Surgical treatment of partial distal biceps tendon ruptures.

PURPOSE: To demonstrate that surgical repair of partial distal biceps tendon ruptures allows return of supination and flexion strength nearly equal to the contralateral side without compromising range of motion. METHODS: We performed a retrospective study of 17 patients with unilateral partial biceps tendon ruptures who underwent surgical repair between 2003 and 2009, and who returned for further evaluation and strength testing. The follow-up examination included questionnaires, x-rays, strength testing, and range of motion with comparison to the opposite side. We used the Baltimore Therapeutic Equipment work simulator to objectively test isometric and dynamic elbow flexion and forearm supination strength of both extremities. RESULTS: A total of 17 patients returned for additional testing, 14 of whom had failed nonsurgical treatment. One patient had asymptomatic heterotopic ossification. Two patients reported mild lateral antebrachial cutaneous nerve dysesthesias. There was one partial re-rupture 4 years after the original surgery. The second repair consisted of suture anchor fixation; 15 months after re-repair, the patient remains asymptomatic. Average postoperative Disabilities of the Arm, Shoulder, and Hand score was 9 (range, 0-33). One patient had limited pronation (50 degrees degrees). The average isometric and dynamic elbow flexion was 3% and 11% stronger, respectively, compared with the opposite side. Average isometric supination was 6% and average dynamic supination was 10% weaker. CONCLUSIONS: After surgical treatment of partial distal biceps tendon tears, most patients achieved good return of strength with full motion. Surgical treatment of partial distal biceps tendon tears is a viable option after failed nonsurgical treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic treatment of internal rotation contracture and glenohumeral dysplasia in children with brachial plexus birth palsy.

BACKGROUND: The purpose of the study was to assess the ability of arthroscopic anterior release, +/- tendon transfers to maintain shoulder joint alignment in children with brachial plexus palsy, and to assess their outcome after arthroscopic reduction. METHODS: Forty-four patients underwent arthroscopic release, +/- tendon transfers to realign a dysplastic glenohumeral joint in children with brachial plexus palsy. Twenty-eight children underwent isolated release and 16 children underwent concomitant tendon transfers. MRI and clinical measurements were used to assess outcome at 1-year follow-up. RESULTS: There was a significant improvement (P < .001) in both retroversion from -34 (+/-15) to -19 (+/-13), and percentage of the humeral head anterior to the middle of the glenoid fossa (PHHA) from 19% (+/-12%) to 33% (+/-12%), at 1 year. Passive external rotation increased from -26 (+/-20) degrees to 47 (+/-17) degrees (P < .001). Active elevation increased from 112 (+/-28) degrees to 130 (+/-38) (P = .008) degrees. Patients that underwent tendon transfers obtained greater active elevation, 147 (+/-9) degrees compared to 119 (+/-6) degrees. Mallet aggregate and domain scores also demonstrated statistically significant improvements. CONCLUSIONS: Our results after arthroscopic release +/- tendon transfers are encouraging with improvements in joint alignment and clinical evaluations following surgery. The clinical improvements paralleled the MRI corrections. Importantly, superior outcomes were associated with better preoperative clinical and MRI status. This indicates that early recognition of glenohumeral dysplasia and timely intervention results in better shoulder motion and improved joint alignment. LEVEL OF EVIDENCE: 4.

Relationship of the anterior humeral line to the capitellar ossific nucleus: variability with age.

BACKGROUND: The anterior humeral line is used to assess displacement and the adequacy of reduction of supracondylar humeral fractures in children. It is said to pass through the middle third of the capitellum in the elbow of a normal child. Few reports in the published literature have discussed this measurement, and the intra-rater and inter-rater reliability of the measurement is not known. The purposes of the present study were to define the position of the anterior humeral line in normal, skeletally immature elbows and to determine the intra-rater and inter-rater reliability of this parameter. METHODS: On two occasions, three observers (a pediatric orthopaedic surgeon, a senior orthopaedic resident, and a senior medical student) recorded the location of the anterior humeral line as it passed through the capitellum as seen on the lateral radiographs of thirty normal elbows in children ranging in age from four months to three years and eleven months and thirty normal elbows in children ranging in age from four to nine years. For these measurements, the capitellum was divided into three regions: the anterior third, the middle third, and the posterior third. All observers received written instructions, and identical rulers were used to make the measurements. RESULTS: Each observer made 120 measurements. Overall, the anterior humeral line passed through the anterior third of the capitellum in 31% of the elbows, the middle third in 52%, and the posterior third in 18%. In children younger than four years of age, the line passed nearly equally through either the anterior or middle third of the capitellum. In older children, the anterior humeral line passed through the middle third in 62% of the elbows. Overall, intra-rater reliability and inter-rater reliability were moderate to substantial. CONCLUSIONS: The anterior humeral line passes through the middle third of the capitellum in the majority of normal children. In children younger than four years of age, it passes nearly equally through the anterior or middle third of the capitellum, whereas in older children it more consistently passes through the middle third of the capitellum. The surgeon must be aware of the variability of the location of the anterior humeral line with age when utilizing it to assess radiographs of the elbow in children after an injury or after the reduction of a displaced supracondylar fracture.

Hip fractures in children.

Hip fractures account for <1% of all pediatric fractures. Most are caused by high-energy mechanisms, but pathologic hip fractures also occur, usually from low-energy trauma. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. Surgical options vary based on the child's age, Delbet classification type, and degree of displacement. Anatomic reduction and surgical stabilization are indicated for most displaced hip fractures. Other options include smooth-wire or screw fixation, often supplemented by spica cast immobilization in younger children, or compression screw and side plate fixation. Achievement of fracture stability is more important than preservation of the proximal femoral physis. Capsular decompression after reduction and fixation may diminish the risk of osteonecrosis. Osteonecrosis, coxa vara, premature physeal closure of the proximal femur, and nonunion are complications that account for poor outcomes.