Radial nerve palsy following plate osteosynthesis of shaft humerus in relation to posterior verses anterolateral approach

Bishnu Prasad Patra, Saroj Kumar Patra


Background: Fracture shaft of humerus is a relatively common upper limb injury. Although it can be managed conservatively still surgical management is the recent trend worldwide. Open reduction and plate osteosynthesis is the gold standard and commonly practiced method of management. Iatrogenic radial nerve palsy following fracture fixation is a usual complication. Though most cases recover with time, but the incidence is variable in different approach. We compared two common approaches for fixation of middle 1/3rd of shaft of humerus fracture based on frequency of secondary radial nerve palsy and fracture healing.

Methods: A prospective comparative study of management of all middle 1/3rd shaft humerus fracture was undertaken in our institute from Jan 2012 to Nov 2014. Total 42 patients were operated in this period of which six patients lost to follow up, so all total 36 cases were included in the study. Among these 36 patients 16 patients were operated by posterior approach and rest 20 were operated by Anterolateral approach. All patients were followed up at 2nd post-operative day, 2 weeks, 6 weeks, 3 months, 6 month and 1year. Frequency of radial nerve palsy with its outcome and fracture union was accessed in postoperative follow-ups.

Results: There were total 3 cases of iatrogenic radial nerve palsy found in patients operated by posterior approach but all these patients recovered by average 5 month (3 to 6 months). There was not a single case of radial nerve palsy seen following humerus fixation by anterolateral approach. All 36 patients had good radiological union by 1 year, of which 2 patients of anterolateral approach and 1 patient from posterior approach required bone grafting to achieve union.

Conclusions: Both the approaches had similar outcome in terms of fracture healing but there was significant difference in frequency of secondary radial nerve palsy, commonly seen in posterior approach.



Humerus fracture, Anterolateral approach, Posterior approach, Radial nerve palsy, Fracture union

Full Text:



Brinker MR, O’Connor DP. The incidence of fractures and dislocations referred for orthopaedic services in a capitated population. J Bone Joint Surg Am. 2004;86:290-7.

Schemitsch EH, Bhandari M. Fractures of the diaphysealhumerus. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma. 3. Toronto: WB Saunders. 2001:1481-1511.

Bohler L. Conservative treatment of fresh closed fractures of humerus. J Trauma.1965;5:464-8.

Sarmiento A, Zagorski JB, Zych DO, Latta LL, Capps CA. Functional bracing for the treatment of fractures of humeral diaphysis. J Bone Joint Surg Am. 2000;82:478-86.

Koch PP, Gross DF, Gerber C. The results of functional (Sarmiento) bracing of humeral shaft fractures. J Shoulder Elbow Surg. 2002;11:143-50.

Rommens PM, Verbruggen J, Broos PL. Retrograde locked nailing of humeral shaft fractures. A review of 39 patients. J Bone Joint Surg Br. 1995;77:84-9.

Ulrich C. Surgical treatment of humeral diaphyseal fractures. In: Flatow E, Ulrich C, editors.Humerus. Oxford: Butterworth-Heinemann. 1996:128-143.

Foulk DA, Szabo RM. Diaphyseal humeral fractures; natural history and occurrence of nonunion. Orthopaedics. 1995;18:333-5.

White WL, Mick GM, Mick CA, Brooker AF, Jr, Weiland AJ. Non union of humeral shaft.ClinOrthop. 1987;219:206-13.

Jupiter JB, Vandec M. Ununited humeral diaphysis. J Shoulder Elbow Surg. 1998;7:644-53.

Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures-the Basal experience. J Trauma. 1993;35:226-32.

Robinson CM, Bell KM, Court-Brown CM, McQueen MM. Locked nailing of humeral shaft fractures; experience in Edinburg over a two-year period. J Bone Joint Surg.1992;74B:558-663.

Brumback RJ, Bosse MJ, Poka A, Burgess AR. Intramedullary stabilization of humeral shaft fractures in patients with multiple trauma. J Bone Joint Surg. 1986;68:960-70.

Chao T-C, Chou W-Y, Chung J-C, Hsu C-J. Humeral shaft fractures treated by dynamic compression plates, Ender nails and interlocking nails. IntOrthop. 2005;29:88-91.

Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14:162-6.

Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures: a meta-analysis. ActaOrthop. 2006;77:279-84.

Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87(12):1647-52.

Paris H, Tropiano P, ClouetD’orval B, Chaudet H, Poitout DG. Fractures of the shaft of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot. 2000;86:346-59.

Cooney WP. Humeral fractures: operative treatment, complication, and reconstruction surgery. In: Evarts CM, editor. Surgery of the musculoskeletal system. 2nd ed. New York: Churchill Livingstone. 1990:1600-33.

Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am. 1996;78(11):1690-5.

Thompson JE. Anatomical methods of approach in operations on the long bones of extremities. Ann Surg. 1918;68(3):309-29.

Lim KE, Yap CK, Ong SC, Aminuddin Plate osteosynthesis of the humerus shaft fracture and its association with radial nerve injury: a retrospective study in Melaka General Hospital. Med J Malaysia. 2001;56(Suppl C):8-12.

Dabezies EJ, Banta CJ, 2nd, Murphy CP, d'Ambrosia RD. Plate fixation of the humeral shaft for acute fracture, with and without radial nerve injuries. J Orthop Trauma. 1992;6(1):10-3.

Holsetin A, Lewis GM. Fractures of the humerus with radial-nerve paralysis. J Bone Joint Surg Am. 1963;45(7):1382-8.

Hoppenfeld S, deBoer P. Surgical exposures in orthopedics: the anatomic approach. Philadelphia: JB Lippincott; 1984.

Tsai CH, Fong YC, Chen YH, Hsu CJ, Chang CH, Hsu HC. The epidemiology of traumatic humeral shaft fractures in Taiwan. IntOrthop. 2009;33:463-7.

Raghavendra S, Bhalodiya HP. Internal fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective study. Indian J Orthop. 2007;41:214-8.

McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg. 2000;82-B:336-9.

Seddon H. Nerve lesions complicating certain closed bone injuries. JAMA. 1947;135:691-4.