Large Nerve Gaps in the Pediatric Patient

University of Wisconsin Hospitals and Clinics - Madison, WI

P. Attaluri, A. Hanna

We present a challenging case of a 14-year-old female who sustained a Gustilo 3C injury of the right upper extremity after falling from a fifty-foot embankment resulting in a median nerve, ulnar nerve, and ulnar artery transection at the level of the distal forearm. An abdominal injury delayed initial operative debridement and fixation of the distal radius fracture. With the hand perfused and significant damage to the ulnar artery the decision was made to not repair the artery at that time. It was also noted that there was significant contamination of the bone and soft tissue as well as damage to a large segment of both the median and ulnar nerves. After final debridement there was a 6cm and 11cm void of the ulnar and median nerves, respectively. Given the distal injury and the length of the nerve gap, autograft utilizing sural nerve cable grafting would provide the best option. Given the gross contamination of the wound immediate nerve reconstruction was delayed. On postoperative day seven the patient was brought back to the OR for nerve reconstruction and gross purulence was found and our reconstruction was aborted. Subsequent debridements and IV antibiotics were performed. Nerve reconstruction using sural nerve cable grafts was performed 4 weeks after initial injury and we have 3 month follow up on our patient who continues to recover. Through this case, we would like to highlight and discuss the decision of immediate versus delayed nerve reconstruction and future options for reconstruction in the pediatric patient.