Fractures of Humerus

with Radial Nerve

Paralysis
Salasatul Aisiyah
20174011119
Radial nerve palsy associated with
fractures of the shaft of humerus is the
most common nerve lession
complicating fractures of long bones.1

• 1. DeFranco MJ, Lawton JN (2006) Radial nerve injuries associated with humeral fractures. J Hand Surg Am
31(4): 655–63.
Anatomy : Humerus
Anatomy : Brachial Plexus
 N. Cutaneus brachii posterior back of the arm

Cutaneous N. Cutaneus lateralis inferior lower lateral of arm

N. Cutaneus antebrachii posterior forearm
m. Triceps brachii
forearm extensor
m. Anconeus
Arm
m. Brachioradialis forearm flexor
m. Extensor carpi radialis hand extensor
m. Supinator forearm supinator
m. Extensor digitorum digiti 2-5 extensor
Motoric
m. Extensor digiti minime digiti 5 extensor
m. Extensor carpi ulnaris hand extensor
Forearm
m. Abductor policis longus digiti 1 abductor
m. Extensor policis brevis
digiti 1 extensor
m. Extensor policis longus
m. Extensor indicis digiti 2 extensor
 The radial nerve does not travel along spiral groove of the
humerus ; it is separated from the humerus by from 1-5
centimeters of muscle.2

For only a short distance near the lateral supracondylar

ridge, the nerve is in direct contact with the humerus, and it is
in this area that the nerve pierces the lateral intermuscular
septum before passing on to the surface of the brachialis
muscle.2
2.Holstein, Arthur. (2011). Fractures of the Humerus with Radial-Nerve Paralysis. The Journal of Joint and Bone
Surgery
 Clinical Manifestation
The classic biomechanical consequence of the radial nerve
paralysis is the inability to extend the wrist, loss of extension
of the fingers in the metacarpophalangeal joints and inability
to extend and abduct the thumb.3

3Fess EE, Gettle KS, Philips CA, Janson JR. Hand and upper extremity splinting: principles and methods. 3rd ed. St.
Louis: Elsevier Mosby; 2005
 How To Diagnose ?

Function test of Radial Nerve :

• Cutaneous
• Motoric
 Forearm flexion and extension (elbow joint)
 Forearm supination
 Hand extension (wrist joint)
 Digiti 1-5 extension
 Digiti 1 abduction
Insidence of Fractures of Humerus
with Radial Nerve Paralysis

341 cases of
humerus fractures 6 radial nerve paralysis
(1,8%)
- 193 cases in proximal third
- 5 cases in distal third
- 63 cases in middle third - 1 case in middle third
- 85 cases in distal third
The fracture is in the distal third of the
humerus, it is usually spiral in type, the
distal bone fragment is always displaced
proximally with its proximal end deviated
radialward, the radial nerve is caught in
the fracture site.2

2.Holstein, Arthur. (2011). Fractures of the Humerus with Radial-Nerve Paralysis. The Journal of Joint and Bone
Surgery
The only part that varies is the degree of
involvement of the nerve; this involvement
varies from contusion to complete severance.
The degree of trauma must be relativelty violent,
and there must be definite displacement of the
fragmens of the shaft ofthe humerus as a result
of the injury if nerve damage is occur.2

2.Holstein, Arthur. (2011). Fractures of the Humerus with Radial-Nerve Paralysis. The Journal of Joint and Bone
Surgery
 Treatment : The Radial Nerve
Early Exploration or not ?

The treatment of radial nerve palsy caused by

closed humeral shaft fracture is a matter of
debate.4

Early exploration is technically easier and safer

than delayed procedure.

4 Han, Soo Hong, et all. (2017) Primary exploration for radial nerve palsy associated with unstable closed humeral
shaft fracture. Ulus Travma Acil Cerrahi Derg, September 2017, Vol. 23, No. 5
 Treatment : The Fracture

Stongly advice againts attempted closed reduction of

fractures of the distal third. Primary open reduction is
recommend through an antero-lateral approach.2
2.Holstein, Arthur. (2011). Fractures of the Humerus with Radial-Nerve Paralysis. The Journal of Joint and Bone
Surgery
Principle of Nerve
Injuries
Pathologi and Treatment
 PATHOLOGY : Neurapraxia

A reversible physiological nerve conduction block in

which there is loss of some types of sensation and
muscle power followed by spontaneous recovery
after a few days or weeks.
 PATHOLOGY : Axonotmesis

Axonotmesis is axonal interruption. There is loss of

conduction but the nerve is in continuity and the
neural tubes are intact. Axonal regeneration starts
within hours of nerve damage and grow at a speed of
1–2 mm per day.
 PATHOLOGY : Neurotmesis

Neurotmesis is division of the nerve trunk, the

endoneurial tubes are destroyed over a variable
segment. The nerve function is totally damage.
 Treatment : Nerve Exploration

Exploration is indicated:
• If the nerve was seen to be divided and needs to
be repaired;
• If the type of injury (e.g. a knife wound or a high
energy injury) suggests that the nerve has been
divided or severely damaged;
• If recovery is inappropriately delayed and the
diagnosis is in doubt.
 Treatment : Primary Repair

A divided nerve is best repaired as soon as this can be

done safely. Primary suture at the time of wound
toilet has considerable advantages: the nerve ends
have not retracted much; their relative rotation is
usually undisturbed; and there is no fibrosis.
 Treatment : Secondary Repair

Secondary repair indicated :

• a closed injury was left alone but shows no sign of
recovery at the expected time;
• the diagnosis was missed and the patient presents
late; or
• primary repair has failed.
Radial Nerve Palsy
Clinical Manifestation and Treatment
 Clinical Manifestation
• Low lesions
The patient complains of clumsiness and, on testing, cannot extend the
metacarpophalangeal joints of the hand. In the thumb there is also weakness of
extension and retroposition. Wrist extension is preserved because the branch to
the extensor carpi radialis longus arises proximal to the elbow.

• High lesions
There is an obvious wrist drop, due to weakness of the radial extensors of the
wrist, as well as inability to extend the metacarpophalangeal joints or elevate the
thumb. Sensory loss is limited to a small patch on the dorsum around the
anatomical snuffbox.

• Very high lesions

Weakness of the wrist and hand, the triceps is paralysed and the triceps reflex is
absent.
Wrist drop accompanied by a sensory deficit in the
first interdigital space
 Treatment
• Open Injury
Should be explored and the nerve repaired or grafted as soon as
possible.

• Closed Injury
Usually first or second degree lesions, and function eventually
returns.
If the palsy is present on admission, one can afford to wait for 12
weeks to see if it starts to recover. If it does not, then EMG should
be performed.
 Ulnar Nerve Palsy
Clinical Manifestation and Treatment
 Clinical Manifestation
• Low lesions
Low lesions are often caused by cuts on shattered glass. There is numbness of the ulnar one
and a half fingers. The hand assumes a typical posture in repose – the claw hand deformity
– with hyperextension of the metacarpophalangeal joints of the ring and little fingers, due
to weakness of the intrinsic muscles.

• High lesions
High lesions occur with elbow fractures or dislocations. The hand is not markedly deformed
because the ulnar half of flexor digitorum profundus is paralysed and the fingers are
therefore less ‘clawed’ (the ‘high ulnar paradox’). Otherwise, motor and sensory loss are the
same as in low lesions.

• ‘Ulnar neuritis’
May be caused by compression or entrapment of the nerve in the medial epicondylar
(cubital) tunnel, especially where there is severe valgus deformity of the elbow or prolonged
pressure on the elbows in anaesthetized or bed-ridden patients.
Claw Hand accompanied by a sensory deficit in the
5th digiti phalang distal
 Treatment
Exploration and suture of a divided nerve are well worthwhile, and
anterior transposition at the elbow permits closure of gaps up to 5 cm.
While recovery is awaited, the skin should be protected from burns.
Hand physiotherapy keeps the hand supple and useful.
Median Nerve Palsy
Clinical Manifestation and Treatment
 Clinical Manifestation
• Low lesions
Low lesions may be caused by cuts in front of the wrist or by carpal dislocations. The patient
is unable to abduct the thumb, and sensation is lost over the radial three and a half digits.

• High lesions
High lesions are generally due to forearm fractures or elbow dislocation, but stabs and
gunshot wounds may damage the nerve at any level. The signs are the same as those of low
lesions but, in addition, the long flexors to the thumb, index and middle fingers, the radial
wrist flexors and the forearm pronator muscles are all paralysed. Typically the hand is held
with the ulnar fingers flexed and the index straight (the ‘pointing sign’).

• Isolated anterior interosseous

The signs are similar to those of a high median nerve injury, but without any sensory loss.
The usual cause is brachial neuritis (Parsonage–Turner Syndrome) which is associated with
shoulder girdle pain after immunization or a viral illness.
Swear Hand or Hand of Benediction accompanied by
a sensory deficit in the 2th digiti phalang distal
 Treatment
If the nerve is divided, suture or nerve grafting should always be
attempted. Postoperatively the wrist is splinted in flexion to
avoid tension; when movements are commenced, wrist
extension should be prevented. Late lesions are sometimes
seen.