gms | German Medical Science

Pediatric supracondylar humerus fractures are often associated with nerve injuries. A recent meta-analysis enrolled 5148 patients suffering 5154 supracondylar fractures with traumatic neurapraxia in 11.3% [1]. Anterior interosseus nerve injury was the dominant palsy in extension-type fractures (34.1%), while ulnar neuropathy occurred most often in flexion-type injuries (91.3%). Injuries to the radial nerve (ICD-10 S44.2) as neurapraxia occurred in 172/5148 cases (3.3%) in the pooled metaanalysis. Sir Herbert Seddon has differentiated neurapraxia leaving the nerve intact, but contused, from axonotmesis with disruption of the axon and neurotmesis with complete disruption of the nerve and the nerve sheath [2].

Notably, in the aforementioned pooled metanalysis the iatrogenic neuropathy rate with radial neuropathy following medial/lateral pinning was 4.8%.

However, to date there is no evidence regarding the sports-activity of pediatric or adolescent patients suffering radial neuropathy following supracondylar humerus fractures. We highlight a remarkable adolescent cheerleader, who presented herself with a fall hand following complete radial nerve disruption following lateral pinning for a supracondylar humerus fracture.

A 14-year-old girl was admitted to our clinic with a complete left-sided radial palsy (Figure 1 [Fig. 1]). 18 months ago she was sustained an accident while performing a human pyramid as a cheerleader and suffered from a spiral humerus fracture.

Osteosynthesis was performed with closed reduction and lateral pinning at a regional trauma center on the first day after injury. The osteosynthesis had to be redone due to dislocation. Subsequent, she reported about a complete loss of wrist and finger extension and numbness in the radial sensory region. The first neurography was performed as late as 14 months after nerve injury and an EMG showed pathological spontaneous activity of the hand and wrist extensors. The colleagues had initiated a conservative approach; however, she did not regain any radial function in that time.

As the patient is a passionate cheerleader, the radial palsy did not keep her from doing sports. She returned to sport despite her complete radial palsy four months after surgery. Wearing a small radial palsy cast she went on with her activity. Daily routine in school and leisure time was almost unchanged with a DASH score of 6 out of 100 (0 perfect, 100 worse). The Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure [3] is a 30-item, self-report validated questionnaire designed to measure physical function and symptoms in patients with any or several musculoskeletal disorders of the upper limb with a German translation published [4].

The patient only experienced some limitations in performing cheerleading movements that imply fine movements of the left hand with the radial palsy. Notably, she was able to perform gymnastic figures such as flick-flacks half a year after trauma with only a small radial palsy cast (Attachment 1 [Attach. 1]). As physiotherapeutic treatment did not improve the palsy significantly the treating therapist recommended seeking surgical help. As the patient was young we planed a nerve reconstruction despite the rather long time after injury (18 months after injury). Tendon transfers to improve the functional outcome had been discussed, but we decided to perform a sural nerve interposition grafting procedure.

The patient was taken to the operating theatre and after neurolysis a complete dissection of the radial nerve was found with a 1×0.8 inch neuroma at the proximal nerve stump and a massive scarring for more than 1 inch at the distal stump (Figure 2 [Fig. 2]). After resection of the neuroma a distance of 2 inches had to be bridged. An ipsilateral sural nerve graft was used as a nerve transplant; it was divided into three cables of 2 inches length each to cover the larger diameter of the radial nerve at the elbow region (Figure 3 [Fig. 3]). The postoperative course was uneventful; however, the long-term result has to be determined.

The most remarkable observation in this case presented is the high level of sport activity achieved in an adolescent cheerleader with complete iatrogenic radial nerve palsy following surgery for supracondylar humerus fracture. Given the high proprioceptive demands performing a flick-flack as demonstrated in the attached video it is surprising in our view as reconstructive surgeons that our female adolescent athlete was that perfectly adopted. Using the small wrist orthesis she was able to overcome the proprioceptive and motor deficit derived from complete surgical iatrogenic radial nerve palsy.

Cheerleading is associated with substantial morbidity. As such, cheerleading fall-related injuries may cause serious to fatal outcomes [5], [6] especially falls from attempted pyramids [7]. Besides, ankle sprains are often encountered among females from the US Military Academy [8]. A retrospective analysis from the National Electronic Injury Surveillance System (NEISS) of the US Consumer Product Safety Commission revealed an estimated 208,800 children age 5–18 being treated in US hospital emergency rooms for cheerleading-related injuries [9].

In terms of reconstructive nerve surgery, the type of surgery suggested depends highly on the timing of presentation following the initial injury. Within 6 months in adults and a maximum of 24 months in young children after nerve injury, the primary surgical approach is to perform a neurolysis or in case of complete disruption with neuroma formation, as in our illustrated case, neuroma resection and nerve grafting. Depending on the size and the location of the nerve defect, nerve grafting using for example sural nerve transplants is an appropriate means to achieve nerve reconstruction. Besides, neurotisation is another option directly combining a concomitant nerve to the injured one, thus minimizing the distance to restore, however, sacrificing some motor and/or sensory function of the donor nerve. As such, medial to radial nerve transfers have been recently suggested [10].

In the above mentioned patient the estimated distance of nerve regeneration is 20 inches. Assuming a regeneration velocity of 0.04 inch/day a time of almost 1.5 years has to be expected for re-neurotisation. Currently, tissue-engineering is on its way to provide some potential solutions with nerve grafts based for example on olfactory sheath cells [11]. Tendon transfers, on the other hand, provide further reconstructive options beyond the aforementioned time frame and should be considered [12], [13].

The authors declare that they have no competing interests.