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Patients with a Holstein-Lewis spiral fracture involving the distal third of the humerus have an increased incidence (22%) of radial nerve palsy on presentation. Despite the higher incidence, clinical recovery occurs in ~70% of patients by 7 weeks with observation and functional bracing alone. Holstein-Lewis fractures represent 7.5% of all humeral shaft fractures. Compared to other humeral shaft fracture variants, these distal third spiral fractures have been shown to present with an increased incidence of radial nerve palsy (22% vs. 8%). Current treatment recommendations include functional bracing for the fracture and observation of the nerve palsy, as nearly all cases achieve complete functional recovery by 3-6 months without operative intervention. Ring, et al. provide a retrospective review of 24 patients with high-energy diaphyseal humerus fractures and complete motor and sensory radial nerve palsy. Eleven of these were open fractures, all of which were operatively explored. Eight were found to be intact upon exploration, and all eight experienced full recoveries. Nine of the 10 unexplored nerves also experienced a full recovery, with an average time to initial clinical signs of recovery of 7 weeks and an average time to full recovery of 6 months. Shao, et al. report an overall prevalence of radial nerve palsy in humeral shaft fractures of 11.8% in a systematic review involving 532 palsies in 4517 fractures. They note that transverse and spiral fractures were most likely to be associated with radial nerve palsy, with spontaneous recovery occurring in 70.7% of cases. Daly, et al. report on treatment algorithms for radial nerve injury in humeral shaft fractures. The authors state that expectant management of nerve injury in conjunction with non-operative treatment includes appropriately timed clinical follow-up with detailed clinical exams and serial electromyograms. They recommend surgical exploration at 3-4 months from injury if no meaningful clinical improvement is noted. Incorrect Answers: 1-3: Current literature demonstrates that an average of 70% of patients with this variant will experience signs of clinical recovery by 7 weeks. 5: By 3 months, more than 90% of patients would be expected to have had spontaneous recovery.
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