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Difficulty: MediumOrthopedic Surgery

A 34-year-old construction worker arrives at the trauma center following a workplace accident. He was struck on the right arm by a swinging metal pipe. He reports severe pain in his right arm. His vital signs are within normal limits. Examination of the right upper extremity reveals marked swelling and an obvious angular deformity in the middle of the upper arm. The overlying skin is intact. When asked to move his hand, the patient demonstrates a "wrist drop" and cannot actively straighten his fingers at the metacarpophalangeal joints. He reports numbness over the back of his right hand near the thumb. Radial and ulnar pulses are strong and symmetrical. An X-ray confirms a closed, displaced transverse fracture of the midshaft of the humerus. Which of the following is the most appropriate initial management for this patient?

  1. Placement of a coaptation splint and clinical observationAnswer
  2. B
    Surgical exploration of the radial nerve with fracture fixation
  3. C
    Nerve conduction studies to assess the severity of the deficit
  4. D
    Doppler ultrasonography of the upper extremity arterial system
  5. E
    External fixator application for temporary stabilization

Answer

Placement of a coaptation splint and clinical observation
The correct initial management for a closed midshaft humerus fracture with a primary radial nerve palsy (present at the time of injury) is conservative, consisting of fracture stabilization (e.g., placement of a coaptation splint) and clinical observation. The radial nerve runs in the spiral groove along the posterior midshaft of the humerus, making it highly susceptible to injury. However, the majority of these injuries are neurapraxias (nerve contusion or stretching) rather than nerve transections, and they will recover spontaneously over 3 to 4 months. Immediate surgical exploration is not required unless the fracture is open, there is an associated vascular injury, or the nerve palsy develops only after an attempted closed reduction (suggesting nerve entrapment).

Step-by-Step Solution

1
Diagnose the primary injury and its complication from the clinical presentation and imaging.
The patient has a closed midshaft humerus fracture complicated by a primary radial nerve palsy (indicated by wrist drop and dorsal web space numbness).
Identifying the specific nerve involved and the nature of the fracture (closed vs. open) dictates the treatment algorithm.
2
Determine the indications for surgical intervention in midshaft humerus fractures.
Surgical indications include open fractures, vascular compromise, polytrauma, or a radial nerve palsy that develops after an attempted closed reduction. None of these are present.
Primary radial nerve palsy in a closed humerus fracture is most often a neurapraxia, which does not require acute surgical exploration.
3
Select the appropriate conservative management.
The correct management is immobilization of the fracture with a coaptation splint (or hanging arm cast) and close observation of the nerve deficit.
Fracture stabilization promotes healing, and allowing time for spontaneous nerve recovery avoids unnecessary surgical risks.

Key Concept

Management of closed midshaft humerus fractures with primary radial nerve palsy
Estimated Time:1m 30s
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Topics

Orthopedic Surgery

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