A 25-year-old man sustains a mid-shaft humeral fracture and develops radial nerve palsy. At 3 months, there is no clinical recovery and nerve conduction studies show absent voluntary motor units in the extensor compartment. The most appropriate next step is:

• A Surgical exploration, and if a neuroma-in-continuity is found, nerve grafting with sural nerve ✓
• B Continue observation for another 6 months as radial nerve palsy always recovers spontaneously
• C Nerve transfer from median nerve fascicles to the posterior interosseous nerve
• D Tendon transfer: pronator teres to ECRB, FCR to EDC, palmaris longus to EPL

Explanation

Primary radial nerve palsy with humeral shaft fracture (Holstein-Lewis fracture) recovers spontaneously in 70-90% of cases — but the expected recovery timeline is 3-4 months. At 3 months with absent voluntary motor units, surgical exploration is warranted. If intraoperative nerve action potential (NAP) testing across a neuroma-in-continuity is absent, neurolysis or nerve grafting (sural nerve cable graft) is performed. If a complete nerve rupture is found, primary end-to-end repair or nerve grafting provides best results up to 6 months from injury. Tendon transfers are reserved for irreversible nerve injury (>12-18 months with no recovery).

Reference: Maheshwari Essential Orthopaedics, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.