Preoperative ultrasound in pediatric supracondylar fracture-related nerve injuries: intraoperative correlation in a tertiary referral retrospective case series

Nerve palsy is a recognized complication of paediatric supracondylar humeral fractures. Most injuries recover spontaneously, a subset require surgical exploration, and identifying those who may benefit from intervention remains challenging. High-resolution ultrasound has emerged as a potential adjunct for assessing nerve injury, although its utility in this setting remains incompletely defined. A retrospective case series was conducted at a tertiary peripheral nerve injury center. Children less than 16 years with persistent supracondylar fracture-related nerve palsy who underwent preoperative ultrasound and surgical exploration between 2018 and 2024 were included. Ultrasound findings were categorized as structural abnormality, compression/tethering, neuroma/swelling, or entrapment and were compared with intraoperative findings. Analysis was descriptive, focusing on ultrasound detection of nerve abnormality and concordance with surgical findings. Twenty-two patients were included (mean age: 7 years). All had surgically confirmed nerve pathology. Ultrasound demonstrated nerve abnormality in 21 out of 22 cases (95%). Compression/tethering was the most common finding (18/22), followed by structural abnormality (14/22), neuroma/swelling (7/22), and entrapment (2/22). Intraoperatively, structural abnormalities were identified in 17 cases, compression/tethering in 21, neuroma in 3, and entrapment in 4. Ultrasound frequently identified nerve abnormality but demonstrated variable concordance with intraoperative findings, including overestimation of neuroma (7 vs. 3 cases) and under-detection of entrapment (2 vs. 4 cases). Preoperative ultrasound frequently demonstrated abnormal nerve features in children with persistent palsy following supracondylar humeral fracture. However, its limited concordance in characterizing specific pathology restricts its role as a standalone decision-making tool. Ultrasound findings should be interpreted alongside clinical assessment when considering surgical exploration.