Christopher J. Coombs

Aplasia cutis congenita : failed conservative treatment

Large scalp defects in aplasia cutis congenita present a management dilemma. In these lesions, prolonged conservative treatment may cause as much risk as does operative treatment. As a result of our experience, we suggest that one should be prepared to undertake early surgical intervention, rather than prolonged conservative treatment, for larger defects. Decreasing the size of the defect should decrease the risk of complications, since these appear to be related. The management of this condition should be a compromise of both operative and conservative modalities.

Carpal tunnel syndrome in children with mucopolysaccaridoses

Carpal tunnel syndrome in children is uncommon. Mucopolysaccharidosis is the most common cause of carpal tunnel syndrome in this age group. With new treatment modalities available for mucopolysaccaridoses, the prognosis of the disease has greatly improved. The musculoskeletal manifestations including carpal tunnel syndrome now assume more importance. Early diagnosis and treatment of carpal tunnel syndrome in these children are important to achieve a good outcome. The authors present their experience in the management of children with mucopolysaccharidosis and carpal tunnel syndrome.

Tissue expansion for the treatment of complete syndactyly of the first web

Tissue expansion is a well-established technique for the management of soft tissue deficiencies. In congenital hand surgery the construction of an adequate first web is paramount. We used tissue expansion in four hands in three patients with complete complex syndactyly of the first web space. Two of these patients had Aperts syndrome and the other an isolated mitten hand anomaly. The expander is preferably placed early in life so that first web construction is completed in the first year. Tissue expander ports are left exposed. There have been no infections, flap or expander loss in our series.

Use of forearm flaps for the severely contracted first web space in children with congenital malformations

Eighteen forearm flaps were used in 12 patients with congenital anomalies following release of severe first web-space contractures. Radial forearm axial pattern flaps were preferred in 10 children, and the dorsal interosseous system was used in 2 patients with incomplete palmar arches and those who had previous surgery. Ten of the flaps were transferred in children younger than 2 years of age. The results were excellent both esthetically and functionally. Superficial skin loss occurred in one patient. These local vascular island flaps are an excellent alternative for coverage in situations where a large tissue deficiency exists after an adequate release.

A Method for Minimizing Donor Site Complications of the Radial Forearm Flap

The great advantages of the radial forearm fasciocutaneous flap are offset by the dilemmas associated with its donor site. The most commonly encountered problems are the functional and cosmetic sequelae of skin graft loss with consequent exposure of volar forearm tendons, the superficial sensory branch of the radial nerve, and the radius. Techniques that minimize donor site morbidity are those that provide a well-vascularized bed for the protection of exposed tendon, nerve, and bone, and for the acceptance of skin grafts. A technique involving the mobilization of the flexor pollicis longus muscle belly in conjunction with the abductor pollicis longus with approximation to the flexor digitorum superficialis muscle belly provides stable, well-vascularized coverage of the radial forearm flap donor site, with reliable skin graft acceptance and no functional sequelae.

Spinal accessory nerve transfer outperforms cervical root grafting for suprascapular nerve reconstruction in neonatal brachial plexus palsy.

Background: The authors evaluated long-term shoulder function in patients with neonatal brachial plexus palsy undergoing suprascapular nerve reconstruction with cervical root grafting or spinal accessory nerve transfer. Methods: A retrospective review was performed on all infants presenting with neonatal brachial plexus palsy between 1994 and 2010. Functional outcomes were compared by type of suprascapular nerve reconstruction. Results: Seventy-four patients met the inclusion criteria (46 transfers, 28 grafts). Both groups presented with an active movement scale score of 2.0 for shoulder abduction and 0.0 for external rotation. Postoperative follow-up was 9.0 years for the graft group and 6.7 years for the transfer group. Both groups achieved an active movement scale score of 5.0 for shoulder abduction at 12, 24, and 36 months postoperatively. Active movement scale scores for shoulder external rotation were 1.0, 2.0, and 2.5 for the graft group versus 2.0, 2.0, and 3.0 for the transfer group at 12, 24, and 36 months postoperatively. None of these differences reached statistical significance. Composite Mallet scores were 13.0 for the graft group versus 15.0 for the transfer group at 3 years (p = 0.06) and 13.0 for the graft group versus 16.0 for the transfer group at 5 years postoperatively (p = 0.07). Secondary shoulder surgery was performed on 57.1 percent (16 of 28) of patients with grafts compared with 26.1 percent (12 of 46) of patients with transfers (OR, 3.17; p = 0.02). Conclusion: Suprascapular nerve reconstruction by cervical root grafting results in poorer shoulder function and a two-fold increase in secondary shoulder surgery compared with spinal accessory nerve transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Functional and cosmetic outcome of surgery for cerebral palsy in the upper limb

Function, cosmesis, hygiene, and ability to dress can be improved by appropriate surgery. This frequently involves multiple simultaneous procedures and addresses the muscles, their tendons, and the joints they pass over. The improvement in cosmesis is most profound in hemiplegic patients. Overall, patients are satisfied with the results of surgery.

Reduction Otoplasty: Correction of the Large or Asymmetric Ear

Reduction otoplasty is an uncommon procedure performed for macrotia and ear asymmetry. Techniques described in the literature for this procedure are few. The authors present their ear reduction approach that not only achieves the desired reduction effectively and accurately, but also addresses and creates the natural anatomic proportions of the ear, leaving a scar well hidden within the fold of the helix.

TOE-TO-HAND TRANSFER IN SYMBRACHYDACTYLY

Symbrachydactyly, or central atypical cleft, is classified as a failure of formation. For the adactylous or monodactylous forms, free toe transfer is the treatment of choice. We present 18 free toe transfers in 13 patients for symbrachydactyly. Despite abnormal anatomy, the functional building blocks have always been available and transfer technically possible. The result has been improved function and high levels of parental satisfaction.

Application of lower extremity injury severity scores in children

PurposeSevere lower extremity trauma presents challenges in decision-making in terms of reconstruction or amputation. While injury severity scores have been developed to aid decision-making in adults, evaluation of their use in children is limited.MethodsChildren presenting with severe lower limb trauma from 2000 to 2010 in a major trauma centre were identified from a trauma registry. Records were reviewed for details of the injury, surgical intervention, amputation and scores for the Mangled Extremity Severity Score, Limb Salvage Index, Predictive Salvage Index, Nerve injury, Ischaemia, Soft tissue injury, Skeletal injury, Shock, Age System and the Hanover Fracture Scale 1998.ResultsTwenty children (average age 8.7 years) were eligible for inclusion. There were three primary amputations and no secondary amputations. All of the scoring systems had poor specificity and would have recommended amputation in several limbs that were successfully reconstructed.ConclusionsCurrently available injury severity scores behave differently in children and adults. In their current format, these scores should not be used as an absolute indication for early amputation in children.