° and retropulsion: 4.8cm/5.0cm. Conclusion: Rerouting the PL to EPL tendon transfer through the second extensor compartment in radial nerve palsy can restore good thumb function especially retropulsion. Level of Evidence: Level IV (Therapeutic).

Anterolateral Thigh Flap for Low-Voltage Fourth-Degree Electrical Burn Injury With Immediate Radial Nerve Palsy at the Elbow: A Case Report.

While high-voltage electrical injuries usually cause severe burn wounds and axonal polyneuropathy, low-voltage electrical injuries cause limited cutaneous wounds and demyelinating mononeuropathy, of which the median and ulnar nerves are the most commonly involved. We present the case of a 42-year-old man who suffered a 480-voltage electrical injury at his right elbow, resulting in a 24 × 10 cm fourth-degree burn wound and immediate radial nerve palsy. The burn wound was debrided with confirmation and preservation of radial nerve continuity. The wound was covered with a free anterolateral thigh flap and it healed uneventfully. The Tinel's sign continued to advance at follow-up, and electrodiagnostic studies showed progressive reinnervation. His radial nerve function recovered completely in 9 months. This is a rare case of low-voltage electrical injury with a fourth-degree burn wound and immediate radial nerve palsy. We treated the wound aggressively with early debridement and prompt flap coverage, but conservatively treated the radial nerve injury. The nerve recovery course indicates that it had a "shocked-cooked" injury and served itself as a well-placed nerve graft for the subsequent regeneration. We believe that our successful outcome in this case can provide more insights into the management of such injuries.

Humeral fractures sustained during arm wrestling.

PURPOSE: The aim of this study was to present our experience of treating humerus fracture sustained during arm wrestling. METHODS: Data of patients treated in our clinic with the diagnosis of humeral shaft fracture due to arm wrestling between 2000 and 2020 was retrospectively reviewed. Data collected included age, sex, dominant arm, history of professional or experienced participation, type and laterality of fracture, presence of radial nerve palsy, other surgical complications, management (surgical or conservative), duration of union defined as the time from injury until callus was evident on the radiograph, and the range of motion of the elbow joint at the last follow-up. RESULTS: Nineteen patients with humeral shaft fracture as a result of the arm wrestling were included. All had right arm fracture and all had right as the dominant side. All of the fractures were spiral at the distal third of the humerus and medial butterfly fragment was present in eleven (57.9%). Seven (36.8%) were treated surgically. Five (26.3%) had radial nerve palsy on admission. At last follow-up, no patient had neural deficit and none had significant loss of range of movement. CONCLUSION: Arm wrestling is an important cause of humerus shaft fracture. The dominant side is invariably affected. In this series all fractures were spiral type and occurred in the distal third of the humerus. One quarter of patients experienced radial nerve palsy, which can resolve spontaneously. Satisfactory results can be obtained with both conservative and surgical treatment. LEVEL OF EVIDENCE: IV.

Atraumatic proximal radial nerve entrapment. Illustrative cases and systematic review of literature.

PURPOSE: The aims of the present study were to describe atraumatic proximal radial nerve entrapment (PRNE) and potential strategies for management. MATERIALS AND METHODS: We performed a comprehensive search of 4 electronic databases for studies pertaining to patients with atraumatic PRNE. Studies published between 1930 and 2020 were included. Clinical presentation, nerve conduction studies, electromyography, and treatment methods were reviewed. In order to outline management strategies, 2 illustrative cases of acute PRNE were presented. RESULTS: We analyzed 12 studies involving 21 patients with 22 PRNE (15 acute and 7 progressive). Sudden or repetitive elbow extension with forceful muscle contraction (n = 16) was the primary mechanism of injury. The two main sites of entrapment were the fibrous arch (n = 7) and hiatus of the lateral intermuscular septum (n = 7). Conservative treatment was performed in 4 patients and allowed for complete clinical recovery in all cases. The remaining 18 patients underwent epineurolysis (n = 16) or resection/repair of hourglass-like constriction (n = 2) between 1.5- and 120-months following diagnosis. Twelve patients experience complete recovery, while partial or no clinical recovery was reported in 1 and 4 cases, respectively; the outcome was unknown in 1 case. CONCLUSIONS: Atraumatic PRNE is rare and remains challenging with respect to diagnosis and treatment. Current literature suggests that primary sites of entrapment are the fibrous arch and hiatus of the radial nerve at the time of forceful elbow extension. LEVEL OF EVIDENCE: Case series (IV) & systematic review (I).

Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies.

PURPOSE: This meta-analysis compares open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures with regard to union, complications, general quality of life and shoulder/elbow function. METHODS: PubMed/Medline/Embase/CENTRAL/CINAHL was searched for observational studies and randomised clinical trials (RCT). Effect estimates were pooled across studies using random effects models. Results were presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95% CI). Subgroup analysis was performed stratified for study design (RCTs and observational studies). RESULTS: Eighteen observational studies (4906 patients) and ten RCT's (525 patients) were included. The pooled effect estimates of observational studies were similar to those obtained from RCT's. More patients treated with nailing required re-intervention (RD 2%; OR 2.0, 95% CI 1.0-3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD 2%; OR 0.4, 95% CI 0.3-0.6). Notably, all but one of the radial nerve palsies resolved spontaneously in each groups. Nailing leads to a faster time to union (mean difference - 1.9 weeks, 95% CI - 2.9 to - 0.9), lower infection rate (RD 2%; OR 0.5, 95% CI 0.3-0.7) and shorter operation duration (mean difference - 26 min, 95% CI - 37 to - 14). No differences were found regarding non-union, general quality of life, functional shoulder scores, and total upper extremity scores. CONCLUSION: Nailing carries a lower risk of infection, postoperative radial nerve palsy, has a shorter operation duration and possibly a shorter time to union. Shoulder impingement requiring re-intervention, however, is an inherent disadvantage of nail fixation. Notably, absolute differences are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities.

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.

Radial nerve injuries and outcomes: Our surgical experience.

BACKGROUND: The aim of this study was to retrospectively evaluate patients who underwent surgery in our department for radial nerve lesions in terms of surgical outcomes. METHODS: Thirty-eight patients were admitted to our department with radial nerve lesion. Twenty-seven of the patients had entrapment neuropathy and 11 had radial nerve injury secondary to other traumas. Various factors such as surgical results, time to surgical intervention, injury mechanism, and reconstruction technique were analyzed. RESULTS: In all of 27 patients who were operated for radial nerve entrapment neuropathy, a complete improvement in wrist dorsal flexion was detected at postoperative 3rd month. Seven of the 11 patients who were operated for radial nerve lesion had different degrees of improvement in wrist dorsal flexion at the postoperative 3rd month. Two of the seven patients underwent anastomosis using a sural nerve graft. The recovery rate in our series was 89%. Three of the 4 patients who did not recover after the radial nerve injury were the patients who were operated within the 1st month after the trauma. CONCLUSION: Better functional results were obtained in the postoperative period in patients who were operated after the 1st month, underwent internal neurolysis and used a short nerve graft for anastomosis in the radial nerve lesions. In patients with entrapment neuropathy, the earliest surgery revealed satisfactory results in the postoperative period.

Primary radial nerve palsy associated with humeral shaft fractures according to injury mechanism: is early exploration needed?

BACKGROUND: Radial nerve palsy is a common complication associated with humeral shaft fractures. The purposes of this study were (1) to evaluate the status of primary radial nerve palsy in patients with humeral shaft fracture according to injury mechanism, (2) to estimate the risk factors of primary RNP, and (3) to evaluate whether early exploration is helpful for radial nerve recovery. METHODS: This study analyzed 162 patients with humeral shaft fractures from January 2014 to December 2019. All patients were surgically treated in our hospital. Of these, 109 high-energy injuries were identified and compared with 53 low-energy injuries. The risk factors of radial nerve palsy were analyzed, and the prevalence of radial nerve palsy and status of radial nerve exploration according to injury mechanism were evaluated. Nerve recovery rate according to early nerve exploration was investigated. RESULTS: There were 31 cases of radial nerve palsy among 162 patients: 27 in the high-energy humeral shaft fracture group and 4 in the low-energy humeral shaft fracture group. Logistic regression analysis for risk factors showed that the injury mechanism was significantly associated with primary radial nerve palsy. Among 31 radial nerve palsy patients, 21 radial nerves were explored and 19 radial nerves recovered completely (80.6%). In the high-energy humeral shaft fracture group, 18 radial nerves were explored during surgery among 27 radial nerve palsy cases, and 16 cases recovered (88.9%). The other 9 radial nerves were not explored, and only 5 cases recovered (55.6%). CONCLUSIONS: This study confirmed that the incidence of radial nerve paralysis was higher in high-energy humeral shaft fractures than in low-energy fractures. The more common fracture patterns were oblique, transverse, wedge, and comminuted in high-energy humeral shaft fracture. This study suggests that these patterns are not directly associated with radial nerve palsy, but that high-energy injury is associated with a specific fracture pattern. Early nerve exploration during surgical treatment in patients with radial nerve palsy associated with humeral shaft fracture was helpful especially after high-energy injury.