Treatment of supination deformity for obstetric brachial plexus injury: a systematic review and meta-analysis.

PURPOSE: To conduct a systematic review and meta-analysis of the literature evaluating treatment outcome for supination deformity in obstetric brachial plexus injury. METHODS: We included studies on brachial plexus and supination deformity with follow-up of at least one year and quantitative measurements of forearm mean passive pronation and position at rest. Meta-analysis was used to explore modifying factors. RESULTS: An elaborate search strategy resulted in 366 studies, of which 13 were included totaling 238 patients (157 osteotomies and 71 biceps rerouting). There was a 75° gain in position at rest and a 65° gain in passive pronation for the osteotomy group, compared to a 79° gain in position at rest for the biceps rerouting group. More severe deformities had greater gains. No influence of age was found. Important adverse effects were hardware failure and a biceps rupture. Recurrence in the osteotomy group was 20% to 40%, versus none in the soft-tissue group. CONCLUSIONS: This review showed an overall benefit for forearm osteotomies and for biceps rerouting for supination deformity with the gain proportionate to the severity of the deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Wrist motion in handrim wheelchair propulsion.

Prevalence rates of carpal tunnel syndrome (CTS) in the wheelchair user population are high. One of the possible causes of CTS in this population is the movement pattern of the wrist during handrim wheelchair propulsion, which could include large wrist joint angles and wrist/finger flexor activity. Combined with the repetitive character of the movement, this could, in time, be detrimental to the soft tissue of the wrist. To study peak wrist joint angles and their relationship with wrist- and finger-flexor activity, a three-dimensional (3-D) analysis of wrist movement during the push phase was performed. Nine subjects (five nonimpaired controls, four wheelchair users) propelled a handrim wheelchair on a treadmill at three different velocities (0.83, 1.11, and 1.39 m/s) and three slopes (1, 2, and 3%), while the surface EMGs of the wrist- and finger-flexor group were recorded. Average peak wrist joint angles during the push phase were: ulnar deviation, -24 +/- 11 degrees; radial deviation, 13 +/- 12 degrees; flexion, -14 +/- 18 degrees; and extension, 34 +/- 16 degrees. The values for ulnar and radial deviation were close to normal values for maximal range of motion (ROM) found in the literature. Peak extension was approximately 50% of ROM. The peak angles, which occurred with concurrent activity of the wrist flexors, were: ulnar deviation, -22 +/- 11 degrees; radial deviation, 13 +/- 10 degrees; flexion, -16 +/- 15 degrees; and extension, 32 +/- 16 degrees. The large deviation and extension angles, especially those recorded simultaneously with wrist flexor activity, are serious risk factors for CTS. This finding may help explain the high rates of CTS in the wheelchair user population.