Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury.

OBJECTIVE: To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment. STUDY DESIGN: Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data. RESULTS: There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%. CONCLUSIONS: In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

Early Predictors of Microsurgical Reconstruction in Brachial Plexus Birth Palsy.

Background: Microsurgical reconstruction is indicated for infants with brachial plexus birth palsy (BPBP) that demonstrate limited spontaneous neurological recovery. This investigation defines the demographic, perinatal, and physical examination characteristics leading to microsurgical reconstruction. Methods: Infants enrolled in a prospective multicenter investigation of BPBP were evaluated. Microsurgery was performed at the discretion of the treating provider/center. Inclusion required enrollment prior to six months of age and follow-up evaluation beyond twelve months of age. Demographic, perinatal, and examination characteristics were investigated as possible predictors of microsurgical reconstruction. Toronto Test scores and Hospital for Sick Children Active Movement Scale (AMS) scores were used if obtained prior to three months of age. Univariate and multivariate logistic regression analyses were performed. Results: 365 patients from six regional medical centers met the inclusion criteria. 127 of 365 (35%) underwent microsurgery at a median age of 5.4 months, with microsurgery rates and timing varying significantly by site. Univariate analysis demonstrated that several factors were associated with microsurgery including race, gestational diabetes, neonatal asphyxia, neonatal intensive care unit admission, Horner's syndrome, Toronto Test score, and AMS scores for finger/thumb/wrist flexion, finger/thumb extension, wrist extension, elbow flexion, and elbow extension. In multivariate analysis, four factors independently predicted microsurgical intervention including Horner's syndrome, mean AMS score for finger/thumb/ wrist flexion <4.5, AMS score for wrist extension <4.5, and AMS score for elbow flexion <4.5. In this cohort, microsurgical rates increased as the number of these four factors present increased from zero to four: 0/4 factors = 0%, 1/4 factors = 22%, 2/4 factors = 43%, 3/4 factors = 76%, and 4/4 factors = 93%. Conclusions: In patients with BPBP, early physical examination findings independently predict microsurgical intervention. These factors can be used to provide counseling in early infancy for families regarding injury severity and plan for potential microsurgical intervention.Level of Evidence: Prognostic Level I.

Imaging assessment of glenohumeral dysplasia secondary to brachial plexus birth palsy.

OBJECTIVE: To assess imaging parameters related to the morphology of the glenohumeral joint in children with unilateral brachial plexus birth palsy (BPBP), in comparison with those obtained for healthy shoulders. MATERIALS AND METHODS: We conducted a retrospective search for cases of unilateral BPBP diagnosed at our facility. Only patients with a clinical diagnosis of unilateral BPBP were included, and the final study sample consisted of 10 consecutive patients who were assessed with cross-sectional imaging. The glenoid version, the translation of the humeral head, and the degrees of glenohumeral dysplasia were assessed. RESULTS: The mean diameter of the affected humeral heads was 1.93 cm, compared with 2.33 cm for those of the normal limbs. In two cases, there was no significant posterior displacement of the humeral head, five cases showed posterior subluxation of the humeral head, and the remaining three cases showed total luxation of the humeral head. The mean glenoid version angle of the affected limbs (90-α) was -9.6º, versus +1.6º for the normal, contralateral limbs. CONCLUSION: The main deformities found in this study were BPBP-associated retroversion of the glenoid cavity, developmental delay of the humeral head, and posterior translation of the humeral head.

OBJETIVO: Avaliar os parâmetros de imagem relacionados com a morfologia da articulação glenoumeral em crianças com paralisia obstétrica do plexo braquial (POPB) unilateral, comparando-os com os observados em ombros saudáveis. MATERIAIS E MÉTODOS: Foi realizada uma busca retrospectiva de casos de POPB unilateral diagnosticados em nossa instituição. Somente foram incluídos os pacientes com diagnóstico clínico de POPB unilateral, e a amostra final do estudo consistiu em 10 pacientes consecutivos avaliados por meio de imagens transversais. Foram avaliados a retroversão da cavidade glenoide, a translação da cabeça do úmero e o grau de displasia glenoumeral. RESULTADOS: A média do diâmetro da cabeça do úmero foi 1,93 cm nos membros afetados e 2,33 cm nos membros normais. Em dois casos, não houve deslocamento posterior significativo da cabeça do úmero, cinco casos apresentaram subluxação posterior da cabeça do úmero, e os três casos restantes apresentaram luxação total da cabeça do úmero. A média do ângulo de retroversão glenoide dos membros afetados (90-α) foi -9,6º, ao passo que a dos membros contralaterais normais foi +1,6º. CONCLUSÃO: As principais deformidades encontradas neste estudo foram retroversão da cavidade glenoide relacionada com POPB, atraso no desenvolvimento da cabeça do úmero e translação posterior da cabeça do úmero.

Imaging assessment of glenohumeral dysplasia secondary to brachial plexus birth palsy / Avaliação de imagens de displasia glenoumeral secundária a paralisia obstétrica do plexo braquial

Abstract Objective: To assess imaging parameters related to the morphology of the glenohumeral joint in children with unilateral brachial plexus birth palsy (BPBP), in comparison with those obtained for healthy shoulders. Materials and Methods: We conducted a retrospective search for cases of unilateral BPBP diagnosed at our facility. Only patients with a clinical diagnosis of unilateral BPBP were included, and the final study sample consisted of 10 consecutive patients who were assessed with cross-sectional imaging. The glenoid version, the translation of the humeral head, and the degrees of glenohumeral dysplasia were assessed. Results: The mean diameter of the affected humeral heads was 1.93 cm, compared with 2.33 cm for those of the normal limbs. In two cases, there was no significant posterior displacement of the humeral head, five cases showed posterior subluxation of the humeral head, and the remaining three cases showed total luxation of the humeral head. The mean glenoid version angle of the affected limbs (90-α) was -9.6º, versus +1.6º for the normal, contralateral limbs. Conclusion: The main deformities found in this study were BPBP-associated retroversion of the glenoid cavity, developmental delay of the humeral head, and posterior translation of the humeral head.

Resumo Objetivo: Avaliar os parâmetros de imagem relacionados com a morfologia da articulação glenoumeral em crianças com paralisia obstétrica do plexo braquial (POPB) unilateral, comparando-os com os observados em ombros saudáveis. Materiais e Métodos: Foi realizada uma busca retrospectiva de casos de POPB unilateral diagnosticados em nossa instituição. Somente foram incluídos os pacientes com diagnóstico clínico de POPB unilateral, e a amostra final do estudo consistiu em 10 pacientes consecutivos avaliados por meio de imagens transversais. Foram avaliados a retroversão da cavidade glenoide, a translação da cabeça do úmero e o grau de displasia glenoumeral. Resultados: A média do diâmetro da cabeça do úmero foi 1,93 cm nos membros afetados e 2,33 cm nos membros normais. Em dois casos, não houve deslocamento posterior significativo da cabeça do úmero, cinco casos apresentaram subluxação posterior da cabeça do úmero, e os três casos restantes apresentaram luxação total da cabeça do úmero. A média do ângulo de retroversão glenoide dos membros afetados (90-α) foi -9,6º, ao passo que a dos membros contralaterais normais foi +1,6º. Conclusão: As principais deformidades encontradas neste estudo foram retroversão da cavidade glenoide relacionada com POPB, atraso no desenvolvimento da cabeça do úmero e translação posterior da cabeça do úmero.

Quality, Safety, and Value in Pediatric Orthopaedic Surgery.

Enhancing patient safety and the quality of care continues to be a focus of considerable public and professional interest. We have made dramatic strides in our technical ability to care for children with pediatric orthopaedic problems, but it has become increasingly obvious that there are also significant opportunities to improve the quality, safety, and value of the care we deliver. The purpose of this article is to introduce pediatric orthopaedic surgeons to the rationale for and principles of quality improvement and to provide an update on quality, safety, and value projects within Pediatric Orthopaedic Society of North America.

Safety and Efficacy of Derotational Osteotomy for Congenital Radioulnar Synostosis.

BACKGROUND: Congenital radioulnar synostosis (CRUS) refers to an abnormal connection between the radius and ulna due to embryological failure of separation. Derotational osteotomy has been advocated for children with functional limitations, although historically this procedure has been associated with a 36% complication rate including compartment syndrome and loss of correction. METHODS: A retrospective evaluation of consecutive patients who underwent derotational osteotomy for CRUS at a single institution was performed. Children with functional limitations secondary to excessive pronation were indicated for surgery with a goal of correction to 10 to 20 degrees of pronation. All patients were treated with a standardized surgical technique including careful subperiosteal elevation, rotational osteotomy at the level of the synostosis, control of the osteotomy fragments, appropriate pinning techniques, and prophylactic forearm fasciotomies. Electronic medical records, preoperative radiographs, and postoperative radiographs were reviewed. RESULTS: Derotational osteotomy was performed in 31 forearms in 26 children (13 bilateral, 13 unilateral) with a mean age of 6.8 years (range, 3.0 to 18.8 y). The mean clinical follow-up was 46 months (range, 6 to 148 mo). The mean preoperative pronation deformity was 85 degrees (range, 60 to 100 degrees). The mean correction achieved was 77 degrees (range, 40 to 95 degrees), resulting in a mean final position of 8 degrees of pronation (range, 0 to 30 degrees). All patients successfully achieved union by 8 weeks postoperatively. There were no cases of compartment syndrome, vascular compromise, or loss of fixation. The overall complication rate was 12% (2 transient anterior interosseous nerve palsies, 1 transient radial nerve palsy, 1 symptomatic muscle herniation). Both transient anterior interosseous nerve palsies occurred in patients with rotational corrections exceeding 80 degrees. CONCLUSIONS: Derotational osteotomy can be safely and effectively performed in children with CRUS. Meticulous surgical technique, including control of the osteotomy, judicious pin fixation, and prophylactic fasiotomies, may diminish the risk of neurovascular compromise and loss of correction. Transient anterior interosseous nerve palsies occurred, and may be related to large rotational corrections.

POSNA Quality Safety Value Initiative: From Vision to Implementation to Early Results.

The POSNA Quality, Safety and Value Initiative (QSVI) formally started with POSNA board approval in early 2011. The initial vision statement was: "To lead in defining our members' value based clinical care. To partner with hospital based and orthopedic organizational efforts to guarantee safe, high quality outcomes for our patients. To communicate our initiatives and results cooperatively with payer, credentialing, and compliance organizations to improve pediatric orthopedic care in North America."