Radial Nerve Compression Secondary to Orthopedic Fixation Plate for Humeral Shaft Fracture: Iatrogenic Double Crush Syndrome

A 24-yr-old woman presented with a left distal humeral shaft fracture after sustaining a fall while snowboarding (Fig. 1A). An open reduction internal fixation (ORIF) including medial and lateral plates was performed 5 days later with no reported complications (Fig. 1B). Upon cast removal 15 days after ORIF, the patient presented with hypoesthesia of the first interdigital space with complete weakness of wrist extension and finger extension, suggesting radial nerve injury. An ultrasound examination was performed to evaluate radial nerve continuity. Ultrasound showed compression of the radial nerve by the surgical material in two locations (Fig. 1C). Based on those findings, a second intervention was performed to remove part of the plate compressing the nerve and the screw that was impaling that same nerve more distally (Fig. 1D). On follow-up approximately 3 months later, the patient had significant recovery of motor response. A second ultrasound examination was done to confirm the resolution of radial nerve conflict with ORIF material (Fig. 1E).FIGURE 1: Initial anteroposterior radiograph showing displaced comminuted fracture of the distal left humerus (A). Post–open reduction internal fixation anteroposterior radiograph showing plates and screws’ location (B). Initial ultrasound showing edema of the radial nerve, with compression between the lateral plate and the humeral shaft on approximately 3 cm in length. There is also a second radial nerve injury caused by a screw from the medial plate going directly through the nerve (C). Postrevision oblique radiograph showing part of the lateral and medial plates that have been removed with removal of proximal screws from both plates (D). Postrevision ultrasound showing no more compression of the radial nerve by the plate and no more impalement of the radial nerve by a screw. As expected, there are some significant changes in the caliber of the nerve (E).Secondary radial nerve palsy after ORIF for humeral shaft fracture can be present in up to 12.2% according to a recent study from Streufert et al.1 involving 261 patients. A recent study of feasibility by Liechti et al.2 (2019) concluded that postoperative ultrasound after humeral shaft fracture ORIF is feasible and reliable to evaluate radial nerve continuity. Cartwright et al.3 (2007) were able to demonstrate a sensitivity of 89% and a sensitivity of 95% in the diagnosis of nerve transection with ultrasound. This vignette supports the idea that ultrasound is a noninvasive technique to evaluate secondary nerve palsy in humeral shaft fracture after ORIF.

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