The Role of Electrophysiology and Ultrasonography in Guiding Early Surgical Management of Traumatic Upper Limb Pediatric Nerve Injuries: A Case Series.

Introduction/aims: There is a lack of clinical guidance regarding when to offer surgical exploration of traumatic nerve injuries in pediatric populations, with clinical examination, electrophysiology, and neuroimaging used variably to guide clinical decisions. This retrospective case series aimed to review the role of electrophysiology and ultrasound in guiding early surgical decisions.

Methods: This is a retrospective case series over a 4-year period at Birmingham Children's Hospital. All patients aged 16 years or under presenting with traumatic upper limb injuries who underwent electrophysiology and ultrasound investigations were included.

Results: The most common cause of traumatic nerve injury in this series was supracondylar fracture, with the ulnar nerve being most commonly injured. Initial electrophysiology and ultrasound findings showed concordance regarding the presence of nerve continuity in most cases, although initial findings were discordant in 3 out of 17 patients. In 14 patients, initial electrophysiology was consistent with incomplete axonotmetic nerve injury. Four patients showed possible neurotmesis. In two instances, initial US findings suggested nerve discontinuity with complete disruption of fascicular architecture, although in both cases, repeat imaging demonstrated the formation of a neuroma in continuity. Three out of 17 patients required surgical intervention, with 2 undergoing neurolysis and 1 nerve grafting.

Discussion: This study demonstrates high concordance between electrophysiology and ultrasound in the initial assessment of traumatic pediatric upper limb peripheral nerve injuries. Results suggest a combination of these investigations may provide better diagnostic accuracy to guide initial management decisions and may also prevent an initial overestimation of injury burden.