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24 Palliative Surgery inObstetrical Brachial Plexus Palsy
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Wrist extension is one of the goals of functional recovery of the upper arm. Lack of extension impairs hand function. Lack of wrist
extension is one of the main indications for early
nerve surgery. Therefore, any considerations
about the outcome should be based on the
expected result of the wrist.
Different patterns of wrist extension defects
can be identied. First of all, wrist extension can
stem from partial involvement of extensor carpi
radialis tendons because of their prevalent innervation from C6 to C7 roots.
Along with physical therapy during the rst
years of life, nocturnal splints can be effective in
balancing wrist muscles. In the event of a child
over ve years of age with persistent extension
defect, despite good exor muscles of the wrist
and ngers, surgery might be appropriate. Flexor
carpi ulnaris transfer onto extensor carpi radialis
muscles is an effective procedure; however, loss
of tension of transferred tendons or on the contrary excessive tension should be taken into
account [42, 43].
When the posterior cord of the brachial plexus
is severely injured with expectations of poor
recovery, repair options considerably decrease.
Wrist exion can be compensated by nger
exor transfers but tendon transfers are often
ineffective or short lasting.
Different patterns of hand defects have been
described so it is hard to standardize hand deformities. Raimondi and Gilbert’s classication of
palsied hand has grouped the majority of clinical
aspects [44].Different from single nerve palsy,
in OBPP, frail muscles do not allow the hand to
reach adequate strength. Lack of sensation in the
hand should discourage any surgical procedure.
Thumb extension and opposition can be
obtained using tendon transfer along with joint
reinforcement or fusion. Other selected transfers
are possible, but the outcome is constantly poor,
particularly when transfers are performed too
early in life. On the other hand, late transfers
result to be constantly poor because the child
neglects his affected hand.
24.3 Conclusions
To sum up, palliative surgery options allow
patients to achieve satisfactory results, particularly those with a favorable prognosis of recovery
but still missing functions.
The main factor determining a good outcome
is the correct timing of surgery based on the age
of the patients. Growth can undo even a satisfactory short term surgical result. Shoulder and
elbow involvement can signicantly improve
through many surgical procedures that merge
orthopedic techniques and nerve surgery. Surgical
procedures for correctingdistal segments are less
effective because of the poor muscle recovery,
particularly when a lack of sensation impairs the
hand.
References
1. Gilbert A, editor. Brachial plexus injuries. London:
Martin Dunitz Ltd; 2001.
2. Nixon M, Trail J.Management of shoulder problems
following obstetric brachial plexus injury. Shoulder
Elbow. 2014;6:12–7.
3. Waters PM. Comparison of the natural history, the
outcome of microsurgical repair and the outcome of
operative reconstruction in brachial plexus birth palsy.
J Bone Joint Surg Am. 1999;81(5):649–59.
4. Mallet J. Paralysie obstétricale. Rev Chir Orthop
Réparatrice Appar Mot. 1972;58(Suppl 1):166–8.
5. Haerle M, Gilbert A. Management of complete
obstetric brachial plexus lesions. J Pediatr Orthop.
2004;24:194–200.
6. Sénès FM, Catena N, Sénès J. Nerve transfer in
delayed obstetrical palsy repair. J Brachial Plex
Peripher Nerve Inj. 2015;10(1):e2–e14.
7. Immermann I, Valencia H, Di Taranto P, Del Sole EM,
Glait S, Price AE, Grossmann JA. Subscapular slide
correction of the shoulder internal rotation contracture
after brachial plexus birth injury: technique and outcomes. Tech Hand Up Extrem Surg. 2013;17(1):52–6.
8. Azburg JM, Kozin SH, Waters PM. Open glenohumeral joint reduction and latissimus dorsi and teres
major tendon transfers for infants and children following brachial plexus birth palsy. Tech Hand Up
Extrem Surg. 2017;21(2):30–6.
9. Breton A, Mainard L, De Gasperi M, Barbary S,
Maurice E, Dautel G.Arthroscopic release of shoulder contracture secondary to obstetric brachial plexus
palsy: retrospective study of children with an average
298
https://t.me/medicina_free
F. M. Senes et al.
follow up of 4.5 years. Orthop Traumatol Surg Res.
2012;98:638–44.
10. Waters PM, Bae DS. Effect of tendon transfers and
extraarticular soft tissue balancing on glenohumeral
development in brachial plexus birth palsy. J Bone
Joint Surg. 2005;87A(2):320–5.
11. Birch R.Late sequelae at the shoulder in obstetrical
palsy in children. In: Randelli M, Karlsson J, editors.
Surgical techniques in orthopaedics and traumatology:
shoulder, vol. 3. Paris: Elsevier; 2001. 55-200-E-210.
12. Waters PM, Bae DS.The early effect of tendon transfers an open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy. J Bone Joint Surg
Am. 2008;90:2171–9.
13. Pagnotta A, Haerle M, Gilbert A.Long term results on
abduction and external rotation after latissimus dorsi
transfer for sequelae of obstetric palsy. Cain Orthop
Relat Res. 2004;426:199–205.
14. Ozben H, Atalar AC, Bilsel K, Demirhan M.Transfer
of latissimus dorsi and teres major tendons without
subscapularis release for the treatment of obstetrical brachial plexus sequela. J Shoulder Elbow Surg.
2011;20(8):1265–74.
15. Chomiak J, Dungl P, Ostadal M, Frydychova M,
Burian M. Muscle transfers in children and adults
improve external rotation in cases of obstetrical
brachial plexus paralysis: a comparative study. Int
Orthop. 2014;38(4):803–10.
16. Abzug JM, Chafetz RS, Gaughan JP, Ashworth S,
Kozin SH.Shoulder function after medial approach
and derotational humeral osteotomy in patients
with brachial plexus birth palsy. J Pediatr Orthop.
2010;30(5):469–74.
17. McRae MC, Borschel GH.Transfer of triceps motor
branches of the radial nerve to axillary nerve with
or without other nerve transfers provides antigravity
shoulder abduction in pediatric brachial plexus injury.
Hand (NY). 2012;7(2):186–90.
18. Aly A, Bahm J, Schuind F.Percutaneous humeral derotational osteotomy in obstetrical palsy: a new technique. J Hand Surg Eur. 2014;39(5):549–52.
19. Chen L, Gu YD, Hu SN. Applying transfer of and/
or latissimus dorsi with teres major for reconstruction of abduction and external rotation of the shoulder in obstetrical brachial plexus palsy. J Reconstr
Microsurg. 2002;18(4):275–80.
20. Gilbert A, Brockman R, Carlioz H. Surgical treatment of brachial plexus birth palsy. Clin Orthop.
1991;264:39–47.
21. Terzis JK, Kokkalis ZT.Primary and secondary shoulder reconstruction in obstetric brachial plexus palsy.
Injury. 2008;39S:S5–S14.
22. Frich LH, Schmidt PH, Torng T.Glenoid morphology in obstetrical brachial plexus lesion: a three
dimensional computed tomography study. J Shoulder
Elbow Surg. 2017;26(8):1374–82.
23. Di Mascio L, Chin FK, Fox M, Sinisi M.Glenoplasty
for complex shoulder subluxation and dislocation in
children with obstetric brachial plexus palsy. J Bone
Joint Surg Br. 2011;93:102–7.
24. Murison J, Jehanno P, Fitoussi F. Nerve transfer to
biceps to restore elbow exion and supination in children with obstetrical brachial plexus palsy. J Child
Orthop. 2017;11(6):455–9.
25. Kawabata H, Shibata T, Matsui Y, Yasui N.Use of
intercostals nerves for neurotization of the musculocutaneous nerve in infants with birth related
brachial plexus palsy. J Neurosurg. 2001;94(3):
386–91.
26. Chwei Chin Chuang D, Hattori Y, Ma HS, Chen
HC.The reconstruction strategy for improving elbow
function in late obstetrical brachial plexus palsy. Plast
Reconstr Surg. 2003;109(1):116–26.
27. El Gammal T, El Sayed A, Kobt MM, Saleh WR,
Ragheb YF, Refai O, Morsy MM.Free functioning
gracilis transplantation for reconstruction of elbow
and hand function in late obstetrical brachial plexus
palsy. Microsurgery. 2015;35(5):350–5.
28. Nath RK, Boutros SG, Somasundaram C. Eplasty.
2017:e34.
29. Senes FM, Catena N, Dapelo E, Senes J. Nerve
transfer for elbow extension in obstetrical brachial
plexus palsy. Ann Acad Med Singap. 2016;45(5)
:221–4.
30. Poyhia TH, Koivikko MP, Peltonen J, Kirjavainen
MO, Lamminen AE, Mietosvaara AY. Muscle
changes in brachial plexus birth injury with elbow
exion contracture: an MRI study. Pediatr Radiol.
2007;37:173–9.
31. Shefer L, Lattanza L, Hagar Y, Bagley A, James
MA. The prevalence, rate of progression and treatment of elbow exion contracture in children with
brachial plexus birth palsy. J Bone Joint Surg A.
2012;94:403–9.
32. Ho ES, Roy T, Stephens D, Clarke HM.Serial casting and splinting of elbow contracture in children with
obstetrical brachial plexus palsy. J Hand Surg Am.
2010;35(1):84–91.
33. Garcia Lopez A, Sebastian P, Martinez LF.Anterior
release of elbow exion contractures in children with
obstetrical brachial plexus lesions. J Hand Surg Am.
2012;37(8):1660–4.
34. Vekris MD, Palas D, Lykissas MG, Soucacos PN,
Beris AE.Correction of elbow exion contracture in
late obstetrical brachial plexus palsy through arthrodiastasis of the elbow (Ioannina method). Tech Hand
Up Extrem Surg. 2010;14(1):14–20.
35. Senes FM, Catena N, Dapelo E, Senes J.Correction
of elbow exion contracture by means of olecranon resection and anterior arthrolysis in obsttetrical brachial plexus sequelae. J Pediatr Orthop B.
2017;26(1):14–20.
24 Palliative Surgery inObstetrical Brachial Plexus Palsy
https://t.me/medicina_free
299
36. Amrani A, Dendane MA, El Alami ZF.Pronator teres
transfer to correct pronation deformity of the forearm
after an obstetrical brachial plexus injury. J Bone Joint
Surg Br. 2009;91(5):616–8.
37. Ruhmann O, Hierner R.Z plasty and rerouting of the
biceps tendon with interosseous membrane release to
restore pronation in paralytic supination posture and
contracture of the forearm. Oper Orthop Traumatol.
2009;21(2):157–69.
38. Metsaars WP, Nagels J, Pijls BG, Langenhoff JM,
Nelissen RG. Treatment of supination deformity
for obstetric brachial plexus injury: a systematic
review and meta-analysis. J Hand Surg Am.
2014;39(10):1948–58.
39. Gladstein AZ, Sachleben B, Ho ES, Anthony A,
Clarke HM, Hopyan S.Forearm pronation osteotomy
for supination contracture secondary to obstetrical
brachial plexus palsy: a retrospective cohort study. J
Pediatr Orthop. 2017;37(6):e357–63.
40. Van Kooten EO, Ishaque MA, Winters HA, Ritt
MJ, Van der Sluijs HA. Pronating radius osteotomy
for supination deformity in children with obstetric
brachial plexus palsy. Tech Hand Up Extrem Surg.
2008;12(1):34–7.
41. Manfrini M, Valdiserri L.Proximal radio ulnar arthrosis in the treatment of supination deformity resulting
from obstetrical paralysis. Ital J Orthop Traumatol.
1985;11(3):309–13.
42. Van Alphen NA, Van Doorn Loogman MH, Mass H,
Van der Sluijs JA, Ritt MJ.Restoring wrist extension
in obstetric palsy of the brachial plexus by transferring wrist exors to wrist extensors. J Pediatr Rehabil
Med. 2013;6(1):53–7.
43. Al Quattan MM.Tendon transfer to reconstruct wrist
extension in children with obstetric brachial plexus
palsy. J Hand Surg Br. 2003;28(2):153–7.
44. Raimondo PL.Evaluation of results in obstetrical brachial plexus palsy: the hand. In: Proceedings of international meeting of brachial plexus palsy, Helen, The
Netherlands; 1993.
Nerve Injuries
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FilippoM.Senes, NunzioCatena, LuigiA.Nasto,
andChiaraArrigoni
25
Abstract
Commonly,peripheral nerve injuries (PNI) of
the upper limb in children result from fractures
or penetrating lesions. Patient’s age signicantly affects epidemiology and demographics
ofthese lesions. In very young chidren,injuries of peripheral nerves can affect nerve maturationsandimpair distal joint motion and limb
residual growth potential.
Nevertheless, child regeneration potential
and neuronal plasticity allow for a better outcome than inadulthood injuries. Concerning
the type and level of skeletal lesion, typical
PNI patterns can be described. Cutting edges
of fracture fragments can cause direct damage
to nearby nerves, whereas joint dislocation
often determines traction injuries. Early iden-
F. M. Senes (*)
Department oh Hand Surgery and Rehabilitation,
San Giuseppe MultiMedica Hospital, Milan
University, Milano, Italy
e-mail: lipposenes@fastwebnet.it
N. Catena
UOSD Microchirurgia Ricostruttiva e Chirurgia
della Mano, IRCCS Istituto Giannina Gaslini,
Genova, Italy
L. A. Nasto
UOC Ortopedia e Traumatologia, IRCCS Istituto
Giannina Gaslini, Genova, Italy
C. Arrigoni
Scuola di Specializzazione in Ortopedia e
Traumatologia, Università degli Studi di Torino,
Torino, Italy
tication of nerve lesion is mandatory for
planning the treatment that, depending on
injury type and gap, consistof wait and see,
direct suture, nerve grafting, andtubulization.
Keywords
Peripheral nerve · Upper limb · Children ·
Fractures · Penetrating lesions · Nerve graft
25.1 Introduction
Peripheral nerve injuries (PNI) of the upper limb
after fractures and cutting lesions are a common
occurrence in children, whereas canalicular
(compression) syndrome is rare.
Although in the past, nerve injuries of the
upper limbs were often grouped regardless
of patient’s age, researchers have focused on
pediatric nerve injuries, particularly on nerve
involvement following supracondylar humeral
fractures.
Age signicantly affects the occurrence of
nerve lesions. Older children report a high rate of
fracture-related PNI, probably because they are
more commonly involved in road and sports accidents, while the youngest are usually under
parental supervision [1].
Moreover, a basic approach to a pediatric
nerve lesion should take into account that differences arise from the amount of myelinization of
the nerve trunks, which is age- dependent.
© Springer Nature Switzerland AG 2023
G. Pajardi (ed.), Pediatric Hand Surgery, https://doi.org/10.1007/978-3-031-30984-7_25
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The absence of myelinated coating in peripheral nerve slows down nerve conduction velocity,
which is about one-half compared with the ones
detected in adults. A complete myelinated sheet
in peripheral nerves develops at about 3 years of
age.
Continue changes in the assessment of neurotrophins, neurotransmitters, and their receptors
inuence the maturation of the nervous system.
In young children, any injury can affect the maturation process of the nerve, impairing motion,
sensibility, and residual growth of the upper limb.
Skeletalmodications of the upper limb, due to
prolonged denervation, are exemplied by the
shortening of the upper limb observed after a
severe obstetrical brachial plexus palsy [2].
Apart from these potential issues, regeneration potential and neuronal plasticity in the child
allow them to achieve a better outcome than in
adulthood. Besides all, the risk of joint stiffness
is very low, with exception of brachial plexus
injuries.
In pediatric population,the age,growth, patterns of injuries and maturity level of peripheral
nerve system will lead to peculiar tratment
modalities.
25.2 Types andSites ofNerve
Lesions
In the upper limb, nerve injuries show typical
features, depending on the single nerve and level
of lesion. A basic distinction is the presence of a
skin defect: open and closed injuries occur with
different patterns at different upper arm levels.
Closed injuries are usually associated with
fractures, which can trigger a direct nerve
involvement by bone fragments; however, joint
dislocation can cause nerve lesions by traction.
Considering nerve pathways, PNI are shown
as follows:
– Axillary: shoulder dislocation and rarely
proximal humeral fractures
– Radial: shaft humeral fractures
– Median, radial, and ulnar (isolated or in com-
bination): supracondylar humeral fractures
– Median, ulnar, and elbow dislocation
– Posterior interosseous: acute or chronic ante-
rior Monteggia lesions
– Median, ulnar; diaphyseal forearm fractures;
median, distal radius fractures
Supracondylar humeral fracture is most com-
monly affected by PNI, because of two peculiar
risk factors. Firstly, the close contact between
nerves and bone at the elbow level is a major predisposing factor to nerve injury. Radial and ulnar
nerves are often damaged because of theirpassage through denite osteobrous tunnel and
septa that prevent from their natural sliding. Secondly, the severe displacement of
Gartland 3 supracondylar humeral fracture
increases the chances of nerve kinking, entrapment, or laceration [3] (Fig.25.1).
The pattern of nerve involvement is closely
related to the type of fracture: the median nerve is
commonly injured in the event of posterolateral
Gartland 3 fractures whereas the radial nerve in
posteromedial ones [4, 5].
Injuries of the ulnar nerve can be occasionally
observed in rare exion-type fractures, while
sometimes iatrogenic lesions may happen after
medial pinning.
Many authors have reported the radial nerve
as the most commonly injured nerve; however,
the recent literature has focused on the median
nerve and particularly on its anterior interosseous
branch (AIB).
In medical literature, anterior interosseous
nerve involvement has been often neglected for
two main reasons: on the one hand, median nerve
trunk and related nerve branch injuries are usually difcult to differentiateeach other, so medical reports group together these lesions as a
whole; on the other hand, a suddendetection of
anterior interosseous nerve involvement is hard
to identify, especially in younger children who
cannot adequately complain their discomfort [6].
Even though its incidence is underestimated,
ABI palsy has to be probably considered the most
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Fig. 25.1 Joint dislocation causing nerve traction and AIB injury
303
common nerve injury related to supracondylar
fractures, even though its origin is far from the
supracondylar region.
The peculiar anatomy of the median nerve
may explain the prevalent involvement of AIB,
which is due to two factors.
First of all, nerve bers devoted to AIB are
located in a posterior position in the main trunk
of the median nerve, so that direct trauma triggered by the free edge of the proximal fragment
of fracture might damage them before AIB
(branch) detachmentfrom the main nerve.
Moreover, after arising from the major
trunk the AIB passes through the interosseous
membrane in a deep position.
The narrow passage and angulation of the
nerve trunk cause reduction of the natural sliding
of the nerve and a predisposition to traction [7]
(Fig.25.2).
The radial nerve is commonly injured in fractures presenting with posteromedial dislocation.Notwithstanding the constant onset of the
palsy, the recovery is usually spontaneous, as
observed in the humeral shaft or Holstein–Lewis
fractures [8, 9]. An unexpected radial nerve
palsythat appears in the rst weeks after trauma
is possiblydue to the compression or wrapping of
the nerve bybone callus. As regards ulnar nerve
injuries, there are minor chances ofdirectnerve
injury in skeletal trauma, apart from rare fractures with exion dislocation (2% of all supracondylar fractures).
Further causes of palsy might be a direct
injury in the event of medial pinning for fracture xation, which inconstantly causes nerve
fascicle disruption or the arising of late palsy secondary to perineural brosis in the cubital
tunnel.
Open injuries are commonly due to glass or
sharp objects.
On the one hand, wounds of the upper arm are
usually observed in older children because of
their autonomy, which exposes them to the risk of
cutting with penetrating glass fragments, metal
plates, knives, or cutting blades. On the other
hand, little children are easily injured by the same
sharp objects but more commonly are suffering
from crush injuries, without signicant impairment ofnerve trunks.
The wrist, palmar surface of the hand, and ngers are the most common sites of injury. Very
often, multiple cuttings are detected, interesting
both the vessels, tendons and muscles, and nerves
as well.
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Fig. 25.2 Kiloh–Nevin syndrome: impossibility to distal phalanx exion of the thumb and index nger after AIB
injury
Physicians must be aware of thoroughly exploring any minimal glass wounds
because askin laceration might be expressionof
deep structuresdamaging.
Although a clinical examination might be difcult in the child, especially in the youngest, vessels,
tendons, and nerve interruption should be detected
in the rst exploration [10] (Fig.25.3).
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Fig. 25.3 Small wound in the palmar region with a lesion of the collateral radial nerve for the index nger
25.3 Diagnosis
To solve the problem, some authors have proposed to assess the sensibility of uncooperative chil-
Early identication of nerve palsy is basic either
for the treatment or forensic aspect. Medical
reports should clearly show if the paralysis were
already present at the admission of the patient to
the emergency room. Although detection of nerve
palsy might be independent of the treatment, very
often reports lack this information, so in case of
legal disagreement, it might be hard to explain a
nerve lesion that occurred at the trauma [11].
Clinical examination should be accurately carried out to give the right information and decide
on strategies for treatment.
Nevertheless, the examination might be challenging, especially in the youngest child presenting with bone fractures. Usually, they are
uncooperative because of their age, anxiety, pain,
and swelling. For those reasons, assessment
methods commonly applied to test active motion
and sensibility cannot be used, because of the
risk of underestimating the palsy.
dren by submergingthe hand in water, soaking or
wet cloth, and then observing the capability to wrinkle [12]. Immediate sign of nerve involvement is
neuropraxia; however, during the rst weeks after
trauma, it does not need to carry out anyearlydiagnostic examination.Closed nerve injury of the upper
limb has a high chance of spontaneous recovery. On
the contrary, in the event of a palsy not showing any
sign of recovery from 4–6 monthsafter the trauma,
it is advisable to study the nerve through ultrasound
and neurophysiological exams. Similarly, early surgery should be performed in the event of persistent
palsy with a Tinel’s sign remaining at the fracture
site, which might be the expression of nerve entrapment in the bone regeneration callus.
The key point is to detectwhether the nerve is
in-continuity or not and about perilesional tissues
[13].
Neurophysiological exams are still considered
the gold standard to study nerve palsy, although
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they are not always reliable, especially in the
acute phase of the palsy or in uncooperative
patients [14]. Sonography, giving more information on the morphology, continuity, and motility
of the nerve, can easily identify nerve damage
that requires early surgical treatment.
Being not inuenced by tissue changes following the trauma or by the presence of metallic
devices, this examination can be carried out during the rst weeks after the injury.
Itis usually well tolerated by the child, allowing it to be repeated to assess the recovery [15].
25.4 Treatment
The approach to PNI differs from the type of
injury, namely, open or closed, and the presence
of a nerve gap.
The treatment of open injuries should be theoretically carried out as soon as possible to avoid
the formation of scar tissue which might hinder
nerve regeneration.
However, a new opinion has arisen about
delayed reconstruction within 3 weeks after the
trauma, especially in the event of extended or
complicated multiple tissue lesions.
Moreover, this option of delayed treatment
could be useful for surgeons who do not usually
deal with nerve surgery, allowing them to address
the injured child at a hub center where nerve surgery is commonly carried out.
According to nerve damage, nerve reconstruction
can be performed through different techniques:direct
suture (Fig.25.4), nerve graft (Fig.25.5), and tubulization are the options (Fig.25.6).
Neurorrhaphyis the best procedurebecause it
can provide the right orientation of the
axons. However, in open injuries, a nerve gap
is often shown so to impose substitution of the
gap through nerve grafts or conduits.
To ll the gap, nerve grafts are the best solution. Schwann cells of interposed nerve graft
contribute to nerve regeneration, both for mixed
and sensitive nerves.
F. M. Senes et al.
Fig. 25.4 Ulnar nerve lesion treated with direct suture
Fig. 25.5 Sural nerve graft for nerve reconstruction
The conduits represent an alternative to bridge
the gap, but some concerns still remain.
Although many types of tubes have been proposed to improve nerve regeneration (i.e., bio-
logical or synthetic), at the time being there are
still contrasting results apart from some good
outcome in sensitive nerves.
On the contrary, regarding mixed nerves its
application remains controversial [16].
Notwithstanding, considering the overall good
recovery of nerve injury in children, the use of
nerve conduits in repairing nerve defects of the
upper limb may be considered even for mixed
nerves [17].
Another matter that is widely debated is the
approach to a closed nerve injury, especially for
those associated with supracondylar humeral
fractures.
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Fig. 25.6 Median nerve reconstruction with saphenous vein tubulization
On the one hand, the majority of these lesions
tend to a complete recovery: a waiting attitude
should be considered, postponing any treatment
before 6 months from the trauma [18, 19].
If nerve palsy does not shortlyappear after the
trauma but is detectedin the following weeks, a
nerve entrapment into bone callus formation
In the event of neglected nerve injuries in
adults, tendon transfers are commonly performed
to restore function. On the contrary, tendon transfers in children should not be considered as a rst
option, because of their nerve spontaneous repair
or recovery achievement through delayed nerve
reconstruction.
should be suspected.
Radial and median nerves are commonly
involved, although the rst one has a major risk
25.5 Conclusion
because of its closelocation to the bone.
Inthe eventof late paralysis, sonography can
show the nerve morphology and surrounding
bone callus formation.
If compression is conrmed, early exploration can establish whether the nerve might be
freed or repaired throughautografts.
To sum up, PNI are common occurrences in pediatric traumatology, particularly in upper limbs
than in the lower ones.
Althoughopen lesions are not negligible, the
majority of lesions are closed injuries. Unlike
adulthood, closed injuries require a waiting atti-
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