HOLSTEIN–LEWIS FRACTURE

A 32-year-old man is admitted with an injury to his right arm. He has a dense radial nerve palsy. He tells you that this happened while arm wrestling.

 

1. Describe these radiographs.

These are an AP radiograph of the right humerus and a lateral radiograph of the distal humerus and elbow. These show a displaced fracture in the distal third of the humerus.

 

2. Do you anticipate any potential problems with this fracture pattern?

This particular fracture pattern is often referred to as a Holstein–Lewis fracture. The fracture is at the distal third of the humerus in close proximity to the radial nerve as it passes posteriorly and around the radial aspect of the humerus and through the lateral intermuscular septum where it is in close contact with bone. The radial nerve may become injured through laceration, contusion or stretch at the time of injury and at surgery it has also been found entrapped between displaced fracture fragments.

There is some debate about how this fracture type should be ideally managed. The evidence shows that the vast majority of nerve injuries involve a neurapraxia and resolve over 3–6 months with non-operative treatment. Many surgeons believe that these distal fractures are difficult to manage with splints or braces although there are several reported series with good results. This fracture pattern is often considered a relative indication for surgery because of the relatively more common association with radial nerve injury and a perceived risk of non-union or elbow

stiffness associated with brace or cast treatment although this is not supported by the literature.

 

3. If this is an isolated closed injury, how would you assess and advise this patient?

I would undertake a full history and examination of the patient, paying particular attention to the condition of the soft tissues, any open injuries and the neurological and vascular status of the patient.

I would discuss the benefits of operative and non-operative treatment with the patient and if amenable, I would apply a coaptation splint and repeat the radio- graphs to assess the reduction. If the fracture is reduced and held in an acceptable position then functional bracing would be my preferred treatment. I would advise that most nerve injuries recover fully over time and I would expect to see clinical signs of improvement within 6–8 weeks, with full recovery by 3–6 months. I would obtain an EMG study after 4 weeks to assess radial nerve recovery.

If  an  acceptable  reduction  cannot  be  achieved,  then  I  would  advise  operative treatment with exploration of the nerve and fracture fixation. I would be prepared to undertake nerve repair or grafting with the assistance of a plastic surgery colleague.

 

4. If you agree with the patient to proceed with surgical management, what proce- dure would you choose to undertake? Do you anticipate any potential problems and what surgical approach would you use?

I would choose to treat this injury surgically with open exploration of the radial nerve and I would recruit the support of a plastic surgery colleague in case I should find that nerve repair is necessary at the time of surgery. My preference for fracture fixation would be compression plating. This is a distal fracture and so there is lim- ited space for screw fixation in the distal fragment. I would use a posterior surgical approach as this offers good access with a flat surface for plate fixation and good visualisation of the nerve. I would identify the nerve on the posterior surface of the humerus above the medial head of the triceps and I would explore it distally to and beyond the fracture to identify and address any nerve injury. I would reduce and plate the fracture in compression mode using a narrow 4.5 mm LC-DC plate for this.

Following fracture fixation, if the nerve is simply contused then I would ensure that it is free of tension and not directly on the plate surface. If the nerve is seen to be lacerated or if there is a segmental injury, then options for treatment would include direct nerve repair, nerve grafting or late tendon transfers if initial treatment fails. I would consider these with the help of my plastic surgery colleague. I would record the final condition and position of the nerve carefully in the operative note so as to make any later surgical approach safer.

I would apply simple soft dressings and allow early movement unless a nerve repair or graft has been performed, as that would need to be protected with a short period of splintage in a plaster backslab