were treated conservatively, and 2 had surgical exploration of the radial nerve.

In 1 of the
patients with a secondary palsy treated operatively, the radial nerve was found to be caught in
the fracture fragments. Ten patients were available for follow-up examination and all had
complete recovery of radial nerve function.
The author agrees with Shao et al2 who stated that the special relationship between this
fracture pattern and radial nerve palsy is not as strong as Holstein and Lewis suggested. As
such, a spiral fracture pattern of the distal humerus with associated nerve palsy is not an
absolute indication for radial nerve exploration.
Timing of EMG, Nerve Exploration, and/or Tendon Transfers
Controversy exists over the recommended timing for surgical exploration of radial nerve
palsies. Debate also exists over whether nerve repair or tendon transfers are the best treatment
option for a transacted or permanently injured radial nerve. Most surgeons suggest obtaining
an initial electromyogram at 6 weeks following the injury if there has been no return of radial
nerve function.
Thomsen and Dahlin8 recommend an electrodiagnostic examination at 5 to 6 weeks after
injury and nerve repair and reconstruction within 2 months, not later than 3 months, after
injury.
Ekholm et al1 recommends exploration at 4 to 6 months if there is no resolution following a
primary radial nerve palsy. However for patients with indications for earlier operative
fixation (eg, multiple trauma, open fractures, segmental or bilateral fractures, floating elbow,
and nonunions), they advocated exploration of the nerve at the time of internal fixation.
Others note that the first sign of nerve recovery may be delayed as long as 6 months
following injury.5 Ring et al5 suggest basing the timing of operative treatment on the patients
willingness to continue wearing a radial nerve brace. For patients wanting to be brace-free
and satisfied with a hand that opens but does not have independent extension, they suggest
tendon transfers at 6 months. For patients who are comfortable wearing a brace, they
recommend waiting until 12 months to see if they are one of the patients whose recovery is
delayed in nature. Nerve exploration may be considered in select patients (eg, patients with
multiple nerve injuries in whom tendon transfer is not an option) at 6 months.
Verga et al9 reported that in the absence of functional recovery, delayed surgical treatment
(neurolysis or nerve grafts) performed 3 to 4 months after primary orthopedic treatment can
be useful in achieving good functional recovery and subjectively satisfying results.
References
1. Ekholm R, Adami J, Tidemark J, et al. Fractures of the shaft of the humerus: An
epidemiologic study of 401 fractures. J Bone Joint Surg Br. 2006; 88:1469-1473.
2. Shao YC, Harwood P, Grotz MRW, Limb D, Giannoudis PV. Radial nerve palsy
associated with fractures of the shaft of the humerus: A systematic review. J Bone
Joint Surg Br. 2005; 87:1647-1652.

3. DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J
Hand Surg Am. 2006; 31:655-663.