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Closed reduction and percutaneous pinning is the preferred surgical intervention for paediatric supracondylar humerus fractures (SCHF). Loss of reduction (LOR) is one of the infrequent complications associated with percutaneous pinning. We aim to analyse the various factors that could lead to LOR. We retrospectively reviewed records of all children with Gartland's type III and IV SCHF who were operated at our institution between 2014 and 2016. A defined set of radiologic indices were measured on postoperative and follow-up radiographs. Correlation between LOR (as defined by Skaggs) and radiologic indices, was calculated. In total 187 children who satisfied the inclusion criteria were included in the study. Major LOR was present in 8 patients (4.28%), mild LOR was seen in 21 patients (11.22%), and there was no LOR in 158 patients (84.49%). A pin-spread fracture width ratio of 0.37 had maximum sensitivity and specificity for predicting LOR. The convergent pin configuration had the highest rate of LOR of 15%, whereas it was about 3% in the crossed pin and lateral divergent pinning group. The incidence of iatrogenic ulnar nerve injury in our series was 4.76%, and all were in the cross pinning group. Pin-spread fracture width ratio is the most crucial factor determining LOR, and a ratio of less than 0.37 has a significantly higher rate of LOR. As the incidence of LOR is not significantly different between the lateral-only and crossed pin groups, a medial pin should be used judiciously to avert the risk of ulnar nerve injury. Level of evidence: Level IV.

Case series Patients: Female, 7-year-old • Male, 6-year-old Final Diagnosis: Flexion-type supracondylar humeral fracture Symptoms: Pain Medication: — Clinical Procedure: — Specialty: Orthopedics and Traumatology Objective: Rare co-existance of disease or pathology Background: Supracondylar humeral fracture is a common fracture in the pediatric population. Although extension-type is the most common fracture pattern (97% to 98%), flexion-type supracondylar fractures are rarely encountered (2% to 3%). The combination of a flexion-type supracondylar humeral fracture with an ulnar nerve injury represents a real challenge for an orthopaedic surgeon. Case Reports: We report 2 cases of flexion-type supracondylar humeral fracture with ulnar nerve injury that open reduction and fixation was necessary because closed reduction could not achieve an acceptable result. An anterior approach to the elbow joint was chosen to explore whether any neurovascular structures were entrapped between the fragments. The ulnar nerve was not found to be compressed in the fracture site. After anatomic reduction, cross K-wire fixation of the fracture was performed. At 6-month follow-up, ulnar nerve injuries (in both patients) were resolved. Conclusions: These case reports enhance the existing literature that flexion-type supracondylar fractures with ulnar nerve injury are associated with higher rates of open reduction. Orthopaedic surgeons should be aware, and family members of those patients should be informed, that the likelihood of an open reduction in these types of injuries is extremely high. Open reduction is needed not only to achieve an anatomic reduction of the fracture but to make sure that the ulnar nerve is not entrapped between the proximal and distal fragment.

Study Design A retrospective cohort study. Introduction Some patients after median or ulnar nerve injury report a diminished sensibility in the fingers that are supplied by the uninjured nerve. Purpose of the Study The purpose of this study was to evaluate the function of the uninjured nerve in patients after peripheral nerve injury to assess the presence and degree of its functional impairment. Methods There were 28 patients with median and 29 patients with ulnar nerve injury examined for sensory disturbances in the injured and uninjured nerves, using several tests assessing touch, temperature, and vibration sensibility. Results In 16 patients after ulnar and 13 patients after median nerve injury, some disturbances in the uninjured nerve were found, mostly in individual tests. Only 8 patients had 3 or more different tests abnormal. Discussion The injured nerve function in patients with functional disturbances in the uninjured nerve was worse than in patients with normal test results. Conclusion Posttraumatic changes in central nervous system are the possible reasons. Level of Evidence Level III study.

There are few studies supporting supercharge end-to-side nerve transfer for high ulnar nerve injury. The current study hypothesized that patients with a supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer would demonstrate superior return of intrinsic function compared with conventional treatment only.A retrospective matched-cohort study matched supercharge end-to-side transfer patients based on age, level of injury, and mechanism to ulnar nerve injury patients who did not have the transfer. The primary outcome was return of ulnar intrinsic function, based on clinical examination and/or electromyography. Dichotomous and continuous variables were compared with Fisher's exact and t tests, respectively.Thirteen supercharge end-to-side patients were identified (1 year follow-up). The average age of both cohorts was 35 years. Ulnar nerve transection above the proximal third of the forearm represented 54 percent of patients; compressive injuries represented 46 percent. Eleven supercharge end-to-side transfer patients (84 percent) demonstrated intrinsic function recovery compared with five (38 percent) non-supercharge end-to-side patients (p0.05). Average time to initial motor recovery was similar between the two groups (supercharge end-to-side, 2.9 months; non-supercharge end-to-side, 3.8 months; p0.2). Intrinsic function return was more likely following nerve transection with the supercharge end-to-side procedure (85 percent versus 14 percent; p = 0.03), whereas compression injuries had comparable intrinsic function return regardless of the supercharge end-to-side transfer (67 percent versus 67 percent; p = 1.0).This matched cohort study demonstrates that the supercharge end-to-side transfer results in increased ulnar intrinsic reinnervation following ulnar nerve injury. This finding may be most relevant following transection injuries. Improved outcomes associated with supercharge end-to-side and ulnar nerve repair warrant further investigation.Therapeutic, III.

Background and Aims: Lateral-only Kirschner-wire pinning of supracondylar humerus fracture is superior in avoiding surgery-related ulnar nerve injury. Their disadvantageous effects on stability may be a consequence of inappropriate surgical techniques. We analyzed whether the surgeon’s preference for lateral-only fixation is associated with his or her orthopedic competence. We also analyzed the surgical technique–related risk factors of redisplacement. Materials and Methods: All children, aged Results: Orthopedic surgeons used lateral-only method in 23.5% of the type-3 fractures (N = 16/68), and other surgeons in 8.2% (N = 8/97)(difference = 15.3%, 95% confidence interval = 4.6%–27.6%, p = 0.005). One-third of the lateral-only treated fractures (29.2%, 95% confidence interval = 12.6%–51.1%) redisplaced. Lateral-entry pins that crossed at the level of the fracture were associated with failure (87.5%), while no patient with appropriate pin configuration failed (difference = 87.5%, 95% confidence interval = 52.1%–97.8%). A shorter distance (5° changed Bauman angle (p = 0.11), rotational displacement (p = 0.25), and the experience or specialty of the surgeon were not associated with redisplacement. Conclusion: Lateral-only pins resulted in poor stability in one in three of the patients. Appropriate configuration of the pins was associated with good fracture healing, but crossing the pins at the fracture level and introducing them close to each other were associated with redisplacement. Surgeons with more orthopedic competence selected lateral-only fixation more usually.

Radial external fixator has been proposed to treat delayed irreducible Gartland type III supracondylar humeral fracture, and this study aims to compare its effects with crossed pinning in a retrospective fashion. Delayed supracondylar humeral fracture is defined as more than 72 hours after injury, 2 or more than 2 times failed attempts of closed reduction can be deemed as irreducible fracture. Between January 2010 and January 2017, patients of Gartland type III supracondylar fractures of the humerus receiving surgery were all selected and reviewed. Overall, 39 patients fitting the inclusion criteria were chosen for the External Fixator Group and patients for control group of crossed pinning with matched age, sex, and clinical parameters (fracture location, injured side, and fracture type) were selected from the database. Surgery duration, number of intraoperative X-ray images, incidence of ulnar nerve injury, postoperative redisplacement, and function of the elbow joint were recorded and analyzed. In this study, 39 patients treated with radial external fixator had significantly shorter surgery duration, fewer intraoperative X-ray images, and lower incidence of ulnar nerve injury, and postoperative redisplacement than those receiving crossed pinning. Patients in 2 groups displayed similar range of motion for elbow joint at follow-up. Radial external fixator is an effective and safe method to treat Gartland type III supracondylar fractures that were diagnosed late.

Purpose Clinical deficits might vary, depending on whether an ulnar nerve lesion is above or below the elbow. Lack of strength and clawing are common manifestations of ulnar nerve paralysis. However, the magnitude of strength deficit relating to different pinch patterns and the rate and range of proximal interphalangeal extension deficits are poorly described. Methods I prospectively evaluated 14 patients with above-elbow and 16 with below-elbow unrepaired ulnar nerve injuries. The completeness of flexion of the ring and little fingers was tested at the metacarpophalangeal and distal interphalangeal joints. Proximal interphalangeal joint extension lag of the ring and little fingers was assessed by goniometry, and adduction and abduction of the little finger. With dynamometers, I bilaterally evaluated grasp, key pinch, and pinch-to-zoom strength. Hand sensibility was evaluated with monofilaments. Results Metacarpophalangeal flexion in the ulnar fingers was absent in all patients, whereas distal interphalangeal joint flexion was preserved in 29 of 30 patients. In above-elbow ulnar nerve injuries, there was no paralysis of the flexor digitorum profundus. One-third of patients exhibited no clawing. There were minimal differences between the rate of clawing and proximal interphalangeal extension lag in above- and below-elbow ulnar nerve lesions, or its occurrence in the ring or little finger. In relation to the normal hand, grasping, key pinch, and pinch-to-zoom decreased by 62%, 51%, and 75% compared with 59%, 61%, and 76% in below- and above-elbow injuries groups, respectively. In both groups, sensory deficits were predominantly over the little finger and ulnar side of the hand. Conclusions Minimal differences were observed in clinical deficits after above- and below-elbow ulnar nerve injuries. Hand weakness was the most frequent problem, whereas pinch-to-zoom strength was highly affected. Type of study/level of evidence Diagnostic IV.

A 43-year-old female is presented who underwent a two-stage tendon reconstruction and developed a low ulnar nerve palsy postoperatively. Exploration found that the tendon graft was passing through Guyon’s canal and that the ulnar nerve was divided. This is a previously unreported complication. The reconstruction is discussed, the literature reviewed and a guide is given on how to identify the correct tissue plane when passing a tendon rod.

The vast majority of displaced pediatric supracondylar humeral fractures can be treated successfully with closed reduction and percutaneous pinning. The need for open reduction is difficult to determine a priori and is typically due to the failure of closed reduction attempts or persistent limb ischemia. The aims of this study were to determine the prevalence of flexion-type supracondylar humeral fractures, the rate of open reduction for flexion-type fractures, and the predictive impact of ulnar nerve injury on the need for open reduction for flexion-type supracondylar humeral fractures.We developed a database of consecutive pediatric supracondylar humeral fractures treated operatively at a tertiary care pediatric trauma center from 2000 to 2015. Data recorded included age, mechanism of injury, fracture type (open or closed), fracture pattern (flexion-type or extension-type), concomitant skeletal injury, neurovascular injury, treatment, and surgeon. Radiographs of all flexion-type supracondylar humeral fractures were reviewed in order to confirm the classification of the injury pattern. The rate of open reduction for fractures with a flexion-type injury pattern and for such fractures with and without ulnar nerve injury at presentation was assessed.Of 2,783 consecutive pediatric supracondylar humeral fractures treated by surgeons at our center, 95 (3.4%) were flexion-type fractures. Ulnar nerve injury was noted for 10 (10.5%) of the 95 flexion-type fractures. Open injuries were identified at presentation in 3 (3.2%) of the 95 cases. Among closed fractures, 21 (22.8%) of 92 flexion-type fractures required open reduction compared with 50 (1.9%) of 2,647 extension-type fractures (odds ratio [OR] = 15.4; 95% confidence interval [CI] = 8.8 to 27.0; p0.001). Among closed flexion-type fractures, open reduction was performed in 6 (60%) of 10 fractures with associated ulnar nerve injury and in 15 (18.3%) of 82 fractures without ulnar nerve injury (OR = 6.7; 95% CI = 1.7 to 26.7; p = 0.003).Among closed supracondylar humeral fractures, the flexion-type injury pattern was associated with a 15.4-fold increase in the odds of open reduction. The presence of an ulnar nerve injury at presentation resulted in an additional 6.7-fold higher risk of open reduction among flexion-type supracondylar humeral fractures. Patients and families should be counseled regarding the high rate of open reduction for flexion-type supracondylar humeral fractures, particularly those with an associated ulnar nerve injury.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A distal median to ulnar nerve transfer for timely restoration of critical intrinsic muscle function is possible in isolated ulnar nerve injuries but not for combined ulnar and median nerve injuries. We used a distal nerve transfer to restore ulnar intrinsic function in the case of a proximal combined median and ulnar nerve injury. Transfer of the nonessential radial nerve branches to the abductor pollicis longus, extensor pollicis brevis, and extensor indicis proprius to the motor branch of the ulnar nerve was performed in a direct end-to-end fashion via an interosseous tunnel. This method safely and effectively restored intrinsic function before terminal muscle degeneration.

Background Closed reduction and percutaneous pinning are the preferred treatment of displaced supracondylar humeral fractures in children. The purpose of this study is to evaluate the non-standard Dorgan’s method and compare its results with those of the standard percutaneous cross pinning method in treatment of unstable or irreducible Gartland type II and III supracondylar humeral fractures in children. Patients and methods This was a prospective evaluation of 138 consecutive patients with Gartland type II or III extension supracondylar humeral fractures referred to University Children’s Hospital during a four-year period. The patients were randomized into two groups: the first group, comprised of 71 patients, was treated with standard pin configuration and the second group, comprised of 67 patients, underwent Dorgan’s method. The study included 88 boys and 50 girls aged 1.5–11.4 years (mean 6.5 ± 2). At initial presentation 8.7% (n-12) fractures were classified as Gartland type IIa, 25.4% (n-35) as Gartland type IIb and 65.9% (n-91) as Gartland type III. Results Flynn’s criteria were used to evaluate the results. An excellent clinical outcome was reported in about 90% of patients (n-90) treated with standard pin configuration and 89.5% (n-60) of patients treated with Dorgan’s method. There were no statistically significant differences in outcomes between the groups in terms of their gender, age, fracture types, function and cosmetics. Neurological lesions were observed in 9.9% of patients (n = 7) who were treated using the standard configuration Kirschner pins, while in those treated by Dorgan’s method neurological complications were not observed. However, the procedure time was longer (mean 36.54 ± 5.65 min) and radiation exposure significantly higher (mean 10.19 ± 2.70 exposures) in the group that was treated using Dorgan’s method, compared to the conventional method (mean 28.66 ± 3.76 min and 7.54 ± 1.63 exposures). Conclusion Two laterally inserted crossed pins provide adequate stability with good functional and cosmetic outcome for most unstable paediatric supracondylar humeral fractures with no risk of iatrogenic ulnar nerve injury.

Background and purpose Ulnar nerve injury may occur after pinning of supracondylar fractures in children. We describe the outcome and compare the rates of iatrogenic injuries to the ulnar nerve in a consecutive series of displaced supracondylar humeral fractures in children treated with either crossed pinning or antegrade nailing. Methods Medical charts of all children sustaining this fracture treated at our department between 1994 and 2009 were retrospectively reviewed regarding the mode of treatment, demographic data including age and sex, the time until implant removal, the outcome, and the rate of ulnar nerve injuries. Results 503 children (55% boys) with an average age of 6.5 years sustained a type-II, type-III, or type-IV supracondylar fracture. Of those, 440 children were included in the study. Antegrade nailing was performed in 264 (60%) of the children, and the others were treated with crossed pins. Iatrogenic ulnar nerve injury occurred in 0.4% of the children treated with antegrade nailing and in 15% of the children treated with crossed pinning. After median 3 (1.6–12) years of follow-up, the clinical outcome was good and similar between the 2 groups. Interpretation Intramedullary antegrade nailing of displaced supracondylar humeral fractures can be considered an adequate and safe alternative to the widely performed crossed K-wire fixation. The risk of iatrogenic nerve injury after antegrade nailing is small compared to that after crossed pinning.

Purpose Peripheral nerve injury of the upper extremity frequently causes changes in the thermoregulatory system of the hands and fingers and leads to reports of cold intolerance. In this study, we aimed to measure the influence of median or ulnar nerve injury on cold-induced vasodilatation (CIVD) during prolonged cooling at low temperatures. Methods We tested 12 patients with a median (n = 6) or ulnar (n = 6) injury 4 to 76 months after nerve repair. The palmar sides of both hands were cooled continuously using a cold plate at 5 degrees C. We measured the skin temperature of the fingers using videothermography and plotted graphs of the temperature changes of the nailbed. The presence of a CIVD reaction was defined as a minimum increase in temperature of 2.5 degrees C starting at the distal phalanx. Furthermore, we measured self-reported symptoms of cold intolerance using the Cold Intolerance Severity Scale questionnaire. Results A CIVD reaction was absent in the affected digits of 4 patients (follow-up, 6-37 mo), whereas the CIVD reaction in the uninjured hand was present. The CIVD was present in 6 patients after 50 months' follow-up (range, 24-76 mo). Two patients had no CIVD reaction in the injured or uninjured fingers. All patients with a CIVD response had at least diminished protective sensation. Presence of the CIVD reaction did not exclude self-reported symptoms of cold intolerance. Conclusions After peripheral nerve injury, it is possible to recover the CIVD reaction. This might be an indication of nerve recovery. However, a positive CIVD reaction does not exclude subjective symptoms of posttraumatic cold intolerance. (J Hand Surg 2011;36A:986-993. Copyright (C) 2011 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Diagnostic III.

This retrospective study evaluated different pinning configurations used in the treatment of displaced supracondylar humeral fractures among children, mainly regarding maintenance of fracture reduction and avoidance of complications. The fractures (41 type II and 67 type III) of 108 children (mean age 6.48 years) were treated by closed reduction and percutaneous pinning: 37 with crossed pins, 37 with two lateral pins and 34 with two lateral and one medial pin. Mean follow-up period was 7.4 months. Type III fractures fixed by two lateral pins were found significantly prone to postoperative instability, late complications and need for medial pin fixation. There was a significant relation between either delay to surgery or postoperative instability and occurrence of complications. Final outcome was significantly poorer in type III than in type II fractures. Fixation by two lateral pins only is not recommended for treating type III supracondylar humeral fractures, but could be used initially to fix severely unstable fractures to allow extension of the elbow before inserting a medial pin. Every effort should be made to avoid iatrogenic ulnar nerve injury while inserting the medial pin.

In adolescents, neurovascular injury, especially ulnar nerve injury, is rare with fracture of the distal radius. We present a 14-year-old boy who sustained fracture of the distal radius in his right wrist, who also had symptoms of ulnar nerve injury. Close reduction with percutaneous pinning and cast to fix the distal radius fracture was done immediately. Then, we decided to observe the recovery of the nerve injury without providing any emergent nerve exploration. Bone union was achieved after 8 weeks of fixation, and the function of the ulnar nerve was restored completely after 16 weeks of observation. The possibility of ulnar nerve injury should be considered following fracture of the distal aspect of the radius, and we recommend observing the recovery of nerve injury, with no need for emergent nerve exploration.

Objectives The objective of this study was to evaluate and compare the outcome of the crossed and the lateral pin configurations in the management of supracondylar humeral fractures in children in the hands of junior trainees. Design Prospective randomized controlled trial. Setting Level I Trauma Center. Patients Sixty children with supracondylar humeral fractures. The mean age was 5.1 years (1.5-9 years). The minimum follow-up period was 6 months, with no patients lost to follow up. Intervention Thirty patients were managed by crossed and 30 by the lateral method. All surgeries were performed by junior trainees in their first 3 years of training. Main outcome measurements Postoperative stability, ulnar nerve injury, range of motions, and pin tract infection. Results The crossed configuration was stable in all the patients, whereas the lateral method was less stable in 20% of the cases because the distal fragment rotated in 5 patients and posteriorly displaced in 1 patient. The difference was statistically significant with a P value of 0.031. Ulnar nerve neurapraxia occurred in 1 patient from the lateral group and it recovered in the fourth month, whereas no ulnar nerve injury occurred in the crossed configuration group. Two patients in the lateral group lost approximately 100 of elbow flexion. Conclusions This prospective randomized controlled trial showed that the crossed pin configuration method provided more stability than the lateral pin configuration, especially, in the hands of junior trainees in their first 3 years of training, and the difference was statistically significant. Level of evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Lateral humeral condyle fractures constitute 16.9% of distal humeral fractures and are rarely associated with acute nerve injuries in children [1]. Skaggs reported that 7.7% of supracondylar fractures are accompanied by nerve injury. The ratio of nerve injury occurring in supracondylar fracture is listed as follows: 41.2% of radial nerve injury, 36% of median nerve injury, and 22.8% of ulnar nerve injury. However, a literature search identified only one report of acute transient radial nerve paralysis after lateral humeral condyle fracture in a child [2]. Here we report a case of rare radial nerve paralysis after lateral humeral condyle fracture in a child.

OBJECTIVE:This prospective study presents repair results after missile-caused ulnar nerve ruptures as well as factors influencing the outcomes.METHODS:Between 1991 and 1994, 128 casualties with missile-caused complete ulnar nerve injury were managed surgically in the Neurosurgical Department of the Belgrade Military Medical Academy. At least 4 years after surgery, we scored sensorimotor recovery, neurophysiological recovery, and patient judgment of the outcome. On the basis of the total score, we defined the final outcome as poor, insufficient, good, or excellent. The last two outcomes were considered to be successful.RESULTS:A successful outcome was obtained in 0% of high-level, 33.8% of intermediate-level, and 77.3% of low-level repairs (P< 0.001). On average, the nerve defect, preoperative interval, and patient age were lower for patients with a successful outcome than for those with an unsuccessful outcome (P= 0.004, P= 0.032, and P= 0.003, respectively). Worsening of the outcome was related to nerve defect longer than 4.5 cm, preoperative interval longer than 5.5 months, and age older than 23 years (P= 0.002, P= 0.034, and P= 0.023, respectively). A successful outcome occurred in 48.8% of patients repaired with direct suture and in 41.2% of patients repaired with a nerve graft (P> 0.05). A successful outcome also occurred 22.2% of combined ulnar-median nerve repairs and in 49.5% of isolated ulnar nerve repairs (P= 0.011). Repair level (P< 0.001), preoperative interval (P= 0.001), length of the nerve defect (P< 0.001), and associated median nerve rupture (P= 0.028) were independent predictors of a successful outcome.CONCLUSION:The outcome of ulnar nerve repair depends significantly on the repair level, preoperative interval, associated median nerve injury, length of the nerve defect, and age of the patient. High-level ulnar nerve repair is probably useless if performed in the classic manner.

Objective: This study reports three cases of ulnar neuropathy after trampoline injuries in children. Methods: A chart review was performed on children who sustained an ulnar nerve injury from a trampoline accident. In all cases, surgical intervention was required. Results: Injuries included upper-extremity fractures in two cases and an upper-extremity laceration in one case. All cases required surgical exploration with internal neurolysis and ulnar nerve transposition. Nerve grafts were used in two cases and an additional nerve transfer was used in one case. All patients had return of intrinsic hand function and sensation after surgery. Conclusion: Children should be followed for evolution of ulnar nerve neuropathy after upper-extremity injury with consideration for electrical studies and surgical exploration if there is no improvement after 3 months.

The aim of the study was to evaluate the results of epiperineural suture repaired primary (clean transaction injury, massive soft-tissue associated injury) and secondary (delayed partial injury) ulnar nerve injuries according to lesion level and type.Forty-two patients diagnosed with ulnar nerve injury between January 2008 and January 2012 were involved in the study. Ulnar nerve lesions were classified according to the level of injury into three types: type 1--lesion located above the flexor carpi ulnaris branch; type 2--lesion located between the flexor carpi ulnaris and the flexor digitorum profundus III and IV; type 3--lesion located below the flexor digitorum profundus III and IV and no more than 10 cm distal from the elbow crease. Additionally, ulnar nerve lesions were classified according to type into three groups: group 1 (n 17)--clean transaction injury; group 2 (n 14)--massive soft-tissue associated injury; group 3 (n 11)--delayed partial clean transaction injury. In follow-up evaluations, sensory and motor recovery was analysed with the most common Highet scale modified by Dellon et al. Functional results were evaluated according to the Disability of Arm, Shoulder, and Hand (DASH) score at final follow-up.There were no statistically significant differences between groups according to men/women ratio, mean age, mean follow-up period and ulnar-nerve injury level. The DASH score was significantly better in the clean transaction injury group than the other groups and significantly better for type 3 than types 1 and 2 injuries in all groups. Sensory recovery of type 1 and 3 injuries in the massive soft-tissue associated injury group was significantly worse than the other groups. The worst motor recovery was evaluated in type 1 injury and the best in type 3 injury according to injury level. According to group, motor recovery of the massive soft-tissue associated group was significantly worse than the other groups in all injury types. There were no statistically significant differences between clean transaction injury and delayed partial clean transaction injury groups in all injury types.Prognostic factors that influenced motor-sensory recovery and functional results were found in interval between trauma and reconstruction, injury level (worse results from proximal to distal) and mechanism of injury (worse results from massive soft-tissue injury to clear, sharp-tissue injury).

The results of 42 children with displaced supracondylar fractures of the humerus (six Gartland Type II and 36 Gartland Type III) treated with crossed pin fixation are reported. In 37 fractures (88%) the teardrop configuration was restored successfully. All fractures healed without loss of reduction. No patients had iatrogenic ulnar nerve injury. Crossed-pin fixation of supracondylar humeral fractures is a safe and effective way of maintaining skeletal stability in children. Careful technique safeguards against ulnar nerve injury.

Objectives:Conduction block (CB) from focal neuropathyis often associated with weakness and fatigue inaffected muscles. Ulnar neuropathy at the elbow(UNE) provides an excellent model to examine therelationships between electrophysiologically de-fined CB and quantitative measurement of weak-ness and fatigue.Methods:Eight healthy control subjects (47 6 14 years) andnine patients (53 6 3 years) with clinical andelectrophysiological features of UNE with CB werestudied. All underwentbilateral, ulnar motor nerveconduction studies recording from the first dorsalinterosseous muscle as well as quantitative mea-surement of strength and fatigue of the first dorsalinterosseous with a custom dynamometer.Results:Strength and fatigue were similar in the dominantand nondominant hands of control subjects andunaffected limb in patients. Varying degrees ofconduction block (14–62%, mean 36%) and con-duction slowing (31 m/s 6 7) were observed inthose with UNE. CB was associated with significantreductions in strength (42%) and fatigue (23%) ona timed fatiguetask. The reductions in strength(r =0.74)andfatigue(r=0.60)were stronglycorrelatedwith the degree of CB.Conclusions:CB in UNE defined by electrophysiological criteriawasstronglycorrelatedwithweaknessandfatigueinthe first dorsal interosseous. Fatigue may be simplyrelated to the reduction in strength, but activity orfrequency dependent CB may also contribute.Key Words: peripheral neuropathy, conductionblock, demyelination, weakness, fatigue

110 patients with injuries to the ulnar nerve were assessed, on average, 12.7 (3–20) years after secondary repair. 89 were male and 21 female, with a mean age of 27.9 years. Most of the nerve lesions were sharp (63) or blunt (41) injuries. Division was total in 76 cases and most were at the forearm level. The average delay from the injury to the operation was 10.1 (1–48) months. Secondary repair was performed in 34 cases and fascicular grafting in 76 cases. The mean graft length was 5.4 (1–30) cm. Four factors of motor and sensory function were assessed and the quantitative evaluation was compared with the MRC classification. Useful results were obtained in only 51.8% and poor in 30.9%. The age of the patient, the width of contusion, the pre-operative delay, and the level of the injury influenced the results significantly.

Purpose Posttraumatic cold intolerance (CI) is a frequent and important sequel after peripheral nerve injury. In this study, it is hypothesized that altered rewarming patterns after peripheral nerve injury are related to the degree of posttraumtic CL This hypothesis is tested by quantitatively comparing rewarming patterns of the digits in controls and in median or ulnar nerve injury patients and by investigating relationships between rewarming patterns, sensory recovery, and CI. Methods Twelve median or ulnar nerve injury patients with a follow-up of 4 to 76 months after nerve repair and 13 control subjects had isolated cold stress testing of the hands. Video thermography was used to analyze and compare rewarming patterns of the injured and uninjured digits after cold stress testin. Temperature curves were analyzed by calculating C the Q value as an indicator of heat transfer (temperature added during the first 10 minutes after start of active rewarming) and the maximum slope. Results Test-retest reliability was 0.64 and 0.79, respectively, for the Q value and maximum slope. High Q values and maximum slopes were interpreted as the presence of active rewarming. Patients with return of active rewarming had better sensory recovery and lower C, Blond McIndoe Cold Intolerance Severity Scale (CISS) scores. Better sensory recovery was correlated with lower CISS scores. Conclusions Test-retest reliability of cold stress testing was good, and we found a difference in rewarming patterns between nerve injury patients and controls. The presence of active rewarming in the nerve injury patients was related to sensory recovery and fewer complaints of posttraumatic CI. (J Hand Surg 2009;34A:54-64. Copyright (C) 2009 by the American Society for Surgery of the Hand. All rights reserved.)

No consensus exists concerning the best pin configuration for displaced supracondylar fractures of the humerus in children. Although cross-pinning is the most stable biomechanically, this configuration may cause iatrogenic ulnar nerve palsy. For the last 7 years, we have been using a three-pin fixation technique with insertion of two K wires from the lateral side (elbow in full flexion) and the third wire through the medial side (elbow in full extension). We used this technique in 67 displaced supracondylar fractures without any complications related to the ulnar nerve. The technique provides excellent stability and eliminates the risk of iatrogenic ulnar nerve palsy.

Improperly placed Norplant implants pose a risk to neurovascular structures at the time of removal. Appropriate attention to insertion and removal should minimize the chance of injury. However, when injuries do occur, a logical and systematic approach to evaluation of the injury can help predict the outcome and establish a plan of care for the patient.Due to the placement of the Norplant contraceptive implant system with respect to the neurovascular bundle of the arm, ulnar nerve injury is a possible complication of implant removal. Presented in this article is a case of ulnar nerve injury with subsequent neuropathy related to removal of improperly placed implants. The patient, a 23-year-old US woman, requested Norplant removal after 3.5 years of complication-free use. Before removal, the implants were noted to lie directly over the most anterior aspect of the triceps muscle, with the lower end of the implants lying about 5 cm from the medial condyle of the elbow. The patient returned to the facility 4 days after uneventful Norplant removal with persistent pain, definite weakness of the ulnar innervated muscles of the right hand, and numbness over the hypothenar eminence and fourth and fifth digits. Clinical neurologic evaluation was consistent with an ulnar nerve injury with diminished motor and sensory amplitude. Repeat studies at 6 weeks demonstrated improved motor response. Potential insertion-related injuries can best be prevented by choosing the appropriate placement site on the medial surface of the arm and by exaggerated tenting of the skin to help assure superficial subdermal placement and avoid deep structures. Before removal, identification of the path of the ulnar nerve and the relationship of the implants to the brachial groove is recommended, especially in thinner women. If pain, paresthesia, or anesthesia persists 4-6 weeks after an injury, repeat nerve conduction studies should be ordered to help outline a rehabilitation plan.

Purpose. To assess the efficacy of our protocol for treatment of displaced Gartland type-3 supracondylar fractures of the humerus in children. Methods. Records of 43 children with displaced Gartland type-3 supracondylar fractures of the humerus admitted from October 1997 to October 2003 were reviewed. Patients were treated within 12 hours of admission by closed reduction (n=33) or open reduction (n=10). Crossed medial and lateral Kirschner wires through a medial approach were used in all patients. A 3-cm incision was made medially to identify the correct entry point of the medial wire, and thus prevent ulnar nerve injury. The incision was extendable for open reduction if closed reduction was unsuccessful. Results. The mean age of the 43 patients was 7.2 years (range, 2–14 years). The mean follow-up period was 48 months (range, 12–84 months). 83% of the fractures occurred in boys. All fractures were closed, extension type, with 28 (65.1%) involved the right elbow. No patient had iatrogenic ulnar nerve injury. All patients showed satisfactory results according to Flynn criteria. Conclusion. If closed reduction is unsuccessful, open reduction and open medial placement of crossed Kirschner wires can provide reliable results. The small medial incision provides a viewing point for entry of the wire and prevents iatrogenic injury of the ulnar nerve. It is cosmetically more acceptable and can be extended to facilitate open reduction.

The aim of this study was to assess the correlation between the occurrence of iatrogenic ulnar nerve injury and frontal and saggital angular insertion of the medial pin in type 3 pediatric supracondylar humerus fractures treated by closed reduction and percutaneous fixation using a cross-pin configuration. Radiographs of 90 children were retrospectively reviewed and two radiographic parameters were measured. The frontal humerus-pin angle was formed between the long axis of the humerus shaft and the axis of the medial pin on an anteroposterior radiograph. The saggital humerus-pin angle was formed between the long axis of the humerus shaft and the axis of the medial pin on a lateral radiograph and expressed as positive and negative values if the insertion direction of the pin was anterior to posterior or posterior to anterior, respectively. There was a significant difference between the mean saggital humerus-pin angle values of ulnar nerve injury and no neurological complication groups (12.1 degrees versus 1.6 degrees , respectively; P=0.001). It was concluded that, anteroposterior insertion of the medial pin in the saggital plane, while the elbow was in hyperflexion, correlated with the occurrence of iatrogenic ulnar nerve injury.

Several recent studies have suggested that medial pinning in pediatric supracondylar humerus fractures leads to increased rates of ulnar nerve injury. The purpose of this study was to determine the risk of iatrogenic ulnar nerve injury in a consecutive series of supracondylar fractures treated using a standardized technique of crossed pin placement.Single cohort retrospective.Metropolitan university tertiary care center.Seventy-one consecutive children with Gartland type II or type III supracondylar humerus were treated surgically by 2 pediatric orthopaedic surgeons at 1 institution between 1995 and 2000 using a medial mini-open and cross-pinning technique. Sixty-five patients were available for follow-up (92%).Patients were treated with a combination of medial and lateral pins using a mini-incision technique.Outcomes analyzed included ulnar nerve injury and clinical and radiographic evidence of healing.The study group consisted of 65 patients, of whom 29 (45%) presented with Gartland type III fractures, and the remaining 36 (55%) presented with a type II fracture. There were no ulnar nerve motor injuries. One patient was noted to have transient sensory changes in the ulnar nerve distribution postoperatively, which resolved by the 1-week follow-up visit. All patients were noted to have normal ulnar motor and sensory nerve function at final follow-up (average 4.5 months). No cases of nonunion, malunion, or infection were identified during the follow-up period.The rate of iatrogenic ulnar nerve injury with this specific technique of crossed pin placement for extension-type supracondylar humerus fractures was extremely low in this series. A single case of transient ulnar sensory neuropraxia occurred. Our series demonstrates that crossed pin fixation can be performed safely and reliably and is an appropriate treatment option for unstable supracondylar humerus fractures.

The purpose of this study is to present the surgical outcome of endoscopic carpal tunnel release (ECTR) for the treatment of carpal tunnel syndrome (CTS). One hundred and thirty-one procedures (36 right hands, 33 left hands and 31 bilateral hands) of single portal ECTR were performed upon 100 patients (age range: 36 - 77 years, mean age: 52.9 years; 98 women and 2 men) with electrodiagnostically proven CTS for 2.5 years from 2001. Preoperative clinical severity and results of electrodiagnostic studies were compared with surgical outcomes at the minimal 3-month postoperative period. Among 131 cases 125 (95.4%) with complete or significant relief of symptoms were satisfied and 6 (4.6%) with partial or no relief of symptoms were dissatisfied. There were 2 cases of major complications (one with ulnar nerve injury and the other with ulnar artery injury) that developed in our early experience of ECTR and 1 case of recurrence. The grade of electrodiagnostic abnormalities was associated with surgical outcome but there was no statistical significance between them. The severity of clinical findings, age at onset and symptom duration were not correlated with surgical outcome. In conclusion, ECTR surgery was effective in relieving the symptoms of CTS with a low complication rate after the learning curve period. Thus, ECTR can be an alternative to the traditional open surgery and can be the first procedure for CTS with several advantages over open methods.

Primary repair of a high ulnar nerve injury results in a uniformly poor outcome as a result of the great distance between the site of injury and the innervated muscles. In this study the authors present two cases of high ulnar nerve injuries in adults. Reconstruction was performed using the distal branch of the anterior interosseous nerve, which was transferred to the distal motor branch of the ulnar nerve. This resulted in timely return of function to the ulnar-innervated intrinsic muscles of the hand, which was documented further by electromyography. For high ulnar nerve injuries, this type of nerve transfer is a much better approach than the traditional primary neurorrhaphy.

This study presents a predicted five-year reference interval for the outcome following repair of the median or ulnar nerve in adults. Forty-four patients were examined with the use of a recently introduced model instrument for documentation after nerve repair that includes “sensory”, “motor”, and “pain/discomfort” outcomes which together constitute a summarized “total score”. Analysis of the “total score” showed that follow-up time and age significantly influence the outcome. There were obvious inferior “motor” results after ulnar nerve injury, but these did not significantly influence the “total score”. Significant improvements in the “total score” were seen throughout the follow-up period.

A series of 44 patients with complete section of the ulnar nerve was reviewed on average 2 years after secondary repair. The procedures applied were fascicular grafting in 33 cases, epineural suture in 7, and suture in 4. Useful ulnar motor function was restored in 22 cases of fascicular grafting, in all 4 of fascicular suture and in 3 of epineural suture. Sensibility recovered in 23 patients operated on by fascicular grafts and in 10 of 11 treated by epineural or fascicular suture. Cases with unsatisfactory results had other associated severe lesions, i.e., median nerve section, vascular damage or tendon injuries. Early repair of clean-cut nerve sections by fascicular or epineural suture gives a good chance for recovery. Grafting should be performed within 3 months and no later than 1 year after the injury.

We describe an accidental injury to the ulnar nerve at the elbow following steroid injection for medial epicondylitis in a patient with undetected recurrent dislocation of the nerve. The chalky substance found on exploration to intermingle with the nerve fascicles was removed and the nerve was placed under the flexor-pronator mass. After surgery, complete resolution of the epicondylar pain was noted, along with significant improvement in two-point discrimination of the ulnar digits. We recommend clinical assessment of the ulnar nerve location prior to injection to avoid injury. Should recurrent dislocation of the nerve be diagnosed, injection should be given cautiously, preferably with the elbow in an extended or semiflexed position.

Information regarding 35 patients who developed signs and symptoms of lesions in the ulnar nerve during the post-anaesthetic period, has been reported. The pertinent anatomical and physiological factors in the aetiology of compression neuropathy of the ulnar nerve have been summarized. The use of electromyography and nerve conduction studies has been discussed in relation to localizing the site, following the progression, estimating the severity of a lesion and helping to differentiate between a recent or a pre-operative lesion. Lesions of the ulnar nerve continue to occur in patients who receive an anaesthetic. In our cases the severity of the lesions was not related to age, sex, type of operation or anaesthetic or the duration of the anaesthetic. Compression neuropathies of the ulnar nerve occurred more commonly in males than females. They may lead to a prolonged disability. Preventive measures and the importance of adequate follow-up have been discussed briefly.

A case of anterior traumatic transposition of the ulnar nerve presenting as a nerve palsy after dislocation of the elbow is described.

Complications of peripheral nerve injury arising from the surgical treatment of carpal tunnel syndrome are not uncommon. No documented report of the association of ulnar nerve injury with carpal tunnel decompression has been found. This case-study describes partial laceration of the ulnar nerve as a complication of carpal tunnel surgery and reviews the literature on this subject.