Median nerve entrapment has been described previously as a rare complication of elbow dislocations and humeral medial epicondyle fracture in older children. In the event delayed diagnosis, this injury pattern may result in significant and sometimes irreversible nerve damage. In limited resources hospital, the fundamental way of making a diagnostic from history taking and physical examination is essential. Median nerve can get behind the epicondyle after a fracture when the medial displacement and the medial rotation could carry the nerve through the gap and entrapped in the fracture site or the healing process in subacute or chronic case. The late diagnosis is not uncommon because the precence of transient neuropraxia created by the contusion or stretching at the time of injury can mimic the sign of an early entrapment.
A 16-year-old adolescent boy initially presented to an outside emergency department with the history of falling onto his left outstretched non dominan hand. He was diagnosed by an orthopedic surgeon with left elbow dislocation and underwent close reduction with posterior splint cast. He presented to our outpatient clinic 3 weeks after initial treatment with high median nervepalsy according to classical appearance of a preacher’s hand confirmed with motoric and sensation examination. A type 2 median nerve entrapment was noticed and median nerve was entrapped medially by medial epicondyle healing process , laterally by brachialis muscle fibrotic scar, posteriorly by healing scar of anterior capsule. Median nerve at the entrapment point was macroscopically intact in diameter compare to proximal and distal. Anterior interosseous nerve was identified and decompressed from deep pronator teres down to flexor digitorum superficialis arch. Motoric branch of pronator teres and flexor digitorum was identified and protected. Decompression was confirmed no entrapment at the elbow joint down to flexor digitorum superficial arch by finger palpation and pronation-supination range of motion. Medial epicondyle fracture was debrided and fixed with 2 convergent K-wire.
Follow up at 3 months after surgery showed a travelling Tinel’s sign approximately 3 cm below the elbow, normal elbow range of motion, able to make an OK sign and good kapandji tip score. Sensation and motoric of the median nerve was back to normal function.
Our study has revealed that median nerve entrapment due to medial epicondyle fracture may develop after initial closed reduction in adolescent and hopefully raise the awareness of this kind of injury with a simple careful physical examination in a limited resources hospital was sufficient for making a surgery intervention decision.
