What is the management of radial nerve lesion after Open Reduction Internal Fixation (ORIF)?

Management of Radial Nerve Lesion After ORIF

For radial nerve palsy identified after ORIF of humeral fractures, initial observation with serial clinical monitoring is the appropriate management for at least 7 months, as 90% of these injuries are recoverable neuropraxias and the probability of spontaneous recovery remains above 50% even at 7 months post-injury. 1, 2

Initial Assessment and Classification

When radial nerve dysfunction is identified after ORIF, the critical first step is determining whether the palsy was present preoperatively or developed postoperatively:

• Preoperative palsies (83% of cases) typically represent neuropraxia from the initial trauma and have excellent recovery rates 2
• Postoperative palsies may indicate iatrogenic injury but still have favorable prognosis with observation 2
• Immediate postoperative assessment should document the specific motor deficits: inability to extend wrist against gravity (Medical Research Council grade <3), finger extension weakness, and thumb extension/abduction deficits 2, 3

Observation Protocol and Timeline

The evidence strongly supports watchful waiting as the initial management strategy:

• 90% of radial nerve injuries after humeral fracture fixation are recoverable (95% CI: 87-92%), representing neuropraxia or recoverable axonotmesis 2
• At 7 months without recovery, the probability of eventual recovery by 18 months remains 56% (range 48-62%) 2
• At 12 months without recovery, probability drops to 17% (range 13-21%), which becomes the critical decision point for surgical intervention 2

Serial clinical monitoring should include:

• Monthly assessment of wrist extension strength against gravity 2, 3
• Documentation of finger and thumb extension recovery 3
• Pain assessment using standardized scales 3
• Functional assessment of activities of daily living 3

Surgical Exploration Indications

Nerve exploration or reconstruction should be considered when:

• No recovery by 12 months post-injury, as probability of spontaneous recovery falls to 17% 2
• Known nerve transection identified intraoperatively during initial ORIF requires immediate primary repair 1, 4
• Progressive neurological deterioration during observation period 1
• Severe associated injuries involving extensive soft tissue damage or vascular injury may warrant earlier exploration 4

Surgical Options When Indicated

When surgical intervention becomes necessary after failed conservative management:

• Nerve grafting provides excellent or good functional recovery in 83% of cases, even for delayed repairs at 7 months 4
• Primary or secondary end-to-end suture repair achieves Grade 3 or better motor recovery in 83-91% of cases 1
• Neurolysis (external or internal) for lesions in continuity achieves 98% recovery to Grade 3 or better 1
• Tendon transfers are reserved for: failed nerve surgery, delays >12 months post-injury, extensive forearm muscle defects, or elderly patients 4

Rehabilitation During Observation Period

Physical therapy should begin immediately after ORIF, regardless of nerve status:

• Active range of motion exercises for all unaffected joints to prevent stiffness 3
• Wrist splinting in functional position to prevent contracture during denervation 3
• Cryotherapy for pain and edema management 3
• Progressive strengthening as motor recovery occurs, including grip strengthening interventions 3
• Functional training for activities of daily living adaptations 3

Critical Pitfalls to Avoid

Early surgical exploration is not beneficial - The high spontaneous recovery rate (90%) and maintained probability of recovery through 7 months makes early surgery (before 7-12 months) unlikely to improve outcomes and risks additional iatrogenic injury 2

Do not miss iatrogenic nerve transection - If nerve disruption is identified during initial ORIF, immediate primary repair achieves 91% recovery to Grade 3 or better motor function 1

Avoid prolonged observation beyond 12 months - Once probability of recovery drops to 17% at 12 months, continued waiting delays definitive reconstruction and may compromise outcomes 2, 4

Patient factors do not predict recovery timing - Age, fracture location, vascular injury, and fixation type show no association with timing of radial nerve recovery, so these should not influence the observation timeline 2

Prognostic Counseling

Patients should be counseled that:

• Most radial nerve palsies after ORIF recover spontaneously (90% overall recovery rate) 1, 2
• Recovery typically occurs within 7 months, but can take up to 18 months 2
• Surgical options remain available if spontaneous recovery does not occur by 12 months 1, 4
• Functional outcomes are excellent with either spontaneous recovery or surgical reconstruction when appropriately timed 1, 4