Postoperative radial nerve palsy in humeral shaft nonunion reconstruction: Can the lateral paratricipital approach prevent this common complication?


      • Of those patients who underwent nonunion reconstruction of the humerus utilizing a lateral paratricipital approach, zero patients (0/16) developed a postoperative radial nerve palsy (RNP).
      • Our overall rate of postoperative radial nerve palsy is consistent with the current literature; however, to our knowledge, our study is the first to include, analyze, and report the rate of postoperative RNP in regards to utilizing the lateral paratricipital approach when addressing nonunion reconstruction of the humerus.
      • The data in our manuscript support the utilization of the lateral paratricipital approach as a surgeon controlled means of decreasing postoperative patient morbidity associated with postoperative RNP. Merits of this approach include triceps muscle preservation, radial nerve identification at the spiral groove, decompression of the nerve at the lateral intermuscular septum, and tension-free mobilization of the nerve for improved protection during manipulation and instrumentation.
      • There was an increased rate of RNP with a longer duration of time between initial treatment and nonunion reconstruction with use of the triceps splitting approach. This suggests that it may be advisable to utilize a lateral paratricipital, rather than triceps splitting approach, if a posterior approach is required when treating a nonunion in cases where there is a greater period of time from initial treatment to nonunion reconstruction.



      Postoperative radial nerve palsy (RNP) is a well-known complication of nonunion reconstruction of the humerus. The purpose of the current study is to determine if the surgical approach for nonunion reconstruction of the humerus influences the rate of postoperative radial nerve palsy.


      A retrospective case-control study of all humeral shaft and extraarticular distal humerus nonunion reconstructions performed between January 1, 2004, and August 31, 2021, was conducted. Patients included were over 18 years of age, had a non-pathologic humerus fracture nonunion and had intact radial nerve function prior to nonunion reconstruction. Exclusion criteria consisted of nonunions involving the proximal humerus, intraarticular fractures, and reconstructive treatment procedures with either intramedullary nail or external fixation methods. Perioperative variables were recorded and analyzed in regard to the development of postoperative RNP. A subgroup analysis was performed to assess the interaction of significant variables on the development of postoperative RNP.


      The overall rate of postoperative RNP in this series was 6/53 (11%). However, no cases of postoperative radial nerve palsy were observed in patients who underwent nonunion reconstruction with a lateral paratricipital approach. A new RNP was seen in 4/9 (44%) of those patients who underwent a triceps splitting approach, which was significantly higher than those utilizing either an anterolateral approach (2/28, 7%) or a lateral paratricipital approach (0/16, 0%, p = 0.007).

      Discussion and conclusion

      Our data suggests that the lateral paratricipital exposure decreases the risk of radial nerve injury with nonunion reconstruction of the humerus. The lateral paratricipital exposure offers the benefit of radial nerve exploration, decompression, neurolysis and protection prior to fracture manipulation and instrumentation. This study shows conventional approaches may predispose patients to a high rate of postoperative RNP, similar to that in the literature.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kakazu R
        • Dailey SK
        • Schroeder AJ
        • Wyrick JD
        • Archdeacon MT.
        Iatrogenic radial nerve palsy after humeral shaft nonunion repair: more common than you think.
        J Orthop Trauma. 2016; 30: 256-261
        • Koh J
        • Tornetta P
        • Walker B
        • Jones C
        • Sharmaa T
        • Sems S
        • et al.
        What is the real rate of radial nerve injury after humeral nonunion surgery?.
        J Orthop Trauma. 2020; 34: 441-446
        • Kumar MN
        • Ravindranath VP
        • Ravishankar MR.
        Outcome of locking compression plates in humeral shaft nonunions.
        Indian J Orthop. 2013; 47: 150-155
        • Lin CL
        • Fang CK
        • Chiu FY
        • Chen CM
        • Chen TH.
        Revision with dynamic compression plate and cancellous bone graft for aseptic nonunion after surgical treatment of humeral shaft fracture.
        J Trauma - Inj Infect Crit Care. 2009; 67: 1393-1396
        • Abalo A
        • Dosseh ED
        • Adabra K
        • Walla A
        • James YE
        • Dossim A.
        Open reduction and internal fixation of humeral non-unions: Radiological and functional results.
        Acta Orthop Belg. 2011; 77: 299-303
        • Crosby LA
        • Norris BL
        • Dao KDMM
        Humeral shaft nonunions treated with fibular allograft and compression plating.
        Am J Orthop (Belle Mead NJ). 2000; 29: 45-47
        • Ayoub MS
        • Tarkin IS.
        Best care paradigm to optimize functionality after extra-articular distal humeral fractures in the young patient.
        J Clin Orthop Trauma. 2018; 9: S116-S122
        • Voigt C
        • Illical E
        • Goyal KS
        • Farrell DJ
        • Van Eck CF
        • Tarkin IS.
        Cadaveric investigation on radial nerve strain using different posterior surgical exposures for extraarticular distal humeral ORIF: merits of nerve decompression through a lateral paratricipital exposure.
        J Orthop Trauma. 2015; 29: e43-e45
        • Zlotolow DA
        • Catalano LW
        • Barron OA
        • Glickel SZ.
        Surgical exposures of the humerus.
        J Am Acad Orthop Surg. 2006; 14: 754-765
        • Schildhauer TA
        • Nork SE
        • Mills WJ
        • Henley MB.
        Extensor mechanism-sparing paratricipital posterior approach to the distal humerus.
        J Orthop Trauma. 2003; 17: 374-378
        • Gerwin M
        • Hotchkiss RN
        • Weiland AJ.
        Alternative operative exposures of the posterior aspect of the humeral diaphysis: with reference to the radial nerve.
        J Bone Jt Surg - Ser A. 1996; 78: 1690-1695
        • Martinez AA
        • Cuenca J
        • Herrera A.
        Two-plate fixation for humeral shaft non-unions.
        J Orthop Surg (Hong Kong). 2009; 17: 135-138
        • Ring D
        • Perey BH
        • Jupiter JB.
        The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients.
        J Bone Jt Surg - Ser A. 1999; 81: 177-190
        • Singh AK
        • Arun GR
        • Narsaria N
        • Srivastava A.
        Treatment of non-union of humerus diaphyseal fractures: a prospective study comparing interlocking nail and locking compression plate.
        Arch Orthop Trauma Surg. 2014; 134: 947-953
        • Atalar AC
        • Kocaoglu M
        • Demirhan M
        • Bilsel K
        • Eralp L.
        Comparison of three different treatment modalities in the management of humeral shaft nonunions (plates, unilateral, and circular external fixators).
        J Orthop Trauma. 2008; 22: 248-257
        • Bernard de Dompsure R
        • Peter R
        • Hoffmeyer P.
        Uninfected nonunion of the humeral diaphyses: Review of 21 patients treated with shingling, compression plate, and autologous bone graft.
        Orthop Traumatol Surg Res. 2010; 96: 139-146
        • Dragoljub MI
        • Borivoje MM
        • Svetomir MD
        • Zoran GV
        • Jeon IH.
        Treatment of the humeral shaft aseptic nonunion using plate or unilateral external fixator.
        J Trauma - Inj Infect Crit Care. 2008; 64: 1290-1296
        • Hsu TL
        • Chiu FY
        • Chen CM
        • Chen TH.
        Treatment of nonunion of humeral shaft fracture with dynamic compression plate and cancellous bone graft.
        J Chinese Med Assoc. 2005; 68: 73-76
        • Kumar A
        • Sadiq SA.
        Non-union of the humeral shaft treated by internal fixation.
        Int Orthop. 2002; 26: 214-216
        • Shoji K
        • Heng M
        • Harris MB
        • Appleton PT
        • Vrahas MS
        • Weaver MJ.
        Time from injury to surgical fixation of diaphyseal humerus fractures is not associated with an increased risk of iatrogenic radial nerve palsy.
        J Orthop Trauma. 2017; 31: 491-496