Surgery about the elbow for brachial palsy.

The results of surgical procedures performed on 21 children to improve their elbow function were reviewed. Five flexor-plasties were performed in children with weak elbow flexors. In five patients with anterior dislocations of the radial head and supination contractures, transfers of the biceps to the ulna were performed. In eight patients with supination contractures and located radial heads, turnabout transfers to make the biceps a pronator were performed. Four of the five children with flexor-plasties had significant functional gains. All five biceps to ulna transfers had increased ability to flex without the necessity of supinating. The eight patients who had the turnabout procedure of the biceps had excellent flexion with the ability to pronate the forearm.

The shoulder in neonatal brachial palsy.

The most common residual weakness in neonatal brachial palsies involve the shoulder muscles. More than 84 tendon transfers were performed for weak external rotators. In addition to the tendon transfers, 10 younger children required closed reduction. Nine glenohumeral fusions were performed in adolescents. These procedures have resulted in improved function with few postoperative problems. Four osteotomies of the dislocated shoulder in older adolescents and two open reductions were performed in the older group of children.

Closed reduction and tendon transfer for treatment of dislocation of the glenohumeral joint secondary to brachial plexus birth palsy.

Dislocation of the glenohumeral joint developed, in the first few years of life, in eight children who had brachial plexus birth palsy. The palsy involved the fifth and sixth cervical nerve roots in six children and the fifth, sixth, and seventh cervical nerve roots in two. All of the children had a release of the insertions of the pectoralis major, latissimus dorsi, and teres major followed by a closed reduction of the glenohumeral joint. The latissimus dorsi and the teres major were then transferred to the rotator cuff. All of the children had a well located glenohumeral joint with at least 25 degrees (mean, 51 degrees) of external rotation and at least 135 degrees (mean, 164 degrees) of abduction at the latest follow-up examination, at least two years postoperatively. Strength in abduction increased at least one grade, and strength in external rotation increased at least two grades. The improved motion and strength allowed the children to place the hands more effectively above the head and helped them to perform activities of daily living easily.

Nonoperative treatment for minimally and nondisplaced lateral humeral condyle fractures in children.

The radiographic and clinical records of 95 children with nondisplaced or minimally displaced fractures of the lateral humeral condyle treated on a nonoperative protocol were reviewed. Acute nondisplaced or minimally displaced fractures were defined as < 24 h old on initial evaluation and displaced < 2 mm in three radiographic planes (anteroposterior, lateral, and internal oblique). Closed treatment and close follow-up in a long-arm cast or splint resulted in a union rate of 98% in 3-7 weeks. Two of the fractures displaced required open reduction and internal fixation and then subsequently went on to union without complications.

Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children's elbows.

From 1991 to 1994, 375 supracondylar fractures had percutaneous pinning after closed or open reduction. Nineteen of these with normal preoprative neurologic examinations had postoperative ulnar nerve palsies. All but two of the 19 were followed up. These 17 patients had complete return of function. Only four of the 17 had the medial pins removed, and two others had explorations, which showed no interruption of the nerve. Many of these patients did not have complete return of function until after 4 months. From this and other studies, it is clear that ulnar nerve palsies occurring after percutaneous pinning of the supracondylar fracture usually resolve spontaneously.

The effect of wrist deviation on grip and pinch strength.

The effect of wrist deviation on grip and pinch strength was evaluated in 12 normal right-handed adults. Wrist positions of neutral, maximal ulnar (average, 41 degrees), and maximal radial deviation (average, 26 degrees) were held in short-arm casts while grip and key and tip pinch were measured. Wrist position was neutral with respect to flexion and extension. A highly significant effect of wrist deviation on grip strength was found (p < 0.0001). The effect on pinch strength was not statistically significant. Wrist deviation deformities arise in several clinical situations, such as radial clubhand and malunions of the distal radius. A loss of grip strength was found in radial deviation in this study. This would support 1 of the premises for surgical correction of such deviation by centralization or osteotomy.

Latissimus dorsi and teres major transfer to rotator cuff for Erb's palsy.

During a 20-year period the authors operated on 56 patients with Erb's palsy to create active external rotation of the shoulder. Thirty-five patients had a follow-up period longer than 2 years (average 5 years), which allowed comparison with preoperative motion and strength. Preoperative passive external rotation averaged 5 degrees, whereas active abduction averaged 74 degrees. Preoperative external rotation strength was less than grade 2, whereas preoperative abduction strength was grade 2 or 3 in 33 of the 35 patients. Postoperative active external rotation averaged 31 degrees with only two recurrent internal rotation contractures. Postoperative active abduction averaged 120 degrees. Postoperative strength in external rotation increased in 29 of the 35 patients, with abduction strength increasing one or more grades in 13 of the 35 patients. Four complications occurred. Three patients continued to lose external rotation and required further surgical procedures, and a fourth had a superficial infection. This procedure compares well with the classic transfers to the proximal humerus in that it provides active external rotation in most cases and in some increases shoulder abduction strength.

Ineffective hip rotation with Pavlik harness. Prospective study of 35 infant dislocations.

35 hips in 31 infants diagnosed as unstable were treated with a Pavlik harness and followed by weekly clinical and monthly ultrasound evaluation to determine eventual stability. 26 hips became stable within 3 months, and 9 dislocations required reduction with hip spica placement; 1 of these subsequently required open reduction. Of the 7 infants with 9 hips that failed, 2 children had a late onset of treatment, 2 children had problems with brace fit or family acceptance, and 3 other children had no problem with use of the orthosis. Internal rotation of a degree not possible with the Pavlik harness was required to reduce 4 of these 9 hips. The Pavlik harness is ineffective in some patients because of the need for internal rotation.

Etiology of children's spinal injuries at Rancho Los Amigos.

A review of 277 patients under the age of 16 years admitted to the pediatric spinal injury unit at Rancho Los Amigos Medical Center from 1960 to 1989 showed that 70% of the patients were male; complete and incomplete injuries were about equal; and the average age was 8.8 years. The cause of spinal injury by time period revealed that earlier time periods had etiologies similar to those reported in previously published series. Although the incidence of these traditional causes remained constant, violent injuries by gunshot steadily increased with time. In the most recent 5-year period, gunshot wounds equaled motor vehicle injuries as the most frequent cause of a child's spinal injury admitted to this hospital. Gunshot wound victims averaged 12 years old, 80% were male, and most were thoracic level paraplegics. Half of the 50 adolescents (12-16 years old) injured during the last 5 years were gunshot victims.

The use of the pathokinesiology laboratory to select muscles for tendon transfers in the cerebral palsy hand.

One hundred nine cerebral palsy hands referred for consideration for tendon transfers were examined clinically and by dynamic electromyography. Wire electromyography as used in gait analysis at the author's institution was employed in each of these cases. Most patients required transfers for release (opening) of the hand. The flexor carpi ulnaris and brachioradialis were the most common muscles active in release, yet even in those muscles, less than half were suitable for transfer. This suggests that the wire electromyogram is helpful in selecting the proper muscle for tendon transfer in the cerebral palsy hand.

Shrapnel wounds in children.

Nineteen children who had open fractures and skin wounds of at least two centimeters due to shrapnel were followed for one to five weeks after they had been injured. All of the patients were managed with débridement at twenty-four to forty-eight-hour intervals and were given cephalosporin antibiotics. Fourteen patients did well. The wounds in the three patients who had the least severe soft-tissue injury were healing well at two weeks, and ten other patients were progressing to soft-tissue and osseous healing at five weeks. One patient had progressive but slower healing, and plastic reconstructive procedures would be advisable. Five patients had major problems. In one of these children, a wound continued to drain after six weeks. Three children had an amputation, and another child died due to a vascular injury.

Extremity amputations in meningococcemia-induced purpura fulminans.

Six children with meningococcemia-induced purpura fulminans were followed. Five of the six required amputations of 14 limb segments. Eight of these amputations required revisions to higher levels.

Necrosis of the capital femoral epiphysis and medial approaches to the hip in piglets.

In an attempt to produce necrosis of the femoral head, the medial femoral circumflex vessels were disrupted in 13 normal piglet hips through a medial approach. Femoral heads were recovered 3-6 months (average 4.2 months) postoperatively. None of these hips showed gross, radiographic, or microscopic evidence of necrosis. This demonstrates that necrosis, which may occur after the medial approach in the hip of a child, is not due to the direct damage to the medial femoral circumflex vessels.

Postoperative electromyographic function of tendon transfers in patients with cerebral palsy.

Electromyographic studies were performed on 13 patients with cerebral palsy before and after flexor carpi ulnaris transfers. No changes in activity of the extensor digit communis were noted in the transferred muscles. This further validates the rationale of pre-operative planning based on such studies.

Arthrodesis of the paralytic shoulder.

Five children, aged 7-15 years, with brachial palsies and flail shoulders, had fusions performed. Four of the five had improved function; however, there was progressive loss of fused abduction position over time.

Equinovarus deformity in arthrogryposis and myelomeningocele: evaluation of primary talectomy.

As initial surgical management for rigid equinovarus deformities, 16 children with arthrogryposis (30 involved feet) and 16 myelodysplastic children (26 involved feet) underwent primary talectomies or extensive posterior-medial releases (PMR). When compared with primary PMRs in arthrogrypotic children, primary talectomies revealed a greater number of good and fair results, decreased recurrence rates, less procedures per foot, and maintenance of ambulatory status. Recurrent forefoot and cavus deformities were present after primary talectomies. Primary talectomy in arthrogrypotic children was more effective than posterior-medial releases or secondary (salvage) talectomy. Because of the small number of feet involved, the role of primary talectomy in myelomeningocele was not clarified by this study. Radical PMRs in myelodysplastic children resulted in a significant number of hindfoot valgus deformities that required secondary procedures.