2002 OITE Question 56

Question

A 30-year-old man sustains the injury shown in figure 9 following a snowmobile accident. The injury is associated with a 10-cm open wound that was managed with local irrigation and functional bracing at a rural hospital. Examination at 1-week follow-up reveals a benign, well-healed wound but no active wrist or finger extension. What is the next most appropriate step in management?

1- electrodiagnostic testing of radial nerve function

2- continued fracture bracing and observation

3- exploration of the radial nerve and plate fixation

4- intramedullary nailing of the fracture

5- external fixation of the fracture

Figures

Answer (click for answer)

Preferred response: 3.

The second reference discusses the need for exploration of a radial nerve palsy with open fractures. In their series of 14 open humeral shaft fractures, 64% had a lacerated or interposed radial nerve. These fractures require rigid fixation after exploration and repair of the nerve. The second answer is appropriate for closed fractures, as discussed in the first reference. In this study, 20 of 59 patients with an immediate complete radial nerve palsy from a closed humeral shaft fracture showed signs of spontaneous recovery within 4 months using conservative management. The mean time to complete recovery was 15 weeks. The 1st, 4th and 5th answers do not involve nerve exploration and thus are not the appropriate management in an open fracture.

Reference: 1) Bostman O, Bakalim G, Vainionpaa S, Wilppula E, Patiala H, Rokkanen P: Immediate radial nerve palsy complicating fracture of the shaft of the humerus: When is early exploration justified? Injury 1985;16:499-502. 2) Forster RJ, Swiontkowski MF, Bach AW, Sack JT: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am 1993;18:121-124.