Diagnosis and Management of Nerve Injuries Caused by Pediatric Upper Extremity Fractures.

Although nerve injuries occur commonly with pediatric upper extremity fractures, there is very little existing literature to guide the management of those nerve injuries that do not recover during routine fracture healing and follow-up, and even less guidance is available regarding the choice of diagnostic tests such as magnetic resonance imaging (MRI) with nerve sequences, electromyography (EMG), nerve conduction velocities, (NCV), ultrasound (US), or other modalities. In addition, patterns of nerve injury and timing of nerve recovery differ amongst different fractures. This review article describes the nerve injuries and specific details of humeral shaft, supracondylar, Monteggia fracture-dislocations, and forearm fractures as well as the various available diagnostic tests. We synthesize the available literature, of which most is in the adult population, as well as the extensive clinical experience of the authors, all of whom specialize in pediatric hand and upper extremity. Key Concepts•The vast majority of nerve injuries associated with pediatric upper extremity fractures are neuropraxias.•The most common nerve injured in humeral shaft fractures is the radial nerve; in supracondylar humerus fractures, it is the median nerve/anterior interosseous nerve; in elbow dislocations, it is the ulnar nerve in conjunction with a medial epicondyle fracture, although the median nerve can become incarcerated during reduction of the dislocation; and in Monteggia fracture-dislocations, it is the posterior interosseous nerve. All nerves are at risk, depending on the apex of the deformity, in forearm fractures.•Observation is the mainstay of early management; progressive documented nerve recovery does not require further diagnostic studies.•Referral to a pediatric upper extremity surgeon or hand surgeon should be strongly considered when there is no documented nerve recovery after 3-4 months post-injury.