Median nerve reconstruction after entrapment in the elbow

Visualization of Median Nerve Entrapment After Reduction of an Elbow Fracture Dislocation Using 3-Dimensional Magnetic Resonance Imaging: A Case Report

CASE

A 10-year-old girl presented after closed reduction of an elbow fracture dislocation. She demonstrated intact vascularity but a dense median nerve palsy. Preoperative magnetic resonance neurography (MRN) precisely mapped the median nerve entrapped within the medial epicondylar fracture. Intraoperatively, the median nerve was freed preceding reduction and fracture fixation. Postoperatively, neurological symptoms completely resolved, and she regained full elbow function.

CONCLUSION

Median nerve injury can present without associated vascular injury. In this case, MRN was helpful in preoperatively illustrating the spatial relationship between the median nerve and the medial epicondyle.

Entrapment of median nerve after elbow fracture dislocations: expected surgical time frame based on cadaver study

INTRODUCTION

Median nerve injuries occur in approximately 3% of pediatric elbow fracture dislocations. These rare injuries can be difficult to diagnose, and the results are poor in delay cases. Surgical timing is one of the most important prognostic factors. We aimed to present three patients with median nerve palsy who were referred to our clinic late, and according to these cases, we emphasized the expected time frame for exploration based on our anatomical cadaver study.

MATERIALS AND METHODS

Between 2008 and 2010, three patients were referred to our clinic because of median nerve paralysis after a treated elbow dislocation. The mean interval between injury and referral was 15 (min: 13-max: 18) months, and the mean age of the patients was 15 (13-18) years. Neurolysis was performed in two patients, and for the third patent, after neurolysis, axonal continuity was observed to be disrupted so sural nerve grafting was performed with four cables. Tendon transfers were performed in all patients. A total number of 20 upper extremities of 10 cadavers were dissected. Due to its proximal innervation and ease of assessment, the muscle innervation of the flexor pollicis longus (FPL) was planned to be evaluated. The distance from the medial epicondyle is calculated in the cadaver study where the nerve injury is found.

RESULTS

The mean length from the medial epicondyle to the motor innervation of FPL was calculated in each specimen and found to be 101.99 millimeters (mm) (range: 87.5-134.2). The mean longest innervation of FPL was 110.83 mm from (range 87.5-148.1) the medial epicondyle calculated by including each specimens longest nerve length. Knowing that the healing time of a nerve lesion is 1 mm per day, we calculated that the recovery of FPL would take approximately 4 months.

CONCLUSION

When nerve healing is expected to be 1 mm a day in axonotmesis type injury, after the median nerve palsy following elbow dislocation, thumb flexion should be achieved in the following 4 months generally if the nerve was not entrapped in the joint. This cadaver-based study objectively defined how long to wait for the innervation of the FPL in median nerve injuries in elbow fracture dislocations.

Post-traumatic entrapment of the median nerve in the ulno-humeral joint: Diagnosis, treatment and literature review

BACKGROUND

The incidence of median nerve injuries in pediatric elbow dislocations is approximately 3% and avulsion of the open medial epicondylar epiphysis in the pediatric population is one predisposing factor that may explain this age predilection. These lesions can be difficult to diagnose in the acute phase because symptoms tend to be mild or delayed, consequently their management can be challenging and functional outcome poorer.

METHODS

We present the case of an unrecognized median nerve entrapment in a 16-year-old boy with posterior dislocation of the elbow and a medial epicondyle fracture, treated initially with close reduction and open stabilization with a cannulated screw. Assessment is supported by a review of similar reported cases available in literature.

RESULTS

We discuss the diagnostic approach and the surgical options that can be used for this type of injury.

CONCLUSIONS

High clinical suspicion of entrapment is imperative in presence of signs of damage to the median nerve in the pediatric patient immediately after the reduction of an elbow dislocation. If diagnosis of entrapment is made the therapeutic choice between neurolysis and nerve graft depends on the lesion severity. In the presence of a Fourrier's type 4 lesion, neurolysis should be avoided, while nerve resection and grafting are recommended.

Type-V Median Nerve Entrapment in a Pediatric Medial Condyle Fracture: A Case Report

CASE

A 30-month-old boy with a displaced medial condyle fracture and no history of an elbow dislocation was found to have an entrapped median nerve.

CONCLUSION

Entrapment of the median nerve is a potential consequence of a displaced medial condyle fracture, even when there are no neurologic deficits on presentation. This provides additional support for open reduction of these fractures rather than percutaneous treatment or nonoperative management. Prompt identification and extraction of an interposed ulnar or median nerve is imperative to prevent the catastrophic consequences of an upper-extremity nerve palsy in children, as well as to optimize fracture-healing and elbow growth and development.

Median Nerve Entrapment after Elbow Dislocation and the Role of Ultrasonography - A Case Report

INTRODUCTION

Median nerve entrapment in the cases of posterior dislocation of elbow is a rare entity. The diagnosis is usually delayed. We describe here a case of median nerve entrapment in the posteromedial dislocation of elbow in a 10-year-old male child and the role of ultrasonography (USG) in localizing the median nerve in the elbow. The nerve release was done by osteotomy of medial epicondyle. USG thus proved to be a useful tool in the management of nerve injury.

CASE REPORT

The authors present here a case of 10-year-old child with a history of dislocation of right elbow that was reduced elsewhere and the child presented to us with stiffness and restriction of movements at the elbow with the features of high median nerve injury. On further evaluation with ultrasound, the median nerve was found to be entrapped in the elbow behind the medial epicondyle. Medial condyle osteotomy was done to release the median nerve and to provide the relief of symptoms.

CONCLUSION

Median nerve entrapment after the elbow dislocation is a very rare entity. High index of suspicion and the ultrasound are quite helpful in arriving at the diagnosis of this rare clinical entity. Timed surgical release of the nerve and can provide good function.