humero fx holstein lewis -data journals jbjs 445 1382
Post on 13-Apr-2018
235 Views
Preview:
TRANSCRIPT
-
7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382
1/8
INTER
MUSCULAR
SEPTUM
RAD IA L NE
RAD IUS
4
R t. A nt.V ie w
F ractu res o f the H um erus w ith R ad ia l-N e rv e
1382 T H F : JO U R N A l. o il. B O N E A N I) J( iIN I S U R G E R Y
Paralys i s
*
B Y A R T H U R H O L S T E IN , M .I).f, A N I) G \\IL iM B . L E W IS , M .D .t, B F :ItK E L E Y , C A L IF O R N IA
In our experience w hen p araly sis o f th e rad ia l ne rve com p lica tes frac tu res of
the shaft. o f th e hun ie rus , a spec ific s itu a tion usua .lly ex is ts . T he frac tu re
is
in the
d is ta l th ird of th e hum erus , it. is sp ira l in ty pe , the ( lis ta l bone frag n iem it is a lw ay s
d isp la (ed prox im ally w ith its p rox im al end d ev iated rad ialw am d , th e
ra d ial ne rve
is cau gh t in the frac tu re s ite , and , if th ere is a con im inu ted fragm ent, it is th e ob l ique
surface I f
the d ista l en d
of the prox im al fragm en t th at dam ages the nerve . \V hen
fr;uetules i n t .h is a re a occur and the in itia l trau m a does no t. Pm o (lu (e g ro ss d isp l;tce -
n ien t
I f
the type desc ribed , theu m i ad i al - mi e rv e p a ra l ys i s m ay not occur (Fig. I ).
F in . I
I
)r a w in g sh o w in g re la tio n sh ip o f n er v e to fr a t t tir t.
I ie lo re (le ft ) am id al ter dis l )ha oe mlle l i t ( r igh t
W ith rad ial d isph atem ent an d overridimig of til( dis ta l lragm eii t
t
li e m iervo , fixe d
to ) t
h o l ir ox ir na l
ilagniomlt.
l)y t.h t
ilit(lI iitiSttllaI s(pt tin ), is
tlapl)ttl h)o t
th o fm a ct t ilt su lfa tes .
T o u nderstand the m echam ii(s o f th is f ractu re sy nd i(Im e , the fo llow iiig ana tom i-
ca l fac to rs a re pertinen t.
A s W hitsou i ( Ien iou istra ted , con tra ry
to tli(
deser ip t iomms iii
stand ard ana tom ica l
tex tbooks 1,2, the rad ia l ne rve
does
iiot tr av el a lon g
the so-called sp ira l
groove of the
* He a ( l at
t i i o
Amimiuah M eeting o il Tlit A n i e n i o a i i A oado n iy o il (lit
hi o l )a e t l i o
Siimgeoimis, Chicago ,
I lh in o iis, J anu ary 28 , 1 96 2 .
t
:30 11 T ele gra ph A v enu e, B e rke lt
5,
Califo rn ia .
-
7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382
2/8
F in . 2
F 1 I A C T U R E S OF TH H U M E R U S
1383
V o l.. 4 5 -A , N O . 7 , O C T O B E R 1 9 6 3
humerus ; in s tead , a lo m ig InoIst o f its co urse , it is sepa la te (l f rom ii the hum erus b y from
on e to fiv e cen t.in iete rs o f n iu sc le , the a \e Iage th iick m iess o f the m usc le b e iiig 3 .4
cen tim e te rs . T he ne rve lie s clo se to the in fe rio r lip o f th e sp ira l
gra ov e, i)u t no t
in the
gro ove . lo r (lilly a sho rt d is t.m tm ice near th e la te ra l supraco ndy la r ridg e is th e nerve
iii d irec t con tac t w ith th e hu m erus, and it is in th is au ea tha t the nerve p ie rces the
la te ra l in t.e rm u scu lau sep tum befo re pass im ig On
to th e
su rface of the brach ia lis
n iu sc le . F ron i o ur ana t(In iical d issections , the nerve has leas t n i(Ib ih ity a t th is po in t,
am id , in our op in io n , it is th is lack of n ioh ility tha t is a p rim e fac to r con trihu itiu ig to
the n erve im iju uy in f rac tu res o f the hun ie ru s a t th is lev el.
T h e fo llow in g case reports a re
reco rded to ca ll a ttem itio n to the
im por tance of
ueco gn iz im m g th is fractu re sy ndron ie tax i th e m ieed
fo r o pen reduc tion to avo id fu rthe r
r lmin i ige
to th e nerv e .
C a se 1 . Lateral 9 .1 1 (1 a m it( m t )p o ste r io r ro em ltg e m m o g r a n ls s lm o t p ita l lrao t tire . N ote th ia rao to ris tic
fea tu res: its lo cat .iou i in th e d ista l o m i(-t .h ird , its sp ira l
to ilto u r , a n ( t iio rad ia l (lev ia tio in o il th e
1 )ro x im na l e li(1 o f the (lis ta l lrag nem it .
S ev eu i typ ica l frac tu res ve i co llec ted , four tu e ;u ted by us and th ree seeu i in
consu lta t.iou i fo r the U uiited S ta tes N av y (A .Il.) . I ii an
eflolrt to
de te rm u itie the
freq uency of th is particu lar sy ndrom e, 34 1
co iis ecu iti\e f ractu re s o f
th e shaft. (If th e
hu n ierus a t one priva te h osp ita l w eue a lso rev iew ed . ( )f th ese , 1 93 w em e in
the p rox i-
m al th ird o f the sha ft o f the hu m erus, six ty -th ree
iii
th e n iid -p ort ion of th e hum erus ,
a iid e igh ty - fiv e iii
the d istal
portion of the h um uerus . O f
th is ho le g rou p , six had
assoc iated rad ia l-im erve illvo lvem em lt, m m in cidem ice o f 1 .8 per (em it. F ive of th e si x
e re d isp laced fract tire s (If th e type we are desc rib ing . T h e o ther as a frac tu re iii
the n iidd le th ird o f th e hu m erus. T h is case is p resen ted h ere m ere ly to i l lu st rate
how th is frac tu re d if fers fron i the sy m id rom e w e are desc rib ing (C ase 8). The low
inc idence o f rad ia l-ne rve invo lven ien t in th is se r ies is o f in te res t in v iew of th e receu it
s tudy by t.he P ennsy lvam iia O rthoped ic S oc ie ty , iii w hich rad ia l-ne rve im ivo lhvem em m t.
-
7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382
3/8
Fw . 3
1384 AIIrHITR HOLSTEIN AN1) G. B. LEWIS
T H F :
J O U R N A L
O F B 0 N F : A N I) J O IN T S U R G E R Y
w as fou nd iii 12 1e1 ccitt. o f a la rg e ser ie s o f m id -sha ft hu tuera l fiac t.u res.
C ase P rese nta tio ns
CASE 1 . A . P ., a w om an fi fty ye ars o ld , w as th now m i aga ins t the side o f the c an i m i a n au tomobi le
accidemit an d expeniellced su(Ideli severe pain in the n igh t arm . O n ad m is sio m i, a
dia gnosis
o f f ra ct ur e
th e h um erus
with
n ad ia l-u ie nv e p ara ly sis
w as
m a d e .
At
operation, tue d is tal fnagm euit
o f th e hu m e rus had im pale d the ra d ia l
m ien ve om i it . s
sh iarp
ti p at th e 1)o in t . w h ere the
ne r v e
passes from th e
I)o stcn io r co m n pa n tm e m it ., th ro u g h th e in te r m u scu la r
sep tum , in to th e an ten ion c om pa rtm ent (F ig . 2 ). T he ne rve w as fre ed f rom the b)o ne frag m e nt
an d
disp laced
laterally
to th is d is ta l lnagm eu it.. T he frac tu re w as red uc ed and fixed w ith tw o screw s
p laced tra nsv ersely across the frac tu re l ine . A palm -to-a x il la plaster cast
wa s
app l ied . Alter dis-
charge
from th ie hosp ital, t.he
pa tien t tran sfe rred to ano the r area fo r
fo l low -up cane.
N o fu rth e r
imifonniation is ava i lab le .
( t st 2 . F ai lu ro
t. ti
ach ieve l)ro P(r aligm im uen t m u u i ( o m it .a t t. (if the f rao t.u m o surf ;u es liv O l(ist d
m l i; Lm ii l) tl la t.i O) mi s ug go s t
5 iu it .en l)os it.ion o il the lao lia l n orv ( nu t m o .la t .ed soft .
t
issomos.
C. E
2. (
;
\\. ,
a m i it il i, t hi rt y- si x y ears o ld , \ 5
i n jur o (1
w lam i h is o ar str tick a tree .
lit
l lad
i1 llI lie( ii t( 1 )tt im i iii Ins le ft. arm
a bove
th e
elbo w , n ian ked paim i in th ie le ft p ant
o f h is ch est am id b )ac k ,
i1 0 0 l 1 )a l ill
th it righ t sh io iu i(le r are a .
Ihi(
a tlm nit tim ig d ia gm io ao es
Ope l i
oollimllinut(( lraoture of
th e
d ista l t m id o f t .h io lo f t litllllerus w it h n di al -m ie rv e l)ares is ; lra ct.u rts o f th e s( to n(I th iro ug h tu e e igh th
rib s o tt t .ii( . righ t. ; a m i d ( O Il if lh il lu te ( f ra ot ur es o f
th e t.h ir(l th rough e ig h th ribs 0 )1 1 the le ft w ith a
I li ti l o h es t.
al i ( l
I L l n ao tu m eo r igh t
s( apu la .
Im iit.ia liy , the re as o i ily sl igh t re str ic tion o f ex ten sio n
0)1 the finge rs at the
m fl ( ta ( a r po phl a l a m i -
goal jo)ilit . s am itl o il the w rist. o n th e left w ith (liffuse hy pes the sia to ligh t . touc h thro ug hou t. the le ft
ha miol ,
espec ially o n its
( lonsona dia l
aspect .
S inc e
th e chest in ju ry took l)reo (d enco, at firs t om ily
o l# {2 3 3} li ni tl em e m it . 0 )1 the w oun d in
th e
arm w a s d one
with im m lio l)iliz atio li o f th e
h itim era l fra cture im i a
iialmii-t.o-axilla
plaster
tas t.
R e(h lec k of the fin ge n-w nis t m ov em ents les s th ian tw e uity -fo un ho lun s
after injury showed complete loss of do )rsiflex ion o f 1)0 th th e wrist and the fingers .
At operationi filt4eii day s after the in ju ry the p rox im al
p o r tio n o f
th e rad ial nerve wa s freed and
t raced (arolullv
int.oI
th e dista l pant o f th io arm. Th e mitrve w as
c om p lete ly en m eshie ti in
th e
f i br o us
t
issu e a r o u nd
th e frac tu re . T he ne rvo w as in co m itin u itv :
a m i o i ,
alter
hi t i m l g
disset.ttoi fre e f rom its
f i h ro u i s tissue 1)0 01 ,
it.
w as d isp lated la tera lly a ual the fra ctu re of th e h ium orus w as re du ced an d
fix ed b y
m e ans o f a pla te a nd fo ur sc rew s.
-
7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382
4/8
F R A C T U R E S O F T H E H U M E R U S 1385
O n e of the fac tons to no te h ere wa s the fa ilu re to o b ta in appo sition of the fragm ents af ter initial
d #{23 3}b n id em en t an d im m ob iliz ation in a p laster c ast
(F ig . 3 ). T h is shou ld have sugg es ted th at the
ne r v e
wa s in terposed b e tw een th e frag m ents as wa s a lso the s itua tion in C ase 5 . T hree m onths
a fte r opera tio n ac tiv ity o f the ex tenso r ca rp i re tu rned and five m on th s afte r op era tion fu ll finger
ex ten sio n w as noted . F u ll re tu rn o f p o w e rfu l fin ge r an d w ris t m otion w as no ted a t eigh t m onths .
T he o n ly residuu m at on e year w as sligh t hypes th esia in the ana tom ica l snuff box .
C A S E 3 . M .W ., a w om an , f ifty yea rs o ld , fe ll in h en b ath tub , lan d in g o n h en left arm . S h e
reported im m edia te pa in and gro ss defo rm ity of the le ft a rm , bu t rem ain ed a t hom e for tw en ty -
fou r h ours. A t th at tim e exam ina tion revea led a sp iral f ractu re o f the sh af t o f th e d is ta l pa rt o f
th e h u m e ru s w ith c om p le te p a ralysis of m otor an d sen sor y com p on en ts of th e r ad ia l n e rve . A t
opera tion fo rty -e igh t h ours af te r the in ju ry , the d ista l hum era l frag m en t wa s im media tely v isib le
in th e p r oxim a l en d o f th e w o u n d .
T h e tip of
th is fragm ent had p ie rced th e m u scle an d com e ou t
th rou g h a r en t in the fasc ia in to the subcu taneous tissue . Im m edia te ly in ev idence , just m ed ia l
to the d ista l fragm ent and la te ra l to the prox im al frag m en t, wa s the rad ial ne rve . A defin ite con-
tu sion of the nerve a t the leve l o f th e frac tu re lin e
wa s
v is ib le . T he n erve w as resting be tw een the
tw o frag m en ts o f bo ne a t the po in t w here it w ou ld no rm ally have p ie rced the la teral sep tum .
T he nerv e
w as
re m o v ed fr o m its p osition be tw een the tw o ends of the frac tu re and
w as
d isp laced
to th e rad ial side of the d ista l frag m ent. T he frac tu re
wa s th en r ed u ced an d
he ld by tw o screw s .
T h e re w as r etu r n o f m u scle fu n c tion in th e fin g er s an d w r ist five m on th s after su r ger y , w ith
persisten t hy pes the sia in the an ato m ical snu ff box and a tin g ling se nsa tio n in the sam e a rea .
C A S E
4 . L W ., a m an , th irty -th ree years o ld , wa s w or k in g o n a sc affo ld o n a b rid g e w h en
he fe ll tw en ty fee t, sus tain ing an op en com m inu ted frac tu re o f the le ft hum eru s w ith com ple te
r a di a l -ne r v e
paralysis. H e a lso fra ctu re d hi s n ig ht cla vicle. In itia lly the w ound wa s debrided and
a
ligh t p laste r cas t w as app lied . T he w ou nd becam e in fec ted and dra ined . E xp lo ra tion of the
fr actu r e s ite w a s d ela yed for th r ee m on th s .
A t opera tion it w as fou nd tha t the n erve w as sev ered an d d isp laced to the m ed ia l s id e of
th e d is tal hum era l fragm ent, w here
it w as bou nd d ow n in m ark ed scar tissue . T he nerve en ds
w er e id en tified a n d r ep air ed b y e nd -t o- en d su ture a fter c u tting ba ck the nerv e en ds to satis fac to ry
nerve tissue. T h is rep air w as don e u nde r m od era te ten sio n .
T h e retu rn of som e d o rsiflex ion p o w e r of th e w rist an d se n sa tio n w as first n ot(( seve n m o n th s
fo llow in g the nerve
r e p air .
C A S E 5*# {149 }.G . (U .S .N .), a m an ,
tw en ty yea rs
o ld , b rok e h is le ft a rm
w hile p lm Ly ing foo tbal l.
T h e ex trem ity w as im m o bilized in a sp lin t and tw o days la ter h e
wa s tra nsferre d from a n av al
d isp en sary to a hosp ita l. O n adm is sio n the re w as ba rely de m o nstrab le w e akn ess o f w rist a nd
fin ge r e xten sion on th e
le ft s id e . T here w as hypes th es ia in the d is tribu tion
of th e rad ia l n er ve .
T he fractu re o f th e hum eru s w as m anipu la ted and he ld in a p laste r su gar -ton g sp lin t. l)u rin g th e
n ex t ten
d ays , w h ile the ar m w as im m ob il iz ed
in
th is sp lin t, th e ra d ia l-ne rve w e akn es s gradu ally
in cre ase d , an d n um bn ess in
the reg ion o f th e ana tom ica l snu ff b ox in the le ft han d deve loped .
At
opera tio n th e rad ia l n erve w as traced upw ard an d foun d , w ith
m u l)O rtio n of m usc le , to
r u m m i
righ t th ro ug h th e prox im a l p ort ion of the f rac tu re cle ft. T he nerve w m t.s
freed up
to
th e po in t
w he r e
it passed th rough the in term u scu lan se p tu m , then th e ho le th rou gh th is w as en larged to
let th e n e rve slid e fr ee . T he in ten l)o sed tis su e w as rem o ved from the frac tu re site , and the
fr a c tur e
w a s re du ced
ana tom ically and
h eld b y m ea ns of tw o scre w s an d a plaste r ca st.
C A S E
6 . C .K . (U .S .N .), a m an , tw en t. - th ree yea rs o ld , w h ile w o rk ing m tb oan d a tu g , stis -
tah ied a com minu ted fra ctu re of th e d ista l th ird of th e sh aft o f the hu m e rus w hen he fell in to th e
w a ter (F ig . 4 ). W rist-d ro p w as n oted on ad m is sio n to the h osp ita l on the d ay of th e acc ide n t.
A K irs ch ne n win e w as p laced th ro ugh the o lec ran on , and the arm w as th en p lac ed in b alan ced
t ra ctio n. E le ctro my og na ph ic
studies
d on e six d ays later sh ow ed n o activ ity in m o to r u n its su p -
p l ie d by th e rad ial ne rve .
O n th e n in th
da y afte r the in ju ry the fra ctu re in th e d is ta l p art o f the n igh t hu m e rus w a s
e xp lor ed an d th e rad ia l n e rve wa s foun d to be con tused over a d is tan ce of ab ou t on e an d on e-h a lf
in ch es at the le vel o f th e frac tu re s ite bu t to be g ros sly in tac t. In je cting sterile sal ine so lu tio n
i n to
th e n e rv e r ev eale d th e n e u n ilem m al sh ea th to b e in ta ct. A c cord in g ly the n erv e w as rem ove d
fr o m th e frac tu re site, an d th e fra ctu re w as re d u ce d an d held
with
tw o sc re w s. M u scle tissu e w as
p laced be tw een the rad ia l ne rve and the frac tu re s ite . A n ax illa -to -pa lm plas te r cast wa s ap p l ie d
a f te r w o und c lo su re.
C A S E 7 . W .B . (U .S .N .) , a b oy eigh tee n ye ars o ld , in a n a u to m o l)ile acc ide n t, sus ta in ed m m .
* N avy p erso nn el tran sfe r to the ir h om e are a an d w e are u na b le to o b ta in fo llow -up .
V O L . 4 5 -A , N O .
7,
O C T O B E R 1 9 6 3
-
7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382
5/8
1386
A R T h U R
HOLSTEIN ANI) G. B. L E W I S
T H I J O UR NA l. O F B O N E A N 1 ) J t) IN T S U R G E R Y
cOIiilliimitittt
lra tt tir ( o il th e shal t o f the r igh t hu ne rus in th e ( lista l tlii ro l w ith tom plete loss of
na i : t l -m i o r v o
lu m ictio m i, am i
o i n ( o m illf liliu t( ( I fr a ctu re
o f th io left tib ia , :011 (1 a clo sod fn acturo o f th e
nig h t litto ra l n ia llo o lus. In i tia l ly a p laster sI)h in t. w as use d for th e lra ttt ired hu m e rus . T h is w as
th ang to l to a h am ig im ig p la sto r cast. Hotmitgetiograms t h itn re vo alo d th at, t h it b on e c I l d S w or t m io it in
o o im i t ac t . T h o r o \ V I O 5 1 1 0 re tu nm i oil rad ial-m ie rve lun tt ion o l ur i m l g t h e f irs t lo iti r v oo ks afto r Ira ct tire .
.-
opo r a t ion twe ntv-n imie o lay s a lter illjtuv, th e
miorve
w a s foun d to l it
approxinlattly
90
iier ten t . stv o roo l at
t he
frao t u ro site w it h i om d a t h iin ten uou s I ia m id o o m ln e( ting the tw o en ds.
iho
n o m v e (m io ls
t.ra iip otI in t h o f ib ro u s callus at t h o f ractu re s ito . T he em itls of t h o miervo w o r e
lresh ionoo l
a mi ol a i i li ro xim n at o o
w it h i (1 000 00 si lk s tit u ros.
The fract tilt
\VIS
iI lilllo iliiliZ tO l im i
a
plaster
ca st . (
)ne m u o in th
la to m
t
lie
tia tiem it fell w it 11
ro ( un-
r e nt t o il pa in at t he l ra ct tm i o s it o , m it . m it i o h ia ng o
im i 1 io is ititill o f
th e
liaot. tire.
Cont. imiuod
i l l imo-
b il iz at io ii n es ul t( o l
in
b on o u mi it in .
W h e n
th e
patio n t w a s l :tst see n , t h ero b at. Ii ten m iti
r t tur n
oi l
nerve f tm n ctiom i. N oi fo llow -im p w a s p oss ih ilo .
F it; . 4 F in . 5 F it ;. (1
l i t i . 4 : ( tso 6 . (
O im liI liiillite (l fra ct u ro
w ith t l Ie
t
h iird lragm iit m it o isp la tt t n lo (iia llv a nd the (list m o l
frag nitm it ill t
lie t li:tm :tct .tristic lio is it .io in
it Ii o )v( rn i thn g a m id ra tlia l (1 ov iatio im l o il i ts tirox im a l end .
F ig . 5 : ( )l 34 1 frao t tire s of the h um noral shal t th is w a s th i t o im ily fra ctu re un it im i the d ista l om ie- tliind
vliioli
assooiatoo. l
i t h ia r s is o il
t
lie
ra d ial ne rve .
Fig .
6:
F ixa tion o il a sin i l)le sP in al lra otu rt w ith tw o i sorow s al to r r (n io iv al o il t he m iorv e fro m th e
l r ao tu r o s i to .
(
AS E
S . 1 . \Io L ., a ho t filteem i
o ld , s tis t :i .im iod a sp i la l fr:n t ou t in th e m nio ld lo o i ie-th ird
oil t h e h iu nio ru s \ t h i in j um y to t .h i( rad ial m io rv e cau sim ig los s of sem isatio m l
(iii
th e (lo rsum of the
h iamio betwt
Ii
t li t firs t and sec o ii( illt tac a .m lia ls l)u t no m tm st lo w eak mie ss (Fig. 5 ). A han gin g p las ter
cas t w as
applied.
( )m i t l it fo llo lw ing t av , it
\s . :ls mlote(
t h at t h io
patient
w as tim ia l ile to e x te m io l th ie
th iu m iib am id
t
hit fim ige rs fu lls a t th it m o ta oa r o ipha lam ig eal jo iin ts . ( ) m i the ten th d ay fo llo iw ing th e
in j u n , w ith m io i a o o itiona l trea tm em it
,
tho ro wa s
o v i o ( m i ( e
0)1 ro ttm rm i o f ra o ia l-m io rvo lu m a -tio n . T he
p at io n t con do a gain txtond t h o thun i l i an t f ingers , am se misa t io in ha m o t m rno t . 1 he re w as li ii
re t u rn o il rao ia l-nem v o lt im ittiom i o um in g im m iio b iliz a t lo in ill tilt
iilas t en
cast .
Ih is ease is m nem iti(Ined m ere ly to illu s tra te w ha t is ho t fliem tiit h W t.h ie syndro m e
lihi(I(
(0
)iisi(l(iltO u 1 . A li io ii g 34 1 h um uera l frac t tire s th is w as the o o il y ( ni e w it in the
d is tal o iie -th iird w hich
a s a sso ci: tt(o l
w ith im iju irv
tti
th ie rad ia l iie rve ,
-
7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382
6/8
F R A C T U R E S O F T F IE H U M E R U S
1 3 8 7
V O L . 4 5 -A , N t) . 7 , O ( TO B ER
1963
D is c us s ion
I ii th is frac tu re syndro n ie, the re a re ce rtain factors w h ich do i io t v ary . Ihe
fracti.ire is a lw ay s in the d ista l one-th ird of t.he hu m erus; it is spiral with rad ia l
m tiig u ia tio ii m it. th e fiacture si te and o verrid ing of th e d ista l fragm eiit; an d the re is
invo lvemen t ,
of the rad ial ne rv e, bo th senso ry and n io to r
co in ipom iem its . T he (lilly part
(If the sy m id rom ue th at v ar ies is the degree o f inv o lvem en t of the n erv e ; t.h is invo lve-
n ie iit va ries from co nt usi ol il to co lm pl et e s ev er an ce. Th e
degree
o f traum ua m u st. be
m e lu tive ly v io len t, and th ie re m u s t l)e d efin ite d isp lacem en t (.)f th e fragm en ts o f the
shaft . of the h um uerus as a re su lt o f the iiiju m y if m ierve d am ag e is to occur.
In a
n un li)e r of
these
f ractu res,
an in itia l c lo sed re (lu ctio m i was attempted
; iii
t .w o , mu n io re p rof i lun d rad ial-nerve paia ly sis resu lted . Iloen
t geno gram s , m ad e
af te r
Fm t;. 7
F ix a t io im i (if I t im a o t tilt t hi a p la to a m ioI lou tim s om tvs . H e m o t OI l in) imlut
io u m li: tt ( st tt irt str e w f ix a t io in
imiil)ti)sililt.
Iliu i i ip I i lmtt i ( )h i , revem tle (1 tha t th e frm tgm u en ts \v em e b eim ig he ld ap m im t ie5uf lim th )ly b y
iiiteipositioii
(If So ft tissue . A ll the frac tu res e re eve iitua lly trea ted surg ica lly ,
am id th e in ter l)ose (l so ft tis su ( w as im ivarim ib ly fou iid to im ich ide the ra (hm il nerve ,
sonietimues
to i th e ex ten t thm it the m ie rve
as su r rounded h) V early ca llus h )e tw ee ii the
bone (lid s.
O n the basis o f uur experience , we strong ly adv ise m tgm uim st at tem pte d clo sed
reduc t ion of fractures ouf the d ista l one-th ird (If the h un ie rus w ith (lem iiom is trab le
rad ia l-ne rve p :u esis . \V e reeon im iiem id p rim ary op en reduc tion th rou gh i m iii m uit ero -
lm ute ra l approach . T he m ie rve sho uld be loca ted , d issec ted free , m lii( l d isp lm tced lm it.erm illy
to the d is tm il frm ig n ien t. T he fractu re shou ld then be reduced ; and , because
of its
sp irm il eh m urm tc ter , it cm iii usu m ully be satisfactorily fixed by tw o screw s p lm uced acm s th e
frm .uc tu re . W hen there is sufhciemit coiiimiiinution to iuake s imple screw f ixm ut io n no t
satis fac tory , a
l igh t
btliie
p la te w ith four
sc r e w s
ca n
be use d .
A very ligh t,
p m u l m - t o -
-
7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382
7/8
1388 A R T H U R H O L S T E IN A N D G . B . L E W IS
ax illa han g ing p la ste r ca st is u sed fo r ex te rna l im m ob iliza tion (F igs . 6 and 7 ). T he
o p tim u m tim e fo r ne rv e repa ir , the best m e tho d fo r rep air ing the rad ial ne rve , and
the trea tm en t o f p erm anen t w eakness o f the w ris t an d fin ge r ex ten so rs a re no t the
con ce rn o f th is p ap e r. W e w ish o n ly to em ph as ize tha t the rm td ial ne rv e is freq uen tly
caugh t be tw een the frac tu re su rfaces in th is read ily recog n ized frac tu re m uiid hence
lik ely to be dam aged e ith er a t th e tim e of im iju ry or during trea tm en t.
S u m m a r y
T his pape r p re sen ts seven cases illu stra ting a hum era l-frac tu re synd ro m e corn -
p lica ted b y rad ia l-ne rv e para lysis . T he frac tu re occurs in th e d ista l one -th ird o f the
hum erus a t a po in t w here the rad ia l ne rve co m es th roug h the late ral in t.e rm uscu la r
sep tum and is in con tac t w ith the bon e. D ue to the fo rce of the in ju ry , the prox im al
fragm en t is d isp laced d ista lly , ca rry ing w ith it the in te rm uscu la r sep tu m and th e
rm udim tl ne rve con ta ined w ith in its fo ram en in th e sep tum . A t the sam e tim e th e ap ex
of the d istal frag m en t is m o ved prox im a lly and rad ia lly , la cera ting or trapp in g the
rad ia l ne rve be tw een
the bo ne frag m e n ts . P rim a ry op en red uc tio n is th e tre atm e n t
o f ch o ice fo r th is in ju ry . C losed m a iiipu latio n is con tra -in d icated w h en th e c rite r ia
o f th e syn drom e are p re sen t.
R e fe re nc e s
1. C U N N IN G H A M S T e xt-B oo k of A n a to m n v.
E d. 9 , p p . 253 , 490 , 10 81 . E d ited b y J. C . B rash , N ew
Y o r k ,
O x fo r d U n iv er sity P re ss ,
1951 .
2. M o R R I S
H u m a n
A na to m y . A C om p le te S yste m atic T r eatise. E d. 1 0 , lP 198 , 440 , 1 106 . E d ited
by J . P . Sch aeffen . P h ila de lph ia , T h e B lak isto n C o., 194 2 .
3. 1 E N N S Y L V A N IA O R T H O P E D IC S o C IE T Y , S C IE N T IF IC R E SE A R C H C O M M IT T E E :
F resh M id sha ft
F nm m .ct.u res o f the H um erus in A dults. E va lua tion o f T rea tm en t d uring 19 52 -19 56 . P en nsy lv an ia
M e d .
J. ,
62: 848 -850 , 1 959 .
4.
\ V H I T S o N ,
R . 0 . : R e la tion of the R ad ia l N erve to th e S haft o f the H um erus . J. B one am itl Jo in t
Su n g . ,
36-A : 85-8 8 , Jan . 1954 .
D I S C U S S I O N
l )mu.
B L A N D
W .
C A N N O N , M E M P H IS , T E N N E S S E E : D isc u ssio n of th is p re sen tation fro m a
n eu r olog ica l su rge on n ec essi ta te s th e assu m p tion th at th e m eth od o f tr ea tm en t of fra ctu re of th e
hume rus ,
w ith rad ia l-ne rv e im pa irm en t, depend s on the in teg rity o f the nerve . W e accep t th is
c om p lim e n t, for w e k n ow th at yo u , as o n th op ae d sts , are a w ar e of s in gu laritie s of th is n er ve
vh iich al low s m m .av ora b le resu lt u ltim ate ly , rega rd less of th e m etho d o f trea tm ent .
F or tun ate ly , the u sua l se qu elae of trm m .u m a tic ne urit is an d oth er p ain fu l syn dro m e s in n erv e
in ju ry are esem u peo l because of the ins ign ifican t senso ry com p onen t o f the rad ia l ne rve . R epa ir o f
th is lac erated o r d iv id ed ne rve usual ly y ield s retu nn i o f fun ctio n to all m usc les of its dom ain .
N ot in fre qu en tly , n ear norm a l ne uro log ica l sta tus is o b ta ined .
T he c ruc ial an ato m ical lo cation fo r ra d ial-ne rve in ju ry in fra ctu re of th e
h u m n e ru s is m is I ) n .
Holste in alld D r. L e w is h ave d es ign a te d . H ow ev er , th e d e cis ion to e ffe ct p r om p t o p em i r ed u ctiom i
sh ou ld n ot
be b ased on the ex istence of n er ve p ara lys is. If severance o f the nerv e h as occurred ,
the im m ed iate po st- in ju ry p erio d is no t the o p tim u m tim e for n erve repa ir. If con tus ion , w ithou t
lace ra tion , is found on inspec tio n of the nerv e, on ly lim ited constru c tive in fo rm ation has b een
g ain ed . A la pse of tim e is a lm ost n ece ssa ry in ev alu ating th e fu nct ion ing s ta tu s of th e n erv e. T h e
ap plicat ion of o ur neu ro phy sio log ica l on electrod iag nos tic aids , such a s elec tro m y ogn ap hy , is
usua l ly
im prac tical dur in g the
tw o w e eks
im m edia tely fo llo w ing th is typ e of traum atic n erve
para lys is. T he s ign ifican t ex cep tion to our adv ised de lay is illustra te d b y tw o of I )n . H o lste in
an d D r . L e w is cases, in w h ich a m o re pro fou nd paraly sis fo l low ed c losed re du ctio n .
If you p rod uce o r increase p ara lys is by m an ipu lat ion , p roc eed ing w ith surg ica l v isu alization
a nd d eco m p res sio n o f the ne rve is w ise .
O f the three ca ses de p ic tin g seve ran ce of the nerve, the lapse of
fifteen
d ays , tw en ty-n in e
d ay s, and three m onths, respe ctiv ely , before surg ica l a tta ck pro bab ly im p rov ed t .he c han ce of
success fu l ne rve rep air and neuro log ica l recovery .
A d e lay
in
ne r v e rep air o f
ap pro x im ate ly fifteen day s fm tcili ta te s
m t m o re a c cu r a te de te rmina-
tio n of the
are a of v iab le ne rve in th e con tused m ind dam ag ed pro x im al
an d d is ta l trun ks.
A l so ,
a su ita b le b ed for pro te ctio n of the su ture d nerve can b e
assured.
S u ch fa ctors are of pr im ary
impor tance
in o b ta in ing the b est resu lts. O therw ise , e v id enc e fav ors th e as sum ption tha t the
Co n tinued o n p aqe 148 4
T H E J O U R N A L O F B O N E A N D J O IN T S U R G E R Y
-
7/27/2019 Humero Fx Holstein Lewis -Data Journals JBJS 445 1382
8/8
1484 H . S . U N G E R , L . H . S C H N E ID E R , A N D J O A N N A S H E R
2 . H IN E S , L . E .
: C o m press ion M yelitis S eco ndary to E c h ino c o c cu s D ise a se o f V er te b ra e an d
K i d n ey .
A rch . P a th o l. a n d L ab . M ed ., 1 : 1 80-181 , 19 26 .
3.
H O W O R T H , I. B .: E chino co cco sis o f B one . J. B one and Jo in t S im ng ., 27
:
4 01-41 1, July 1945.
4 . H UT CH IS O N, W . F .;
T H O M P S O N ,
W . B .; and D E R I A N , P . 5 .:
Osse ous
H yda tid (E ch ino coc cus )
I) isea se: R ep ort o f an Ind igen ous C a se. J . A m . M ed. A ssn ., 1 82 : 81-83 , 1 962 .
5.
M I L L S ,
T . J .: P a rap le gia D u e to H y d atid 1)ise ase. J. B one
an d
Jo in t S u rg. , 38 -B : 88 4-8 9 1 ,
Nov. 1 9 5 6 .
6 . R oB IN soN ,
R . G .:
H yd atid D isease of the S p ine and Its N euro log ical C om plicm otions . B ritish
J. Sung . , 47 : 301-3 06, 1 959 .
D I S C U S S I O N
F R A C T U R E S O F T H E
H U M E R U S
C on t inu ed from pa ge 138 8
de gre e m on d ra te o f m m en ve recov ery afte r su tun im u g is m oot in f lue moc e d by lem ig th of tim e b etw een
iiijilry
1 0 1 0 ( 1 o p e r a ti o n .
W e kno w of
n o cm ose o f fra ctu re o f th e h u m eru s im u w h u ich re a i)p n o xim a tion o f a sev ere d rad ia l
m u en ve c ou ld n o t b e effected , p rov id in g n o a vu lsion or tis su e lo ss oc cu rre d .
T hu s, a
neurosurg eo n m igh t su ggest pos tponem ent o f the chosen open reduc tion fo r a t
hem ost tha t pe riod o f t im e n ece ssa ry to cre ate a m ore d es ira b le a p p roa ch to c or rec tin g n e rve d ys -
fu l i c t i o l u .
R E F E R E N C E S
0 1 -1 -o S IT I0 N O F T H E T H U M B A N 1 ) IT S R E S T o R A T Io N
C on tinu ed fron t page 1396
9.
N IC U L A Y SE N , J O H A N :
T ram usp lan t:o tion des M . abd uc to r (jig . V . be i Feh iender ( )ppos i t io io Fbh ig -
k eit de s I)aum en s. l)e u ts che Z eit .sch n . f. C h in ., 16 8 : 1 33 -13 5 , 1 922 .
1 0. R O WN T RE E ,
T o M :
A no m alo us In nerva tion of the H and M usc les . J. B om ie tim id
Jo in t
Sun g., 31 -B :
505 -51 0 , N o v.
1949.
11 .
S A B A T I E R ,
R . B .: T rait#{2 33} d A n ato m ie. P ar is , 1764 .
12 . Sc Ho r r s T A E o T , E . I t.; L A R S E N ,
L . J .; a nd B O S T , F .
C .: C o m p lete M u sc le T r an sp o sitiom u . J .
B o ne a m id Jo in t S t ing ., 37-A : 89 7-919 , O ct. 19 55 .
13 . S U N D E R L A N D , S ., a nd H U G H E S , E . S . It. : M etrica l and N om u-M etn ica l F e to tunes o f the M usc u la r
B ranches of the U lnar N erve .
J.
C om np. N eu no l.,
85
: 1 1 3-123 , 194 6.
14 .
T H O M P S O N ,
T . C . : A Modif ied O p er atio li fo r O p p om oe n s P ara lys is. J. B om ie 9 11(1 Join t S u n g ., 24:
632 -64 0 , J u ly 19 42 .
R E F E R E N C E S
TH E Os O D O N T O I D U E M
C on t inuedfrom page 1471
13 .
P E N n E R G R A s S , E . P .;
S C H A E F F E R , J . P .;
an d H O D E S , P . J .: T h e H e ad a rid N e ck in
Roe n tge l i
l)iagm u osis . E d . 2 , p p . 1 529-1530 . Spn im u gfie ld , Illino is , C harles C . T h om as, 19 56 .
14. S Y M ON DS ,
C . P .;
M E A D O W S ,
S . P .; a nd
T A Y L O R ,
J. : C o m p res sio m o of the S p ina l C ord
in
th e
N eigh bo urh ood o f th e F o r a m e n
M a g n u m
w ith a N ote o n S u r gica l A p p ro ach . B r ain , 60 : 5 2-84 ,
1937 .
15. W A T S O N -JO N E S , R E G IN A L D : F rac tu re s a n d Jo im u t In ju rie s. E d . 4 , V o l. 2 , p . 980 . E d in b u rg h , E .
a n d S . L iv in g sto n e , 19 55 .
T H E J O U R N A L O F B O N E A N D J O IN T S U R G E R Y
top related