gms | German Medical Science

Objectives/Interrogation: Traumatic and iatrogenic neurological complications associated with paediatric supracondylar humeral fractures are well recognised. The severity of the nerve injury associated with supracondylar humeral fractures can be difficult to assess clinically and relies upon clinical progression or absence of recovery and neurophysiology. It is accepted that complete nerve palsy with neurophysiological complete block and absence of clinical recovery after three months requires surgical exploration and reconstruction. However, we argue that even a partial nerve palsy that is failing to recover as expected by three months should be explored even when the neurophysiology suggests the nerve is in-continuity.

Methods: We report two cases of closed Gartland type III paediatric extension-type supracondylar humeral fractures treated with open reduction and internal fixation. Both children developed persistent post-operative radial nerve motor palsy. Neurophysiological studies sought prior to exploration indicated a degree of sensory nerve function in both cases, indicating a nerve in-continuity.

Subsequent surgical exploration revealed interfragmentary radial nerve compression at the fracture site at two levels in one case and at one level in the second case. The site of compression was excised and the nerve grafted. Excellent near normal radial nerve recovery was achieved except for the persistent loss of extensor carpi radialis function in the first child.

Results and Conclusions: We publish these findings to highlight the possibility of misinterpreting the incomplete nerve lesion and the neurophysiology of a nerve incontinuity, as a nerve that would spontaneously recover. At exploration, in these two cases, it was clear by the level of inter-fragmentary compression, that the nerve would not have recovered without surgical intervention. We discuss the short-comings in neurophysiology test interpretation that may lead to this synopsis.

We propose that the decision to explore a peripheral nerve should be based solely on clinical acumen. We recommend prompt referral and urgent surgical exploration of persistent peripheral neuropathy associated with supracondylar humeral fractures, even where the nerve palsy is partial and in the face of neurophysiological evidence of an intact nerve. Delays in referral vastly compromise nerve regenerative potential and increase the likelihood of secondary reconstructive procedures.