Major Upper Limb Replantation and Nerve Repair under Intraoperative Neurophysiologic Monitoring in a One-Year-Old Infant.

Major upper extremity replantation in pediatric patients remains a challenge despite advances in techniques and surgical devices. We present the case of a one-year-old child from an underserved rural area who sustained a traumatic transhumeral amputation caused by a farming machine. Replantation was performed within four hours of the injury, followed by staged reconstructive microsurgery. The initial surgery focused on vascular, musculoskeletal, and soft tissue repair, with delayed nerve reconstruction performed under intraoperative neurophysiologic monitoring (IONM). Sural nerve grafts were used for neurorrhaphy of the median, ulnar, and musculocutaneous nerves. At the three-year follow-up, the patient achieved a Chen Grade three functional outcome. This case highlights the value of IONM as an innovative tool in pediatric nerve reconstructive microsurgery, offering a potential novel dimension of intraoperative precision that may enhance surgical decision-making and improve functional outcomes in replantation.