PERIPHERAL NERVE INJURIES ASSOCIATED WITH FRACTURES

Tardy Ulnar Nerve Palsy

Tardy ulnar nerve palsy is a chronic clinical condition characterized by a delayed onset ulnar neuropathy after an injury to the elbow. Typically, tardy ulnar nerve palsy occurs as a consequence of nonunion of pediatric lateral condyle fractures at the elbow, which eventually lead to a cubitus valgus deformity. While the child grows, the deformity worsens and the ulnar nerve is gradually stretched until classic symptoms of ulnar nerve neuropathy appear. Other childhood elbow trauma has also been associated with tardy ulnar nerve palsy, including supracondylar fractures resulting in cubitus varus, fractures of the medial condyle and of the olecranon, as well as radial head or Monteggia fractures/dislocation, with or without deformity. The clinical assessment includes obtaining a complete history, physical examination, nerve conduction tests, and elbow imaging studies. Treatment consists of ulnar nerve decompression, with or without corrective osteotomy, with overall successful results usually achieved.

Acute Carpal Tunnel Syndrome in Inpatients With Operative Distal Radius Fracture

Acute carpal tunnel syndrome (CTS) may occur concomitantly with distal radius fracture (DRF) and is often managed with carpal tunnel release (CTR). Carpal tunnel syndrome may also develop postoperatively after DRF fixation. The authors sought to determine the rate of CTS with DRF, prophylactic CTR, and postoperative development of CTS. Furthermore, they also sought to identify predictors of these. The Nationwide Inpatient Sample database was queried (2002 to 2014) to identify adult inpatients undergoing surgical fixation of DRFs. They were segregated by the presence of CTS and further stratified by the timing of CTR in relation to DRF fixation. Those with a CTS diagnosis undergoing CTR on the same day as or prior to DRF fixation were classified as having CTS concomitantly. Patients undergoing CTR without a CTS diagnosis were considered prophylactically released. Carpal tunnel releases on any day after fracture fixation were considered complications. The authors identified 275,052 inpatients who had fixation of DRFs. Of these, 11,816 patients (4.3%) had CTS concomitantly. A total of 530 patients developed CTS after their DRF fixation (0.3%). Of those without CTS, 4420 patients (1.6%) underwent prophylactic CTR. Male sex, age younger than 50 years, and polytrauma status were associated with concomitant CTS and prophylactic CTR. Age younger than 50 years and polytrauma status were associated with postoperative development of CTS. The authors identified the rate of concomitant CTS, prophylactic CTR, and CTS developing postoperatively in inpatients undergoing DRF fixation. As early recognition and treatment optimizes outcomes after acute CTS, these data draw attention to the high rate of CTS and may be useful to surgeons treating patients with DRFs. [Orthopedics. 2019; 42(4):227-234.].

Fracture related ulnar and sciatic nerve transections: a report of two cases and literature review

INTRODUCTION

Case reports, case series, and case control studies have looked at the incidence of complete nerve transection in the setting of fracture and the need for surgical exploration dating back to the 1920s. We present two cases of nerve laceration accompanying traumatic fracture with a thorough review of the literature.

METHODS

We used the following search terms: "ulnar nerve" OR "sciatic nerve" AND "laceration" OR "transection" AND "fracture." Results were reviewed and included for discussion if they specifically reported ulnar or sciatic nerve laceration accompanying traumatic fracture.

RESULTS

Our search yielded 15 papers reporting a total of 10 ulnar nerve lacerations and nine sciatic nerve lacerations. We present two additional cases. The first is a patient with a humerus fracture and complete ulnar nerve transection. The second case is a patient who suffered a femur fracture and complete transection of the sciatic nerve.

CONCLUSION

Nerve laceration accompanying traumatic fracture is rare. We review the reported cases of nerve laceration and present two cases treated at our institution. Though uncommon, nerve laceration should be considered in the setting of traumatic fracture with neurological injury, particularly open fractures.

Carpal Tunnel Syndrome and Distal Radius Fractures

Carpal tunnel syndrome (CTS) after distal radius fractures can present in 3 forms: acute, transient, and delayed. Acute CTS requires an emergent carpal tunnel release. Many patients with transient CTS after distal radius fracture do not require surgical release of the carpal tunnel once the fracture is repaired. Prophylactic carpal tunnel release in the absence of signs and symptoms of CTS after a distal radius fracture is not indicated. For patients with delayed CTS after a distal radius fracture, all possible causes of nerve compression should be considered and addressed in standard fashion.

Carpal tunnel syndrome after distal radius fracture

Carpal tunnel syndrome is a common condition and is a well-recognized phenomenon following a distal radius fracture. The treating surgeon should be vigilant in noticing the signs and symptoms. If acute carpal tunnel syndrome is noted, then surgical release of the carpal tunnel and fracture fixation should be performed urgently. If early carpal tunnel syndrome findings are noted during distal radius fracture management, all potential causes should be evaluated. Delayed carpal tunnel syndrome presenting after a distal radius fracture has healed is best managed in standard fashion. There is no role for prophylactic carpal tunnel release at the time of distal radius fixation in a patient who is asymptomatic.