American Society for Peripheral Nerve

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Time to Intervention Affecting Outcomes in Pediatric Nerve Injuries following Supracondylar Humerus Fractures
Megan E Friend, MD1; Elizabeth A Newman, MD1; Daniel Bracey, MD, PhD1; Shea Comadoll, BS1; Rebecca Senehi, BS1; Zhongyu Li, MD, PhD2; (1)Wake Forest School of Medicine, Winston-Salem, NC, (2)Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC

Introduction: Supracondylar humerus fractures are the most common pediatric elbow fractures, and nerve injury is a well-documented complication associated with these fractures. While most nerve injuries following supracondylar humerus fractures spontaneously resolve, other injuries require operative intervention by a nerve specialist. The aim of this study was to determine if time from injury to surgical intervention affects clinical outcomes in nerve injuries following pediatric supracondylar humerus fractures.

Materials and Methods: We performed a retrospective chart review of pediatric patients treated by the senior author for nerve injuries following supracondylar humerus fractures between 2006 and 2016. Sixteen patients with nerve injury requiring surgical intervention were identified. Chart review was performed to identify date of injury, fracture pattern, time to intervention by the senior author, and neurologic outcomes. British Medical Research Council scores for muscle strength and sensation were used to gauge recovery. A correlation analysis was performed to determine the effect on time to intervention on neurologic recovery.

Results: Average time to treatment by the senior author was 8.2 5.5 mo. The majority of fractures in this group were Gartland type III supracondylar fractures (62.5%). The most commonly injured nerve was the ulnar (56%), followed by the median (31%), and radial (19%). Surgical indications included neuropathic pain, worsened neurologic exam after initial reduction, muscle atrophy, nerve conduction study findings, and lack of recovery at the time of referral. There was a statistically significant correlation of decreased time to surgery and improved outcomes when patients were treated <6 months from injury (Spearman correlation coefficient r= -0.54, p=0.04).

Conclusion: Our study reveals that a decreased delay to surgery improves neurologic outcomes in pediatric patients with neurologic injury following supracondylar humerus fractures. Increased index of suspicion for more severe neurologic injury should be prompted by fractures with >100% displacement, presence of vascular compromise, open and ipsilateral fractures, neuropathic pain, and worsening neurologic exam following reduction. While a larger scale study is needed to further validate our findings, this study indicates the need for earlier referrals to a nerve specialist when there is neurologic compromise following a pediatric supracondylar humerus fracture, such that intervention can take place within 6 months of injury.

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