Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.
Harvard Combined Orthopaedic Surgery Program, Boston, MA, USA.
J Shoulder Elbow Surg. 2021 Dec;30(12):2711-2719. doi: 10.1016/j.jse.2021.04.025. Epub 2021 May 5.
Nerve palsy is common after humeral shaft fracture, with the radial nerve being the most commonly injured nerve. Isolated nerve injuries usually recover spontaneously, and operative intervention is rarely indicated. Our goal was to study the predictors of traumatic nerve injury and recovery in a large cohort of patients with humeral shaft fractures.
A total of 376 patients with humeral shaft fracture, including 96 patients with documented traumatic nerve palsy and 280 with intact neurovascular examination on presentation, were retrospectively included in the study. The primary outcome was incidence of a traumatic nerve palsy, and the secondary outcome was nerve recovery.
Nerve palsy was present in 96 patients (25.5%) at the time of injury. Radial nerve was the most commonly injured nerve (93.6%), followed by the ulnar (5.1%) and axillary (1.2%) nerves. Seventeen patients (17.7%) had multiple nerves palsies. A multivariable regression analysis revealed that the concomitant vascular injury (odds ratio [OR] 52, 95% confidence interval [CI] 5.6-480.6), distal one-third fractures (OR 6.3, 95% CI 2.7-14.7), and middle one-third (OR 2.8, 95% CI 1.2-6.5) vs. proximal fractures, open fracture (OR 2.1, 95% CI 1.1-4.4), and high-energy trauma (OR 1.7, 95% CI 1.1-2.9) were independent predictors of nerve palsy. Iatrogenic nerve injury was detected in 7 patients (4.6%), all affecting the radial nerve. Spontaneous recovery of traumatic nerve injuries was detected in 87 patients (91%), with 19% partial and 72% complete recovery. The initial sign of recovery was observed at median times of 7 and 9 weeks for those managed conservatively or fracture fixation. Operative treatment of the fracture had no effect on the outcome of nerve recovery (88.5% vs. 100%, P = .14). Ten patients (14.1%) had transected nerves at the time of exploration and open fractures (22.7% vs. 6.8%, P = .04), and concomitant vascular injury (33.3% vs. 7.3%, P = .02) were associated with nerve transection, portending a worse prognosis for nerve recovery compared with nerves in continuity (40% vs. 95.3%, P = .004).
The incidence of nerve injury after humeral shaft fracture was 25%, reflecting an abundance of high-energy and open injuries in this cohort. Ninety-one percent of patients experienced improvement in their nerve function with a median time to recovery of 7-9 weeks. Operative treatment of the fracture did not change the rate of nerve recovery. Patients with multiple nerve palsies and concurrent vascular insult had worse nerve recovery. We recommend nerve studies if no sign of recovery is observed by 9 weeks.
肱骨干骨折后常发生神经麻痹，其中桡神经最易受损。单纯性神经损伤通常会自发恢复，很少需要手术干预。我们的目标是在肱骨干骨折的大样本患者中研究创伤性神经损伤和恢复的预测因素。
回顾性纳入了 376 例肱骨干骨折患者，其中 96 例有明确的创伤性神经麻痹，280 例在就诊时神经血管检查正常。主要结局是创伤性神经麻痹的发生率，次要结局是神经恢复情况。
96 例（25.5%）患者在受伤时存在神经麻痹。桡神经最常受累（93.6%），其次是尺神经（5.1%）和腋神经（1.2%）。17 例（17.7%）患者有多处神经麻痹。多变量回归分析显示，合并血管损伤（比值比[OR]52，95%置信区间[CI]5.6-480.6）、远段三分之一骨折（OR 6.3，95%CI 2.7-14.7）和中段三分之一（OR 2.8，95%CI 1.2-6.5）与近端骨折相比、开放性骨折（OR 2.1，95%CI 1.1-4.4）和高能外伤（OR 1.7，95%CI 1.1-2.9）是神经麻痹的独立预测因素。7 例（4.6%）患者发生医源性神经损伤，均累及桡神经。87 例（91%）创伤性神经损伤患者出现自发性恢复，其中 19%部分恢复，72%完全恢复。接受保守治疗或骨折固定的患者，最初的恢复迹象分别在 7 周和 9 周时观察到。手术治疗骨折对神经恢复的结果没有影响（88.5% vs. 100%，P =.14）。10 例（14.1%）患者在探查时神经断裂，开放性骨折（22.7% vs. 6.8%，P =.04），合并血管损伤（33.3% vs. 7.3%，P =.02）与神经断裂相关，与连续性神经相比，预后更差（40% vs. 95.3%，P =.004）。
肱骨干骨折后神经损伤的发生率为 25%，反映出该队列中存在大量高能和开放性损伤。91%的患者神经功能改善，恢复的中位数时间为 7-9 周。骨折的手术治疗并未改变神经恢复的比率。有多发性神经麻痹和同时发生的血管损伤的患者神经恢复较差。如果在 9 周时没有观察到恢复迹象，我们建议进行神经研究。
