90 THE JOURNAL OF BONE AND JOINT SURGERY

Clinical outcome of nerve injuries associated

with supracondylar fractures of the humerus
in children

THE EXPERIENCE OF A SPECIALIST REFERRAL CENTRE

M. Ramachandran,
R. Birch,
D. M. Eastwood

From The Royal
National
Orthopaedic
Hospital, Stanmore,
England

"

M. Ramachandran, MB,
FRCS(Orth), Specialist
Orthopaedic Registrar

"

D. M. Eastwood, MB,
FRCS, Consultant
Orthopaedic Surgeon

"

R. Birch, MChir, FRCS,
Professor, Consultant
Orthopaedic Surgeon
The Royal National
Orthopaedic Hospital,
Brockley Hill, Stanmore,
Middlesex HA7 4LP, UK.
Correspondence should be
sent to Miss D. M. Eastwood;
e-mail: DMEastwood@
btinternet.com

2006 British Editorial
Society of Bone and
Joint Surgery
doi:10.1302/0301-620X.88B1.
16869 $2.00

J Bone Joint Surg [Br]

2006;88-B:90-4.

Received 20 June 2005;
Accepted after revision
26 July 2005

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar
fracture of the humerus who were referred to a nerve injury unit were identied. There
were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review
of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten
and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial
presentation and 23 were diagnosed after treatment of the fracture. After referral,
exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three
because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma
and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, ve a
good and one a fair outcome.

Neurological complications associated with
supracondylar fractures of the humerus in chil-
dren are well recognised.

1,2

The relative inci-
dences of traumatic and iatrogenic nerve
injuries associated with this fracture have been
reported as being 12% to 20%

1,3,4

and 2% to
6%,

5,6

respectively. The radial and anterior
interosseous nerves are thought to be those
most commonly involved by the fracture
itself

2,3,7

while iatrogenic damage most often
affects the ulnar nerve.

8-10

Several studies have suggested that 86% to
100% of these nerve injuries are neurapraxias
which resolve spontaneously within six
months, with the mean time to recovery being
between two and three months.

3,4,8,11

By con-
trast, other reports have noted inadequate
recovery and the need for surgical intervention
in selected cases.

1,6,9

Our aim was to report the referral pattern
and the outcome of nerve injuries associated
with supracondylar fractures of the humerus in
children seen over a period of ve years at a
dedicated peripheral nerve injury unit in the
UK.

Patients and Methods

The database of our peripheral nerve injury
unit was reviewed to identify all patients under
the age of 16 years who had been referred for
the further management of a nerve injury asso-
ciated with a supracondylar fracture of the
humerus between January 1, 1998 and Decem-
ber 31, 2002.
Children with other injuries to the elbow,
such as condylar fractures and physeal injuries,
were excluded from the study.
We identied 32 patients with 32 fractures
and 37 nerve injuries. There were 19 boys and
13 girls with a mean age at referral of 7.9 years
(3.6 to 12.5; Table I). The mechanism of injury
in 31 patients was a fall from a height. The
remaining patient (case 18) had been the front-
seat passenger in a car involved in a road-traf-
c accident. All the fractures were closed, dis-
placed extension-type injuries. The fractures
were classied using the Gartland classication
at the referring hospital

12

(Table II), and this
was conrmed, when possible at the rst con-
sultation in our unit. Eight of the 32 fractures
were classied as Gartland type II and 24 as
Gartland type III. At the referring hospital, two
of the fractures had been treated by closed
reduction and above-elbow casting, 20 by
closed reduction and percutaneous cross Kir-
schner (K-) wire xation with a mini-open
medial approach to protect the ulnar nerve,
and ten by formal open reduction and cross K-
wire xation. A lateral approach to the frac-
ture had been used in nine of ten open reduc-
tions, with an anterior approach in the nal
case to allow concomitant exploration of a
vascular injury. One further patient had an
anterior incision for a delayed exploration for
vascular compromise (Table I). The neural
injuries were initially managed by observation
at the treating hospital, and referred when
inadequate recovery was noted.

Trauma
CLINICAL OUTCOME OF NERVE INJURIES ASSOCIATED WITH SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN 91
VOL. 87-B, No. 1, JANUARY 2006

All children presented to our unit within three months of
the injury. The indications for operative intervention were
either a complete degenerative lesion on neurophysiological
studies or failure of the anticipated clinical recovery. The
operative ndings and details of the surgical procedure
were recorded. Post-operative follow-up was carried out at
six weeks, three months and subsequently every three
months until full recovery. The clinical outcome at the last
follow-up was assessed according to the criteria of Birch,
Bonney and Wynn Parry

13

and graded as excellent, good,
fair or poor (Table III).

Results

Clinical details are shown in Table I. Nineteen (51.4%) of
the referred nerve injuries involved the ulnar, ten (27%) the
median and eight (21.6%) the radial nerve. Out of 37 neu-
ropathies 14 (37.8%) were directly related to the injury
itself and were noted at the time of presentation. The
remaining 23 (62.2%) were diagnosed after reduction and
xation. Of the 14 neuropathies related to the injury, ve
were to the ulnar, ve to the median and four to the radial
nerve. Of the 23 diagnosed after initial intervention, 14
were to the ulnar, ve to the median and four to the radial
nerve. Nine of the 14 (64%) injuries to the ulnar nerve were
associated with closed reduction and percutaneous pin x-
ation of the fracture. There were no cases of compartment
syndrome. In two of the 32 patients, there had been a sug-
gestion of vascular compromise. One case was noted at
presentation and an anterior approach was used with
crossed K-wire xation of the fracture (case 16) and in the
other, vascular compromise was noted after closed reduc-
tion and percutaneous xation and an anterior approach to
the vessels was performed 24 hours later (case 29).

Table I.

Details of the patients at the time of referral to the specialist unit

Case Gender

*

Age at referral
(yrs) Gartland grade

12

Initial treatment

Associated injuries Nerve(s) injured
Time lesion
noted

1 M 5.9 III CRPP None Ulnar Post-operative
2 M 9.4 III CRPP None Median Post-operative
3 F 6.4 III CRPP None Ulnar Post-operative
4 M 9.8 II CR None Ulnar Injury
5 M 11.3 II CRPP None Median Injury
6 M 10.2 III ORP None Ulnar Post-operative
7 F 9.5 III CRPP None Median Post-operative
8 M 5.9 III ORP None Ulnar, median Post-operative
9 F 7.3 III ORP None Ulnar Post-operative
10 F 9.8 III CRPP None Ulnar Post-operative
11 M 7.1 III CRPP None Median Post-operative
12 F 7.3 II CRPP None Ulnar Post-operative
13 M 5.0 II CRPP None Radial Injury
14 F 9.2 III ORP None Radial Post-operative
15 F 6.1 III CRPP None Ulnar Post-operative
16 M 6.5 III ORP Brachial artery entrapment fracture
site freed at ORP
Ulnar, median Injury
17 M 5.2 III CRPP None Ulnar Post-operative
18 M 12.5 III CRPP None Ulnar Injury
19 F 8.3 III ORP None Median
Ulnar, radial
Injury
Post-operative
20 F 5.8 III CRPP None Median Injury
21 F 8.0 III CRPP None Ulnar Post-operative
22 M 3.6 III CRPP None Radial Injury
23 M 9.3 III CRPP None Radial Post-operative
24 M 10.4 II CR None Ulnar Injury
25 F 7.3 III ORP None Radial Injury
26 M 10.5 II CRPP None Ulnar Post-operative
27 M 5.8 III ORP None Radial Injury
28 M 6.8 II ORP None Ulnar Post-operative
29 F 10.8 III CRPP Brachial artery spasm on exploration
by vascular surgeons prophylactic
exor compartment decompression
Ulnar, median Post-operative
30 M 8.3 III ORP None Radial Post-operative
31 M 6.2 II CRPP None Median Injury
32 F 7.3 III CRPP None Ulnar Injury
* F, female; M, male
CR, closed reduction and above-elbow cast; CRPP, closed reduction and percutaneous xation; ORP, open reduction and xation
Table II. The Gartland
12
classication of extension-
type supracondylar fractures
Type Displacement
I Undisplaced
II Displaced (with intact posterior cortex)
III Displaced (no cortical contact)
92 M. RAMACHANDRAN, R. BIRCH, D. M. EASTWOOD
THE JOURNAL OF BONE AND JOINT SURGERY

Spontaneous neurological recovery occurred in 19
patients (24 nerves) at a mean of 7.7 months (3 to 15) after
injury, with 16 patients having an excellent and three a
good outcome.
Operative intervention was planned for 13 patients (13
nerves) either because of a complete degenerative lesion or
because of clinical failure of recovery (Table IV). In three,
surgery was cancelled on the day of admission as there
were signs of recovery of nerve function and two of these
recovered fully by six months from the time of the injury,
while the third recovered by nine months. All had an excel-
lent outcome.
Ten patients underwent exploration of their nerve
lesions at a mean of 7.7 months (6 to 9) after injury. At
exploration, nine nerves were noted to be in continuity. A
nerve stimulator was used to assess functional continuity
across the site of the injury. When distal function was noted
with proximal stimulation, conservative surgery was per-
formed.
An external neurolysis was performed in six ulnar
nerves, four were trapped within callus and two in brous
scar tissue within the cubital tunnel. Four patients had an
excellent and two had a good outcome.
The remaining four nerve lesions (two radial, one ulnar
and one median) required nerve grafting to establish func-
tional continuity, three because of the formation of a
neuroma with no distal response to proximal stimulation,
and one because of laceration, retraction of nerve ends and
resultant gap. The medial cutaneous nerve of the forearm
was used as the donor in three patients, and the supercial
radial nerve in one. There were no operative complications.
Of these four patients, three had an excellent, and one a fair
outcome. The last child did not regain extension of the
thumb after a radial nerve injury treated by supercial

Table III.

Grading of the results after nerve injury in the forearm according to the criteria of Birch et al

13

Grade Motor function Sensation

*

Comments

Excellent MRC

grade 5 Normal Normal
Good MRC grade 4+ Minimal alteration in all modalities Essentially normal
Fair MRC grade 3 Decreased texture recognition and
two-point discrimination
Skin atrophy, brittle nails and
possible growth disturbance
Poor MRC grade less than 3 Pain As above
* the presence of pain or painful sensations automatically downgrades the result to poor
MRC, Medical Research Council

Table IV.

Details of the 13 patients in whom surgery was planned

Case
Nerve
injured Progress
Findings at operation
(if performed)
Source of nerve graft
(if necessary)

*

Time to recovery from
surgery or injury (mths) Outcome

1 Ulnar Complete degenerative
lesion
Neuroma related to site of
wiring; grafting
MCNF 3 (from grafting) Excellent
2 Median Complete degenerative
lesion
Neuroma surrounded by
scar tissue; grafting
MCNF 3 (from grafting) Excellent
3 Ulnar Complete degenerative
lesion
Nerve entrapment at
fracture site within callus;
neurolysis
6 (from neurolysis) Good
4 Ulnar Complete degenerative
lesion
Nerve entrapment at
fracture site within callus;
neurolysis
3 (from neurolysis) Excellent
7 Median Complete degenerative
lesion
Surgery cancelled on admission 6 (from injury) Excellent
9 Ulnar Inadequate recovery after
initial injury noted post-
operatively
Nerve entrapment at
fracture site within callus;
neurolysis
3 (from neurolysis) Excellent
10 Ulnar Complete degenerative
lesion
Nerve entrapment at
fracture site within callus;
neurolysis
3 (from neurolysis) Excellent
12 Ulnar Complete degenerative
lesion
Nerve in scar tissue in
cubital tunnel; neurolysis
3 (from neurolysis) Good
13 Radial Complete degenerative
lesion
Surgery cancelled on admission 9 (from injury) Excellent
14 Radial Complete degenerative
lesion
Surgery cancelled on admission 6 (from injury) Excellent
22 Radial Complete degenerative
lesion
Nerve entrapment,
laceration and gapping at
fracture site; grafting
MCNF 6 (from grafting) Excellent
23 Radial Complete degenerative
lesion
Neuroma within fracture
site; grafting
SRN 24 (from grafting) Fair

26 Ulnar Complete degenerative
lesion
Nerve in scar tissue in
cubital tunnel; neurolysis
3 (from neurolysis) Excellent
* MCNF, medial cutaneous nerve of forearm; SRN, supercial radial nerve
lack of thumb extension requiring transfer of palmaris longus to extensor pollicis longus 17 months after grafting
CLINICAL OUTCOME OF NERVE INJURIES ASSOCIATED WITH SUPRACONDYLAR FRACTURES OF THE HUMERUS IN CHILDREN 93
VOL. 87-B, No. 1, JANUARY 2006

radial nerve grafting. She subsequently underwent transfer
of palmaris longus to extensor pollicis longus.
Although 50% (four of eight) of the lesions of the radial
nerve occurred in association with a lateral approach for an
open reduction only two of the four were iatrogenic. All
four recovered spontaneously although surgery was
planned in two.
Overall, 26 patients (81.3%) had an excellent, ve
(15.6%) a good and one (3.1%) a fair outcome. In 13
patients 14 lesions were noted at presentation of the frac-
ture; two of these patients subsequently underwent surgical
exploration. Of the 13 patients, 12 (92%) had an excellent
outcome. Twenty-three nerve lesions in 20 patients were
classied as iatropathic in that the nerve injury was noted
after intervention either in terms of a manipulation or per-
cutaneous xation or open reduction. One patient (case 19)
had a lesion of the median nerve identied at presentation
and injury to the ulnar and radial nerves after open reduc-
tion and percutaneous xation. Eight patients (40%) with
iatropathic injuries underwent a surgical procedure. Of the
20 patients 15 (75%) had an excellent outcome.

Discussion

Nerve injuries after supracondylar humeral fractures occur
primarily due to tenting or entrapment of the nerve on the
sharp proximal humeral fragment, while iatrogenic injuries
occur either during closed manipulation or percutaneous
xation of the fracture fragments or occasionally during
open procedures.

8,9,14

The median or anterior interosseous
nerves are most commonly damaged by extension-type
injuries, while the less common exion-type injuries affect
the ulnar nerve more often.

15-17


It has been reported that iatrogenic injuries most com-
monly affect the ulnar nerve, with percutaneous crossed K-
wire xation being associated with the highest risk of
injury.

10

In a smaller study by Green et al,

18

only one case of
neurapraxia of the ulnar nerve was identied in 65 patients
treated in this way. This study which was based on late
referrals to a specialist nerve injury unit similarly showed a
relationship between lesions of the ulnar nerve and closed
reduction and percutaneous crossed K-wire xation. Our
unit accepts referrals from all over the country. We cannot
comment on the true incidence of supracondylar-associated
neural injuries since referrals were only made to us by the
treating hospitals when the initial period of observation
had failed to show recovery. Therefore, transient neurap-
raxias, whether traumatic or iatrogenic in origin, are not
included in our gures. This may explain the low incidence
of anterior interosseous nerve lesions in our study. In addi-
tion, we assume that some neural injuries would have been
treated locally by other appropriate units.
Most studies in the orthopaedic literature have reported
a good to excellent prognosis for nerve injuries associated
with supracondylar fractures in children.

3,4,8,11

A few have
emphasised the need for surgical intervention in selected
cases.

1,6,9

Culp et al

1

reported 18 nerve injuries in a retro-
spective review of 101 displaced extension-type supra-
condylar fractures. They explored nine cases when there
was no clinical or electromyographic evidence of return of
function at a mean 7.5 months after injury; eight lesions
were in continuity, with nerve function recovering well
after neurolysis. One complete laceration of the radial
nerve, however, did not recover even after grafting and
underwent tendon transfers.
Birch and Achan

6

reported 118 cases of repaired nerve
lesions associated with fractures and dislocations at the
elbow displayed at operation, of which 91 were in con-
junction with supracondylar fractures. Of these, 43
involved the median, 35 the ulnar and 13 the radial nerve.
Seven cases were iatropathic, although it was unclear if any
or all of these were related to the supracondylar fractures.
They specied that 22 of the 91 injured nerves associated
with supracondylar fractures were found to be entrapped
within the fracture or impaled on a bone spike, while the re-
mainder were compressed by swelling or brosis at or distal
to the fracture, the latter showing uniformly good recovery
after decompression. No reference was made to the need
for grafting.
In regard to iatrogenic injuries, the reported prevalence of
injury to the ulnar nerve with the use of crossed K-wires has
ranged from 2.5% to 6%.

8-10

Brown and Zinar,

8

in
reviewing 162 fractures, identied four iatrogenic lesions of
the ulnar nerve. All were explored and in all the medial wire
was found to be injuring the nerve. They recommended
urgent re-exploration in cases of post-operative nerve palsy.
By contrast, Lyons et al

9

reported injuries to the ulnar nerve
noted post-operatively after percutaneous cross K-wire x-
ation in 375 Gartland type-III supracondylar fractures. Of
these cases 17 were followed up and all did well irrespective
of whether the wire was removed, the nerve explored or the
patient treated conservatively. The authors comment that
placement of the wire is only one of several factors impli-
cated in the development of a post-operative nerve palsy. It
is common practice now to ensure that the medial wire is
placed through a mini-medial approach in an attempt to
reduce the risk of nerve injury. Skaggs et al

19

reported no
signicant reduction in iatrogenic injuries to the ulnar nerve
when such an approach was used. By contrast, Green et al

18

reported only one case of transient sensory symptoms in the
ulnar nerve in a two-surgeon series of 65 patients treated
using a mini-incision technique. In all the cases in our series
the medial wire had been introduced through a mini-medial
incision. Rasool

5

documented nerve injury occurring sec-
ondary to constriction by the cubital tunnel retinaculum.
Cases 12 and 26 were examples of this phenomenon in
which scar tissue in the cubital tunnel had caused a com-
plete degenerative lesion of the ulnar nerve, with a good to
excellent outcome after neurolysis. Skaggs et al

19

reported
no iatrogenic injury to the ulnar nerve when only lateral
wires were used, and conrmed that adequate xation of
unstable supracondylar fractures was achieved by such a
technique. De las Heras et al

20

identied two lesions of the
94 M. RAMACHANDRAN, R. BIRCH, D. M. EASTWOOD
THE JOURNAL OF BONE AND JOINT SURGERY

ulnar nerve in 77 patients using a lateral technique and
emphasised the need for stability of the fracture, if necessary
using a third wire, to reduce the risk of nerve injury. None
of these studies reported the incidence of traumatic nerve
injury documented at presentation. As pointed out by Lyons
et al

9

the observation of nerve injury post-operatively does
not imply that it occurred as a result of the intervention it
is possible that it had simply not been recognised at the time
of presentation. Similarly, the trauma associated with the
reduction may injure the nerve irrespective of whether per-
cutaneous wiring techniques are used. In our patients all the
wires had been removed before referral to our unit and we
are unable to comment on whether or not the nerve lesions
were due to penetration by the wires or damage associated
with their introduction. Only two wires in two patients had
been removed early because of the presence of a nerve
palsy. Cases of direct damage by K-wires may have been rec-
ognised and treated locally and if recovery of nerve function
followed they would not have been referred to our unit. Of
the ten patients who underwent exploration, one neuroma
appeared to be related to the site of insertion of the wire but
most nerve lesions were secondary to entrapment within
fracture callus or scar tissue.
A conduction block may progress to a degenerative
lesion if the compressive element of the original injury is
not relieved. The presence of persistent neuropathic pain
implies ongoing nerve compression and injury and should
dictate further investigation and relief of compression.
Clinical examination should also concentrate on sympa-
thetic function. A warm dry digit implies that there is nerve
dysfunction and indicates the need for exploration of the
nerve. Our suggested indications for exploration are given
in Table V.
We conclude that contrary to the implications in the
recent literature that nerve injuries associated with supra-
condylar fractures invariably recover spontaneously and
well, certain nerve injuries with complete lesions on neuro-
physiological studies and those in whom the anticipated
clinical recovery does not occur require assessment and
management in a specialist unit.

No benets in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.

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Table V. Suggested indications for nerve exploration after trauma
Nerve lesion incurred during closed or open reduction and stabilisation
of fracture, particularly in the presence of an inadequate/incomplete
reduction when the nerve has not been visualised
Neuropathic pain
Complete lesion with sympathetic paralysis
A nerve lesion which deepens progressively between 8 and 12 hours
Coexisting ischaemia