What is the best course of action for a patient with periscrew loosening post Open Reduction Internal Fixation (ORIF) for a mid shaft humeral fracture and a radial nerve lesion?

Management of Periscrew Loosening Post-ORIF Mid-Shaft Humeral Fracture with Radial Nerve Lesion

This patient requires revision surgery with hardware removal/revision fixation and concurrent radial nerve exploration, given the dual complications of mechanical failure (periscrew loosening) and neurological compromise.

Immediate Surgical Intervention Required

Hardware Failure Management

• Periscrew loosening represents mechanical failure of the initial fixation and necessitates revision surgery to prevent further displacement, nonunion, or complete hardware failure 1
• The loosening indicates inadequate stability for fracture healing and must be addressed surgically rather than observed 1
• Revision options include:
  • Removal of loose hardware with new plate fixation using different screw trajectories
  • Conversion to intramedullary nailing if bone quality permits
  • Bone grafting if there is evidence of nonunion or bone loss 1

Radial Nerve Management Strategy

The presence of radial nerve injury in the setting of hardware complications strongly favors acute surgical exploration rather than expectant management 2, 3:

• In traumatic radial nerve palsy associated with humeral shaft fractures requiring surgical fixation, 62% of surgeons prefer ORIF with acute nerve exploration 3
• The combination of hardware failure and nerve injury creates a compelling indication for exploration, as the nerve may be:
  • Entrapped by loose hardware or callus
  • Compressed by the failing construct
  • Lacerated or severely contused requiring repair 2, 4

Surgical Approach and Technique

Perform open reduction and internal fixation revision with concurrent radial nerve exploration and neurolysis 5:

• Use a posterior or posterolateral approach to access both the fracture site and radial nerve in the spiral groove 4
• Identify the radial nerve proximal and distal to the fracture site before hardware manipulation 4
• Consider transhumeral anterior radial nerve transposition if multiple future revisions are anticipated, as this protects the nerve from implant irritation and simplifies subsequent procedures 6
• Document nerve continuity and perform neurolysis if the nerve is intact but compressed 5
• If nerve laceration or neuroma is identified, perform primary repair or nerve grafting as indicated 2

Timing Considerations

• Surgery should be performed urgently (within days to 1-2 weeks) rather than emergently, allowing time for:
  • Preoperative planning and imaging assessment
  • Optimization of soft tissues if significant swelling present
  • Coordination with peripheral nerve surgery expertise if available 2
• The combination of hardware failure and nerve dysfunction does not permit prolonged observation, as progressive displacement or nerve compression may worsen outcomes 3, 4

Postoperative Management

Nerve Recovery Monitoring

• Serial clinical examinations every 4-6 weeks to assess motor and sensory recovery 2
• Electrodiagnostic studies (EMG/NCS) at 6-8 weeks postoperatively if no clinical improvement to assess for nerve regeneration and guide further management 2, 5
• If no recovery by 3-4 months post-exploration with confirmed nerve continuity, consider delayed nerve reconstruction or tendon transfers 2

Fracture Healing Surveillance

• Radiographs at 2 weeks, 6 weeks, 12 weeks, and as needed until union 1
• Monitor for signs of re-loosening, infection, or nonunion requiring additional intervention 1

Critical Pitfalls to Avoid

• Do not pursue expectant management of the hardware failure hoping for spontaneous nerve recovery—the mechanical instability will compromise both fracture healing and nerve recovery potential 3, 4
• Do not delay nerve exploration beyond the revision surgery, as this represents the optimal opportunity to assess nerve integrity without requiring a separate procedure 5, 3
• Avoid inadequate proximal and distal nerve exposure, which may miss the site of injury or entrapment 4
• Do not assume nerve recovery will occur without addressing the mechanical cause (loose hardware) that may be contributing to ongoing compression 2, 4