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Review Question - QID 214152

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QID 214152 (Type "214152" in App Search)
Which of the following fracture patterns depicted in figures A-E is associated with the highest risk of radial nerve palsy?
  • A
  • B
  • C
  • D
  • E

Figure A

0%

2/1535

Figure B

1%

12/1535

Figure C

5%

75/1535

Figure D

93%

1425/1535

Figure E

1%

12/1535

  • A
  • B
  • C
  • D
  • E

Select Answer to see Preferred Response

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Spiral distal third humeral shaft fractures, called Holstein-Lewis fractures, have a 22% chance of having associated radial nerve palsy at presentation. Overall, 11% of humeral shaft fractures have associated radial nerve palsies.

Distal one-third humeral shaft fractures have an association with radial nerve palsies. The proposed mechanism is that the radial nerve is closely associated with the bone in that area and when the bone breaks, the nerve becomes interposed. The resulting compression causes the radial nerve palsy at the time of injury. Overall humeral shaft fractures have an 11% rate of radial nerve palsy, but this is 22-24% in distal one-third shaft fractures. Treatment for nerve palsies in this scenario is with observation alone as 70% spontaneously recover within 7 weeks. Indications for early exploration are open humeral fracture, high-velocity penetrating injury, and vascular injury. Controversial indications for surgery are nerve deficits after closed reduction and Holstein-Lewis fractures.

Carroll et al. published in JAAOS a review of the management of humeral shaft fractures. In their review, they discuss anatomy, evaluation, nonsurgical and surgical management, and complications. For humeral shaft fractures with radial nerve palsies on presentation, they recommend observation except in the specific scenarios: open humeral fracture, high-velocity penetrating injury, segmental fractures, floating elbow, coma, and vascular injury. Controversial indications for surgery are radial nerve deficits after closed reduction and Holstein-Lewis fractures.

Shao et al. performed a systematic review of radial nerve palsy associated with humeral shaft fractures on initial presentation. They found 11.8% overall association with humeral shaft fracture with 88.1% overall recovery rate, with 70% recovering with conservative management alone. They did not find a difference in those managed with early observation and early exploration.

Figure A demonstrates a transverse fracture through the surgical neck of the proximal humerus. Figure B is a transverse humeral shaft fracture. Figure C is a spiral proximal humeral shaft fracture. Figure D is a spiral distal one-third humeral shaft fracture, consistent with a Holstein-Lewis fracture. Figure E is a comminuted intra-articular distal humerus fracture. Illustration A is the recommended treatment algorithm for humeral shaft fractures with radial nerve palsies.

Incorrect Answers:
Answers 1-3 and 5: These humerus fractures do not have a high association with radial nerve palsy.

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