International Orthopaedics (SICOT)

DOI 10.1007/s00264-016-3397-7

ORIGINAL PAPER

Transfracture medial transposition of the radial nerve associated

with plate fixation of the humerus
Ali Hassan Chamseddine 1,2 & Amer Abdallah 1 & Hadi Zein 1,2 & Assad Taha 3

Received: 31 August 2016 / Accepted: 28 December 2016

# SICOT aisbl 2017

Abstract Conclusion Transfracture transposition of the radial nerve

Purpose The aim of this study was to illustrate safety, feasi- during open reduction and internal fixation of humeral shaft
bility and advantages of transfracture medial transposition of fractures is a safe, harmless and feasible procedure when ap-
the radial nerve during the lateral approach and lateral plating plied for fractures of the middle and distal humeral shaft; it
of humeral fractures located in the mid and distal shaft. removes the nerve from the surgical field during fracture ma-
Methods This was a retrospective review and analysis of med- nipulation and fixation, with a gain in length of the nerve by
ical records and radiographs of 19 patients who underwent a transforming its course from spiral to straight. Following ra-
transfracture medial transposition of the radial nerve. Fifteen dial nerve transposition across the fracture, a repeat surgical
patients were treated for fresh fracture and four for nonunion. approach to the humerus for hardware removal or treatment of
All patients were followed up clinically and radiographically nonunion transforms the procedure into a simple one; the skin
for a minimum of 12 months. incision is carried straight down to the bone without the need
Results Pre-operative radial nerve paralysis was present in to identify or dissect the nerve that was previously transposed
four patients in the fresh fractures group; post-operative paral- to the medial compartment of the arm.
ysis occurred in two. All patients completely recovered a few
months after the index procedure. Except for two, all patients
achieved bone healing. One patient from the fresh-fracture Keywords Humeral shaft fracture . Open reduction and
group developed nonunion, and one from the nonunion group internal fixation . Humeral shaft fracture . Humerusnonunion .
experienced persistent nonunion; both underwent successful Radial nerve . Radial nerve transposition
revision surgeries. In addition, four patients with a fresh frac-
ture underwent revision surgery for hardware removal. All but
two patients showed no restricted elbow or shoulder joint Introduction
motion compared with the opposite side.
The unique anatomic location and trajectory of the radial
nerve in the arm generally causes technical difficulties during
open reduction and internal fixation (ORIF) of humeral shaft
* Ali Hassan Chamseddine fractures [1–4]. In addition, a revision surgery for nonunion or
achamsedine@hotmail.com hardware removal is always hazardous because of the in-
creased risk of injuring the radial nerve that runs directly over
1
Division of Orthopaedic and Trauma Surgery, Faculty of Medical
the plate and is usually surrounded by fibrous scar tissue [5].
Sciences, Lebanese University, Hadat, Beirut, Lebanon The aim of transfracture transposition of the radial nerve is to
2
Division of Orthopaedic and Trauma surgery, Sahel General
displace the nerve from the plate so there is virtually no danger
Hospital. University Medical Centre, PO Box 99/25, of injury during revision surgery. This technical method has
Ghoubeiry, Beirut, Lebanon seldom been reported in the literature, in either clinical or
3
Division of Orthopaedic surgery, American University of Beirut cadaveric studies [5–10]. We report our experience with 19
Medical Centre, Beirut, Lebanon patients in whom a transfracture medial transposition of the
 International Orthopaedics (SICOT)

radial nerve was performed during open reduction and lateral fracture and another with nonunion, underwent revision sur-
plating of the humerus. geries for occurrence and persistence of nonunion respectively.

Operative procedure
Materials and methods
The surgical procedure for fresh fractures followed the de-
This was a retrospective review of medical records and X-rays scription previously reported by two of the authors [10].
of patients in whom a transfracture radial nerve transposition Under general anaesthesia, the patient is placed in a
was performed between January 2008 and December 2015. semisitting position, with the forearm resting on an arm board.
There were 19 patients, six of whom were the subject of a The skin incision is along a portion of a line extending from
preliminary report by two of the authors [10]. In 15 patients, the deltoid insertion on the humerus (deltoid V) to the lateral
the procedure was carried out during plating of a fresh frac- epicondyle and extended proximally into the deltopectoral
ture, while in the remaining four, it was performed during interval when needed. The radial nerve is initially identified
treatment of nonunion and autologous iliac bone grafting. between the vertical fibres of the brachialis muscle and the
There were ten men and nine women ranging in age between oblique fibres of the brachioradialis muscle. The nerve is then
20 and 74 (mean 39) years. The right side was affected in 11 dissected anteriorly and distally between these two muscles.
patients and the left side in eight. The cause of the fracture The lateral intermuscular septum is carefully opened at the
could be specified from the medical records of 13 patients, as emergence of the radial nerve. The proximal part of the nerve
follows: road traffic accident (5), sports injury (3), fall at home is dissected proximally and posteriorly to create a space be-
(3), fall from the first floor (1) and blast injury (1). All frac- tween it and the radial groove at the posterior aspect of the
tures, excluding the blast injury, were closed and displaced humerus. This step typically consists of blind careful dissec-
upon presentation. Fracture location and Arbeitsgemeinschaft tion of this part of the nerve using the tip of the index finger,
für Osteosynthesefragen (AO) classification is shown in along with a cautious pulling manoeuvre of the proximal hu-
Table 1 for fresh fractures and Table 2 for nonunion. Pre- meral fragment using a bone clamp or a thumb–index pinch
operative radial nerve paralysis was present in four fresh frac- using the other hand; this should result in complete separation
tures (Table 1). No patient in the nonunion group had radial of the radial nerve from the posterior aspect of the humerus. A
nerve paralysis at the time of the index procedure. Plate and limited elevation of the brachialis and brachioradialis muscles
screw types used for fixation are detailed in Table 3. from the distal humeral fragment is performed as needed,
All patients had an arm sling for seven to ten days after along with dissection of the medial intermuscular septum in
surgery and underwent immediate post-operative rehabilitation order to prepare the future anteromedial bed of the nerve. At
with active and active-assisted mobilisation for range of mo- the end of the dissection, the radial nerve should be complete-
tion (ROM) recovery of shoulder and elbow joints. All were ly liberated and freely movable from its most proximal to
clinically and radiographically evaluated at one to two month distal part as it emerges from the lateral intermuscular septum.
intervals and up to 12 months after surgery to assess fracture The two main bone fragments are then gently distracted, and
healing, ROM and radial nerve function. Four patients with the fracture site is angulated to allow gentle transposition of
fresh fractures presented back two to three years postfixation the nerve from the lateral to the medial side of the humerus;
for hardware removal because of annoyance and pain at the the nerve should ideally Bfall^ from lateral to medial through
lateral aspect of the distal humerus due to soft tissue irritation the two main humeral fragments, which have been distracted
by a prominent end of the plate. Two patients, one with fresh and angulated (Fig. 1). Fracture reduction and plating is next

Table 1 Fifteen patients treated

for fresh fracture: Location AO type
Arbeitsgemeinschaft für (n)
Osteosynthesefragen (AO) type Simple spiral: Transverse < 30°: A3 (4) Spiral wedge: B1 (8) Total
according to location and preop- A1 (3)
erative radial nerve paralysis
Mid shaft 0 2 (pre-operative radial nerve 4 6
paralysis in 1)
Distal 3 0 4 (pre-operative radial nerve 7
third paralysis in 3)
Distal 0 2 0 2
fourth
Total 3 4 8 15
International Orthopaedics (SICOT)

Table 2 Four patients treated for

nonunion: Arbeitsgemeinschaft AO type
für Osteosynthesefragen (AO)
type according to location and Location (n) Transverse < 30°: A3 (3) Spiral wedge: B1 (1) Total
previous method of fixation
Distal third 0 1 1
Distal fourth 3 0 3
Previous fixation Plate and Screws: 2 IM nail
IM nail + plate and screws + cerclage: 1
Total 3 1 4

IM intermedullary nail

carried out according to AO principles and as dictated by each plate and the Lecestre distal humerus plate, all 17 other plates
particular fracture pattern (Fig. 2). The radial nerve is now were intra-operatively molded to fit the proximal and distal
displaced to its new location at the medial aspect of the hu- lateral aspects of the humerus, as needed.
merus and lies within the muscular mass of the brachialis,
lateral and anterior to the medial intermuscular septum Repeat surgical procedure after radial nerve transposition
(Fig. 3).
When the procedure is applied to patients with nonunion, A repeat procedure was necessary in six patients: hardware
the same surgical steps for radial nerve dissection are per- removal in four patients from the group with fresh fractures,
formed after careful identification of the nerve within the sur- and two new cases of nonunion (one patient from each group).
rounding fibrous scar tissue; transposition of the nerve through Exposure of the lateral plate inserted during radial nerve trans-
the nonunion site is accomplished after removal of the pre- position was performed using a straightforward incision from
existing hardware [plate and screws or intermedullary (IM) the skin down to the plate, without attempting to identify or
nail] and complete surgical release of the nonunion site. expose the radial nerve, which had already been transposed
After nerve transposition, the nonunion is treated according medially (Fig. 6). Plates used to treat the two new cases of
to the initial fracture pattern: parallel cuts of the nonunion nonunion were molded to fit the lateral aspect of the humerus.
edges with mild shortening of the humerus (1 cm) and fixation
with compression technique in three cases (AO type A3)
(Figs. 4 and 5) and reduction with interfragmentary compres- Results
sion along with careful debridement and refreshment of the
nonunion area in one case (AO type B1). A bone graft, har- Radiographic bone healing
vested earlier from the inner table of the posterior iliac crest,
was applied at the site of nonunion for all four cases at the end Fourteen patients with fresh fractures showed complete bone
of fixation. Except for the anatomic proximal humerus locking healing between three and five months postfixation. One patient

Table 3 Plate and screw types

according to Arbeitsgemeinschaft AO type & location (number) A1: A3: A3: B1: B1: A3: B1: Total
für Osteosynthesefragen (AO) Hardware for fixation (number) FF FF FF FF FF NU NU
fracture type, patient group and D 1/3 MS D 1/4 MS D 1/3 D 1/4 D 1/3
fracture location (A1, A3, B1: AO
type) (3) (2) (2) (4) (4) (3) (1)

Conventional broad plate (1) 1

CS 4.5
Conventional lecestre plate (1) 1
CS 3.5
LCP anatomic PHP (1) 1
LHS 3.5
LCP metaphyseal plate (2) (2) 4
LHS 5.0 & 3.5
LCP broad plate (3) (2) (2) (1) (3) (1) 12
LHS 5.0
Total 3 2 2 4 4 3 1 19

FF fresh fracture, NU nonunion, D 1/3 distal third, D 1/4 distal fourth, MS mid shaft, PHP proximal humerus
plate, LCP locking plate, CS conventional screws, LHS locking head screws
 International Orthopaedics (SICOT)

group had persistent nonunion after the index procedure; he

underwent two further operations in another centre and present-
ed back to us with a 10-cm bone loss at the nonunion site. He
was successfully treated according to a three-stage protocol: (1)
hardware removal with extensive debridement, culture and ap-
plication of back slap; (2) three weeks later, a broad locking
plate and screws with antibiotic-impregnated cement spacer
was inserted, which restored humeral length; (3) six weeks later,
the spacer was removed and replaced with a hemifibula, along
with abundant cancellous iliac bone graft.

Radial nerve paralysis

The four patients with preoperative radial nerve paralysis from

Fig. 1 Intra-operative photograph showing medial transposition of the the fresh fracture group completely recovered between three
radial nerve through the fracture site after distraction and angulation of the
two main bony fragments (from [10], with permission
and seven months post-operatively. Two other patients from
the same group developed a transient post-operative radial
with a fresh fracture was a 59-year-old woman who sustained a nerve paralysis, which completely recovered after two and
midshaft spiral wedge fracture extending to the proximal third six months, respectively. None of the four patients treated
(AO type B1) and treated with a long anatomic proximal hu- for nonunion or the six who underwent revision surgery de-
merus locking plate. She developed nonunion and was consid- veloped post-operative radial nerve paralysis.
ered a technical failure; she was successfully revised at one year
with insertion of a broad locking plate, debridement of the Shoulder and elbow range of motion
nonunion site and application of cancellous iliac bone graft.
Three patients in the nonunion group achieved bone healing At the 12-month follow-up, a 42-year old man from the non-
between seven and nine months. A 48-year old man from this union group treated with shortening, compression and bone

Fig. 2 Radiographs of distal third

fracture [Arbeitsgemeinschaft für
Osteosynthesefragen (AO) type
B1] a before and b after fixation
using interfragmentary compres-
sion and metaphyseal locking
plate following medial radial
nerve transposition
International Orthopaedics (SICOT)

graft had a 10° extension lag of the elbow but a full range of
shoulder motion. The 59-year old woman from the fresh-
fracture group who developed nonunion due to technical rea-
sons underwent successful revision but with a resultant 10°
limitation of forward elevation and external rotation in shoul-
der abduction. All other patients showed no restricted elbow
or shoulder ROM compared with the opposite side.

Discussion

The unique anatomic location of the radial nerve in the arm

puts it in danger of injury during humeral shaft fractures and
surgical intervention. As many as one third of radial nerve
palsies associated with humeral fractures occur at the time of
surgery [2, 4]. Although preoperative radial nerve paralysis
was reported in 10–18% of cases, with spontaneous recovery
in the majority [1, 3, 11–15], faster and more complete recov-
ery has been associated with early ORIF [16]. Post-operative
radial nerve paralysis occurs in 4–6.5% of patients, with spon-
taneous recovery in 80–90% [1, 11, 12, 14, 15]. Finally, non-
union and infection may complicate humeral ORIF in 2.8–
Fig. 3 Intra-operative photograph after medial transposition of the radial 5.8% and 1–5% of cases, respectively [12].
nerve and fracture fixation. Note the lateral position of the plate and the Causes of post-operative radial nerve paralysis are poorly
new location of the radial nerve, which is now completely running medial
to the humerus into the bed of the brachialis muscle in the medial documented in the literature. This complication is generally
compartment of the arm (from [10], with permission] thought to be related to laborious reduction manoeuvres, in-
appropriate placement of bone holders and retractors,

Fig. 4 a, b Pre-operative
anteroposterior (AP) and lateral
radiographs of a 32-year-old pa-
tient with nonunion of the distal
fourth of the humerus
[Arbeitsgemeinschaft für
Osteosynthesefragen (AO) frac-
ture type A3]. c, d Post-operative
radiographs showing fixation
with compression after shortening
and copious application of can-
cellous bone graft following radi-
al nerve transposition. e, f
Radiographs at 9 months showing
complete bone healing
 International Orthopaedics (SICOT)

humerus. We prefer using a broad plate (Table 3), and this

necessitates further nerve dissection, resulting in more ten-
sion–elongation by the additional mass and bulk effect of
the plate itself [5, 8]. Insertion of the plate on the medial aspect
of the humerus through an anterolateral skin incision has been
reported [3, 16, 17]: the interval between biceps and brachialis
muscles is dissected with protection of the musculocutaneous
nerve; the medial aspect of the humerus is then exposed by
longitudinal division of the medial aspect of the brachialis
after external rotation of the arm. This procedure is usually
performed without exposure of the radial nerve, and it avoids
any conflict between nerve and plate. Plate positioning on the
anterior surface of the humerus using an anterior approach for
fractures of the distal shaft [18] includes radial nerve control,
with plate placement relatively distant from the nerve. A pos-
terior approach to the humeral shaft, with plate insertion un-
derneath the radial nerve on the posterior aspect of the humer-
Fig. 5 Intra-operative photographs showing position of the radial nerve us has also been used [19].
(black arrow) in a 42-year-old patient with nonunion of the distal fourth
of the humerus [Arbeitsgemeinschaft für Osteosynthesefragen (AO) frac-
Although transfracture transposition of the radial nerve
ture type A3]: a Nerve running over the pre-existing plate before trans- during lateral and posterior approaches has sometimes been
position; b nerve located medial to the humerus after transposition and proposed in association with ORIF of humeral shaft fractures,
fixation of the nonunion using a broad locking plate it has not been advised as a routine procedure [5–10]. The aim
of transposition was to remove the radial nerve from the sur-
overstretching of the nerve over the plate, unintended com- gical field (particularly during complex reduction–fixation
pression of the nerve underneath the plate and inadvertent manoeuvres), reduce tension on the nerve during surgical ma-
direct injury from the surgical blade [6]. The nerve is frequent- nipulation, avoid wrapping of the nerve around the plate at the
ly encountered and manipulated during reduction and plating end of fixation and thus avoiding a stretched nerve [5–10].
of humeral shaft fractures. The usual application of the plate Mutz [20] reported that anterior transposition of the radial
underneath the radial nerve causes overstretching, which is nerve induces length gain in the nerve by converting it from
directly related to plate thickness and width [6]. Elongation spiral to straight course. Pollock and Birch [21] reported an
of the nerve by 5 mm has been reported over a lateral humeral amazing case of traumatic medial transposition of the radial
narrow plate 3.2-mm thick and 13-mm wide in a cadaveric nerve with paralysis complicating an open fracture of the hu-
study by El Ayoubi et al. [6]; these authors recorded 11-mm meral shaft; the nerve was returned to its anatomical location
length gain in the nerve when it was experimentally trans- during treatment of nonunion after a few months. In 1949,
posed through the fracture site to the medial aspect of the Schnitker [22] described a technique for transhumeral fracture
transposition of the radial nerve, with cadaveric illustrations,
and recommended this procedure in complicated cases of
midshaft humeral fractures during ORIF; however, supportive
clinical data was not provided.
Besides our preliminary report [10], we found two with
limited clinical series on transfracture radial nerve transposi-
tion during ORIF of humeral shaft fractures [5, 6]. Another
preliminary clinical report in the Korean language [9] was not
really exploitable, except for its English abstract. All these
reports stated that this procedure is technically feasible, harm-
less and safe. Three articles [6–8] reporting this procedure on
cadaveric specimens concluded that it does not compromise
nerve (or any nerve-branch) anatomy in terms of measure-
ment. However, the decision for transposition should be con-
sidered intra-operatively [6] on the basis of surgeon experience
Fig. 6 Intra-operative photograph during a lateral humeral plate removal.
and judgment [5, 6]. It is usually advised if the risk of non-
Note complete plate exposure and absence of the radial nerve from the union and revision surgery is high [5]. Olarte et al. [5] reported
surgical field that pre-existing stripping at the fracture site is suitable for
International Orthopaedics (SICOT)

transposition and is a contributing factor for potential devel- existing injury to the nerve; in contrast, the gain in nerve
opment of nonunion, which makes even more sense for trans- length secondary to transposition may contribute to its func-
position in such situations. El Ayoubi et al. [6] stated that the tional recovery. On the other hand, like others [5], we believe
suitable indication for transposition is a comminuted fracture that transposition has great and distinct advantages,
of the middle and distal third of the humerus, with a transverse preventing complications during subsequent procedures such
or oblique fracture line running in the same direction of the as hardware removal or treatment for nonunion; the radial
spiral groove and associated with radial nerve paralysis. nerve is constantly surrounded by fibrous scar tissue in such
However, this procedure would also be very helpful even circumstances.
when the radial nerve is not affected, especially if the surgeon A repeat surgical approach to the previous site of fixation
encounters laborious reduction–fixation manoeuvres and faces was performed in six patients in our series: four with fresh
difficulties inserting a lateral plate under the nerve during the fractures underwent hardware removal due to irritation from
lateral approach [6]. The ideal situation for transposition in- a prominent place at the lateral aspect of the distal humerus, as
cludes a fracture location that lies between 2 cm proximal and reported by the patients themselves. Another patient from the
7 cm distal to the midshaft of the humerus, a comminution that same group experienced nonunion and was eventually suc-
results in humeral shaft shortening and soft tissue disruption cessfully revised. Lastly, one patient from the nonunion group
with traumatic spontaneous dissection of the radial nerve [6]. continued to have a resistant nonunion; he underwent five
After reporting our preliminary experience [10], we inten- revision surgeries that finally achieved bone healing. None
tionally began using this technique during ORIF of all humer- of these six patients developed radial nerve paralysis after
al shaft fractures located in the area defined by El Ayoubi et al. repeat surgery, which was very simple. The lateral incision
[6]. In addition, we extended our indications to the treatment was carried from the skin to the plate without the need to
of humeral shaft nonunions in the same area. As far as we identify the radial nerve, which had been previously trans-
know, this procedure has not previously been reported for posed to the medial aspect of the humerus. El Ayoubi et al.
such an indication. [6] and Olarte et al. [5] made the same comment after treating
Pre-operative radial nerve paralysis was seen in four pa- one and two cases, respectively, of nonunion that occurred in
tients (26.6%) in our group of 15 fresh fractures, in three their respective series of six and ten cases with previous radial
(30%) in the series of ten patients by Olarte et al. [5], in three nerve transposition.
(50%) in the series of six by El Ayoubi et al. [6] and in two Although radial nerve dissection in the four patients in our
(33%) of the Korean series of six by Lee et al. [9]. Although nonunion group was technically more difficult (the nerve was
those incidences are high, all patients recovered after surrounded by a fibrous scar tissue), reduction of the nonunion
transfracture medial transposition of the radial nerve and frac- site was easier after transposition, and there was no post-
ture fixation (no mention regarding radial nerve recovery in operative radial nerve paralysis. In addition, we noticed that
8). El Ayoubi et al. noted that the radial nerve was in continu- the new location of the nerve makes it safer when positioning
ity in their three cases with pre-operative paralysis: contused the bone graft around the nonunion, avoiding enclosing or
in two and stretched in one. Although we also noted absence encircling the nerve in all six cases treated for nonunion (four
of macroscopic discontinuity of the radial nerve in our four at initial presentation and two following the index procedure)
cases with pre-operative paralysis, the nerve was trapped in (Fig. 4).
the fracture site in one patient and compressed by bony frag- This technique can be criticized because of the potential for
ments in the other three. Olarte et al. [5] did not clarify the additional devascularisation of the humerus related to a more
condition of the radial nerve in their three cases that presented extensive dissection. However, there was no increased inci-
with pre-operative paralysis. Post-operative radial nerve paral- dence of nonunion in our series compared with the literature:
ysis occurred in two patients in our group of 15 fresh fractures 6.6% for fresh fractures and 10.5% for the whole series. In
and in none of the four in the nonunion group or the six who addition, we believe the only case of nonunion in the group of
underwent revision surgery after transposition. Olarte et al. [5] 15 patients with fresh fracture was due to a lack of stability
mentioned no iatrogenic radial nerve paralysis in their report, secondary to using a long proximal humerus locking plate
and El Ayoubi et al. [6] observed one case of post-operative with 3.5-mm locking screws; this plate is relatively thinner,
paralysis, which they attributed to laborious reduction ma- less rigid and less stable than the classically recommended
noeuvres performed before transposing the nerve. All in- broad plate. Treatment of nonunion in this patient was suc-
stances of post-operative paralysis eventually recovered cessfully achieved by easily removing the pre-existing plate
completely (our two cases and the case by El Ayoubi et al.). and refreshing the nonunion site, followed by another fixation
We also believe, like these authors [6], that radial nerve dis- using a broad locking plate with locking head screws of 5.0-
section and transposition does not jeopardise nerve function as mm diameter and iliac bone graft.
much as fracture manipulations do. We hypothesise that radial A broad locking plate was used in 12 patients in our series
nerve transposition per se neither harms nor worsens any pre- (Table 3). This plate is 5.2-mm thick and 17.5-mm wide [23]
 International Orthopaedics (SICOT)

and consequently thicker and wider than that used in the ca- 4. Guse TR, Ostrum RF (1995) The surgical anatomy of the radial
nerve around the humerus. Clin Orthop Relat Res 320:149–153
daveric study by El Ayoubi et al. [6]. It is, therefore, expected
5. Olarte CM, Darowish M, Ziran BH (2003) Radial nerve transposi-
to cause more nerve stretching if the nerve is left in its original tion with humeral fracture fixation. Preliminary results. Clin Orthop
anatomic location, thus wrapping around the plate and extend- Relat Res 413:170–174. doi:10.1097/01.blo.0000072470.32680.60
ing across its width at the end of fixation. The case of persis- 6. El Ayoubi L, Karmouta A, Roussignol X, Auquit-Auckbur I,
tent nonunion that occurred in a patient with initial nonunion Milliez PY, Duparc F (2003) Transposition antérieure du nerf radial
dans les fractures du 1/3 moyen de l’humérus: bases anatomiques et
might be expected because of the devascularisation during the applications cliniques. Rev Chir Orthop 89:537–543
initial surgery, which consisted of combined ORIF using a 7. Bacakoglu AK, Kiray A, Muratli K, Ekin A, Ergur I (2007)
plate, an IM nail and cerclage wires. Medial transposition of the radial nerve for anterolateral
plate fixation of the humerus: cadaveric study. Anat Sci Int
82:116–120. doi:10.1111/j.1447-073x.2007.00174.x
8. Yakkanti MR, Roberts CS, Murphy J, Acland RD (2008) Anterior
Conclusion transposition of the radial nerve: a cadaveric study. J Orthop
Trauma 22:705–708
We believe that transfracture medial transposition of the radial 9. Lee SU, Kim WY, Kang SH, Park YS, Rhee SK (2008) Medial
nerve is a feasible and safe procedure. The ideal fracture po- transposition of radial nerve in distal humerus shaft fracture: a re-
port of six cases. J Korean Fract Soc 21:240–243
sition in which to use this technique lies between 2 cm prox-
10. Chamseddine AH, Zein HK, Alasiry AA, Mansour NA, Bazzal AM
imal and 7 cm distal to the midshaft of the humerus. After (2013) Trans-fracture transposition of the radial nerve during the
medial transposition, the radial nerve is removed from the open approach of humeral shaft fractures. Eur J Orthop Surg
surgical field, routed away from the fixation hardware and Traumatol 23:725–730. doi:10.1007/s00590-012-1065-1
protected by the brachialis muscular bed in a good and favor- 11. Bonnevialle P (1996) Fractures récentes et anciennes de la diaphyse
humérale. In: Duparc J (ed) Conférences d’enseignement de la
able vascular environment, resulting in a shorter course with
SOFCOT 1996. Cahiers d’enseignement de la SOFCOT № 55.
less tension. We favour this procedure during the lateral ap- Expansion Scientifique Française, Paris, pp 79–96
proach to the humerus when treating fresh fractures and non- 12. Paris H, Tropiano P, Clouet D’Orval B, Chaudel H, Poitout DG
union of the middle and distal humeral shaft, especially when (2000) Fracture diaphysaire de l’humérus: ostéosynthèse
laborious intra-operative manipulations are needed for reduc- systématique par plaque. Rev Chir Orthop 86:346–359
13. Holstein A, Lewis GB (1963) Fractures of the humerus with radial
tion and fixation. In addition, it has important advantages nerve paralysis. J Bone Joint Surg Am 45-A:1382–1388
when a potential revision surgery is highly expected, as in 14. Osman N, Touam C, Masmejean E, Asfazadourian H, Alnot JY
the treatment of nonunion or hardware removal. This transpo- (1998) Results of nonoperative and operative treatment of humeral
sition avoids the difficult and hazardous revision step of dis- shaft fractures. A series of 104 cases. Ann Chir Main 17:195–206.
secting the nerve that is engulfed in scar tissue. Finally, the doi:10.1016/S0753-9053(98)80039-2
15. Alnot JY, Le Reun D (1989) Les lésions traumatiques du tronc du
patient should be clearly informed by the surgeon about the nerf radial au bras. Rev Chir Orthop 75:433–442
procedure and provided with a detailed report to be handed to 16. Pailhé R, Mesquida V, Rubens-Duval B, Saragaglia D (2015)
any surgeon that may be involved in subsequent treatment. Plate osteosynthesis of humeral diaphyseal fractures associ-
ated with radial palsy: twenty cases. Int Orthop 39:1653–
Compliance with ethical standards 1657. doi:10.1007/s00264-015-2745-3
17. Dayez J (1999) Plaque vissée interne dans les fractures récentes de
Conflict of interest None. la diaphyse humérale de l’adulte. Rev Chir Orthop 85:238–244
18. Kim SJ, Lee SH, Son H, Lee BG (2015) Surgical result of plate
osteosynthesis using a locking plate system through an anterior
Funding None.
humeral approach for distal shaft fracture of the humerus that oc-
curred during a throwing motion. Int Orthop. doi:10.1007/s00264-
Ethical approval None. 015-2895-3
19. Capo JT, Debkowska MP, Liporace F, Beutel BG, Melamed E
(2014) Outcomes of distal humerus diaphyseal injuries fixed with
References a single-column anatomic plate. Int Orthop 38:1037–1043.
doi:10.1007/s00264-013-2213-x
20. Mutz SB (1974) Anterior transposition of radial nerve. J Bone J
1. Böstman O, Bakalim G, Vainionpää S, Wilppula E, Pätiälä H,
Surg (Am) 56-A:1092
Rokkanen P (1986) Radial palsy in shaft fracture of the humerus.
Acta Orthop Scand 57:316–319 21. Pollock RC, Birch R (1999) Complete transposition of the radial
2. Samardzic M, Grujicic D, Milinkovic ZB (1990) Radial nerve le- nerve complicating an open fracture of the shaft of the humerus.
sions associated with fractures of the humeral shaft. Injury 21:220– Injury 30:623–625
222 22. Schnitker MT (1949) A technique for transplant of the
3. Bèzes H, Massart P, Fourquet JP, Finet P, Tazi F, Tourné Y, Faigt B musculorspiral nerve in open reduction of fractures of the mid-
(1995) De l’intérêt de synthéser par plaque vissée bon nombre de shaft of the humerus. J Neurosurg 6:106–113
fractures de la diaphyse humérale. A propos de 246 synthèses. Int 23. Mathys, Synthes®,Catalogue 2003/2004. www.mathysmedical.
Orthop 19:16–25 com