Abstract
Medial epicondyle fractures account for 11% to 20% of pediatric elbow fractures. While most are managed conservatively, ulnar nerve palsy, present in up to 16% of cases, is an accepted indication for surgical treatment. Neurologic symptoms may begin in a delayed fashion and, in rare cases, persist or progress despite surgical intervention. In adults, distal nerve transfers such as anterior interosseous nerve (AIN) to ulnar motor branch transfer have demonstrated promising outcomes, but their role in pediatric patients remains limited. We report the case of a 13-year-old, right-handed gymnast who developed delayed progressive ulnar nerve palsy after a nondisplaced right medial epicondyle fracture managed conservatively. Despite undergoing anterior ulnar nerve transposition at 8 months after injury, she exhibited persistent motor and sensory deficits, with a QuickDASH score of 90.6. At 31 months after the injury, she underwent further surgery, with ulnar nerve decompression and submuscular transposition, ulnar nerve decompression at Guyon’s canal, and supercharged end-to-side (SETS) AIN-to-ulnar motor nerve transfer. Eight months postoperatively, she showed substantial recovery of hand strength, fine motor coordination, and ulnar nerve-mediated sensation. At 4-year follow-up, QuickDASH score was 6.8, indicating near-complete functional recovery. To our knowledge, this is the first reported pediatric case of SETS AIN-to-ulnar motor nerve transfer after failed decompression of the ulnar nerve, following a late ulnar nerve palsy complicating a medial epicondyle fracture of the humerus. Distal nerve transfer may offer a viable strategy for enhancing intrinsic hand function in a pediatric chronic ulnar neuropathy, even beyond the conventional reinnervation window.
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