Nina Lightdale-Miric

Iatrogenic nerve injuries in the treatment of supracondylar humerus fractures: are we really just missing nerve injuries on preoperative examination?

Background: Recent studies report the rate of iatrogenic nerve injury in operatively treated supracondylar humerus (SCH) fractures is 3% to 4%. A reliable neurological examination can be difficult to obtain in a young child in pain. We hypothesized that nerve injuries may be missed preoperatively, later noted postoperatively in a more compliant patient, and then falsely considered an iatrogenic injury. Methods: A prospective study was conducted on patients who presented between April 2011 and April 2013 with an extension-type SCH fracture that was managed surgically. A neurological examination was performed preoperatively, postoperatively, and at follow-up visits by a fellowship-trained attending pediatric orthopaedic surgeon. Only patients in whom the attending surgeon felt a reliable neurovascular examination was obtained were included in this study. Results: Of the 100 patients, 16% had a nerve injury recognized on preoperative examination and 3% had a new nerve injury on postoperative examination (1 anterior interosseous, 1 median sensory, and 1 radial motor). The Gartland type (P=0.421), type of reduction (open vs. closed; P=0.720), and number of lateral-entry (P=0.898) or medial-entry (P=0.938) pins used were not associated with patients who had a new nerve injury found postoperatively. A trend was seen between fracture severity and rate of a preoperative nerve injury: type II 7% (2/28), type III 19% (9/58), and type IV 36% (5/14) (P=0.058). Preoperatively, nerve injuries were noted at the following rates: median 12% (12/100) (including 8 anterior interosseous nerve injuries), radial 8% (8/100), ulnar 3% (3/100). Conclusions: In this prospective study, in patients who were able to comply with a preoperative neurological examination done by an attending pediatric orthopaedic surgeon, the rate of iatrogenic nerve injury after operative treatment of SCH fractures is 3%. We conclude that this finding is true, and not a result of inadequate preoperative neurological examinations. Level of Evidence: Level I prognostic study.

Long term functional outcomes after early childhood pollicization

STUDY DESIGN Retrospective Cohort INTRODUCTION Important outcomes of polliciation to treat thumb hypoplasia/aplasia include strength, function, dexterity, and quality of life. PURPOSE OF THE STUDY To evaluate outcomes and examine predictors of outcome after early childhood pollicization. METHODS 8 children (10 hands) were evaluated 3-15 years after surgery. Physical examination, questionnaires, grip and pinch strength, Box and Blocks, 9-hole pegboard, and strength-dexterity (S-D) tests were performed. RESULTS Pollicized hands had poor strength and performance on functional tests. Six of 10 pollicized hands had normal dexterity scores but less stability in maintaining a steady-state force. Predictors of poorer outcomes included older age at surgery, reduced metacarpophalangeal and interphalangeal range of motion, and radial absence. DISCUSSION Pollicization resulted in poor strength and overall function, but normal dexterity was often achieved using altered control strategies. CONCLUSIONS Most children should obtain adequate dexterity despite weakness after pollicization except older or severely involved children. LEVEL OF EVIDENCE IV.

A line drawn along the radial shaft misses the capitellum in 16% of radiographs of normal elbows.

Background: The radiocapitellar line (RCL) is a routinely referenced radiographic measurement for evaluating injury of the pediatric elbow, such as a Monteggia fracture. It is most commonly described as a line drawn along the radius that should intercept the center of the capitellum in a normal elbow. However, the RCL has not been rigorously defined or validated in young children. Methods: The RCL was drawn out on the anteroposterior and lateral radiographs of 116 normal pediatric elbows by 3 examiners. On each radiograph, lines were drawn along the longitudinal center of the radial neck as well as the radial shaft. The distance from each of these lines to the center of the capitellum was defined as the line-capitellar distance (LCD). The LCD was standardized to the patient size and correlated with patient variables. Results: Of the 2052 RCLs drawn, 50% (1029/2052) fell outside the middle third of the capitellum and 8.6% (176/2052) missed the capitellum completely. Lines drawn along the radial neck in the anteroposterior and lateral views missed the capitellum less frequently (1.2% vs. 12.7%, P<0.0001) and passed through its central third less (77.8% vs. 44.7%, P<0.0001) when compared with lines drawn using the radial shaft. Lines along the radial neck intersected the capitellum significantly more often on the lateral view than on the anteroposterior view (98.8% vs. 96.8%, P=0.06) and were more likely to pass through the center third of the capitellum (77.8% vs. 55.5%, P<0.0001). With both techniques of drawing the RCL, the percent of measurements falling within the middle third of the capitellum was higher in patients above 5 years of age (P<0.001). The RCL is more reliable in older patients and shows considerable variation in infants. Conclusions: The RCL does not invariably bisect or fall within the middle third of the capitellum in normal pediatric elbows. Therefore, an abnormal RCL is suggestive but not pathognomonic for injury such as Monteggia fracture. An RCL drawn along the radial shaft will miss the capitellum in 15.6% of elbows. The most consistent RCL is drawn along the radial neck on the lateral view. Patient variables such as age and sex should be considered in the ability of the RCL to identify elbow injury. Level of Evidence: Diagnostic Level 3.

Quantitative assessment of dynamic control of fingertip forces after pollicization

Dexterity after finger pollicization (reconstruction to thumb) is critical to functional outcomes. While most tests of hand function evaluate a combination of strength, coordination, and motor control, the Strength-Dexterity (S-D) paradigm focuses on the dynamic control of fingertip forces. We evaluated 10 pollicized and 5 non-pollicized hands from 8 participants ages 4-17 years (2 female, 6 male; 10.6 ± 4.5 years). Participants partially compressed and held an instrumented spring prone to buckling between the thumb and first finger to quantify dynamic control over the direction and magnitude of fingertip forces. They also completed traditional functional tests including grip, lateral pinch, and tripod pinch strength, Box and Blocks, and 9-hole peg test. Six of 10 pollicized hands and all non-pollicized hands had S-D scores comparable to typically developing children. However, dynamical analysis showed that pollicized hands exhibit greater variability in compression force, indicating poorer corrective action. Almost all pollicized hands scored below the normal range for the traditional functional tests. The S-D test Z-scores correlated moderately with Z-scores from the other functional tests (r = 0.54-0.61; p = 0.02-0.04) but more weakly than amongst the other functional measures (r = 0.58-0.83; p = 0.0002-0.02), suggesting that the S-D test captures a different domain of function. A higher incidence of radial absence in the hands with poor S-D scores (3/4 vs. 0/6 in hands with normal S-D scores, p = 0.03) was the only clinical characteristic associated with S-D outcome. Overall, these results suggest that while most pollicized hands can control fingertip forces, the nature of that control is altered.

Advances in 3d-printed Pediatric Prostheses for Upper Extremity Differences.

➤The prohibitive cost of cutting-edge prostheses prevents many children with a limb difference from obtaining them; however, new developments in 3-dimensional (3D) printing have the potential to increase the accessibility, customization, and procurement of such devices.➤Children with upper limb differences are ideal candidates for currently available 3D-printed devices because they quickly damage and outgrow prostheses, and the low cost of 3D printing makes repairs and upgrades substantially more affordable.➤Physicians and medical practitioners should become familiar with the possibilities of 3D-printed devices in order to determine the benefits and utility for their patients.

Assessing Shoulder Motion in Children: Age Limitations to Mallet and ABC Loops

BackgroundShoulder ROM and function of the shoulder are difficult to evaluate in young children. There has been no determination of the age at which children can comply with the current assessment tools in use, but doing so would be important, because it gives us more accurate insight into the development and assessment of shoulder functional ROM in young children.Questions/purposesWe (1) determined whether age would limit the use of two different observational scales used to assess shoulder ROM and function in young children (the Mallet scale and the ABC Loops protocol); and (2) compared the two scales in terms of intra- and interobserver reliabilities.MethodsSixty-five able-bodied children (32 boys, 33 girls; mean age, 3.9 years; range, 0.5–7.0 years) were recruited from local preschools and evaluated using the Mallet scale and ABC Loops protocol. Children were assessed on their ability to complete the examinations and time to completion for each measurement protocol. Intra- and interobserver reliability was tested by percentage agreement. Forty-eight children (mean age, 4.4 years; SD, 1.3 years) were able to complete the Mallet and ABC Loops measurement protocols; 17 children (mean age, 2.3 years; SD, 1.1 years) failed to complete either test.ResultsYounger children had more difficulty completing the examinations; there was a strong negative correlation between age and failure: probability of failure increased with decreasing age (Pearson r = −0.601, p < 0.001). Children who were able to complete one test were able to complete the other. Interobserver and intraobserver agreement was very high for both scales (in excess of 95% for all comparisons), and with the numbers available, there were no differences between the scales.ConclusionsThe Mallet scale and ABC Loops protocol have high reliability metrics in children younger than 6 years, but very young children (those younger than 3 years) generally will not be able to complete the examinations. The ABC Loops test took longer to perform than the Mallet scale but may more comprehensively evaluate a child’s functional capabilities. We therefore state that both assessment tools can be reliably used in children older than 3 years; we believe the ABC Loops gives a more accurate assessment of shoulder ROM.

Variability of the Anterior Humeral Line in Normal Pediatric Elbows.

Background: The anterior humeral line (AHL) is considered a valuable radiographic tool in the assessment of pediatric elbow sagittal plane alignment following injury. However, few studies exist that examine the validity of the AHL. The purpose of this study is to report the variability of the AHL in skeletally immature children with normal elbows. Methods: A total of 124 true lateral elbow radiographs of normal pediatric elbows were retrospectively identified and examined for the relationship of the AHL to the capitellum. The percentage of AHLs falling outside the middle third of the capitellum was compared among different age and sex groups using Fisher exact tests. Results: In 100% of patients, the AHL touched the ossific nucleus of the capitellum. In 100% (52/52) of patients ≥5 years the AHL goes through the middle third of the capitellum, but this is significantly different from patients less than 5 years of age in whom 25% (18/72) of patients the AHL fell outside of the middle third of the capitellum (P<0.001). In children less than 2 years of age, the AHL was in the anterior third in 30% of the cases. Conclusions: Traditional teaching that the AHL touches the capitellum on a lateral radiograph of a normal elbow in a child is correct, so if the AHL does not touch the capitellum it is appropriate to look for pathology. Similarly, in children 5 years and older the AHL goes through the middle third of the capitellum in all patients, so if it does not, it is appropriate to look for pathology. However, with decreasing age variability increases, with the AHL touching the anterior third of the capitellum in almost 1/3 of children. Level of Evidence: Level III.

Silent compartment syndrome in children: a report of five cases.

Compartment syndrome does not always present classically in the pediatric population, making clinical diagnosis uniquely challenging. The purpose of this study was to identify signs and symptoms of compartment syndrome that may help risk-stratify pediatric patients upon presentation, as well as to report outcomes of ‘silent’ compartment syndrome in children. A retrospective review of cases of ‘silent’ compartment syndrome at a level I pediatric trauma center between 2000 and 2010 was conducted. Patient demographics and clinical data were reviewed, including complications and patient outcomes. Radiographs taken at presentation, on intraoperative fluoroscopy, and at postoperative follow-up were reviewed for fracture type, and severity and outcome analyses. Five patients were found to have compartment syndrome without the presence of significant pain at rest or on passive range of motion. The study included three male and two female patients with a median age of 7 years. Three upper-extremity and two lower-extremity fractures were involved. The mean time from presentation to surgery was 14 h. At presentation, three of five patients had muscle paralysis, whereas at diagnosis of compartment syndrome, four of five had paralysis. Of the classic five P’s, a maximum of two were found at diagnosis. The mean clinical follow-up period was 11 months (2–26 months). Long-term complications from compartment syndrome were found in one of five patients, who at the most recent follow-up, continued to be debilitated. This study reviews a series of cases of ‘silent’ compartment syndrome and confirms its atypical presentation. It is recommended that caution be used when assessing fractures with high risk for compartment syndrome in children, especially those complicated by nerve injury, as they do not always present in the classic manner, with missed diagnosis leading to significant functional deficits. Level of evidence: IV.

Clavicle Fracture Is Not Predictive of the Need for Microsurgery in Brachial Plexus Birth Palsy

Background:Brachial plexus birth palsy (BPBP) and clavicle fractures occur concurrently as well as in isolation during difficult deliveries. The concept that concurrent clavicle fracture may spare nerve injury has been advocated. Our aim was to compare those children with BPBP presenting to a tertiary care center with and without concurrent clavicle fractures and assess the utility of the presence of a clavicle fracture as a predictor of injury severity in children with BPBP. Methods:Records of all patients belonging to a large prospective multicenter cohort study of infants with BPBP (Treatment and Outcomes of Brachial Plexus Injuries study) were analyzed for demographic information and birth information including risk factors, comorbidity, presence of clavicle fracture, and injury severity. Results:The records of 639 children with BPBP were examined. Thirteen patients were excluded for incomplete data. Ninety-six children who sustained concurrent birth fracture and BPBP were identified (15%). Of these, 57 sustained clavicle fractures (9%), 44 sustained humerus fractures, and 4 sustained other fractures. Of the demographic factors analyzed, only the presence of gestational diabetes was found to be significantly higher in those children with fractures versus those without. The presence of a clavicle fracture did not change the rate of microsurgical intervention, nor did clavicle fracture rates differ by Toronto score, suggesting that there was no difference in injury severity between the 2 groups. Conclusions:In a large multicenter prospective study, 9% of children presenting with BPBP also sustained a clavicle fracture at birth. The presence of a clavicle fracture did not correlate with the severity of brachial plexus injury. We suggest that in study populations of children with severe enough BPBP to present to a tertiary care center, compared with studies collected in the obstetric population, the presence of a clavicle fracture is neither protective from nerve injury nor predictive of injury severity. Level of Evidence:Level 2—prognostic.

Delayed reconstruction of a flexor digitorum profundus tendon lacerated during cesarean delivery: case report.

We present a case of primary tendon grafting in a 14-month-old infant for an index finger flexor digitorum profundus tendon laceration sustained during cesarean section with excellent functional results at 2-year follow-up.