Combined Median, Ulnar, and Radial Nerve Injury after a Spiral Humeral Shaft Fracture

Abstract

Summary: We report the case of a 43-year-old woman who presented with combined radial, median, and ulnar nerve palsies and a spiral humeral shaft fracture after falling down stairs. Postinjury, the patient did not recover full median, ulnar, and radial nerve function despite aggressive hand therapy. Electrodiagnostic studies and imaging findings were concerning for traction neuropraxia or transection, radial nerve neuroma, and scar encasement of the radial, median, and ulnar nerves. The patient underwent radial, median, ulnar, and musculocutaneous nerve neuroplasty, nerve wrap application, nerve stimulation and laser angiography. Surgical exploration revealed no transection injuries to the median, ulnar, or musculocutaneous nerves. The radial nerve was tethered to the fracture site and enlarged, but no neuroma was observed. Laser angiography demonstrated intact perfusion to all nerves. The patient went on to recover full nerve function. Although isolated radial nerve palsies associated with closed humeral shaft fractures are typically observed initially, management of combined nerve palsies is controversial. This case serves to caution surgeons to perform a thorough neurovascular examination on patients with humeral shaft fractures to identify combined nerve palsies.