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Neural injuries associated with supracondylar fractures of the humerus in children
R W Culp1, A L Osterman, R S Davidson
1Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Pennsylvania 19104.
Insights
Neural injuries from pediatric humerus fractures often resolve with observation. Delayed exploration and neurolysis are recommended if function doesn't return within five months, offering excellent outcomes for nerves in continuity.
Area of Science:
- Pediatric Orthopedics
- Pediatric Neurology
- Trauma Surgery
Background:
- Supracondylar humerus fractures are common in children.
- Associated neural injuries can occur, impacting limb function.
- Management strategies for these injuries require careful consideration.
Purpose of the Study:
- To evaluate the outcomes of neural injuries associated with pediatric supracondylar humerus fractures.
- To determine optimal timing and methods for intervention.
Main Methods:
- Retrospective review of 101 children with displaced extension-type supracondylar humerus fractures.
- Analysis of 18 neural injuries in 13 children.
- Assessment of outcomes for observation, neurolysis, and nerve grafting.
Main Results:
- Nine neural injuries (in 8 patients) resolved spontaneously within 5 months.
- Nine injuries (in 5 patients) without recovery underwent exploration and neurolysis.
- All 5 patients treated with neurolysis showed functional recovery; 1 patient with nerve grafting did not recover.
Conclusions:
- Observation and supportive therapy are the preferred initial approach for pediatric neural injuries with these fractures.
- Surgical exploration and neurolysis are indicated if no functional recovery is evident by 5 months.
- Neurolysis offers an excellent prognosis for nerves in continuity.
Abstract:
A retrospective review of displaced extension-type supracondylar fractures of the humerus in 101 children who were seen consecutively revealed eighteen associated neural injuries in thirteen children. Nine of the neural injuries in eight patients spontaneously resolved at a mean of 2.5 months (range, 1.5 to five months) after injury. The remaining nine lesions in five patients were explored at a mean of 7.5 months (range, five to fourteen months) after injury, because clinical and electromyographic studies showed no return of function. Neurolysis was performed on eight of the nerves that were explored (in five patients), and the remaining radial nerve was found to be completely lacerated and needed nerve-grafting. The length of follow-up after neurolysis averaged twenty-five months (range, thirteen to forty-four months). All five patients had functional recovery, as documented by range-of-motion, grip-strength and lateral pinch-strength, and von Frey and two-point-discrimination sensory testing. The patient who had had nerve-grafting never recovered neural function, and tendon transfers were needed. We concluded that observation and supportive therapy is the preferred initial approach for children who have a neural injury associated with a closed, displaced supracondylar fracture of the humerus. However, if there is no clinical or electromyographic evidence of return of neural function at five months after injury, exploration and neurolysis should be performed. If the nerve is in continuity, the prognosis after neurolysis is excellent.