title: Iatrogenic nerve injuries in the treatment of supracondylar humerus fractures: are we really just missing nerve injuries on preoperative examination?
abstract: BACKGROUND
  Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury.
  
  
  METHODS
  A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study.
  
  
  RESULTS
  Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100).
  
  
  CONCLUSIONS
  In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations.
  
  
  METHODS
  Level I prognostic study.
authors.affiliation: Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA.
authors.forename: Elizabeth R A
authors.initials: ER
authors.lastname: Joiner
authors.forename: David L
authors.initials: DL
authors.lastname: Skaggs
authors.forename: Alexandre
authors.initials: A
authors.lastname: Arkader
authors.forename: Lindsay M
authors.initials: LM
authors.lastname: Andras
authors.forename: Nina R
authors.initials: NR
authors.lastname: Lightdale-Miric
authors.forename: J Lee
authors.initials: JL
authors.lastname: Pace
authors.forename: Deirdre D
authors.initials: DD
authors.lastname: Ryan
mesh_terms: D001858:Bone Nails; D015984:Causality; D002648:Child; D015897:Comorbidity; D005260:Female; D005592:Fracture Fixation; D006801:Humans; D006810:Humeral Fractures / Q000453:epidemiology* / Q000601:surgery*; D006811:Humerus / Q000601:surgery; D007049:Iatrogenic Disease / Q000453:epidemiology*; D008297:Male; D008475:Median Nerve / Q000293:injuries; D009104:Multiple Trauma / Q000175:diagnosis / Q000453:epidemiology*; D009460:Neurologic Examination; D059348:Peripheral Nerve Injuries / Q000175:diagnosis* / Q000453:epidemiology*; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology*; D011300:Preoperative Care; D011446:Prospective Studies; D011826:Radial Nerve / Q000293:injuries; D012189:Retrospective Studies; D014459:Ulnar Nerve / Q000293:injuries