Rev. bras. ortop. vol.51 número4

r e v b r a s o r t o p . 2016;51(4):475–477

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Ulnar

nerve

paralysis

after

forearm

bone

fracture

夽

Carlos

Roberto

Schwartsmann

,

Paulo

Henrique

Ruschel

,

Rodrigo

Guimarães

Huyer

a_{UniversidadeFederaldeCiênciasSaúdedePortoAlegre,PortoAlegre,RS,Brazil}

b_{SantaCasadePortoAlegre,Servic¸odeOrtopediaeTraumatologia,PortoAlegre,RS,Brazil}

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Articlehistory:

Received19August2015 Accepted22September2015 Availableonline12July2016

Keywords:

Ulnarnerve Forearminjuries Peripheralnerveinjuries

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Paralysisornerveinjuryassociatedwithfracturesofforearmbonesfractureisrareandis morecommoninexposedfractureswithlargesoft-tissueinjuries.Ulnarnerveparalysisis arareconditionassociatedwithclosedfracturesoftheforearm.Inmostcases,thecauseof paralysisisnervecontusion,whichevolveswithneuropraxia.However,nervelacerations andentrapmentatthefracturesitealwaysneedtobeborneinmind.Thisbecomesmore importantwhenneuropraxiaappearsorworsensafterreductionofaclosedfractureofthe forearmhasbeencompleted.Theimportanceofdiagnosingthisinjuryanddifferentiatingits featuresliesinthefactthat,dependingonthetypeoflesion,differenttypesofmanagement willbechosen.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Paralisia

do

nervo

ulnar

seguida

de

fratura

dos

ossos

do

antebrac¸o

Palavras-chave:

Nervoulnar

Traumatismosdoantebrac¸o Traumatismosdosnervos periféricos

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Aparalisiaoulesãonervosaassociadaàfraturadosossosdoantebrac¸oérara,émaiscomum nasfraturasexpostascomgrandelesãodepartesmoles.Aparalisiadonervoulnaréuma condic¸ãoincomumassociadaafraturasfechadasdoantebrac¸o.Nagrandemaioriadoscasos, acausadaparalisiaéacontusãodonervo,queevoluicomneuropraxia.Noentanto,devemos sempreestar atentosàslacerac¸õesdonervo eaoencarceramentodonervonofoco de fratura.Issosetornamaisimportantequandoocorreosurgimentodaneuropraxiaoupioria apósafeituradareduc¸ãodafraturafechadadoantebrac¸o.Aimportânciadodiagnóstico dalesãoediferenciarsuascaracterísticasestãonofatodeque,conformeotipodelesão, diferentestiposdemanejoserãoescolhidos.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedattheSantaCasadePortoAlegre,Servic¸odeOrtopediaeTraumatologia,PortoAlegre,RS,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](C.R.Schwartsmann).

http://dx.doi.org/10.1016/j.rboe.2015.09.017

476

Introduction

Theauthorspresentacaseoffractureofbothbonesofthe forearm associated with neuropraxia in the sensitive area oftheulnarnerve,whichpresentedworseningof neurolog-icalsymptomsafterclosedreductionofthefracture.Simple nerve injuries should be treated conservatively. Additional tests,suchasmagneticresonanceimaging(MRI),canbeused to diagnose the status of the nerve in case of worsening ofneuropraxia.Conversely,surgicalexplorationofthenerve andfracturefixationshouldbedoneincasesof emergenc-ingorworseningneuropraxia,especiallyafterclosedfracture reduction,associatedwithsuspectednervelacerationornerve entrapmentatthefracturesite.Paralysisoftheulnarnerve isanuncommonconditionassociatedwithclosedfractures ofthe forearm.1–3 _{In mostcases, the cause ofparalysis is}

thenerveinjury.Nevertheless,orthopedistsmustalwaysbe watchfulforlacerationsandentrapment.Thisbecomesmore importantincasesofonsetorworseningofneuropraxiaafter aclosedreductionofaforearmfracture.Theimportanceof diagnosingthisinjuryanddifferentiatingitsfeaturesliesin thefactthat,dependingonthetypeoflesion,differenttypes ofmanagementwillbechosen.4,5

Case

report

Amalepatient, 17,presentedtothe emergencyroom with complaintofforearmpainduetoaskateboardingfall, func-tionallimitationoftheupperlimb,and“tingling”ofthefifth finger. Radiological examination indicated fracture of both radiusandulna.Aclosedreductionwasperformed,followed byimmobilizationofthefracture(Figs.1and2).

Post-reduction control radiographs showed satisfactory results.However,thepatientreportedworseningofthe tin-glingsensationinthefifthfingerandworseningofsensitivity. Basedonthesymptoms, ulnarnervelaceration/injuryafter fracturereductionwassuspected.Thus,surgicalexploration

Fig.1–X-rayafterclosedreductionofforearmfracture.

Fig.2–Ulnarnerveentrapment.

of the nerve was performed, with internal fixation of the forearmfracture.Duringsurgery,aftercarefuldissection,the ulnarnervewasfoundtobeentrappedintheulnarfracture (Figs.3and4).Aftercarefulnervereleaseandmicrosurgical sutureofthelacerationwith8.0nylonsuture,bothfractures werefixatedwithaDCPplateand3.5-mmscrews.

Discussion

Ulnarnerveinjuryisararecomplicationofclosedfracturesof theforearm.Fewcaseshavebeendocumentedandpublished. Therapyrangesfromconservativetreatmentandobservation ofthe neuropraxia tonerve exploration,neurolysis,and/or microsurgicalrepairofinjuries.1,3,5,6_{Atfirstevaluationinthe}

rev bras ortop.2016;51(4):475–477

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Fig.3–Nerveinjuryafterneurolysis.

Fig.4–Sutureoftheulnarnerve.

contractures.Specificsignsobservedafterfracturereduction canleadtodiagnosis ofpost-reductionneuralentrapment, directing treatment and avoiding paralysis of the affected nerve.2,3,7

A nerve injury should always be suspected after wors-eningofneurologicalsymptomspriortofracturereduction.

Despite satisfactory reduction and the possibility of con-servative treatment if nerve damage is not observed, the managementchanges;orthopedistsshouldbeaggressiveand adoptasurgicalapproachwithsuchpatients.4,6,8_Nerve

explo-ration, neurolysis, microsurgical treatment of the injury if necessary,andinternalfixationofthefractureareessentialfor afavorableoutcome,andforcompletereturnoftheforearm andhandfunctionaftertheinjury.2,3

Ulnar nerve injuries associated with closed forearm fracture are uncommon. When they occur, they are usu-ally associated with a contusion, and the treatment is conservative.1_{Itisimportanttorecognizeanddiagnosethe}

etiologyofthelesion.Nerveexplorationandfracturefixation shouldbeperformedupon suspicionofnervelacerationor entrapment, inorder topreventnerve sequelae;additional testsarenotrequiredtoindicatesurgicalprocedure.3,7

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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4.StahlS,RozenN,MichaelsonM.Ulnarnerveinjuryfollowing midshaftforearmfracturesinchildren.JHandSurgBr. 1997;22(6):788–9.

5.HirasawaH,SakaiA,TobaN,KamiuttanaiM,NakamuraT, TanakaK.Bonyentrapmentofulnarnerveafterclosed forearmfracture:acasereport.JOrthopSurg(HongKong). 2004;12(1):122–5.

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