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Iatrogenic Nerve Injuries in the Treatment of Supracondylar Humerus Fractures: Are We Really Just Missing Nerve Injuries on Preoperative Examination?

Joiner, Elizabeth R. A. BS; Skaggs, David L. MD, MMM; Arkader, Alexandre MD; Andras, Lindsay M. MD; Lightdale-Miric, Nina R. MD; Pace, J. Lee MD; Ryan, Deirdre D. MD

Journal of Pediatric Orthopaedics: June 2014 - Volume 34 - Issue 4 - p 388–392
doi: 10.1097/BPO.0000000000000171

Background: Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury.

Methods: A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study.

Results: Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100).

Conclusions: In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations.

Level of Evidence: Level I prognostic study.

Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA

This study has been carried out with approval from the Committee on Clinical Investigations at Children’s Hospital Los Angeles.

David L. Skaggs, MD, MMM is a co-investigator for grants funded by POSNA and SRS (paid to Columbia University); consultant for Biomet and Medtronic, board member for the Growing Spine Study Group, Growing Spine Foundation and Medtronic Strategic and Advisory Board; Committee Chair for the Scoliosis Research Society; provides expert testimony in medical malpractice cases (≤5% of income); receives payment for lectures including service on speakers’ bureaus for Biomet, Medtronic, and Stryker; patent holder for Medtronic; receives royalties from Wolters Kluwer Health - Lippincott Williams & Wilkins, receives payment for the development of educational presentations for Stryker, Biomet and Medtronic and receives institutional support from Medtronic (fellowship program). All other authors declare no conflict of interest.

Reprints: David L. Skaggs, MD, MMM, Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 W Sunset Blvd., Mailstop #69, Los Angeles, CA 90027. E-mail:

© 2014 by Lippincott Williams & Wilkins