The Bead Maze Hand Function Test for Children.

IMPORTANCE: There is a need for a pediatric hand function test that can be used to objectively assess movement quality. We have developed a toy-based test, the Bead Maze Hand Function (BMHF) test, to quantify how well a child performs an activity. This is achieved by assessing the control of forces applied while drawing a bead over wires of different complexity. OBJECTIVE: To study the psychometric properties of the BMHF test and understand the influence of age and task complexity on test measures. DESIGN: A cross-sectional, observational study performed in a single visit. SETTING: Clinical research laboratory. PARTICIPANTS: Twenty-three participants (ages 4-15 yr) were recruited locally. They were typically developing children with no illness or conditions that affected their movement. Interventions/Assessments: Participants performed the BMHF test and the Box and Block test with both hands. OUTCOMES AND MEASURES: Total force and completion time were examined according to age and task complexity using a linear mixed-effects model. We calculated intraclass correlation coefficients to measure interrater reliability of the method and estimated concurrent validity using the Box and Block test. RESULTS: Total force and completion time decreased with age and depended on task complexity. The total force was more sensitive to task complexity. The Box and Block score was associated with BMHF completion time but not with total force. We found excellent interrater reliability. CONCLUSIONS AND RELEVANCE: A familiar toy equipped with hidden sensors provides a sensitive tool to assess a child's typical hand function. Plain-Language Summary: We developed the Bead Maze Hand Function (BMHF) test to determine how well a child performs an activity with their hands. The BMHF test is a toy equipped with hidden sensors. Twenty-three typically developing children with no illnesses or conditions that affected their hand movement participated in the study. We asked the children to perform the BMHF test with both hands. Our study found that occupational therapists can reliably use the BMHF test to assess a child's hand function.

Dexterity of the Less Affected Hand in Children With Hemiplegic Cerebral Palsy.

BACKGROUND: To determine if the "unaffected" hand in children with hemiplegic cerebral palsy (CP) is truly unaffected. METHODS: We performed a retrospective review of manual dexterity as measured by the Functional Dexterity Test (FDT) in 66 children (39 boys, 27 girls, mean age: 11 years 4 months) with hemiplegic CP. Data were stratified by Manual Ability Classification System (MACS) level, birth weight, and gestational age at birth, and compared with previously published normative values. RESULTS: The FDT speed of the less affected hand is significantly lower than typically developing (TD) children (P < .001). The development of dexterity is significantly lower than TD children (0.009 vs. 0.036 pegs/s/year, P < .001), with a deficit that increases with age. MACS score, birth weight, and age at gestation are not predictors of dexterity. The dexterity of the less affected hand is poorly correlated with that of the more affected hand. CONCLUSIONS: Both dexterity and rate of fine motor skill acquisition in the less affected hand of children with hemiplegic CP is significantly less than that of TD children. The less affected hand should be evaluated and included in comprehensive treatment plans for these children.

Persistence of bacterial DNA in orthopedic infections.

Polymerase chain reaction (PCR) has been proposed as a method to identify bacteria in clinical samples because it is more sensitive than culture techniques and can produce results rapidly. However, PCR can detect DNA from dead cells and thus cannot distinguish between live and dead cells in a tissue sample. Killed Staphylococcus aureus cells were implanted into the femurs and knee joints of rats to determine the length of time that DNA from dead cells is detectable in a living animal under conditions similar to common orthopedic infections. In the joint infection model studied here, the DNA from the dead planktonic bacteria was detected using PCR immediately after injection or 24 h later, but was undetectable 48 and 72 h after injection. In the biofilm implanted-device model studied, the DNA from these dead biofilm cells was detected by PCR immediately after implantation and at 24 h, but not at 48 or 72 h. Thus, our results indicate that DNA from dead cells does not persist in these animal model systems for more than 2 days, which should reduce concerns about possible false positive results using molecular DNA-based techniques for the detection of pathogens.

Validity and reliability of the Functional Dexterity Test in children.

STUDY DESIGN: Clinical measurement study. INTRODUCTION: The Functional Dexterity Test (FDT) has not been validated in children. PURPOSE OF THE STUDY: To determine reliability and validity of the FDT in a pediatric population. METHODS: Intraclass Correlation Coefficients (ICCs) were used to calculate interrater and test-retest reliability in typically developing children. Pearson correlation coefficients were used to compare FDT speed with the Jebsen-Taylor Hand Function Test (JHFT) and with 2 activities of daily living tasks to establish validity in children with congenital hand differences. RESULTS: The FDT demonstrated excellent interrater (ICC, 0.99) and test-retest (ICC, 0.90) reliability. Pearson correlation coefficients exceeded 0.67 for JHFT subsets of fine dexterity and were all less than 0.66 for JHFT subsets of gross grasp. Correlations with the activities of daily living tasks were good to excellent. FDT speeds in TD children exceeded those of children with congenital hand differences (P < .001), demonstrating discriminant validity. DISCUSSION: Children with congenital hand differences are often treated early in life, making it important to reliably assess hand function of these young children to distinguish developmental change from changes due to interventions. The FDT can reliably measure functional progress over time, help clinicians monitor the efficacy of treatment, and provide families realistic feedback on their child's progress. CONCLUSION: The FDT is a valid and reliable instrument for the measurement of fine motor dexterity in children.

Contribution of tactile dysfunction to manual motor dysfunction in type II diabetes.

INTRODUCTION: Changes in sensory and motor functions of the hand in type II diabetes (T2D) patients have been reported; there is speculation that these changes are driven by tactile dysfunction. The purpose of this study was to evaluate the effects of tactile feedback on manual function in T2D patients. METHODS: T2D patients and healthy controls underwent median nerve blocks at the wrist and elbow. All participants underwent traditional timed motor evaluations, force dynamometry, laboratory-based kinetic evaluations, and sensory evaluation. RESULTS: Tactile sensation in the T2D group at baseline was found to be equivalent to tactile function of the control group after median nerve block. Traditional timed evaluation results were negatively impacted by anesthesia, but more sensitive kinetic measures were not impacted. CONCLUSIONS: These data suggest that mechanisms outside of tactile dysfunction play a significant role in motor dysfunction in T2D. Muscle Nerve 54: 895-902, 2016.

Three-Dimensional Printing of Prosthetic Hands for Children.

Children with hand reductions, whether congenital or traumatic, have unique prosthetic needs. They present a challenge because of their continually changing size due to physical growth as well as changing needs due to psychosocial development. Conventional prosthetics are becoming more technologically advanced and increasingly complex. Although these are welcome advances for adults, the concomitant increases in weight, moving parts, and cost are not beneficial for children. Pediatric prosthetic needs may be better met with simpler solutions. Three-dimensional printing can be used to fabricate rugged, light-weight, easily replaceable, and very low cost assistive hands for children.

Perspectives on glenohumeral joint contractures and shoulder dysfunction in children with perinatal brachial plexus palsy.

Shoulder joint deformities continue to be a challenging aspect of treating upper plexus lesions in children with perinatal brachial plexus palsy (PBPP). It is increasingly recognized that PBPP affects the glenohumeral joint specifically, and that abnormal scapulothoracic movements are a compensatory development. The pathophysiology and assessment of glenohumeral joint contractures, the progression of scapular dyskinesia and skeletal dysplasia, and current shoulder imaging techniques are reviewed.

Innovative evaluation of dexterity in pediatrics.

STUDY DESIGN: Review paper. INTRODUCTION: Hand dexterity is multifaceted and essential to the performance of daily tasks. Timed performance and precision demands are the most common features of quantitative dexterity testing. Measurement concepts such as rate of completion, in-hand manipulation and dynamic force control of instabilities are being integrated into assessment tools for the pediatric population. PURPOSE: To review measurement concepts inherent in pediatric dexterity testing and introduce concepts that are infrequently measured or novel as exemplified with two assessment tools. METHODS: Measurement concepts included in common assessment tools are introduced first. We then describe seldom measured and novel concepts embedded in two instruments; the Functional Dexterity Test (FDT) and the Strength-Dexterity (SD) Test. DISCUSSION: The inclusion of novel yet informative tools and measurement concepts in our assessments could aid our understanding of atypical dexterity, and potentially contribute to the design of targeted therapy programs.

Evaluation of antibiotic-impregnated microspheres for the prevention of implant-associated orthopaedic infections.

BACKGROUND: Prevention of infection associated with uncemented orthopaedic implants could lead to improved implant stability and better patient outcomes. We hypothesized that coating porous metal implants with antibiotic-containing microspheres would prevent infections in grossly contaminated wounds. METHODS: Bioresorbable polymer microspheres containing tobramycin were manufactured and pressed into porous metal cylinders that were then implanted into radial defects in rabbits. Control implants that did not contain antibiotic microspheres were also implanted into the contralateral limbs. Each implant was then contaminated with Staphylococcus aureus prior to closure of the wound. The animal was euthanized after clinical signs of infection appeared, or at two weeks after surgery. Periprosthetic tissue was cultured for the presence of S. aureus, and integration of the implant with the surrounding bone was measured. RESULTS: The antibiotic microspheres successfully prevented infection in 100% of the eleven limbs with treated implants, which represented a significant improvement (p = 0.004) compared with the infection rate of 64% (seven of eleven) for the limbs with control implants. Implant integration averaged 38.87% ± 12.69% in the fifteen uninfected limbs, which was significantly better (p = 0.012) than the average of 19.46% ± 14.49% in the seven infected limbs. CONCLUSIONS: The antibiotic delivery system successfully prevented infection in 100% of the cases studied, resulting in an increase in implant integration. CLINICAL RELEVANCE: Antibiotic delivery utilizing the system described here may be effective in preventing implant-associated infections after orthopaedic surgery and increasing the longevity of orthopaedic implants.

Hand dexterity in children: administration and normative values of the functional dexterity test.

PURPOSE: To document normative values from the Functional Dexterity Test (FTD) for typically developing children and to optimize test administration and interpretation. METHODS: A total of 175 typically developing children aged 3 to 17 years participated in the study. Children completed the 16-peg FDT with both hands, and elapsed time was recorded in seconds. Data were analyzed as 16/time, interpreted as speed (pegs per second). A linear regression analysis predicted speed from age and hand dominance. RESULTS: Functional Dexterity Test speed increased linearly in typically developing children by 0.04 pegs/s for each year of age. This rate of increase was the same for dominant and nondominant hands. Dominant hands were faster than nondominant hands by 0.09 pegs/s at all ages. There was no sex difference. CONCLUSIONS: This study provides age-specific normative values for functional dexterity in typically developing children in 2 formats: as a growth chart of FDT speed versus age and as a regression model that calculates expected speed given a child's age and tested hand dominance. Recommended pediatric modifications to the FDT are to use speed (pegs per second) instead of time (seconds) to report results, and to not assess penalties. The norms presented allow clinicians to compare both speed and rate of change over time of pediatric patients with typically developing children, which makes it possible to distinguish developmental change from intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Computer adaptive test approach to the assessment of children and youth with brachial plexus birth palsy.

This study examined the psychometric properties of item pools relevant to upper-extremity function and activity performance and evaluated simulated 5-, 10-, and 15-item computer adaptive tests (CATs). In a multicenter, cross-sectional study of 200 children and youth with brachial plexus birth palsy (BPBP), parents responded to upper-extremity (n = 52) and activity (n = 34) items using a 5-point response scale. We used confirmatory and exploratory factor analysis, ordinal logistic regression, item maps, and standard errors to evaluate the psychometric properties of the item banks. Validity was evaluated using analysis of variance and Pearson correlation coefficients. Results show that the two item pools have acceptable model fit, scaled well for children and youth with BPBP, and had good validity, content range, and precision. Simulated CATs performed comparably to the full item banks, suggesting that a reduced number of items provide similar information to the entire set of items.

Mutations in ECEL1 cause distal arthrogryposis type 5D.

Distal arthrogryposis (DA) syndromes are the most common of the heritable congenital-contracture disorders, and ~50% of cases are caused by mutations in genes that encode contractile proteins of skeletal myofibers. DA type 5D (DA5D) is a rare, autosomal-recessive DA previously defined by us and is characterized by congenital contractures of the hands and feet, along with distinctive facial features, including ptosis. We used linkage analysis and whole-genome sequencing of a multiplex consanguineous family to identify in endothelin-converting enzyme-like 1 (ECEL1) mutations that result in DA5D. Evaluation of a total of seven families affected by DA5D revealed in five families ECEL1 mutations that explain ~70% of cases overall. ECEL1 encodes a neuronal endopeptidase and is expressed in the brain and peripheral nerves. Mice deficient in Ecel1 exhibit perturbed terminal branching of motor neurons to the endplate of skeletal muscles, resulting in poor formation of the neuromuscular junction. Our results distinguish a second developmental pathway that causes congenital-contracture syndromes.

Evaluation of the box and blocks test, stereognosis and item banks of activity and upper extremity function in youths with brachial plexus birth palsy.

BACKGROUND: One of the greatest limitations to measuring outcomes in pediatric orthopaedics is the lack of effective instruments. Computer adaptive testing, which uses large item banks, select only items that are relevant to a child's function based on a previous response and filters items that are too easy or too hard or simply not relevant to the child. In this way, computer adaptive testing provides for a meaningful, efficient, and precise method to evaluate patient-reported outcomes. Banks of items that assess activity and upper extremity (UE) function have been developed for children with cerebral palsy and have enabled computer adaptive tests that showed strong reliability, strong validity, and broader content range when compared with traditional instruments. Because of the void in instruments for children with brachial plexus birth palsy (BPBP) and the importance of having an UE and activity scale, we were interested in how well these items worked in this population. METHODS: Cross-sectional, multicenter study involving 200 children with BPBP was conducted. The box and block test (BBT) and Stereognosis tests were administered and patient reports of UE function and activity were obtained with the cerebral palsy item banks. Differential item functioning (DIF) was examined. Predictive ability of the BBT and stereognosis was evaluated with proportional odds logistic regression model. Spearman correlations coefficients (rs) were calculated to examine correlation between stereognosis and the BBT and between individual stereognosis items and the total stereognosis score. RESULTS: Six of the 86 items showed DIF, indicating that the activity and UE item banks may be useful for computer adaptive tests for children with BPBP. The penny and the button were strongest predictors of impairment level (odds ratio=0.34 to 0.40]. There was a good positive relationship between total stereognosis and BBT scores (rs=0.60). The BBT had a good negative (rs=-0.55) and good positive (rs=0.55) relationship with the clinical category of BPBP and Raimondi classification, respectively. There was a moderate negative (rs=-0.36) and moderate positive (rs=0.47) relationship between total stereognosis and clinical category of BPBP and Raimondi, respectively. Individual stereognosis items had moderate (rs=0.34 to 0.45) to good (rs=0.52 to 0.74) correlation with total stereognosis score. CONCLUSIONS: In children with BPBP, there was little to no DIF with item banks of activity and UE functioning. The BBT is a good predictor of degree of impairment. Stereognosis with 2 items may provide comparable information as 12 items. LEVELS OF EVIDENCE: Level II.

Peg Restrained Intrinsic Muscle Evaluator (PRIME): development, reliability, and normative values of a device to quantify intrinsic hand muscle strength in children.

PURPOSE: There is a need for objective measures of pediatric intrinsic hand muscle strength as the current standard, the manual muscle test, lacks sensitivity to clinically important changes in muscle strength. We report the development, reliability, and normative values of the Peg Restrained Intrinsic Muscle Evaluator (PRIME), a device that quantifies intrinsic hand muscle strength. METHODS: Typically developing children, ages 4 to 16 years (n = 119), established normative values of intrinsic strength for thumb palmar abduction, thumb opposition, and index and small finger abduction. A subset of 30 children (15 boys, 15 girls), ages 7 to 16 years, determined inter-rater and intra-rater reliability. We calculated mean, standard deviation, intraclass correlation coefficients, and smallest detectable differences. RESULTS: Normative results indicate that gender and age were significant predictors of strength. Although the dominant hand generated higher strength measurements on average, differences were not statistically significant. Mean index and small finger abduction strength was significantly lower than thumb abduction and opposition in both genders. Intraclass correlation coefficients ranged from 0.85 to 0.94 for inter-rater reliability and 0.88 to 0.98 for intra-rater reliability. Bland-Altman plots showed an even distribution across the zero line. CONCLUSIONS: The PRIME device is a reliable tool for the quantification of intrinsic hand muscle strength in children. Age-specific and gender-specific normative values in typically developing children can serve as a future resource for clinicians treating pediatric hand or neuromuscular conditions.

Use of the Pediatric Outcomes Data Collection Instrument to evaluate functional outcomes in arthrogryposis.

BACKGROUND: The Pediatric Outcomes Data Collection Instrument (PODCI) is a subjective measurement tool designed to provide a standardized method of assessing outcomes in pediatric musculoskeletal conditions. It has earlier been shown to be useful in several pediatric musculoskeletal conditions, but there is currently no widely accepted subjective outcome measurement tool for children with arthrogryposis. METHODS: The PODCI was administered to parents of 74 children diagnosed with amyoplasia. The score distributions were compared with values published earlier for children without musculoskeletal disorders. For those patients with repeated PODCI administrations over time, the initial score was compared with the most recent score. Comparisons were made using the Student t test. RESULTS: PODCI scores in children with amyoplasia were significantly lower than those for typically developing children in all 6 domains. The scores were also more normally distributed than those for typically developing children in all 6 domains. Over an average follow-up period of approximately 3 years, children with amyoplasia had a statistically significant increase in scores for upper extremity function, sports participation, and global functioning. CONCLUSIONS: These results show that the PODCI is useful in evaluating functional outcomes of children with amyoplasia, and is sensitive to change in function over time. The PODCI shows promise as a tool to evaluate long-term outcomes of surgical management in amyoplasia. LEVEL OF EVIDENCE: Diagnostic Study, Level III.

Long head of the triceps muscle transfer for active elbow flexion in arthrogryposis.

Arthrogryposis is a condition characterized by symmetric, nonprogressive joint contractures and weak or absent musculature that is present at birth. The amyoplasia form is the most common, and in this group, the elbow is frequently involved, typically in an extension contracture bilaterally. Active elbow flexion is weak or absent, but active extension is spared. This elbow dysfunction poses a significant disability for affected children. Sensation and cognitive development is normal in children with arthrogryposis, and as a group they demonstrate a remarkable degree of adaptability to their deformities. The goal of any treatment is to facilitate the child's functional independence. This article describes the surgical technique of transfer of the long head of the triceps into the proximal ulna to provide active elbow flexion in children with arthrogryposis. The goal of the procedure is to reliably achieve antigravity active flexion while preserving active extension. It has the advantages of technical simplicity and minimal donor site morbidity. By adding this procedure to the existing options for treating this challenging condition, a surgeon is better able to tailor intervention to an individual child's strength and available donor muscles.

Pediatric humeral condyle fractures.

Condylar and epicondylar fractures differ from other pediatric upper extremity fractures because of the anatomy and ossification of the distal humerus. These fractures are prone to nonunion,and initial deformities do not remodel well. Radiographic diagnosis and severity are difficult to determine, and adjunct studies, particularly arthrography and MRI, often are needed. The correlation of an intact cartilaginous hinge and subsequent fracture stability has helped identify fractures at risk for displacement and nonunion,prompting closer follow-up or more aggressive initial treatment. Although many humeral condylar fractures can be treated successfully with cast immobilization, operative treatment often is warranted. Specific treatment recommendations continue to evolve. The general trend is toward treating more fractures and nonunions with surgical fixation while using less invasive techniques.

Effective treatment of osteomyelitis with biodegradable microspheres in a rabbit model.

Biodegradable microspheres were manufactured from a high molecular weight copolymer of 50% lactic and 50% glycolic acid and the antibiotic tobramycin. It was hypothesized that the microspheres would be more effective than polymethylmethacrylate beads in the local delivery of tobramycin and that the microspheres would not inhibit bone healing. Osteomyelitis was established in 40 New Zealand White rabbits using Staphylococcus aureus. All animals had irrigation and debridement of the infected radii four weeks after inoculation and were divided into five treatment groups: debridement alone, microspheres alone, microspheres containing tobramycin plus parenteral treatment with cefazolin, polymethylmethacrylate beads containing tobramycin plus parenteral cefazolin, and parenteral cefazolin. All animals were sacrificed after 4 weeks of treatment. The group treated with microspheres plus parenteral antibiotics was the only group to have a significantly higher percentage of animals without bacteria after 4 weeks of treatment when compared with the control group. Additionally, the animals treated with microspheres had a higher degree of bone healing in the defect than the animals treated with bone cement. The most effective treatment was biodegradable microspheres combined with parenteral antibiotic in this rabbit osteomyelitis model.

Antibiotic microspheres: preliminary testing for potential treatment of osteomyelitis.

Osteomyelitis is a difficult problem for orthopaedic surgeons. The current standard of treatment requires high doses of antibiotic to be administered parenterally, which can damage vital organs. A local drug delivery system, which targets only the infected tissues, would eliminate some of the complications associated with extended courses of parenteral antibiotic treatment. In the current study, biodegradable microspheres were manufactured from a high molecular weight copolymer of 50% lactic and 50% glycolic acid and the antibiotic tobramycin. Various formulations of microspheres were tested for in vitro elution characteristics to determine the optimum formulation for linear release of antibiotic for at least 4 weeks. The optimal formulation then was implanted into a pouch created in the quadriceps muscle of mice to evaluate the in vivo elution of the antibiotic and the inflammatory response elicited by the microspheres. Results indicate that a sustained linear release of antibiotic from the microspheres is possible for a period of at least 4 weeks and that the inflammatory response was within levels required for the microspheres to be considered biocompatible.