Radial nerve palsy due to supracondylar open fracture in a child.

Yoshida N, Tsuchida Y. BMJ Case Rep 2017. doi:10.1136/bcr-2017-222303 Description A 9-year-old boy presented to the emergency department with severe left elbow pain after a fall from a skateboard. On physical examination, an open injury in his left elbow that exposed the humeral lateral epicondyle was observed (Gustilo grade; figure 1A). The radial pulse was well palpated, but the neurological diagnosis was impossible because of severe pain. A radiograph revealed a supracondylar humeral fracture in which the distal fragment was remarkably displaced (Figure 1B, C). After adequate preanaesthetic clearance, the patient was planned for surgery. On further exploration, the radial nerve was tenting strongly by the displaced bone fragment (figure 1D). Hence, the radial nerve was carefully released, and its continuity was maintained. In addition, the supracondylar humeral fracture was stabilised with Kirschner wires. On postoperative day 1, because a left wrist drop associated with hypoesthesia was observed, we diagnosed radial nerve palsy (figure 2A, B). The radial nerve was found almost intact after releasing; therefore, we decided to carefully follow-up for palsy. Five months later, palsy had completely recovered. Reportedly, supracondylar humeral fractures are one of the most common fractures around the elbow joint in the paediatric age group. Paediatric supracondylar humeral fractures are rarely associated with a radial nerve injury. Generally, radial nerve palsy results from traction injury, contusion, tenting and entrapment at the fracture site. The management of radial nerve palsy is controversial, as some will advocate a conservative approach because majority will resolve spontaneously. Others will advocate open reduction and exploration to prevent entrapment and iatrogenic laceration. Especially, in the ‘pink, pulseless hand’, a concurrent nerve palsy prompts early exploration as it is strongly predictive of nerve and vessel entrapment. Our patient needed open reduction to prevent entrapment and iatrogenic laceration because the radial nerve was tenting strongly by the remarkably displaced bone fragment. When managed appropriately, nerve recovery and clinical outcomes for this paediatric population are extremely favourable. It is important to examine and treat paediatric supracondylar fracture with a radial nerve injury in mind.