Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model.

PURPOSE: When managing radial nerve palsy associated with a humerus fracture, both surgeon and patient must balance the risks and benefits of performing an invasive surgical procedure to address a functional deficit that is likely, but not certain, to recover with nonsurgical management. The purpose of this study was to better understand the determinants of optimal management strategy using expected-value decision analysis.

METHODS: Probabilities for the occurrences of the potential outcomes after initial observation or early surgery were determined from a systematic review of the literature. Scores for these outcomes were obtained from a questionnaire on patient preferences completed by 82 subjects without a history of humerus fracture and radial nerve palsy and used in the model as a measure of utility. A decision tree was constructed, fold-back analysis was performed to determine optimal treatment, and sensitivity analyses were used to determine the effect on decision making of varying outcome probabilities and utilities.

RESULTS: Observation was associated with a value of 8.4 and early surgery a value of 6.7 given the outcome probabilities and utilities studied in this model, making observation the optimal management strategy. When parameters were varied in sensitivity analysis, it was noted that when the rate of recovery after initial observation falls below 40% or when the utility value for successful early surgery rises above 9.4, early surgery is the preferred management strategy.

CONCLUSIONS: Initial observation was the preferred strategy. In clinical settings in which the likelihood of spontaneous recovery of nerve function is low or when an informed patient has a strong preference for surgery, early surgery may optimize outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis II.