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Nerve Injuries in Children
Symposium on Operative Nerve Injuries and Their Repair
Nerve Injuries in Children Luis Schut, MD.*
Trauma to the peripheral nervous system in children is a relatively rare occurrence and, except for some cases that we will discuss below, does not differ greatly from the injuries encountered in the general adult practice. Regarding the injuries that are more common in the pediatric population, the first to consider, and the most important, is the brachial plexus injury encountered after traumatic deliveries, particularly those in breech presentation. At this point, it would be good to review once again the normal anatomy of the brachial plexus. The brachial plexus is formed by the anterior division of C5, 6,7,8 and Tl nerve roots with C5 occasionally receiving a portion of the C4 nerve root, and Tl frequently one from T2. From these roots, two important nerves arise,' the long thoracic and the dorsoscapular nerves. Later on, these rami unite to form the upper trunk with fibers coming from C4, 5,6, the middle trunk, which is a continuation of C7, and the lower trunk with fibers from C8, Tl, and sometimes from T2. These are divided later into anterior and posterior divisions, and later on they unite again in the lateral cord, derived from the anterior division of the upper and middle trunks, the medial cord from the anterior division of the lower trunk, and sometimes from the middle one, and the posterior cord from the posterior division of all three trunks. These cords will give off the majority of the peripheral nerves to the upper extremity, with the lateral ones giving the musculocutaneous and the lateral head of the median nerve, the medial cord, the median anterior thoracic nerve, the ulnar nerve, the median cutaneous nerve of the forearm and arm, and the medial head of the median nerve, and a branch to the intercostobrachial nerve. From the posterior cord, the axillary, radial, thoracodorsal, and the two subscapular nerves will be divided later on. All of these components are in close relationship with blood vessels, particularly the subclavian artery, the bones, the clavicle and the first rib. It is to be noted that sympathetic fibers are present in all portions of the plexus, and could be involved in lesions of this anatomic structure. ':'Associate Professor, University of Pennsylvania School of Medicine; Chief, Neurosurgery, Children's Hospital of Philadelphia Surgical Clinics of North America- Vol. 52, No.5, October 1972 1307
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A frequent point of confusion in the nomenclature arises when talking about a pre-fixed plexus and a post-fixed plexus. All the components are shifted upward one segment in the pre-fixed plexus, and they are shifted downward one segment, with very little supply from C5 and an important branch from T2, in the case of the post-fixed plexus. The most common type of brachial plexus injury at birth is the one seen when, because of the stretching of the plexus with traction of the shoulders in the delivery of the head in a breech presentation, the fifth and sixth cervical roots are injured. This sometimes happens after drawing the head and neck away from the shoulders in a forceful manner in difficult cephalic presentations. In these cases there is usually some hemorrhage around the nerve roots, and on pathologic examination, the nerve sheath is seen with compression of the fibers with hemorrhage and swelling. In other cases, the nerves could be completely ruptured with separation of the ends, or in extreme cases the nerve roots themselves could be avulsed from the spinal cord with injury to the cord itself. This usually will result in a complete brachial plexus palsy, and also a Horner's syndrome, which is much more commonly observed with an intraspinal nerve root injury. The most common type of injury seen is the so-called Erb's palsy with lesions at the level of the fifth and sixth cervical roots as they unite to form the upper trunk. This injury is usually noticed a short time after birth; it is almost always unilateral, but cases of severe bilateral Erb's palsy have been reported. A characteristic posturing of the upper extremity is noticed, with adduction, internal rotation of the shoulder, extension of the elbow, and often pronation of the forearm with some flexion of the wrist. The deltoid, the upper part of the pectoralis, biceps, and anterior brachial muscles are more often affected, and there is usually some weakness of the supinators and long extensors of the wrist. The Moro reflex is grossly abnormal on the affected side of the newborn infant. In a great majority of the cases, it is impossible to demonstrate any sensory loss, but the biceps and radial reflexes are commonly absent.
TREATMENT The best treatment available at the present time is conservative management, with the arm kept abducted and externally rotated at the shoulder, flexed 90 degrees at the elbow, and extended at the wrist. This can be readily accomplished by an airplane type of splint that, when carefully fitted, will be well tolerated by all infants. It should be supplemented by intensive physiotherapy to prevent muscle atrophy. Surgical treatment of Erb's palsy has been almost completely abandoned because of the very poor result that is obtained. The best that can be done in surgery is careful neurolysis if there has been no spontaneous recovery after 6 months of conservative management. In cases in which there is an actual avulsion of the nerve roots on the spinal cord, no neurosurgical procedure should be attempted.
NERVE INJURIES IN CHILDREN
1309
CASE PRESENTATION
S.B. was born after 40 112 weeks of gestation to a gravida II, para I mother, who was found to have diabetes mellitus shortly before the delivery. The delivery was complicated by shoulder arrest owing to the large size of the body, and immediately after birth, the baby was found to weigh 12 lb. 12 oz. with a length of 231J. inches, a head circumference of 14112 inches, a chest circumference of 151J. inches, and an abdominal circumference of 16 inches. A right Erb's type brachial plexus palsy was evident, with no particular masses or tenderness in the supraclavicular area. The triceps, finger extensors and flexors were normal, but there was no motion of the biceps or deltoid group. Treatment consisted of an airplane splint, physiotherapy and faradic stimulation of the muscles. By the first birthday, with this program, the baby was able to move the right upper extremity spontaneously, with the only detectable neurologic deficit being weakness of the deltoid and a slight decrease in size of the upper extremity when compared to the left.
Other types of brachial plexus injuries, such as the one described by Klumpke, are very rarely observed in the pediatric population. In these cases, the injuries are confined to the seventh and eighth cervical nerve roots, the lower trunk or the plexus. There is paralysis of the intrinsic muscles of the hand with weakness of the long flexors of the wrist and fingers. There could be some trophic disturbances because of the sympathetic involvement, and a Horner's syndrome is frequently seen. Cases of complete paralysis of the brachial plexus are quite rare, and they are usually accompanied by major penetrating lesions of the supraclavicular and/or axillary region. In these cases, the sensory involvement is extremely marked, and the arm is flaccid, with rapid muscle wasting. This could also be accompanied by paralysis of the diaphragm because of the involvement of the roots to the phrenic nerve.
FACIAL PALSIES Another type of injury that is peculiar to the neonatal group is the one occasionally seen in traumatic deliveries, with contusion and/or laceration of the facial nerve, usually at the stylomastoid foramina or distal to it. These injuries are usually recognized promptly because of the contusions in the face, and in some cases, an actual disruption of the tissues can be observed. The child presents a typical appearance with a peripheral type of facial palsy that involves all of the portions of the nerve, and this is more marked when the baby is crying. There could be evidence of other types of trauma secondary to delivery, such as deformities of the head itself, cephalohematoma, or evidence of depressed skull fracture. In the treatment of this lesion, surgery would be indicated only in cases in which there is an actual disruption of the facial nerve by a deep laceration, and a primary suture of the nerve under magnification should be attempted. In the majority of the cases, the facial palsy is due to either neuroplexia or axonotmesis, which is a physiologic disruption of the nerve without any anatomic discontinuity in the first case, or a section of the axons without an anatomic disruption of the neural tubes in the second
1310
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case. In those cases, recovery is usually spontaneous and well underway in 3 months. If conservative management is recommended, the mother should be instructed to provide for passive motion of the muscles of the face by massaging the affected side, and also to instruct the mother on the meticulous care of the cornea with artificial tears three or four times a day to prevent corneal ulcerations. When peripheral degeneration of the facial nerve is complete, and no improvement is noticed from one to two years after the trauma, surgical anastomosis could be considered. In these cases, the hypoglossal or spinal accessory nerve is used to graft the distal portion of the facial nerve. However, in our clinic, our usual procedure has been to do a facial sling support for the upper lip in the cases where this has become necessary.
CASE REPORT
Wendy H. was the product of a normal pregnancy with a traumatic delivery, necessitating the use of low forceps. According to the mother, the child had marks on the face in the posterior parietal region, and she noticed an asymmetrically shaped face with the baby being unable to close the left eyelid. On examination, there was a very definite peripheral facial palsy that involved the brow, the upper and lower eyelids and the upper lip, with good motion of the lower lip and the lateral commissura. Skull x-rays were obtained, and they showed no evidence of increased intracranial pressure or skull fractures. The mother was instructed regarding the care of the child with massaging and artificial tears to prevent corneal ulcerations. Six months later, it was noticed that the child had motion on the affected side, with the eye tearing profusely and some motion of the muscle of the forehead. With conservative management, the child continued to improve, and no surgery was indicated.
INJECTION INJURIES An important point regarding the prevention and treatment of nerve injuries in children is the one involved with the injections in or around major nerves, involving particularly the radial and sciatic nerves. The sciatic nerve appears to be the one most frequently involved, and is seen usually injured distal to the sciatic notch. In our clinic, we had several examples of this injury, most frequently secondary to the injection of penicillin. This seems to be more than just a mechanical injury, and there is strong evidence to suspect a chemical action of the drug itself. In a typical case, there has been a history of intense and excruciating pain immediately after the injection, with a concurrent motor loss, foot drop, and sensory loss in the outer aspect of the leg and foot involved. If the injection injury is a partial one, there is usually spontaneous recovery of some degree. If at the time of the examination the lesion appears to be total or becomes total shortly after the injury, the prognosis is very poor, and recovery should not be expected. Surgical exploration
1311
NERVE INJURIES IN CHILDREN
should be carried out with neurolysis under appropriate magnification. If there is no evidence of nerve tissue within the scar, end to end anastomosis should be attempted. As mentioned above, the other types of nerve injuries seen are quite similar to the ones in the general population, but it should be mentioned that in lacerations of nerves in children treated properly with early exploration, neurolysis and primary nerve suture under magnification without undue tension, there would be a rapid regeneration with recovery of function far more complete than the ones that we are accustomed to expect in the adult.
CASE REPORT
Ten months prior to adInission in our hospital, Kim M., a 6 year old girl, suffered a penetrating wound of the left arm above the elbow. Immediately after the injury, the patient noticed weakness of the inner side of her hand. The child was seen at the local hospital where the wound was closed. Eventually, when it was noticed that she had the classical signs of ulnar nerve palsy, she was referred to this clinic for further treatment. On examination, there was marked weakness of the flexor carpi ulnaris, the medial half of the flexor digitorum profundus, and atrophy of the interossei and third and fourth lumbricales with atrophy of the hypothenar eminence and sensory loss in the ulnar distribution of the hand. Shortly after admission, the patient was taken to the operating room, where the ulnar nerve was exposed, and a neuroma was clearly visualized. Nerve stimulation above the neuroma failed to elicit any response below the site of the trauma, and because of that, the neuroma was resected, and an end to end anastomosis was performed. The nerve was transplanted to the flexor surface of the elbow and fixed there with subcutaneous tissues. The arm was placed in a cast that was removed after 6 weeks, and intensive physiotherapy was instituted. Very soon after, evidence of regeneration was elicited by the Hoffman-Tinel sign. Eighteen months later, neurological examination revealed complete disappearance of the typical ulnar claw, and return of sensory perception that included the tip of the little finger. A word of caution is that in children, it is sometimes difficult to elicit either the site or the history of an injury, as is documented in the following case. Kim S. was admitted to The Children's Hospital of Philadelphia at the age of 11 years for evaluation of a peripheral neuropathy. She had a history of progressive weakness of the left leg for two years,1 manifested by a limp, and an inability to walk on the left heel. The child also complained of a very mild low back pain, and because of that, a possibility of a spinal cord lesion was raised. There was also a marked sensory loss over the lateral aspect of the left leg. Numerous studies, including a myelogram, were performed by the Neurology Service, and they were all reported within normal limits. An EMG, however, demonstrated decrease of the conduction velocity of the left common peroneal nerve. Palpation of the nerve itself at the head of the fibula demonstrated thickening with
1312
LUIS SCHUT
no tenderness. While more esoteric reasons for thickening of the nerve were being considered, a repeat EMG and nerve conduction study showed loss of conduction, again particularly at the head of the fibula. When questioning Kim closely, she recalled being stabbed in the region with a lead pencil. Because of that, an exploration was undertaken, where the nerve was exposed through an S-shaped incision in the left popliteal fossa, and a neuroma, in continuity, extending from the middle distal third of the common peroneal nerve to the deep peroneal branch was easily identified. Neurolysis was carried out under magnification, and faradic nerve stimulation demonstrated continuity of the fascicles through the neuroma. Because of that, the neuroma was incised in several places, and an internal neurolysis was performed. Several months later, the patient had partial peroneal nerve recovery. In summary, except for the above-mentioned brachial plexus injuries, facial nerve injuries, and injection injuries to the large nerves, the great majority of peripheral nerve lesions in children do not differ greatly from the ones encountered in the rest of the population, except for the fact that they are of a more favored prognosis. The Children's Hospital of Philadelphia 1740 Bainbridge Street, Philadelphia, Pennsylvania
Nerve Injuries in Children Luis Schut, MD.*
Trauma to the peripheral nervous system in children is a relatively rare occurrence and, except for some cases that we will discuss below, does not differ greatly from the injuries encountered in the general adult practice. Regarding the injuries that are more common in the pediatric population, the first to consider, and the most important, is the brachial plexus injury encountered after traumatic deliveries, particularly those in breech presentation. At this point, it would be good to review once again the normal anatomy of the brachial plexus. The brachial plexus is formed by the anterior division of C5, 6,7,8 and Tl nerve roots with C5 occasionally receiving a portion of the C4 nerve root, and Tl frequently one from T2. From these roots, two important nerves arise,' the long thoracic and the dorsoscapular nerves. Later on, these rami unite to form the upper trunk with fibers coming from C4, 5,6, the middle trunk, which is a continuation of C7, and the lower trunk with fibers from C8, Tl, and sometimes from T2. These are divided later into anterior and posterior divisions, and later on they unite again in the lateral cord, derived from the anterior division of the upper and middle trunks, the medial cord from the anterior division of the lower trunk, and sometimes from the middle one, and the posterior cord from the posterior division of all three trunks. These cords will give off the majority of the peripheral nerves to the upper extremity, with the lateral ones giving the musculocutaneous and the lateral head of the median nerve, the medial cord, the median anterior thoracic nerve, the ulnar nerve, the median cutaneous nerve of the forearm and arm, and the medial head of the median nerve, and a branch to the intercostobrachial nerve. From the posterior cord, the axillary, radial, thoracodorsal, and the two subscapular nerves will be divided later on. All of these components are in close relationship with blood vessels, particularly the subclavian artery, the bones, the clavicle and the first rib. It is to be noted that sympathetic fibers are present in all portions of the plexus, and could be involved in lesions of this anatomic structure. ':'Associate Professor, University of Pennsylvania School of Medicine; Chief, Neurosurgery, Children's Hospital of Philadelphia Surgical Clinics of North America- Vol. 52, No.5, October 1972 1307
1308
LUIS SCHUT
A frequent point of confusion in the nomenclature arises when talking about a pre-fixed plexus and a post-fixed plexus. All the components are shifted upward one segment in the pre-fixed plexus, and they are shifted downward one segment, with very little supply from C5 and an important branch from T2, in the case of the post-fixed plexus. The most common type of brachial plexus injury at birth is the one seen when, because of the stretching of the plexus with traction of the shoulders in the delivery of the head in a breech presentation, the fifth and sixth cervical roots are injured. This sometimes happens after drawing the head and neck away from the shoulders in a forceful manner in difficult cephalic presentations. In these cases there is usually some hemorrhage around the nerve roots, and on pathologic examination, the nerve sheath is seen with compression of the fibers with hemorrhage and swelling. In other cases, the nerves could be completely ruptured with separation of the ends, or in extreme cases the nerve roots themselves could be avulsed from the spinal cord with injury to the cord itself. This usually will result in a complete brachial plexus palsy, and also a Horner's syndrome, which is much more commonly observed with an intraspinal nerve root injury. The most common type of injury seen is the so-called Erb's palsy with lesions at the level of the fifth and sixth cervical roots as they unite to form the upper trunk. This injury is usually noticed a short time after birth; it is almost always unilateral, but cases of severe bilateral Erb's palsy have been reported. A characteristic posturing of the upper extremity is noticed, with adduction, internal rotation of the shoulder, extension of the elbow, and often pronation of the forearm with some flexion of the wrist. The deltoid, the upper part of the pectoralis, biceps, and anterior brachial muscles are more often affected, and there is usually some weakness of the supinators and long extensors of the wrist. The Moro reflex is grossly abnormal on the affected side of the newborn infant. In a great majority of the cases, it is impossible to demonstrate any sensory loss, but the biceps and radial reflexes are commonly absent.
TREATMENT The best treatment available at the present time is conservative management, with the arm kept abducted and externally rotated at the shoulder, flexed 90 degrees at the elbow, and extended at the wrist. This can be readily accomplished by an airplane type of splint that, when carefully fitted, will be well tolerated by all infants. It should be supplemented by intensive physiotherapy to prevent muscle atrophy. Surgical treatment of Erb's palsy has been almost completely abandoned because of the very poor result that is obtained. The best that can be done in surgery is careful neurolysis if there has been no spontaneous recovery after 6 months of conservative management. In cases in which there is an actual avulsion of the nerve roots on the spinal cord, no neurosurgical procedure should be attempted.
NERVE INJURIES IN CHILDREN
1309
CASE PRESENTATION
S.B. was born after 40 112 weeks of gestation to a gravida II, para I mother, who was found to have diabetes mellitus shortly before the delivery. The delivery was complicated by shoulder arrest owing to the large size of the body, and immediately after birth, the baby was found to weigh 12 lb. 12 oz. with a length of 231J. inches, a head circumference of 14112 inches, a chest circumference of 151J. inches, and an abdominal circumference of 16 inches. A right Erb's type brachial plexus palsy was evident, with no particular masses or tenderness in the supraclavicular area. The triceps, finger extensors and flexors were normal, but there was no motion of the biceps or deltoid group. Treatment consisted of an airplane splint, physiotherapy and faradic stimulation of the muscles. By the first birthday, with this program, the baby was able to move the right upper extremity spontaneously, with the only detectable neurologic deficit being weakness of the deltoid and a slight decrease in size of the upper extremity when compared to the left.
Other types of brachial plexus injuries, such as the one described by Klumpke, are very rarely observed in the pediatric population. In these cases, the injuries are confined to the seventh and eighth cervical nerve roots, the lower trunk or the plexus. There is paralysis of the intrinsic muscles of the hand with weakness of the long flexors of the wrist and fingers. There could be some trophic disturbances because of the sympathetic involvement, and a Horner's syndrome is frequently seen. Cases of complete paralysis of the brachial plexus are quite rare, and they are usually accompanied by major penetrating lesions of the supraclavicular and/or axillary region. In these cases, the sensory involvement is extremely marked, and the arm is flaccid, with rapid muscle wasting. This could also be accompanied by paralysis of the diaphragm because of the involvement of the roots to the phrenic nerve.
FACIAL PALSIES Another type of injury that is peculiar to the neonatal group is the one occasionally seen in traumatic deliveries, with contusion and/or laceration of the facial nerve, usually at the stylomastoid foramina or distal to it. These injuries are usually recognized promptly because of the contusions in the face, and in some cases, an actual disruption of the tissues can be observed. The child presents a typical appearance with a peripheral type of facial palsy that involves all of the portions of the nerve, and this is more marked when the baby is crying. There could be evidence of other types of trauma secondary to delivery, such as deformities of the head itself, cephalohematoma, or evidence of depressed skull fracture. In the treatment of this lesion, surgery would be indicated only in cases in which there is an actual disruption of the facial nerve by a deep laceration, and a primary suture of the nerve under magnification should be attempted. In the majority of the cases, the facial palsy is due to either neuroplexia or axonotmesis, which is a physiologic disruption of the nerve without any anatomic discontinuity in the first case, or a section of the axons without an anatomic disruption of the neural tubes in the second
1310
LUIS SCHUT
case. In those cases, recovery is usually spontaneous and well underway in 3 months. If conservative management is recommended, the mother should be instructed to provide for passive motion of the muscles of the face by massaging the affected side, and also to instruct the mother on the meticulous care of the cornea with artificial tears three or four times a day to prevent corneal ulcerations. When peripheral degeneration of the facial nerve is complete, and no improvement is noticed from one to two years after the trauma, surgical anastomosis could be considered. In these cases, the hypoglossal or spinal accessory nerve is used to graft the distal portion of the facial nerve. However, in our clinic, our usual procedure has been to do a facial sling support for the upper lip in the cases where this has become necessary.
CASE REPORT
Wendy H. was the product of a normal pregnancy with a traumatic delivery, necessitating the use of low forceps. According to the mother, the child had marks on the face in the posterior parietal region, and she noticed an asymmetrically shaped face with the baby being unable to close the left eyelid. On examination, there was a very definite peripheral facial palsy that involved the brow, the upper and lower eyelids and the upper lip, with good motion of the lower lip and the lateral commissura. Skull x-rays were obtained, and they showed no evidence of increased intracranial pressure or skull fractures. The mother was instructed regarding the care of the child with massaging and artificial tears to prevent corneal ulcerations. Six months later, it was noticed that the child had motion on the affected side, with the eye tearing profusely and some motion of the muscle of the forehead. With conservative management, the child continued to improve, and no surgery was indicated.
INJECTION INJURIES An important point regarding the prevention and treatment of nerve injuries in children is the one involved with the injections in or around major nerves, involving particularly the radial and sciatic nerves. The sciatic nerve appears to be the one most frequently involved, and is seen usually injured distal to the sciatic notch. In our clinic, we had several examples of this injury, most frequently secondary to the injection of penicillin. This seems to be more than just a mechanical injury, and there is strong evidence to suspect a chemical action of the drug itself. In a typical case, there has been a history of intense and excruciating pain immediately after the injection, with a concurrent motor loss, foot drop, and sensory loss in the outer aspect of the leg and foot involved. If the injection injury is a partial one, there is usually spontaneous recovery of some degree. If at the time of the examination the lesion appears to be total or becomes total shortly after the injury, the prognosis is very poor, and recovery should not be expected. Surgical exploration
1311
NERVE INJURIES IN CHILDREN
should be carried out with neurolysis under appropriate magnification. If there is no evidence of nerve tissue within the scar, end to end anastomosis should be attempted. As mentioned above, the other types of nerve injuries seen are quite similar to the ones in the general population, but it should be mentioned that in lacerations of nerves in children treated properly with early exploration, neurolysis and primary nerve suture under magnification without undue tension, there would be a rapid regeneration with recovery of function far more complete than the ones that we are accustomed to expect in the adult.
CASE REPORT
Ten months prior to adInission in our hospital, Kim M., a 6 year old girl, suffered a penetrating wound of the left arm above the elbow. Immediately after the injury, the patient noticed weakness of the inner side of her hand. The child was seen at the local hospital where the wound was closed. Eventually, when it was noticed that she had the classical signs of ulnar nerve palsy, she was referred to this clinic for further treatment. On examination, there was marked weakness of the flexor carpi ulnaris, the medial half of the flexor digitorum profundus, and atrophy of the interossei and third and fourth lumbricales with atrophy of the hypothenar eminence and sensory loss in the ulnar distribution of the hand. Shortly after admission, the patient was taken to the operating room, where the ulnar nerve was exposed, and a neuroma was clearly visualized. Nerve stimulation above the neuroma failed to elicit any response below the site of the trauma, and because of that, the neuroma was resected, and an end to end anastomosis was performed. The nerve was transplanted to the flexor surface of the elbow and fixed there with subcutaneous tissues. The arm was placed in a cast that was removed after 6 weeks, and intensive physiotherapy was instituted. Very soon after, evidence of regeneration was elicited by the Hoffman-Tinel sign. Eighteen months later, neurological examination revealed complete disappearance of the typical ulnar claw, and return of sensory perception that included the tip of the little finger. A word of caution is that in children, it is sometimes difficult to elicit either the site or the history of an injury, as is documented in the following case. Kim S. was admitted to The Children's Hospital of Philadelphia at the age of 11 years for evaluation of a peripheral neuropathy. She had a history of progressive weakness of the left leg for two years,1 manifested by a limp, and an inability to walk on the left heel. The child also complained of a very mild low back pain, and because of that, a possibility of a spinal cord lesion was raised. There was also a marked sensory loss over the lateral aspect of the left leg. Numerous studies, including a myelogram, were performed by the Neurology Service, and they were all reported within normal limits. An EMG, however, demonstrated decrease of the conduction velocity of the left common peroneal nerve. Palpation of the nerve itself at the head of the fibula demonstrated thickening with
1312
LUIS SCHUT
no tenderness. While more esoteric reasons for thickening of the nerve were being considered, a repeat EMG and nerve conduction study showed loss of conduction, again particularly at the head of the fibula. When questioning Kim closely, she recalled being stabbed in the region with a lead pencil. Because of that, an exploration was undertaken, where the nerve was exposed through an S-shaped incision in the left popliteal fossa, and a neuroma, in continuity, extending from the middle distal third of the common peroneal nerve to the deep peroneal branch was easily identified. Neurolysis was carried out under magnification, and faradic nerve stimulation demonstrated continuity of the fascicles through the neuroma. Because of that, the neuroma was incised in several places, and an internal neurolysis was performed. Several months later, the patient had partial peroneal nerve recovery. In summary, except for the above-mentioned brachial plexus injuries, facial nerve injuries, and injection injuries to the large nerves, the great majority of peripheral nerve lesions in children do not differ greatly from the ones encountered in the rest of the population, except for the fact that they are of a more favored prognosis. The Children's Hospital of Philadelphia 1740 Bainbridge Street, Philadelphia, Pennsylvania