Diagnosing and treating nerve injuries in children and adolescents

Dr. Andrea Bauer nerve injuries Notes blog
PHOTO ILLUSTRATION: PATRICK BIBBINS/BOSTON CHILDREN’S HOSPITAL

Nerve injuries in children and adolescents aren’t all that common, and may be difficult to diagnose. When these injuries do occur, the referral process can also present further complications.

“With peripheral nerve injuries, it’s common to think a patient needs a neurosurgeon or plastic surgeon,” says Andrea Bauer, MD, an orthopedic surgeon in the Hand & Orthopedic Upper Extremity Program at Boston Children’s Hospital. “But because of the legacy Dr. Peter Waters has built, the specialists in our Orthopedic Center actually have a great amount of experience with these injuries.”

Bauer’s experience treating a wide range of nerve injuries both surgically and non-surgically in pediatric populations has helped her understand the difficulties that often arise in both diagnosis and treatment. Here, she provides insight on what PCPs and pediatricians should be aware of when it comes to nerve injuries in children.

What are some of the challenges in diagnosing nerve injuries?

Kids often don’t know how to describe the sensations that come with these injuries. And some nerve injuries are rare enough that many PCPs won’t have seen it before. They should be asking their patients about sensation and testing their sensation, otherwise they’re unlikely to tell you that anything is off. Loss of sensation can be tested using a paperclip.

The main message is that children with these injuries don’t present in the same way adults do.”

If a child (especially a younger one) is feeling a tingling sensation, they may have a hard time describing it. Asking if it feels like something is crawling on their arm may help them understand the sensation better. Strength testing is also important; testing out the muscles of the arm or leg that is affected.

What are some of the more common nerve injuries you see in clinic?

Probably the most common nerve injury people will have heard of would be “burners” and “stingers” in a sport like football. Those are actually a stretch injury of the brachial plexus, and it can be hard to diagnose because many physicians don’t ask kids about sensation, and they don’t necessarily test the strength of every little muscle in the arm.

If the injury doesn’t get better within a week, the child should definitely see a specialist. It’s rare, but I’ve seen football players get a serious operative injury to the brachial plexus from just one tackle. The brachial plexus injuries we see in sports often come from high energy situations; football tackles, motocross, skiing and snowboarding accidents.

Nerve injuries can also be the result of another injury — like a shoulder dislocation can affect the axillary nerve. Knowing what other injuries can lead to nerve injury is important and can help you make sure you’re asking the right questions. We see nerve injuries all the time with supracondylar fractures as well.

The other really common nerve we see get injured in sports is the ulnar nerve, especially in baseball players. Medial elbow pain in a baseball player can be a result of multiple issues that are all related, including irritation of the ulnar nerve.

How are most nerve injuries treated?

Most nerve injuries will get better without an operation, but for both the upper and lower extremities, there are surgeries we can do. The newest treatment is nerve transfers. For an isolated nerve injury, if the nerves around it are working, we can borrow a piece of a nearby nerve and transfer it to the injured nerve. This helps with faster recovery and it’s a simpler surgery. It’s a game changer for things like a peroneal nerve palsy, which can happen after knee surgery. There are things that we can do now because of these nerve transfers that they weren’t able to do ten years ago.

Most of the pitchers we see have medial elbow pain, and they don’t complain of numbness in their finger or of weakness. Their MRI can even be negative, or we may do an EMG that shows up negative. But if we perform surgery to transpose the ulnar nerve, they feel better. So, some players who might think they need Tommy John surgery actually just need the ulnar nerve addressed, and the recovery is around 3 to 6 weeks versus about 12-18 months for a Tommy John surgery. I’ve seen at least 3 or 4 high school athletes over the last year who, after having their nerve transposed, did not needed that second operation.

What are some things PCPs and pediatricians should be aware of when it comes to nerve injuries?

The main message is that children with these injuries don’t present in the same way adults do. For younger kids, a nerve injury can provoke anxiety because they don’t know what they’re feeling. I’ve had parents of a patient told by outside providers, “your kid is just trying to get out of school,” and it was actually that their median nerve was injured after a supracondylar fracture. It feels terrible and weird whenever someone touches their hand, so they don’t want to be around other people, which is why they don’t want to go to school. If you don’t know the right questions to ask, you may miss it.

Learn more about the Hand & Orthopedic Upper Extremity Program at Boston Children’s Hospital