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Surgical approach, especially posterior and lateral approaches to the humerus, are associated with the highest rate of radial nerve palsy when treating humeral shaft fractures, 11% and 20%, respectively. Humeral shaft fractures are relatively common injuries with a bimodal distribution. Numerous treatment options exist including coaptation splinting, functional bracing, ORIF through various approaches (anterolateral, lateral, posterior), and the use of an intramedullary nails. Radial nerve palsy in the setting of humeral shaft fractures occur at an overall rate of about 7% and may occur at the time of injury or iatrogenically during surgery. Regarding iatrogenic injuries, only the approach used to fix the fracture has been associated with increased risk of radial nerve injury, with posterior and lateral approaches being most commonly indicted. The increased soft tissue dissection and variable anatomy of the radial nerve have been cited as reasons for this increased risk. The radial nerve is also at risk when placing a medial to lateral locking screw through an IMN, however, this risk is lower than that seen with ORIF via lateral or posterior approaches. Zhao et al review surgical interventions to treat humeral shaft fractures. They report that ORIF was associated with a higher incidence of radial nerve palsy when comparted to minimally invasive (MIPO) techniques or the use of intramedullary nails. They conclude that, when possible, MIPO techniques should be used given the lower rate of nerve injury. Classen et al review factors associated with radial nerve palsies following the treatment of diaphyseal humeral shaft fractures. They report an overall incidence of 7% with approach being the factor most closely related to nerve injury. They conclude that the highest risk was with the lateral approach (1 in 5), followed by the posterior approach (1 in 9). The anterolateral approach had the lowest rate of injury (1 in 23). Figure A is an AP radiograph demonstrating a diaphyseal humeral shaft fracture. Illustration A demonstrates the labeled brachial plexus Incorrect Answers: Answers 1, 2, 4, & 5: The most common iatrogenically injured nerve during the posterior approach to the humerus is the radial nerve.
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