Current concepts in diagnosis and management of common upper limb nerve injuries in children

Abstract

Peripheral nerve injuries (PNI) of the upper limb are a common event in the paediatric population, following both fractures and soft tissues injuries. Open injuries should in theory be easier to identify and the repair of injured structures performed as soon as possible in order to obtain a satisfying outcome. Conversely, due to the reduced compliance of younger children during clinical assessment, the diagnosis of a closed nerve injury may sometimes be delayed. As the compliance of patients is influenced by pain, anxiety and stress, the execution of the clinical manoeuvres intended to identify a loss of motor function or sensibility, can be impaired. Although the majority of PNI are neuroapraxias resulting in spontaneous recovery, there are open questions regarding certain aspects of closed PNI, e.g. when to ask for electrophysiological exams, when and how long to wait for a spontaneous recovery and when a surgical approach becomes mandatory. The aim of the article is therefore to analyse the main aspects of the different closed PNI of the upper limb in order to provide recommendations for timely and correct management, and to determine differences in the PNI treatment between children and adults.

Successful Delayed Neurolysis of the Median Nerve in a Teenager 7 years After Supracondylar Fracture

“…Once a nerve lesion has been confirmed and there is an absence of motor recovery at 6 months after the injury, surgery should be considered 15,20,21 . The decision for surgical exploration in this patient was not straightforward, because of the delayed referral to our services, patient's and family's choice, and the difficulty in reliably prognosticating the functional outcome with and without surgical intervention.…”

“…If so at what age does this factor become less relevant? (3) Would early timing of surgery still be considered a crucial factor in nerve surgery? 14,15 …”

“…(3) Would early timing of surgery still be considered a crucial factor in nerve surgery? 14,15 Children have biological advantages compared with adult population, usually attributed to the greater nerve regeneration potential and their neural plasticity, especially in proximal nerve injuries. 16,17 Recovery of 2-point discrimination is also superior in patients below 20 years of age.…”

“…[17][18][19] At present, the general consensus for electrophysiological examinations and management of closed injuries should be to wait-and-see for 6 months, as up to 92% of neural deficits in children are transitory. 7,8,15 Although the 6-month mark is generally considered as the limit for spontaneous recovery, the distance from the repair site to the affected muscle has to be taken into account, and the 6 month cutoff has to be evaluated on a case-by-case basis. 15 Electrophysiological studies have a role in guiding interventions for nerve lesions; however, there is a paucity of studies on the healing process of nerve lesions after fractures in children.…”

“…7,8,15 Although the 6-month mark is generally considered as the limit for spontaneous recovery, the distance from the repair site to the affected muscle has to be taken into account, and the 6 month cutoff has to be evaluated on a case-by-case basis. 15 Electrophysiological studies have a role in guiding interventions for nerve lesions; however, there is a paucity of studies on the healing process of nerve lesions after fractures in children. As a result, there are no reliable cutoff values for interventions.…”