Long-Term Outcomes following Pediatric Peripheral Nerve Injury Repair

Surgical Management of Nerve Injuries Caused by Pediatric Upper Extremity Fractures

While most nerve injuries associated with fractures resolve on their own, there is limited literature regarding the optimal management of persistent palsies. This review outlines nonoperative treatment strategies and provides guidance on the indications and management of cases when surgery is necessary for major upper extremity nerve injuries. It covers indications and techniques for surgical exploration, neurolysis, nerve repair, resection with grafting, and late reconstruction options. We synthesize the existing pediatric and adolescent literature and pertinent adult studies. Furthermore, we share the extensive clinical expertise of the authors, all of whom specialize in pediatric hand and upper extremity surgery.

Key Concepts

(1)Associated nerve injuries following pediatric upper extremity trauma are uncommon, yet optimal upper extremity function is dependent on prompt diagnosis and referral to a team of hand surgeons and therapists.(2)Understanding the potential mechanisms/locations of injury and the natural history will enable these teams to diagnose and prognosticate outcomes efficiently.(3)Physical examination, nerve conduction studies, radiographs, ultrasound, and advanced imaging (MRI) are often required.(4)Treatment of nerve deficits can include combinations of observation, neurolysis, nerve repair, nerve grafting, nerve transfer, and muscle transfer.

Indications and Outcomes of Nerve Reconstructions After Resection of Extremity Tumors: A Systematic Review

Objective: Peripheral nerve injuries resulting from tumor resection are unusual, but occasionally unavoidable. It can result in serious morbidity in motor deficits, sensory deficits, and even chronic pain. Nerve reconstruction after tumor resection is possible and seems to have positive recovery outcomes. However, nerve reconstructions are rarely performed and clear outcomes of nerve reconstructions after tumor resection are missing. This review aims to create an overview of the indications and outcomes in these patients. Methods: A systematic review was performed in May 2024 in PubMed and Embase databases according to the PRISMA guidelines. Search terms related to "tumor" and "nerve reconstruction" were used. Studies evaluating nerve reconstructions (nerve graft, transfer or coaptation) after tumor resection were included. Tumors not located in the extremities were excluded. A qualitative synthesis was performed on all studies. Where possible, motor, and sensory grades were recalculated according to the Medical Research Council (MRC)-scale. Results: Fifty-nine articles were included for quality synthesis after full-text screening. A total of 90 patients were described of which 44 after resection of malignant tumors. Most patients improved in motor and sensory function after nerve reconstruction. In both benign and malignant tumors, 77% demonstrated functional recovery on the MRC scale of ≥3. Most of the patients, >80%, recovered to a protective sensation of S2 or higher. Conclusion: Nerve reconstruction after tumor resection can help recover both sensory and motor function and may avoid chronic nerve pain. Nerve reconstructions should therefore be considered in tumor surgery.

The Forgotten Flap: The Pedicled Trapezius Flap's Utility in Pediatric Head and Neck Reconstruction-A Systematic Review

BACKGROUND

 When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction.

METHODS

 A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted.

RESULTS

 A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (n = 11) and case series (n = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (n = 46, 73.0%) and chronic wounds secondary to H&N masses (n = 9, 14.3%). Defects were most commonly located in the neck (n = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm2 and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (n = 48, 71.6%) and based on the dorsal scapular artery (n = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (n = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years.

CONCLUSION

 This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.

Pediatric Peroneal Nerve Palsy Secondary to Fibular Osteochondroma

Peripheral nerve injuries due to mass effect from bony lesions can occur when the nerve exists in an anatomically constrained location, such as the common peroneal nerve at the fibular head which passes into the tight fascia of the lateral leg compartment. We report a case of a pediatric patient who developed a common peroneal nerve palsy secondary to an osteochondroma of the fibular head and describe the clinical evaluation, radiographic findings, and surgical approach. Rapid diagnosis and nerve decompression after the onset of symptoms restored full motor function at the 8-month postoperative mark.

Peripheral nerve injuries of the upper extremity in a pediatric population: outcomes and prognostic factors

Peripheral nerve injuries of the upper limb are rare in children and poorly documented. The aim of this retrospective study was to analyze long-term sensory and motor results, and to determine predictive factors for recovery after surgery. Eleven children, with a mean age at injury of 9.7 years (5-15), operated on between 2006 and 2018, were included. Sensory perception was measured on monofilament test and static 2-point discrimination test. Grip strength was measured with a dynamometer and motor strength was assessed on the Medical Research Council scale. Quality of life was assessed on QuickDASH. The injury involved the radial (n = 1), median (n = 9), or combined median and ulnar (n = 1) nerves and was repaired by primary direct suture (n = 11). The mechanism involved glass laceration (n = 10) or a road accident (n = 1). The dominant limb was involved in 7 cases. At a mean 7.7 years' follow-up, touch sensitivity was normal or slightly deficient on monofilament test. Discrimination test was normal or adequate. Strength was complete in 10 patients. Mean QuickDASH score was 5.99 (range, 0-18.18). There was no significant difference in sensory or motor recovery according to partial or complete lesion or to injury location. There was better sensory recovery in children <12 years (p < 0.05). Sensory prognosis was also better in the absence of associated lesions (p < 0.05). Sensory, motor and functional results after surgical treatment of peripheral nerve injuries of the upper limb in children were globally satisfactory. Sensory recovery was better at an early age and in the absence of associated lesions. LEVEL OF EVIDENCE: IV.