Holstein–Lewis fracture

A spiral fracture of the distal third of the humeral shaft, classically associated with radial nerve palsy due to entrapment or laceration at the point where the nerve transitions from the posterior to anterior compartment via the lateral intermuscular septum.

The radial nerve lies unprotected at the distal humerus as it pierces the lateral intermuscular septum, making it especially vulnerable in spiral fractures with radial displacement.

First described in 1963, this fracture pattern was associated with nerve entrapment or laceration by the sharp edge of displaced bone fragments.

Though originally managed with open reduction and internal fixation (ORIF), contemporary studies support conservative management for most closed injuries, given a high rate of spontaneous radial nerve recovery.

Functional bracing, ORIF, and intramedullary nailing remain viable depending on fracture displacement, nerve integrity, and patient factors.

Anatomical Insight

  • This point of reduced nerve mobility explains its vulnerability in this fracture pattern
  • The radial nerve lies in direct contact with the humerus only in the distal third
  • Pierces the lateral intermuscular septum at ~10–14 cm above the lateral epicondyle
Associated Injuries

Radial nerve palsy:

  • Incidence in Holstein–Lewis fractures: 22%
  • Versus general humeral shaft fracture risk: ~8–12%

Nerve damage ranges from neuropraxia to laceration. EMG, serial exams, and delayed exploration are part of the modern diagnostic algorithm

Management
  • Conservative treatment: Functional bracing with close monitoring for radial nerve recovery (preferred in closed fractures)
  • Surgical exploration: Indicated for:
    • Open fractures
    • Progressive neurologic decline
    • Failure of nerve recovery within 3–4 months
  • Both operative and nonoperative approaches show excellent union and functional outcomes

History

1962Arthur Holstein and Gwilym B. Lewis presented a paper at the annual meeting of the American Academy of Orthopedic Surgeons, Chicago. They presented 7 cases with this fracture type associated with radial nerve palsy

1963 – Holstein and Lewis published a study of 341 consecutive distal humerus fractures in the JBJS, 6 patients with radial nerve palsies were found, 5 of whom showed this specific fracture pattern. They hypothesized that the high association with radial nerve palsy was that the fracture occurred at the site of radial nerve runs through the lateral intermuscular septum in direct contact with the bone and with limited mobility.

The fracture is in the distal third of the humerus, spiral in type, with the distal bone fragment displaced proximally and the proximal end deviated radially. The radial nerve is caught at the fracture site.

Holstein A, Lewis GB. JBJS Am. 1963;45:1382–1388

Holstein–Lewis fracture
Holstein–Lewis fracture 1963

2005 – Shao et al. Radial nerve injuries in this context are often neuropraxia or axonotmesis, with a high rate of spontaneous recovery. Spontaneous recovery in 70.7% of conservatively managed patients. No significant difference in final outcomes between expectant and early surgical exploration

2006 – DeFranco & Lawton. Radial nerve lies unprotected in the distal third—hence high vulnerability in Holstein–Lewis fractures. The mechanism of displacement can lacerate or entrap the nerve between fragments.

2017 – Updegrove et al

  • Nonoperative treatment (functional bracing) remains first-line in many cases
  • Operative options include:
    • ORIF with plating
    • Intramedullary nailing (used more cautiously near the radial groove)
  • Careful attention to radial nerve anatomy and safe zones is critical in surgical exposure

Associated Persons

References

Historical articles

Review articles

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the names behind the name

BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

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