Surgical Management of Nerve Injuries Caused by Pediatric Upper Extremity Fractures

Abstract

While most nerve injuries associated with fractures resolve on their own, there is limited literature regarding the optimal management of persistent palsies. This review outlines nonoperative treatment strategies and provides guidance on the indications and management of cases when surgery is necessary for major upper extremity nerve injuries. It covers indications and techniques for surgical exploration, neurolysis, nerve repair, resection with grafting, and late reconstruction options. We synthesize the existing pediatric and adolescent literature and pertinent adult studies. Furthermore, we share the extensive clinical expertise of the authors, all of whom specialize in pediatric hand and upper extremity surgery.

Key concepts: (1)Associated nerve injuries following pediatric upper extremity trauma are uncommon, yet optimal upper extremity function is dependent on prompt diagnosis and referral to a team of hand surgeons and therapists.(2)Understanding the potential mechanisms/locations of injury and the natural history will enable these teams to diagnose and prognosticate outcomes efficiently.(3)Physical examination, nerve conduction studies, radiographs, ultrasound, and advanced imaging (MRI) are often required.(4)Treatment of nerve deficits can include combinations of observation, neurolysis, nerve repair, nerve grafting, nerve transfer, and muscle transfer.

Keywords: Fracture associated nerve injury; Nerve grafting; Nerve repair; Nerve transfer; Pediatric nerve injury; Pediatric upper extremity fracture.

Figure 1

Ulnar nerve palsy causing Wartenberg's Sign (A) and clawing, corrected with a low-profile daytime splint (B) to keep the small finger adducted and prevent MCP hyperextension. (Figures courtesy of Micah Sinclair, MD). MCP, metacarpophalangeal.

Figure 2

A 12-year-old male sustained a closed humeral shaft fracture with associated radial nerve palsy. X-rays at 3 months demonstrate a healed fracture with lucency indicating probable nerve entrapment (A). Surgical exploration revealed that the radial nerve (loops) was entrapped in the healed fracture site (B). Resection of the damaged nerve tissue produced a 5 cm gap (C), which was managed with a cabled sural nerve autograft (D). (Figures courtesy of Krister Freese, MD).

Figure 3

Transfer of the nerve branch from the ECRB (forceps) to the AIN (loop on the left) for the management of median nerve injury. (Figure courtesy of Sonia Chaudhry, MD). ECRB, extensor carpi radialis brevis.

Figure 4

An 11-year-old male sustained a displaced pediatric forearm fracture (A) with median nerve palsy. Though he healed after closed reduction and immobilization, nerve deficit persisted at 12 weeks, and x-rays demonstrated persistent lucency (B). MRI suggested entrapment of the nerve within the fracture site (C), which was confirmed during exploration (D). The nerve was intact after detethering (E), therefore neurolysis and fascicular stimulation were performed (F), with full sensorimotor recovery. (Figures courtesy of Sonia Chaudhry, MD).

Figure 5

Median nerve palsy classically causes a “hand of benediction” from the finger and thumb extensors being unopposed by the radial flexors, with preserved ulnar-innervated FDP muscles (Figure courtesy of Sonia Chaudhry, MD). FDP, flexor digitorum profundus.

Figure 6

X-rays show a pediatric distal 1/3 humeral shaft fracture healed with nonoperative management (A). A concomitant ulnar nerve palsy eventually led to first dorsal interosseous (B) and hypothenar (C) wasting. This patient had spontaneous resolution of their palsy with full strength and muscle bulk restoration by 1 year postinjury. (Figures courtesy of Micah Sinclair, MD).

Figure 7

Fourteen-year-old male sustained a gunshot to the medial elbow, causing an olecranon fracture (A). Acute exploration revealed transection of the ulnar nerve with a 2 cm gap (B) managed with nerve grafting and repair. (Figures courtesy of Micah Sinclair, MD).

Figure 8

11-year-old male playing baseball presented with persistent elbow pain as well as ring and small finger numbness and tingling 4 months after sustaining a medial epicondyle fracture shown on AP and lateral X-rays (A) when he presented. At the time of surgery, the ulnar nerve was found to be enlarged distal to the site of compression (B). (Figures courtesy of Micah Sinclair, MD).

Figure 9

A 7-year-old male sustained a distal radius and ulna fracture (A) accompanied by ulnar nerve palsy, which was managed with closed reduction. Examination at three months showed the nerve encased in the fracture callus of the radius (B), along with the FDP tendons of the ring and small fingers. After detethering (C), the ulnar nerve began to recover. (Figures courtesy of Micah Sinclair, MD).