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OPEN ACCESS Case Report

Active cheerleading with radial nerve palsy following


supracondylar humerus fracture

Cheerleading mit Radialisparese nach suprakondylärer Humerusfraktur

Abstract
Cheerleading is associated with substantial morbidity. As such, cheer- Christian Herold1
leading fall-related injuries may cause serious to fatal outcomes espe-
Jörn Redeker2
cially falls from attempted pyramids.
We report on a female adolescent cheerleader age 14 suffering a Karsten Knobloch3
supracondylar humerus fracture related to a fall from a pyramid. Unfor- Peter M. Vogt4
tunately, lateral pinning led to complete iatrogenic radial nerve palsy.
However, given an intriguing compensatory athletic function of the wrist
1 Sana Klinikum Hameln-
she was able to perform cheerleading artistic figures such as flic-flac
Pyrmont, Hameln, Germany
within four months after the injury with a radial nerve palsy, which is
highlighted in an attached video. 18 months after the radial palsy she 2 St. Barbara-Hospital,
was admitted to our hospital and underwent neuroma resection of the Duisburg, Germany
initially transsected radial nerve at the elbow and sural nerve grafting 3 Sportpraxis, Hannover,
for radial nerve palsy. Germany
4 MHH, Hannover, Germany
Zusammenfassung
Cheerleading kann zu verschiedensten Unfällen führen. Insbesondere
bei dem Versuch Pyramiden zu bilden sind bereits Todesfälle aufgetre-
ten. Wir berichten von einer 14-jährigen Cheerleaderin welche bei dem
Versuch eine Pyramide zu bilden stürzte und sich eine suprakondyläre
Humerusfraktur zuzog. Bei der osteosynthetischen Versorgung kam es
leider zu einer kompletten Durchtrennung des N. radialis. Dennoch
konnte sie bei der gegebenen erstaunlichen Kompensation ihrer
Handgelenksgeweglichkeit weiterhin schwierige Cheerleading Übungen
wie Flick-Flack durchführen, was im beigefügten Video verdeutlicht wird.
18 Monate nach Eintreten der Radialisparese wurde sie in unserer Klinik
vorstellig und es wurde nach einer Neuromresektion eine Suralis Inter-
position zur Nervenrekonstruktion durchgeführt.

Introduction However, to date there is no evidence regarding the


sports-activity of pediatric or adolescent patients suffering
Pediatric supracondylar humerus fractures are often as- radial neuropathy following supracondylar humerus
sociated with nerve injuries. A recent meta-analysis en- fractures. We highlight a remarkable adolescent cheer-
rolled 5148 patients suffering 5154 supracondylar frac- leader, who presented herself with a fall hand following
tures with traumatic neurapraxia in 11.3% [1]. Anterior complete radial nerve disruption following lateral pinning
interosseus nerve injury was the dominant palsy in exten- for a supracondylar humerus fracture.
sion-type fractures (34.1%), while ulnar neuropathy oc-
curred most often in flexion-type injuries (91.3%). Injuries
to the radial nerve (ICD-10 S44.2) as neurapraxia oc- Case report
curred in 172/5148 cases (3.3%) in the pooled
metaanalysis. Sir Herbert Seddon has differentiated A 14-year-old girl was admitted to our clinic with a com-
neurapraxia leaving the nerve intact, but contused, from plete left-sided radial palsy (Figure 1). 18 months ago
axonotmesis with disruption of the axon and neurotmesis she was sustained an accident while performing a human
with complete disruption of the nerve and the nerve pyramid as a cheerleader and suffered from a spiral hu-
sheath [2]. merus fracture.
Notably, in the aforementioned pooled metanalysis the Osteosynthesis was performed with closed reduction and
iatrogenic neuropathy rate with radial neuropathy follow- lateral pinning at a regional trauma center on the first
ing medial/lateral pinning was 4.8%. day after injury. The osteosynthesis had to be redone due

GMS German Plastic, Reconstructive and Aesthetic Surgery 2013, Vol. 3, ISSN 2193-7052 1/4
Herold et al.: Active cheerleading with radial nerve palsy following ...

Figure 1: Fall hand following iatrogenic radial palsy subsequent to a supracondylar humerus fracture

to dislocation. Subsequent, she reported about a com- found with a 1×0.8 inch neuroma at the proximal nerve
plete loss of wrist and finger extension and numbness in stump and a massive scarring for more than 1 inch at
the radial sensory region. The first neurography was per- the distal stump (Figure 2). After resection of the neuroma
formed as late as 14 months after nerve injury and an a distance of 2 inches had to be bridged. An ipsilateral
EMG showed pathological spontaneous activity of the sural nerve graft was used as a nerve transplant; it was
hand and wrist extensors. The colleagues had initiated a divided into three cables of 2 inches length each to cover
conservative approach; however, she did not regain any the larger diameter of the radial nerve at the elbow region
radial function in that time. (Figure 3). The postoperative course was uneventful;
As the patient is a passionate cheerleader, the radial however, the long-term result has to be determined.
palsy did not keep her from doing sports. She returned
to sport despite her complete radial palsy four months
after surgery. Wearing a small radial palsy cast she went Discussion
on with her activity. Daily routine in school and leisure
time was almost unchanged with a DASH score of 6 out The most remarkable observation in this case presented
of 100 (0 perfect, 100 worse). The Disabilities of the Arm, is the high level of sport activity achieved in an adolescent
Shoulder and Hand (DASH) Outcome Measure [3] is a cheerleader with complete iatrogenic radial nerve palsy
30-item, self-report validated questionnaire designed to following surgery for supracondylar humerus fracture.
measure physical function and symptoms in patients with Given the high proprioceptive demands performing a flick-
any or several musculoskeletal disorders of the upper flack as demonstrated in the attached video it is surpris-
limb with a German translation published [4]. ing in our view as reconstructive surgeons that our female
The patient only experienced some limitations in perform- adolescent athlete was that perfectly adopted. Using the
ing cheerleading movements that imply fine movements small wrist orthesis she was able to overcome the
of the left hand with the radial palsy. Notably, she was proprioceptive and motor deficit derived from complete
able to perform gymnastic figures such as flick-flacks half surgical iatrogenic radial nerve palsy.
a year after trauma with only a small radial palsy cast Cheerleading is associated with substantial morbidity. As
(Attachment 1). As physiotherapeutic treatment did not such, cheerleading fall-related injuries may cause serious
improve the palsy significantly the treating therapist re- to fatal outcomes [5], [6] especially falls from attempted
commended seeking surgical help. As the patient was pyramids [7]. Besides, ankle sprains are often en-
young we planed a nerve reconstruction despite the rather countered among females from the US Military Academy
long time after injury (18 months after injury). Tendon [8]. A retrospective analysis from the National Electronic
transfers to improve the functional outcome had been Injury Surveillance System (NEISS) of the US Consumer
discussed, but we decided to perform a sural nerve inter- Product Safety Commission revealed an estimated
position grafting procedure. 208,800 children age 5–18 being treated in US hospital
The patient was taken to the operating theatre and after emergency rooms for cheerleading-related injuries [9].
neurolysis a complete dissection of the radial nerve was

GMS German Plastic, Reconstructive and Aesthetic Surgery 2013, Vol. 3, ISSN 2193-7052 2/4
Herold et al.: Active cheerleading with radial nerve palsy following ...

Figure 2: Intraoperative situs of the presented patient. A massive neuroma after complete disruption of the radial nerve was
found.

Figure 3: Intraoperative situs after sural nerve graft to bridge the defect after neuroma resection

In terms of reconstructive nerve surgery, the type of sur- to achieve nerve reconstruction. Besides, neurotisation
gery suggested depends highly on the timing of presenta- is another option directly combining a concomitant nerve
tion following the initial injury. Within 6 months in adults to the injured one, thus minimizing the distance to restore,
and a maximum of 24 months in young children after however, sacrificing some motor and/or sensory function
nerve injury, the primary surgical approach is to perform of the donor nerve. As such, medial to radial nerve
a neurolysis or in case of complete disruption with neuro- transfers have been recently suggested [10].
ma formation, as in our illustrated case, neuroma resec- In the above mentioned patient the estimated distance
tion and nerve grafting. Depending on the size and the of nerve regeneration is 20 inches. Assuming a regener-
location of the nerve defect, nerve grafting using for ex- ation velocity of 0.04 inch/day a time of almost 1.5 years
ample sural nerve transplants is an appropriate means has to be expected for re-neurotisation. Currently, tissue-

GMS German Plastic, Reconstructive and Aesthetic Surgery 2013, Vol. 3, ISSN 2193-7052 3/4
Herold et al.: Active cheerleading with radial nerve palsy following ...

engineering is on its way to provide some potential solu- 7. Shields BJ, Smith GA. Epidemiology of cheerleading fall-related
injuries in the United States. J Athl Train. 2009 Nov-
tions with nerve grafts based for example on olfactory
Dec;44(6):578-85. DOI: 10.4085/1062-6050-44.6.578
sheath cells [11]. Tendon transfers, on the other hand,
provide further reconstructive options beyond the afore- 8. Waterman BR, Belmont PJ Jr,Cameron KL, Deberardino TM,
Owens BD. Epidemiology of ankle sprain at the United States
mentioned time frame and should be considered [12], Military Academy. Am J Sports Med. 2010 Apr;38(4):797-803.
[13]. DOI: 10.1177/0363546509350757
9. Shields BJ, Smith GA. Cheerleading-related injuries to children
5 to 18 years of age: United States, 1990-2002. Pediatrics. 2006
Notes Jan;117(1):122-9. DOI: 10.1542/peds.2005-1139
10. Brown JM, Tung TH, Mackinnon SE. Median to radial nerve
Competing interests transfer to restore wrist and finger extension: technical nuances.
Neurosurgery. 2010 Mar;66(3 Suppl Operative):75-83; discussion
The authors declare that they have no competing in- 83. DOI: 10.1227/01.NEU.0000354364.13224.C8
terests. 11. Radtke C, Kocsis JD, Vogt PM. Chapter 22: Transplantation of
olfactory ensheathing cells for peripheral nerve regeneration. Int
Rev Neurobiol. 2009;87:405-15. DOI: 10.1016/S0074-
7742(09)87022-0
Attachments
12. Gohritz A, Fridén J, Herold C, Aust M, Spies M, Vogt PM.
Ersatzoperationen bei Ausfall motorischer Funktionen an der
Available from Hand [Tendon transposition to restore muscle function in the
http://www.egms.de/en/journals/gpras/2013-3/gpras000019.shtml hand]. Unfallchirurg. 2007 Sep;110(9):759-76. DOI:
1. Attachment1_gpras000019.mpeg (1637 KB) 10.1007/s00113-007-1322-7
Video: The patient is performing flic-flac with radial 13. Sammer DM, Chung KC. Tendon transfers: part I. Principles of
nerve paresis before nerve reconstruction. transfer and transfers for radial nerve palsy. Plast Reconstr Surg.
2009 May;123(5):169e-177e. DOI:
10.1097/PRS.0b013e3181a20526

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Pediatr Orthop. 2010 Apr-May;30(3):253-63. DOI: PD Dr. Christian Herold
10.1097/BPO.0b013e3181d213a6 Department of Plastic and Aesthetic Surgery, Sana
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Copyright
6. Shields BJ, Smith GA. The potential for brain injury on selected ©2013 Herold et al. This is an Open Access article distributed under
surfaces used by cheerleaders. J Athl Train. 2009 Nov- the terms of the Creative Commons Attribution License
Dec;44(6):595-602. DOI: 10.4085/1062-6050-44.6.595 (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You
are free: to Share — to copy, distribute and transmit the work, provided
the original author and source are credited.

GMS German Plastic, Reconstructive and Aesthetic Surgery 2013, Vol. 3, ISSN 2193-7052 4/4