Holstein-Lewis Fracture

Note on terminology: "Holenstein-Lewis syndrome" is not a recognised entity in the medical literature. The correct eponym is the Holstein-Lewis fracture (named after Arthur Holstein and Gwilym B. Lewis), first described in their landmark 1963 paper in the Journal of Bone and Joint Surgery (JBJS 1963). The term "syndrome" is sometimes informally used because the fracture consistently comes with a characteristic nerve injury pattern.

Definition

• Represents approximately 7% of all humeral shaft fractures
• Radial nerve palsy incidence: ~22% (vs. ~8-12% for humeral shaft fractures in general)

Anatomy - Why This Fracture Is Unique

Figure: Left - normal radial nerve course spiraling around the humerus. Right - Holstein-Lewis fracture with the nerve trapped at the fracture site (Rockwood and Green's Fractures in Adults, 10th ed.)

• The nerve lies directly against the periosteum of the bone
• It has minimal mobility - it is tethered by the lateral intermuscular septum
• It has no muscular protection

1. Entrapment between fracture fragments
2. Laceration by a sharp bone edge
3. Stretch injury from fragment displacement
4. Contusion/compression from haematoma

Mechanism of Injury

Figure: Original Holstein-Lewis (1963) illustration. (A) Normal radial nerve coursing through the lateral intermuscular septum. (B) Spiral fracture with lateral displacement - the nerve is caught between the displaced fragments, alongside the X-ray of a typical case.

Common causes:

Signs and Symptoms

1. Fracture Itself

• Acute pain in the upper arm, worst at the distal third
• Swelling and bruising over the lateral arm
• Deformity - arm appears shortened or angulated
• Crepitus on movement
• Inability to use the arm - arm held adducted, supported by the other hand
• Tenderness over the distal humeral shaft

2. Radial Nerve Palsy (the hallmark neurological complication)

Figure: Sensory distribution affected in radial nerve palsy - numbness/paraesthesia over the dorsoradial aspect of the hand and dorsal aspect of the lateral 3.5 digits (Rockwood and Green's Fractures in Adults, 10th ed.)

• Numbness / paraesthesia over the dorsum of the thumb, index, middle, and lateral half of the ring finger
• Dorsoradial wrist area sensory loss
• Sensory loss may be incomplete or subtle in neuropraxia

Types of Nerve Injury (Seddon Classification)

Investigations

1. Plain Radiography (First-line)

• AP and lateral X-ray of the humerus - gold standard for fracture diagnosis
• Shows: spiral fracture at distal 1/3 humerus with lateral/radial displacement of distal fragment
• Must also obtain: elbow and shoulder views to rule out associated fractures/dislocations

2. CT Scan

• Used when X-ray is inconclusive or to plan operative fixation
• Better delineates comminution, fragment position, and intra-articular extension

3. Neurological Assessment

• Thorough motor exam: wrist extension, finger extension, thumb extension, brachioradialis
• Sensory exam: dorsoradial hand, first web space
• Document neurological status before and after any manipulation

4. Electromyography (EMG) and Nerve Conduction Studies (NCS)

• Not done acutely - Wallerian degeneration takes 3 weeks to show on EMG
• Performed at ~3 months if no spontaneous recovery is occurring
• Assesses: site and severity of nerve injury, reinnervation potential
• Guides decision between continued observation vs. surgical exploration

5. Ultrasound of Radial Nerve

• Emerging role: can detect nerve entrapment within fracture gap
• Erra et al. used ultrasound in 35 patients to assess posterior interosseous nerve integrity
• Helps guide surgical decision-making in select cases

6. MRI (selective)

• If neurotmesis/laceration suspected and surgical planning needed
• Assesses nerve continuity and surrounding soft tissue injury

Treatment

Decision Framework

Holstein-Lewis Fracture
        │
        ├─ Closed fracture?
        │       │
        │       ├─ YES: Conservative management preferred
        │       │        + Expectant radial nerve management
        │       │
        │       └─ NO (open fracture, vascular injury,
        │              polytrauma, failed conservative):
        │               → ORIF + Nerve exploration
        │
        └─ Radial nerve palsy present?
                │
                ├─ Closed injury → Expectant management
                │   (70-90% spontaneous recovery)
                │
                └─ Open/sharp injury, progressive palsy,
                   no recovery at 3-6 months → Surgery

A. Non-Operative (Conservative) Treatment

1. Coaptation splint / sugar-tong splint initially (first 1-2 weeks for pain/swelling)
2. Functional brace (Sarmiento brace) applied at 1-2 weeks - the workhorse of treatment
   • Prefabricated or custom-molded polyethylene brace
   • Allows shoulder and elbow motion
   • Brace maintained for average of 10 weeks
   • Sarmiento (1990): 96% union rate in 85 distal 1/3 fractures

• Varus/valgus angulation: <20°
• Anterior/posterior angulation: <20°
• Shortening: <3 cm
• Rotation: <15°

• Physiotherapy: maintain passive joint range of motion
• Dynamic wrist extension splint (cock-up splint) - prevents contracture, restores functional grip
• Serial clinical assessments every 4-6 weeks
• EMG at 3 months if no signs of recovery
• At 6 months without recovery: refer for nerve grafting ± tendon transfer consideration

B. Operative Treatment

• Open fracture
• Vascular injury requiring repair
• Ipsilateral forearm fracture ("floating elbow")
• Polytrauma / multiple injuries
• Inability to maintain fracture alignment conservatively
• Progressive radial nerve palsy (nerve being trapped by ongoing displacement)

• Bilateral humeral fractures
• Pathological fracture
• Morbid obesity

• Open fracture (sharp mechanism)
• Secondary radial nerve palsy (palsy developing after initial normal exam - suggests entrapment)
• No recovery at 3-6 months
• Operative fixation being performed anyway

• Posterior approach: humerus is flat posteriorly; plate reaches further distally; direct radial nerve visualisation
• Anterolateral approach: allows nerve exploration; modified approach described specifically for Holstein-Lewis fractures

• If nerve in continuity during surgery: leave in anatomical position, protect, document relation to hardware
• If transected: primary repair (end-to-end neurorrhaphy) if tension-free; otherwise nerve grafting (sural nerve graft most common)
• At 6 months without recovery despite conservative care: nerve grafting ± tendon transfer (e.g., pronator teres to ECRB for wrist extension)

C. Adjuncts and Rehabilitation

• Pain management: NSAIDs, opioids short-term, neuropathic pain agents (pregabalin, gabapentin) for nerve pain
• Physiotherapy: Early shoulder mobilisation to prevent stiffness; progressive strengthening
• Smoking cessation: Optimises nerve and bone healing
• Glycaemic control in diabetics: Poor glycaemia impairs nerve regeneration
• Hand therapy: Dynamic splinting, oedema control, sensory re-education

Prognosis

Summary Table

• Rockwood and Green's Fractures in Adults, 10th ed. (2025) - Chapter 37, Nerve Injury
• Campbell's Operative Orthopaedics, 15th Ed. (2026) - Humeral Shaft section
• Holstein A, Lewis GB. Fractures of the humerus with radial nerve paralysis. J Bone Joint Surg Am. 1963;45:1382-1388 (PMID 14069777)
• Ekholm R et al. The Holstein-Lewis humeral shaft fracture. J Orthop Trauma. 2008 [PMID 18978544]
• LITFL Eponymictionary - Holstein-Lewis fracture
• AO Foundation - Radial Nerve Palsy Following Humeral Fractures