Ulnar Nerve Injury in Pediatric Midshaft Forearm Fractures: A Case Series

Abstract

Objectives: To describe a midshaft forearm fracture pattern that places the ulnar nerve at risk in the pediatric population and provide 7 clinical case examples describing the injury pattern and treatment methods.

Design: Retrospective observational case series, review of literature, cadaver dissection, and treatment recommendations.

Setting: Multi-institutional, Southeast United States.

Patients: Seven pediatric patients (5 male and 2 female) with mean age of 8.7 years (range, 3-14) who sustained a significantly displaced closed, or grade I open, middle to distal one-third both-bone forearm fracture with subsequent ulnar nerve dysfunction.

Interventions: Manual reduction and casting of both-bone forearm shaft fractures, operative debridement, fracture fixation, nerve exploration, neurolysis, nerve repair, and nerve grafting.

Main outcome measurements: Radiographic fracture union, clinical ulnar nerve motor and sensory function testing, along with selective electric nerve testing and advanced imaging were monitored throughout follow-up postinjury.

Results: Five of 7 patients underwent surgical treatment and 2 others were treated with conservative measures. The ulnar nerve was entrapped within the fracture site of one patient with an open fracture along with partial nerve transection, and 4 patients were found to have the nerve encased in hypertrophic scar tissue or bony callus upon surgical exploration at 3-12 months postinjury.

Conclusions: The ulnar nerve lies in a precarious position in the middle to distal one-third forearm and is bound by anatomic constraints that place the nerve at risk of injury. This article offers a treatment algorithm that includes conservative treatment, acute exploration, early exploration (≤3 months), and late exploration (>3 months).

Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.