Emily S. Ho

Serial Casting and Splinting of Elbow Contractures in Children With Obstetric Brachial Plexus Palsy

PURPOSE Elbow flexion contractures are a common sequela in obstetric brachial plexus palsy. The etiology and best management of these contractures is unclear. Nonsurgical treatment involving serial casting and splinting is supported in the literature. The purpose of this study is to evaluate the effectiveness of serial casting and splinting of elbow flexion contractures in children with obstetric brachial plexus palsy. METHODS A retrospective review of children with obstetric brachial plexus palsy who participated in serial casting and splinting for an elbow flexion contracture was conducted. Elbow extension passive range of motion measurements at initial, best-achieved, and final outcome were compared. RESULTS Nineteen patients, aged 2 to 16 years, were studied. Elbow passive range of motion improved from initial to best-achieved and final outcome measurements. Fifty-three percent of patients were noncompliant between the time of best-achieved and final outcome. Loss of passive range of motion during the noncompliant period was statistically significant. Compliant patients had better treatment results. A clinical decision tree for elbow contractures in obstetric brachial plexus palsy was formulated. CONCLUSIONS Serial casting and splinting of elbow contractures in children with obstetric brachial plexus palsy is effective. Successful maintenance of treatment effects is dependent on patient age and compliance. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Evaluation of the sensory deficit after sural nerve harvesting in pediatric patients.

Background: The sural nerve is a sensory nerve that innervates the proximal part of the lateral aspect of the foot. The sural nerve is often harvested for nerve grafting. Sensory loss in the area supplied by the sural nerve could be expected, causing a lack of protective sensation and a potential risk of injury. The sensory outcome of sural nerve harvesting has not been documented in children. The aim of this study was to evaluate the sensory deficit following sural nerve harvest in infants. Methods: The authors conducted a controlled study. Evaluation and mapping of the sensory thresholds in the sural nerve distribution were performed using the Semmes-Weinstein monofilament method on four predetermined sites on the foot. A questionnaire was used to elicit subjective findings. The inclusion criteria were children older than 6 years who had undergone bilateral sural nerve harvesting for brachial plexus reconstruction in the first year of life. Normal volunteers served as controls. Results: Fourteen patients and 14 controls were enrolled in the study. Eighty-six percent of the feet that were operated on had a sensory deficit (p = 0.0001). The patients reported no concerns regarding the sensation of their feet. Conclusions: Sural nerve harvesting in children leaves a measurable sensory deficit; however, this deficit does not seem to have clinical implications for the patients.

The Brachial Plexus Outcome Measure: Development, Internal Consistency, and Construct Validity

PURPOSE The purpose of this article was to report the development of a new assessment tool, the Brachial Plexus Outcome Measure (BPOM) and the evaluation of its internal consistency and construct validity. METHODS A retrospective case series of children aged 4-19 years with obstetrical brachial plexus palsy (OBPP) was conducted. Intraclass coefficients were calculated for the BPOM Activity Scale items. Correlation between the Active Movement Scale (AMS) and BPOM Activity Scale scores were conducted to determine the convergent validity. RESULTS The BPOM Activity Scale items (N=306) had good internal consistency (Cronbachs α=0.87). A strong correlation between the BPOM Activity Scale and AMS (n=284) was found (r=0.71, p=0.001, α=0.05). CONCLUSIONS The BPOM Activity Scale demonstrates good internal consistency and construct validity as a discriminative functional outcome measure in children with OBPP. LEVEL OF EVIDENCE IV.

Long-term outcomes following lower extremity sarcoma resection and reconstruction with vascularized fibula flaps in children.

Background: Limb salvage operations in patients with bony oncologic defects carry technical challenges and may require long recoveries. This study aimed to evaluate functional outcomes, donor-site morbidity, and complications in lower limb bony oncologic defects reconstructed with vascularized fibula flaps in children. Methods: The authors performed a retrospective review of consecutive pediatric patients undergoing this procedure between 1994 and 2012. Data on operative details, functional outcomes, and complications were analyzed. A telephone survey was conducted to assess patient satisfaction and quality of life. Results: Eighteen patients who underwent 19 reconstructions were included. Mean age at resection was 10 years (range, 1.5 to 17 years). No patients developed local recurrence, although two patients had metastatic lung nodules resected. All patients were alive at last review, with a mean follow-up of 57 months (range, 10 to 145 months). Flap survival was 95 percent. Median time to bony union was 24 months (range, 9 to 72 months). The fibula flap fracture rate was 52.6 percent. At the end of the study period, 72 percent of patients were fully weight-bearing, all school-age children had returned to full-time school, and 50 percent were involved in sports. Fifty-six percent of patients participated in the follow-up telephone survey; of these, 90 percent expressed satisfaction with the outcome of the surgery. Conclusions: This study demonstrates that the vascularized fibula flap is an excellent option for reconstruction of lower limb oncologic defects in children. Despite complications, long-term follow-up suggests that most children are able to lead active lifestyles. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcome analysis after helmet therapy using 3D photogrammetry in patients with deformational plagiocephaly: The role of root mean square

Deformational plagiocephaly (DP) is a multifactorial non-synostotic cranial deformity with a reported incidence as high as 1 in 7 infants in North America. Treatment options have focused on non-operative interventions including head repositioning and the use of an orthotic helmet device. Previous studies have used linear and two dimensional outcome measures to assess changes in cranial symmetry after helmet therapy. Our objective was to demonstrate improvement in head shape after treatment with a cranial molding helmet by using Root Mean Square (RMS), a measure unique to 3D photogrammetry, which takes into account both changes in volume and shape over time. Three dimensional photographs were obtained before and after molding helmet treatment in 40 infants (4-10 months old) with deformational plagiocephaly. Anatomical reference planes and measurements were recorded using the 3dMD Vultus(®) analysis software. RMS was used to quantify symmetry by superimposing left and right quadrants and calculating the mean value of aggregate distances between surfaces. Over 95% of the patients demonstrated an improvement in symmetry with helmet therapy. Furthermore, when the sample of infants was divided into two treatment subgroups, a statistically significant correlation was found between the age at the beginning of treatment and the change in the RMS value. When helmet therapy was started before 7 months of age a greater improvement in symmetry was seen. This work represents application of the technique of RMS analysis to demonstrate the efficacy of treatment of deformational plagiocephaly with a cranial molding helmet.

A prospective study of pediatric hand fractures and review of the literature.

Objective Hand fractures represent a leading cause of morbidity in children. However, little information exists correlating the mechanisms and environment of injury with outcomes and treatments. We examine the demographics, etiology, anatomic location, mechanism, and management of pediatric hand fractures in our center’s hand unit. Methods We conducted a prospective observational study on all children with acute hand fractures evaluated in the Plastic Surgery Emergency Clinic during a 3-month period in 2010. Data pertaining to demographics, referral patterns, injury pattern, clinical outcomes, and other factors related to hand fractures were then analyzed and interpreted. Results Most children were referred by our institution’s emergency department. More than 60% were boys, and nearly half were between 10 and 15 years old. The right and left hands were injured at equal rates. Most of the injuries (90%) occurred in the afternoon or evening. More than 85% occurred in urban, rather than rural, environments. Crush injuries were the leading cause in toddlers, whereas sports-related injuries became the major cause of injury in older groups. Proximal phalanges were the most common bone injured, and the fifth digit was the most commonly injured digit. More than 80% of the fractures were managed nonsurgically. Conclusions The pattern of pediatric hand fracture in different age groups is highlighted in this article. The observations from this study will hopefully encourage further review with a larger cohort and a focus on preventative measures for pediatric hand fractures.

Evaluation of pediatric upper extremity peripheral nerve injuries

INTRODUCTION The evaluation of motor and sensory function of the upper extremity after a peripheral nerve injury is critical to diagnose the location and extent of nerve injury as well as document functional recovery in children. PURPOSE The purpose of this paper is to describe an approach to the evaluation of the pediatric upper extremity peripheral nerve injuries through a critical review of currently used tests of sensory and motor function. METHODS Outcome studies on pediatric upper extremity peripheral nerve injuries in the Medline database were reviewed. RESULTS The evaluation of the outcome in children less than 10 years of age with an upper extremity peripheral nerve injury includes careful observation of preferred prehension patterns, examination of muscle atrophy and sudomotor function, provocative tests, manual muscle testing and tests of sensory threshold and tactile gnosis. CONCLUSION The evaluation of outcome in children with upper extremity peripheral nerve injuries warrants a unique approach.

Pain in children following microsurgical reconstruction for obstetrical brachial plexus palsy.

PURPOSE To determine the prevalence and characteristics of pain experienced by children who have had microsurgical reconstruction for obstetrical brachial plexus palsy (OBPP). METHODS A prospective case series study was conducted of 65 children aged 6 to 18 years with a diagnosis of OBPP and who had microsurgery at less than 12 months of age with nerve grafting or transfer. A total of 28 patients (43%) had upper OBPP and 37 (57%) had total OBPP. We evaluated pain using the Faces Pain Scale-Revised and the Adolescent Pediatric Pain Tool. Sensory symptoms in the affected limb were also collected. Mean age was 11.0 ± 3.3 years. RESULTS We evaluated 65 children. The point prevalence of pain (pain at the time of assessment) was 25%. The reported lifetime prevalence of pain (experienced anytime during life) was 66%. A total of 71% reported that the affected extremity felt different at least once in their lifetime. Average intensity of those with pain (n = 43) was 40 ± 19 mm on a 100-mm visual analog scale. Seventy percent of children reported that symptoms occurred every day or at least once a week. Anatomical distribution of pain was throughout the affected upper extremity irrespective of the severity of injury, with the exception of children with upper plexus injuries who did not report pain in their hand. Words typically used to describe neuropathic or musculoskeletal symptoms were chosen by the children to represent their pain. CONCLUSIONS Children with OBPP who had microsurgical reconstruction commonly reported pain. These symptoms were typically frequent but were episodic and low in intensity. The descriptions of the type of pain include terms typical of both neuropathic and musculoskeletal origins. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.

Measuring Hand Function in the Young Child

Assessing outcomes is vital in any hand therapy practice setting, as it is the primary method of determining whether or not a treatment program is working. In the pediatric population, determining improvements in hand function can be challenging. The author describes using a developmental perspective to evaluate hand function for infants and young children. The utilization of a consistent approach to play along with standard toys is described in this article as a method to evaluate the quality of hand function throughout developmental grasp patterns.

Restoration of Trigeminal Cutaneous Sensation with Cross-Face Sural Nerve Grafts: A Novel Approach to Facial Sensory Rehabilitation.

UNLABELLED Although treating facial palsy is considered debilitating for patients, trigeminal nerve palsy and sensory deficits of the face are overlooked components of disability. Complete anesthesia leaves patients susceptible to occult injury, and facial sensation is an important component of interaction and activities of daily living. Sensory reconstruction is well established in the restoration of hand sensation; however, only one previous report proposed a surgical strategy for sensory nerve reconstruction of the face with use of nerve transfers. Nerve transfers, when used alone, have limited application because of their restricted arc of rotation in the face; extending their arc by adding nerve grafts greatly expands their utility. The following cases demonstrate the early results after V2 and V3 reconstruction with cross-face nerve grafts in three patients with acquired trigeminal nerve palsy. Cross-face nerve grafts using the sural nerve permit more proximal reconstruction of the infraorbital and mental nerves, which allows reinnervation of their entire cutaneous distribution. All patients demonstrated improved sensation in the reconstructed dermatomes, and no patients reported donor-site abnormalities. Cross-face nerve grafts result in minimal donor-site morbidity and are promising as a surgical strategy to address sensory deficits of the face. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.