Does Surgical Technique Influence Radial and Axillary Nerve Injury After Long PHILOS Plate Fixation in Proximally Extending Humeral Shaft Fractures?

Öz

Abstract Background: Proximally extending humeral shaft fractures (PEHSFs) pose significant surgical challenges due to the complex fracture anatomy and proximity to the axillary and radial nerves. While long proximal humeral internal locking system (PHILOS) plates are commonly used, the impact of surgical technique and implant length on neurological safety remains unclear. This study aimed to evaluate the relationship between surgical technique (Open Reduction–Internal Fixation [ORIF] versus Minimally Invasive Plate Osteosynthesis [MIPO]) and the occurrence of iatrogenic nerve palsy in patients with PEHSFs. Methods: A retrospective study was conducted on 18 patients treated with long PHILOS plates for PEHSFs between January 2022 and January 2025. Patients were stratified into ORIF (n=10) and MIPO (n=8) groups. Axillary and radial nerve functions were assessed preoperatively, immediately postoperatively, and at the final follow-up. The impact of surgical approach, intraoperative nerve exploration, and plate length (9-, 11-, and 12-hole) on neurological outcomes were analyzed. Results: The overall rate of immediate postoperative nerve palsy was 16.7% for the axillary nerve and 22.2% for the radial nerve. After a median follow-up of 8 months, persistent nerve palsy was observed in 3 patients (16.7%). Although the difference did not reach statistical significance (p=0.147), all permanent nerve injuries occurred in the ORIF group (30%), whereas no long-term deficits were observed in the MIPO group (0%). A statistically significant association was identified between plate length and persistent nerve palsy (p=0.002); all cases of permanent nerve palsy were associated with the use of 12-hole plates. Conclusion: While MIPO demonstrated a favorable safety profile with no permanent nerve injuries, the use of 12-hole long locking plates emerged as a significant independent risk factor for persistent neurological deficit in PEHSFs. These findings suggest that adopting soft-tissue-sparing techniques and selecting the shortest implant capable of providing adequate stability may reduce the risk of iatrogenic nerve injury.

Anahtar Kelimeler

• HUMERUS FRACTURE
• AXİLLARY NERVE PALSY
• RADIAL NERVE INJURY

Proksimale Uzanan Humerus Cisim Kırıklarında Uzun PHILOS Plak Fiksasyonu Sonrası Radial ve Aksiller Sinir Yaralanmalarını Cerrahi Teknik Etkiler mi?

Öz

Amaç: Proksimale uzanan humerus cisim kırıkları (PEHSF’ler), karmaşık kırık anatomisi ve aksiller ile radial sinirlere olan yakınlık nedeniyle önemli cerrahi zorluklar oluşturur. Uzun proksimal humerus internal kilitli sistem (PHILOS) plakları yaygın olarak kullanılmasına rağmen, cerrahi teknik ve implant uzunluğunun nörolojik güvenlik üzerindeki etkisi net değildir. Bu çalışmanın amacı, PEHSF’li hastalarda cerrahi teknik (Açık Redüksiyon–İnternal Fiksasyon [ARİF] ve Minimal İnvaziv Plak Osteosentezi [MIPO]) ile iyatrojenik sinir felci gelişimi arasındaki ilişkiyi değerlendirmektir. Yöntemler: Ocak 2022–Ocak 2025 tarihleri arasında PEHSF nedeniyle uzun PHILOS plakları ile tedavi edilen 18 hasta retrospektif olarak incelendi. Hastalar ARİF (n=10) ve MIPO (n=8) gruplarına ayrıldı. Aksiller ve radial sinir fonksiyonları preoperatif dönemde, ameliyat sonrası erken dönemde ve son kontrolde değerlendirildi. Cerrahi yaklaşım, intraoperatif sinir eksplorasyonu ve plak uzunluğunun (9, 11 ve 12 delikli) nörolojik sonuçlar üzerindeki etkisi analiz edildi. Bulgular: Ameliyat sonrası erken dönemde sinir felci oranı aksiller sinir için %16,7, radial sinir için %22,2 olarak saptandı. Medyan 8 aylık takip süresi sonunda, 3 hastada (%16,7) kalıcı sinir felci izlendi. İstatistiksel olarak anlamlılığa ulaşmamakla birlikte (p=0,147), kalıcı sinir yaralanmalarının tamamı ORIF grubunda (%30) görülürken, MIPO grubunda uzun dönem nörolojik defisit izlenmedi (%0). Plak uzunluğu ile kalıcı sinir felci arasında istatistiksel olarak anlamlı bir ilişki saptandı (p=0,002); kalıcı sinir felci gelişen tüm olgularda 12 delikli plak kullanılmıştı. Sonuç: MIPO tekniği kalıcı sinir yaralanması izlenmemesiyle daha güvenli bir profil sergilerken, 12 delikli uzun kilitli plak kullanımı PEHSF’lerde kalıcı nörolojik defisit için anlamlı ve bağımsız bir risk faktörü olarak belirlendi. Bu bulgular, yumuşak dokuya saygılı cerrahi tekniklerin tercih edilmesinin ve yeterli stabiliteyi sağlayabilecek en kısa implantın seçilmesinin iyatrojenik sinir yaralanması riskini azaltabileceğini düşündürmektedir. Anahtar Kelimeler: Humerus kırığı; Radial sinir felci; Aksiller sinir felci; PHILOS plak; MIPO; ORIF.

Anahtar Kelimeler

• HUMERUS KIRIĞI
• AKSİLLER SİNİR
• LONG PHİLLOS
• RADİAL SİNİR FELCİ

Kaynakça

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