Entrapment of median nerve after elbow fracture dislocations: expected surgical time frame based on cadaver study
DOI:
https://doi.org/10.2340/jphs.v59.15323Keywords:
Elbow fracture dislocations, flexor pollicis longus, median nerve entrapment, nerve injuryAbstract
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.
Downloads
References
Montanari S, Sartore R, Spina V, et al. Post-traumatic entrapment of the median nerve in the ulno-humeral joint: diagnosis, treatment and literature review. J Orthop Sci. 2022 May 1;27(3): 627–634.
https://doi.org/10.1016/j.jos.2021.02.006 DOI: https://doi.org/10.1016/j.jos.2021.02.006
Rao SB, Crawford AH. Median nerve entrapment after dislocation of the elbow in children. A report of 2 cases and review of literature. Clin Orthop Relat Res [Internet]. 1995 [cited 2023 Apr 1];312(312):232–237. Available from: https://pubmed.ncbi.nlm.nih.gov/7634608/
Kamble P, Prabhakar A, Wankhade AM, et al. A rare case of lat
eral displacement of median nerve in a dislocated elbow and its management. J Orthop Case Rep [Internet]. 2021 [cited 2023 Apr 1];11(12):80–83. Available from: https://pubmed.ncbi.nlm.nih.gov/35415152/
Cengiz Ö. Median nerve entrapment in an adolescent medial epicondyle fracture of humerus: A case report. Turk J Trau-ma Emrg Surgery. 2022 Aug;28(8):1200-1203. doi: 10.14744/tjtes.2020.45742 DOI: https://doi.org/10.14744/tjtes.2020.45742
Simon D, Masquijo JJ, Duncan MJ, et al. Intra-articular median nerve incarceration after spontaneous reduction of a pediat-ric elbow dislocation: case report and review of the literature. J Pediatr Orthop. 2010 Mar;30(2):125–129.
https://doi.org/10.1097/BPO.0b013e3181cf3bfd DOI: https://doi.org/10.1097/BPO.0b013e3181cf3bfd
Robinson LR. Traumatic injury to peripheral nerves. Muscle Nerve. 2022 Dec 7;66(6):661–670.
https://doi.org/10.1002/mus.27706 DOI: https://doi.org/10.1002/mus.27706
MacKay BJ, Cox CT, Valerio IL, et al. Evidence-based approach to timing of nerve surgery: a review. Ann Plast Surg. 2021;87:e1–e21. DOI: https://doi.org/10.1097/SAP.0000000000002767
Lopes B, Sousa P, Alvites R, et al. Peripheral nerve injury treatments and advances: one health perspective. Int J Mol Sci. 2022 Jan 14;23(2):918.
https://doi.org/10.3390/ijms23020918 DOI: https://doi.org/10.3390/ijms23020918
Fourrier P, Levai JP, Collin JP. [Median nerve entrapment in elbow dislocation]. Rev Chir Orthop Reparatrice Appar Mot. 1977;63(1):13–16.
Al-Qattan MM, Zuker RM, Weinberg MJ. Type 4 median nerve entrapment after elbow dislocation. J Hand Surg. 1994 Oct 29;19(5):613–615.
https://doi.org/10.1016/0266-7681(94)90127-9 DOI: https://doi.org/10.1016/0266-7681(94)90127-9
Aggarwal A, Jana M, Kumar V, et al. MR neurography in intraosseous median nerve entrapment. World J Radiol. 2017 Oct 28;9(10):400–404.
https://doi.org/10.4329/wjr.v9.i10.400 DOI: https://doi.org/10.4329/wjr.v9.i10.400
Korus L, Morhart M, Jarman A, et al. Median nerve reconstruction after entrapment in the elbow. Can J Plast Surg. 2009 Dec 1;17(4):130–132.
https://doi.org/10.1177/229255030901700408 DOI: https://doi.org/10.1177/229255030901700408
Akansel G, Dalbayrak S, Yilmaz M, et al. MRI demonstration of intra-articular median nerve entrapment after elbow disloca-tion. Skeletal Radiol. 2003 Sep 1;32(9):537–541.
https://doi.org/10.1007/s00256-003-0667-4 DOI: https://doi.org/10.1007/s00256-003-0667-4
Matev I. A radiological sign of entrapment of the median nerve in the elbow joint after posterior dislocation. A report of two cases. J Bone Joint Surg Br. 1976 Aug;58-B(3):353–355.
https://doi.org/10.1302/0301-620X.58B3.956256 DOI: https://doi.org/10.1302/0301-620X.58B3.956256
Packer GJ, Lennox CM. Median nerve entrapment after elbow dislocation: a new radiological sign. Br J Clin Pract. 1995;49(4):221.
https://doi.org/10.1111/j.1742-1241.1995.tb09958.x DOI: https://doi.org/10.1111/j.1742-1241.1995.tb09958.x
Russell T. Surgical disorders of the peripheral nerves. R. Birch, G. Bonney, C. B. Wynn Parry. 283 × 223 mm. Pp. 539. Illus-trated. 1998. Edinburgh: Churchill Livingstone. £95. Br J Surg. 2003 Jan 2;86(3):429.
https://doi.org/10.1046/j.1365-2168.1999.1056c.x DOI: https://doi.org/10.1046/j.1365-2168.1999.1056c.x
Shergill G, Bonney G, Munshi P, et al. The radial and posterior interosseous nerves. J Bone Joint Surg. 2001 Jul 1;83(5):646–649.
https://doi.org/10.1302/0301-620X.83B5.0830646 DOI: https://doi.org/10.1302/0301-620X.83B5.0830646
O’Brien AC, Teh Z, Rinaldi M, et al. Intraosseous Type 2 Median Nerve Entrapment After Posterior Elbow Dislocation Diag-nosed on Ultrasound With MRI and Surgical Correlation. Cureus. 2021 Oct 8;13(10):e18606. doi: 10.7759/cureus.18606 DOI: https://doi.org/10.7759/cureus.18606
O’Callaghan PK, Freeman K, Davis LC, et al. A rare case of type 2 entrapment of the median nerve after posterior elbow dislo-cation with MRI and ultrasound correlation. Skeletal Radiol. 2019 Oct 13;48(10):1629–1636.
https://doi.org/10.1007/s00256-019-03201-4 DOI: https://doi.org/10.1007/s00256-019-03201-4
Dolderer JH, Prandl EC, Kehrer A, et al. Solitary paralysis of the flexor pollicis longus muscle after minimally invasive elbow procedures: anatomical and clinical study of the anterior interosseous nerve. Plast Reconstr Surg. 2011 Mar;127(3):1229–1236.
https://doi.org/10.1097/PRS.0b013e3182043ac0 DOI: https://doi.org/10.1097/PRS.0b013e3182043ac0
Liu J, Pho RWH, Pereira BP, et al. Distribution of primary motor nerve branches and terminal nerve entry points to the fore-arm muscles. Anat Rec. 1997 Jul;248(3):456–463. DOI: https://doi.org/10.1002/(SICI)1097-0185(199707)248:3<456::AID-AR19>3.3.CO;2-A
https://doi.org/10.1002/(SICI)1097-0185(199707)248:3<456::AID- AR19>3.0.CO;2-O
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Yener Yoğun, Uğur Bezirgan, Tülin ŞEN ESMER, Sırrı Sinan Bilgin, Mehmet Armangil
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Acta Chirurgica Scandinavica Society owns the copyright for all material published until Volume 57 (2023) unless otherwise specified. As from Volume 59 (2024) all published articles, unless otherwise specified, are published under CC-BY licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, with the condition of proper attribution to the original work.
