One case illustrates many things, not the least of which is the importance of an accurate clinical history.
It is also a good example of how hematomas can rarely enhance, particularly along their periphery.
Cases have been described of chronically expanding hematomas which enhance, simulating a neoplasm (Skel Rad 35:1432, 2006)
Although gadolinium enhancement is often associated with neoplasms, in some cases it can be a red herring, as this case illustrates.
Radial nerve palsy associated with radial shaft fracture is a common occurrence.
Approximately one in ten patients with a humeral shaft fractures will also have associated radial nerve palsy.
In an epidemiologic study of 1.4 million people, the overall incidence of radial nerve palsy in 401 humeral shaft fractures was 8.5%.1
In my own non operative orthopedic study, from 1983 to 1989 of 120 000 people, the overall incidence of radial nerve palsy in 40 humeral shaft fractures is also 8.5% (Basse-Terre, Saint-Claude, Camp Jacob General Hospital, unpublished data).
In a systematic literature review, Shao and investigators2 identified 532 radial nerve palsies in 4,517 radial shaft fractures; an 11.8% incidence of radial nerve palsy.
The management of radial nerve palsy associated with a humeral shaft fracture is a topic of debate.
Although it is known that the majority of these injuries are neuropraxias that will recover spontaneously, the indication and need for operative exploration has been disputed, with authors offering conflicting opinions.
While some surgeons have advocated different treatment algorithms for radial nerve palsies that occur secondary to a closed fracture reduction, others believe that the timing of the nerve palsy is irrelevant to the management decision.
Primary nerve palsies occur at the time of injury and are discovered during the patients initial evaluation.
Approximately 10% to 20% of nerve palsies develop during the course of treatment, commonly noted more often (Basse-Terre) following an open than a closed reduction, and are termed secondary nerve palsies.3
Complete motor loss is present in 50% to 68% (large majority in Basse Terre) of cases of radial nerve palsy, while the others are only partial motor loss or sensory loss.3
While some of the studies reported solely on patients with radial nerve palsies, 21 of the studies included the denominator of total radial palsy and shaft fractures.
In these studies, there were 532 radial nerve palsies in 4517 radial shaft fractures; an 11.8% incidence of radial nerve palsy.
Based on the studies that described the fracture location, the highest incidence of radial nerve palsy occurred for fractures in the distal third.
The incidence of palsies was significantly lower for fractures located in the proximal third, then in the middle or distal third.
Table 1. Incidence of radial nerve palsy based on fracture location.
| Fracture location | Incidence | # Palsies/# Total fractures |
| Proximal third | 1.8% | 1/57 |
| Middle third | 15.2% | 27/178 |
| Distal third | 23.6% | 37/157 |
Transverse and spiral fracture patterns were significantly (P < .001) more likely to be associated with a radial nerve palsy than oblique or comminuted fractures .
Table 2. Incidence of radial nerve palsy based on fracture pattern.
| Fracture pattern | Incidence | # Palsies/# Total fractures |
| Transverse | 21.2% | 47/222 |
| Spiral | 19.8% | 19/96 |
| Oblique | 8.4% | 15/179 |
| Comminuted | 6.8% | 26/382 |
They reported no statistical difference in the incidence of radial nerve palsy in open vs closed fractures.2
Table 3. Incidence of radial nerve palsy based in open versus closed fractures.
| Fracture Type | Incidence | # Palsies/# Total fractures |
| Open | 18.2% | 51/280 |
| Closed | 14.8% | 137/929 |
In this literature review, which included a total of 1045 radial nerve palsies, the overall recovery rate was 88.1% (921/1045).
No significant difference in the recovery rate between primary (occurring at the time of injury) and secondary (occurring after the injury, or as a result of a closed reduction) nerve palsies was reported.
The mean time to the onset of recovery, reported in only five studies that included 101 patients, was 7.3 weeks (range: 2 weeks to 6.6 months).
The mean time to full recovery, reported in only five studies that included 110 patients, was 6.1 months (range: 3.4 months to 12 months).
Table 4. Recovery rate of radial nerve palsies.
| Type of palsy | Recovery rate | # Recovery/# Total palsies |
| Overall rate | 88.1% | 921/1045 |
| Primary | 88.6% | 632/713 |
| Secondary | 93.1% | 121/130 |
Controversy exists over the recommended timing for surgical exploration of radial nerve palsies.
Debate also exists over whether nerve repair or tendon transfers are the best treatment option for a transacted or permanently injured radial nerve.
Most surgeons suggest obtaining an initial electromyogram at 6 weeks following the injury if there has been no return of radial nerve function.
Thomsen and Dahlin8 recommend an electrodiagnostic examination at 5 to 6 weeks after injury and nerve repair and reconstruction within 2 months, not later than 3 months, after injury.
Ekholm and colleagues1 recommends exploration at 4 to 6 months if there is no resolution following a primary radial nerve palsy.
However for patients with indications for earlier operative fixation (eg, multiple trauma, open fractures, segmental or bilateral fractures, floating elbow, and nonunions), they advocated exploration of the nerve at the time of internal fixation.
Others note that the first sign of nerve recovery may be delayed as long as 6 months following injury.5
Ring and investigators5 suggest basing the timing of operative treatment on the patients willingness to continue wearing a radial nerve brace.
For patients wanting to be brace-free and satisfied with a hand that opens but does not have independent extension, they suggest tendon transfers at 6 months.
For patients who are comfortable wearing a brace, they recommend waiting until 12 months to see if they are one of the patients whose recovery is delayed in nature.
Nerve exploration may be considered in select patients (eg, patients with multiple nerve injuries in whom tendon transfer is not an option) at 6 months.
Verga and colleagues9 reported that in the absence of functional recovery, delayed surgical treatment (neurolysis or nerve grafts) performed 3 to 4 months after primary orthopedic treatment can be useful in achieving good functional recovery and subjectively satisfying results.
My experience is one of conservative treatment with early bracing both of the fracture (Sarmiento functional brace) and of the palsy.
1. Ekholm R, Adami J, Tidemark J, et al. Fractures of the shaft of the humerus: An epidemiologic study of 401 fractures. J Bone Joint Surg Br. 2006; 88:1469-1473.
2. Shao YC, Harwood P, Grotz MRW, 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; 87:1647-1652.
3. DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006; 31:655-663.
4. Foster RJ, Swiontkowski MF, Bach AW, Sack JT. Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am. 1993; 81:121-124.
5. Ring D, Chin K, Jupiter JB. Radial nerve palsy associated with high-energy humeral shaft fractures. J Hand Surg Am. 2004; 29:144-147.
6. Shah JJ, Bhatti NA. Radial nerve paralysis associated with fractures of the humerus. A review of 62 cases. Clin Orthop Relat Res. 1983; 172:171-176.
7. Holstein A, Lewis GM. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am. 1963; 45:1382-1388.
8. Thomsen NO, Dahlin LB. Injury to the radial nerve caused by fracture of the humeral shaft: Timing and neurobiological aspects related to treatment and diagnosis. Scand J Plast Reconstr Surg Hand Surg. 2007; 41:153-157.
9. Verga M, Peri Di Caprio A, Bocchiotti MA, Battistella F, Bruschi S, Petrolati M. Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: Review and evaluation of the long-term results of 52 cases. J Hand Surg Eur. 2007; 32:529-533.
