Holstein–Lewis fracture

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

1962 – Arthur 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

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

• Arthur Holstein (1913-2000)
• Gwylim Lewis (1914-2009)

References

Historical articles

• Holstein A, Lewis GM. Fractures of the humerus with radial-nerve paralysis. J Bone Joint Surg Am. 1963 Oct;45:1382-8.

Review articles

• Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005 Dec;87(12):1647-52.
• Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br. 2006 Nov;88(11):1469-73
• DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006 Apr;31(4):655-63.
• Ekholm R, Ponzer S, Törnkvist H, Adami J, Tidermark J. The Holstein-Lewis humeral shaft fracture: aspects of radial nerve injury, primary treatment, and outcome. J Orthop Trauma. 2008 Nov-Dec;22(10):693-7.
• Prodromo J, Goitz RJ. Management of radial nerve palsy associated with humerus fracture. J Hand Surg Am. 2013 May;38(5):995-8
• Somford MP, Wiegerinck JI, Hoornenborg D, van den Bekerom MP, Eygendaal D. Eponyms in elbow fracture surgery. J Shoulder Elbow Surg. 2015 Mar;24(3):369-75
• Updegrove GF, Mourad W, Abboud JA. Humeral shaft fractures. J Shoulder Elbow Surg. 2018 Apr;27(4):e87-e97.