Pediatric upper extremity injuries

The pediatric musculoskeletal system differs greatly from that of an adult. Although these differences diminish with age, they present unique injury patterns and challenges in the diagnosis and treatment of pediatric orthopedic problems.

Das asymptomatische Thoracic-outlet-Kompressionssyndrom

The thoracic outlet compression syndrome has a great number of clinical variations. Arterial and venous perfusion impairment is an associated symptom, nerve irritation can occur with or without vascular problems. The degree of nerve damage ranges from transient irritation to permanent motoric and sensory defects. The lack of space in the supracostoclavicular compartment is the cause for nerve compression. The degree of neural damage depends on the degree and duration of the compression. Anatomic variations between the clavicle and first rib are frequent causes for the TOS: accessory ribs and muscles, and fibrous bands have been described. A preexisting chronic compression may lead to a subclinical TOS, in this case an inadequate trauma of minor degree may be sufficient to manifest a plexus palsy. Intraoperative findings in children with incomplete and complete brachial plexus palsy and the corresponding findings in adults prompted us to present this communication.

Muscle transfer for shoulder reconstruction in obstetrical brachial plexus lesions

A prospective study was performed on a group of 32 consecutive obstetrical brachial plexus lesions (OBPL). Seventeen were girls and 15 were boys with an age ranging between 2.3 years to 7 years (mean 3.5 years). Patients were treated operatively for a functionally disturbing unilateral internal rotation contracture of the shoulder with a good deltoid function (grade IotaIota or greater) and no significant active external rotation. The Hoffer technique of muscle transfer in the form of transferring the latissimus dorsi and teres major muscles to the rotator cuff posteriorly through a transaxillary approach with or without subscapularis muscle release was used in all cases. Preoperatively the patients were assessed clinically according to the modified Gilbert shoulder grading system. All patients were of grade 1 and 2. Eighteen patients had a lesion of the superior trunk of the brachial plexus (C5 and C6 roots) and ten patients had various degrees of involvement of the entire plexus while in four patients previous microsurgery reconstruction was performed. All patients improved to grade 4 and 5. The follow-up period ranged from 1.5 to 3.5 years (mean 2.3 years). There were no significant complications except for recurrence of minimal internal rotation in six patients that required no further surgery. Our results suggest that the Hoffer technique for shoulder reconstruction in OBPL is a reliable and safe technique.

Friday night palsy: an unusual case of brachial plexus neuropathy

Brachial plexopathy can result from traction injury, radiation injury, local or metastatic cancer, hereditary, or idiopathic causes. However, brachial plexopathy resulting from malposition of an arm during sleep, similar to Saturday night palsy, has not been reported. We report a case of brachial plexus neuropathy that occurred after the patient slept on his shoulder and arm following excessive alcohol consumption on a Friday night.

[Shoulder dystocia from a legal standpoint]

Even though a shoulder dystocia occurs very seldom it plays an important part in obstetrical medical opinions since it is quite often associated with infant plexus brachialis injuries. In legal medical discussions it is necessary to determine whether there were certain antepartal risks, if diagnosis and therapy were carried out correctly and whether a shoulder dystocia resp. plexus brachialis injury could have been prevented. In general one is looking for answers to prevent both serious complications. In the past a great number of articles were published referring to these answers. Especially in Anglo-American literature of the last few years one can find more and more indications that a clear cause-effect between shoulder dystocia and plexus brachialis injuries does not exist in every case. Also the value of typical or historical factors concerning association between the two are criticised in different publications. In addition the therapy strategies for shoulder dystocia treatments are momentarily analyzed in scientific discussions. Which treatment should be used first? Which ones are actually effective or do they even increase the risk of plexus brachialis injuries? Answers to these questions are given in the following abstract.

[Self-mutilation as a consequence of the perinatal brachial plexus palsy]

In this study we presented 2 cases of the self-mutilation of the hand following obstetrical brachial plexus palsy. The mechanism of this behaviour was also discussed.

Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy?

Out of 210 children suffering from severely displaced supracondylar fractures, 76 (36%) presented with immediate neurovascular complications: 47 (22%) were neurological, 16 (8%) vascular and 13 (6%) both. Injury to two nerves simultaneously was observed in six patients. The median nerve was affected in 28 cases, the ulnar nerve in 25 and the radial nerve in 13. Posterolateral displacement was associated with 86% of damage to the median nerve and 56% of damage to the ulnar nerve. Posteromedial displacement was associated with all incidents of injury to the radial nerve with one exception. Each patient made full neurological recovery, spontaneously and following primary or secondary neurolysis performed on nerve injuries in continuity. Two situations of primary abolition of the radial pulse were encountered, one involving a pink hand in 12.5% of cases and the other involving a white hand in 1.5% of cases. There was posterolateral displacement in three out of four patients. Postoperative vascularization was revealed by immediate return of the radial pulse in 26 patients and delayed return in three others. Urgent anatomical reduction of the fracture and its early fixation are crucial. A conservative therapeutic approach is customary in the majority of neurovascular complications. Prognosis is generally excellent. Ischaemia of the limb and total ruptures of the nerve are very rare.

Early and late reconstruction in brachial plexus palsy: a preliminary report

OBJECTIVE

To evaluate the most effective surgical procedures in the early and late reconstruction of brachial plexus after its traumatic injury.

MATERIAL AND METHODS

A total of 14 consecutive patients with brachial plexus injuries were examined and operated on at the Department of Plastic and Reconstructive Surgery and Burns at Kaunas University of Medicine Hospital. Less than half of them (43%) came for surgery in the early stage of disease--within 12 months after injury--and 57% in the late stage--1-15 years after trauma. Altogether, 23 operations--neurolysis, nerve transfer, tendon transfer, and arthrodesis--were performed. Patients were followed up for an average of 12.5 months (range 4 to 19 months) after surgery. Postoperative motor assessment of hand function was based on the motor classification M0-M6 of Mallet and British Medical Research Council Muscle grading system. Results were considered positive if the range of active movements increased no less than 5-10 degrees odependently from the level of injury and motor strength--no less than 1-2 grades (M0-->M2 or M2-->M3).

RESULTS

Of the eight investigated, six patients from early group showed positive results. The most effective surgical procedures were neurolysis and nerve transfer. A significant improvement in the patients of late group was observed after tendon transfer procedure. Nevertheless, the recovery process of motor function was too slow or even minimal in 31% of patients to satisfy the patient and the surgeon.

CONCLUSIONS

Neurolysis or nerve transfer in the early stage or tendon transfer in the late stage after brachial plexus injury may result in a significant improvement of motor function of the hand. Sharing the information concerning brachial plexus reconstruction with neonatologists, neuropathologists, traumatologists, and hand therapists would be helpful in operating such patients timely and treating them adequately after surgery.

Late appearance of dropped head syndrome after radiotherapy for Hodgkin's disease

We present three cases of dropped head syndrome that occurred as a complication of mantle field (i.e., lymph nodes of the neck, axillae, and mediastinum) or whole-body radiation therapy for Hodgkin's disease. These cases are characterized by a late onset (2-27 years after radiation treatment), fibrosis, and contraction of the anterior cervical muscles, and atrophy of the posterior neck and shoulder girdle. This report adds to the increasing literature about the late neurological complications of radiation therapy and describes a previously unrecognized cause of dropped head syndrome.

Complete recovery of spinal cord injury without radiographic abnormality and traumatic brachial plexopathy in a young infant falling from a 30-feet-high window

The laxity and elasticity of the infant or child spine may predispose him to cervical spine injury without bony disruption. The term 'SCIWORA' syndrome (Spinal Cord Injury Without Radiographic Abnormalities) is commonly used to characterize this condition. We report a 14-month-old infant who fell from a fourth-story window, with delayed onset of SCIWORA and brachial plexopathy. The infant initially presented with complete limb paralysis, but had a full recovery 6 months later. In contrast to the classical grave prognosis of these two conditions, our case represents one of the few exceptions in the literature with excellent recovery. Corresponding to previous reports, we suggest that the initial normal appearance of the spinal cord and nerve roots on magnetic resonance image may serve as a good prognosticator, regardless of the severity of initial neuroelectrophysiological studies or clinical manifestations.

Modified Steindler procedure for the treatment of brachial plexus injuries

A retrospective follow-up study was completed on ten patients who suffered from a brachial plexus injury that was treated with a modified Steindler procedure. The mean postoperative period was 6.8 years. The postoperative elbow joint range of motion was -42 degrees of extension (range -5 degrees to -65 degrees ) and 107 degrees of flexion (range 90 degrees -130 degrees ). Manual muscle testing showed grade 4 or 5 in eight patients and grade 3 in two patients. In the subjective assessment, the patients scored 20 out of 30 points and were able to perform almost all activities with the exception of shoulder elevation. Innervation of the musculocutaneous nerve was evaluated by electromyography and no correlation was seen between preoperative and postoperative amplitude of the biceps brachii by electromyogram. Based on these results, we concluded that a modified Steindler procedure is useful for reconstruction of upper brachial plexus injuries, and recovery of the biceps brachii was difficult to predict by an electromyogram.

"Stingers" in adolescent athletes

Brachial plexus injuries commonly occur in athletes participating in contact sports. The incidence of transitory brachial plexus injury is approximately 30% to 50% over the course of a high school, college, or professional football player's career. These injuries are called "stingers" or "burners" because of the associated tingling that occurs in the upper extremity after the injury. Brachial plexus injuries are poorly understood and sometimes are difficult to manage. Appropriate knowledge and understanding of these injuries along with prompt recognition, diagnosis, and treatment are essential for optimal care of the injured athlete and for the athlete's timely return to play. Most injuries occur by one of three mechanisms: traction, compression, or hyperextension and compression. Injuries are clinically classified as neurapraxia, neurapraxia/axonotmesis, and neurotmesis according to their symptomatology and the pattern of symptom resolution. Most injuries are either a neurapraxia or a neurapraxia/axonotmesis. Most athletes recover completely and can return to play after they are asymptomatic and have regained full sensation, strength, and range of motion. Protective equipment has been introduced to decrease the occurrence of stingers. Education of the athlete, the family, and coaches is important to help them to understand and to assist in managing these injuries.

Method for surgical access to the brachial plexus

Problem of brachial plexus injuries is deemed one of the most topical in contemporary surgery. Irrespective of the newest achievements in medical science and technique, outcomes of treatment of brachial plexus injuries are yet incapable to be estimated as satisfactory. Quality of technical performance in many respects depends on convenience of access to the structures to be operated. The deficiency of the offered methods is that they are incapable to ensure sufficiently wide access to indicated structures, thus making operation more complicated and long and depressing functional and esthetical outcomes of the surgical treatment. The method, offered by us, is deemed to be solution of the above-mentioned problems. The core of the method is making of additional incision along lateral side of the horizontal wound, cutting out collarbone segment along the sides of wound and peeling up the formed rectangular clout, ensuring the wide access to the appropriate structures. We have examined and operated 59 patients with pathologies of brachial plexus and nearby structures. In 22 cases, where we applied the methodology offered by us, the above-mentioned complications did not arise: wide access facilitated technical aspect of the operation, reducing the duration of corresponding operation by in average 13-20%. Healing of wounds in both cases -- singularity-free. Controlling X-ray have shown successful coalescence of cut-off segments of collarbone without any deformation along axis. Method for ensuring access to brachial plexus, offered by us, provides more extensive and easier mobilization of plexus elements and nearby structures, facilitates technical side of the operation, shortens duration of surgical operation, and, finally, improves outcomes of treatment.

Canadian frame and bilateral brachial plexus neurapraxia

A reported case of postoperative bilateral brachial plexus neurapraxia associated with the use of a Canadian frame in a patient who had thoracolumbar spinal surgery under general anesthesia. Symmetrical misposition of the upper pads of the Canadian frame underneath both shoulder heads during prolonged surgery led to direct compression on or stretching of the bilateral brachial plexus. This complication should be prevented by carefully placing the patient on this sort of frame.

Erb's palsy after delivery by Cesarean section. (A medico-legal key to a vexing problem.)

Despite impressive progress in perinatology, fetal injuries from arrest of the shoulders at birth have not decreased in recent decades. Based upon sporadic reports of Erb's palsy in neonates born by Cesarean section, some obstetricians embraced the theory recently that brachial plexus lesions often derive from spontaneous forces acting in utero. Having reviewed three hundred malpractice claims involving fetal injuries attributed to shoulder dystocia at birth, the authors found only two cases connected with abdominal deliveries. One followed manual replacement of the already delivered fetal head into the pelvis after sequential vacuum and forceps procedures and failed manual extraction of the body. The other was an elective repeat Cesarean section where extensive adhesions limited the available space for the lower segment transverse uterine incision. Coincidental fracture of the clavicle and absence of contractures or deformities indicated that the brachial plexus injury was acute, having resulted from forceful traction at delivery.

Risk Factors for Obstetric Brachial Plexus Palsy Among Neonates Delivered by Vacuum Extraction

OBJECTIVE

The risk of obstetric brachial plexus palsy (OBPP) is increased in infants delivered instrumentally. The aim of this study was to identify risk factors for OBPP and to evaluate the association between possible risk factors linked to the duration of the vacuum extraction procedure and the subsequent risk.

METHODS

A population-based retrospective design was adopted. Using a national registry of operative vaginal deliveries linked to the Medical Birth Registry in Sweden, we evaluated by univariate and multiple logistic regression analyses the risk factors for OBPP in 13,716 women delivered by vacuum extraction. The variables assessed in the multiple logistic regression analysis were shoulder dystocia, fetal birth weight of 3,999 g or greater, fundal pressure, number of tractions, vacuum application time, parity, vacuum silicone cup, epidural anesthesia, and fetal head at the level of the ischial spines at vacuum application time.

RESULTS

Obstetric brachial plexus palsy was recorded in 153 (1.1%) infants. The following variables increased significantly the risk of OBPP in the newborn: shoulder dystocia (odds ratio 16.0; 95% confidence interval 8.9-28.7), fetal birth weight of 3,999 g or greater (7.1; 4.8-10.5), and administration of fundal pressure (1.6; 1.1-2.3). The probability of the risk of OBPP in vacuum-assisted deliveries increased in relation to vacuum extraction time (minutes).

CONCLUSION

Shoulder dystocia in the setting of vacuum extraction is a prominent risk factor for OBPP in the newborn. The risk of OBPP increases with the time required for vacuum extraction.

LEVEL OF EVIDENCE

II-3.

Part 2. Distinguishing physical characteristics and management of brachial plexus injuries

Brachial plexus injuries (BPI) are usually readily apparent at or shortly after birth. Failure of caregivers to recognize and appropriately treat BPI may contribute to the risk of life-long neuromuscular dysfunction for the infant and represents a serious medical-legal liability for the delivery provider. This article is the second in a series on BPI and provides a standard classification and a systematic guide to physical examination of the infant with suspected BPI. Conditions that mimic BPI are discussed along with diagnostic studies used to confirm this disorder. The natural history and predictors of outcome are presented along with a sample treatment protocol. Pictures and video clips are provided to enhance the reader's understanding of the consequences of this injury and the potential for improvement with surgical treatment. Useful Internet resources for parents, focused discharge planning, and guidelines for appropriate monitoring and follow-up are provided. Advantages of early referral and management by a multidisciplinary team at a brachial plexus specialty center are discussed.

Brachial Plexus Injury During Open Heart Surgery - Controlled Prospective Study

BACKGROUND

Postoperative brachial plexus injury is often reported because the brachial plexus is stretched by sternotomy and the use of sternal retractors during open heart surgery. In many studies, brachial plexus injuries have been demonstrated by postoperative electrophysiological studies in susceptible patients. In this study, we estimated the incidence, severity, and type of brachial plexus injuries by routine preoperative and postoperative electrophysiological studies of patients undergoing open heart surgery.

METHODS

Patients undergoing coronary artery bypass grafting (CABG) surgery (Group 1), heart valve surgery (Group 2), or peripheral vascular surgery (Group 3) were included in the investigation. Electrophysiological studies of both upper extremities were performed five days before and three weeks after the operation.

RESULTS

Peripheral nerve problems were found preoperatively in 23 of the 112 patients (21 %). These problems persisted, but similar findings were obtained postoperatively from the left upper extremities of six of the 42 CABG (14 %) and two of the 24 heart valve (8 %) patients who had had normal preoperative evaluations. The patients with injured nerves were older and had undergone longer operation times. There were no differences between the patients with injured nerves and the others with respect to mammary artery harvesting or other operative variables.

CONCLUSIONS

There are no reports in the literature of routine preoperative and postoperative electrophysiological studies in large patient groups to evaluate brachial plexus injury during open heart surgery. It is known that heart surgery sometimes causes partial brachial plexus injury, especially in the lower trunk. However, these peripheral nerve problems are usually not considered clinically important and are not investigated. Patients undergoing open heart surgery must be closely followed up for peripheral nerve injury during the postoperative period.

Clinical usefulness of somatosensory evoked potentials for detection of brachial plexopathy secondary to malpositioning in scoliosis surgery

STUDY DESIGN

A retrospective longitudinal study of 434 consecutive pediatric patients who underwent surgical correction of scoliosis, while being monitored for positional brachial plexopathy.

OBJECTIVE

To evaluate the effectiveness of intermittent monitoring of ulnar nerve somatosensory evoked potentials (SSEPs) for detecting brachial plexus injury caused by malpositioning during scoliosis surgery.

SUMMARY OF BACKGROUND DATA

Continuous intraoperative SSEP monitoring for spinal cord function has been well reported, and is widely accepted as the standard for spinal deformity correction surgery to detect and avoid neurologic injury. The use of SSEPs for the monitoring of ulnar nerve function intraoperatively as an indicator of brachial plexus function is becoming more accepted as a valid and useful technique to minimize intraoperative neurologic injuries during deformity corrections.

METHODS

A review was conducted to assess the effect of ulnar nerve SSEP monitoring, as a measure of brachial plexus function, during anterior, posterior, or combined approach surgeries. The type of scoliosis, type of surgery and positioning, and surgical event at noted amplitude decrease were included in an analysis of variance for repeated measures, and a Student t test was performed for significant differences.

RESULTS

A total of 27 patients had ulnar nerve amplitude decreases of > or =30%, resulting in a point prevalence of 6.2% for positional brachial plexopathy during positioning for all scoliosis surgeries. A significant difference was noted between the types of positioning, with prone positioning accounting for a higher rate of brachial plexopathy compared with anterior approach positioning (P < 0.01). No statistical difference exists as to the type of scoliosis present and the incidence of brachial plexopathy (P < 0.01).

CONCLUSIONS

Avoidance of neurologic injury to the brachial plexus during scoliosis surgery is possible by early detection with ulnar nerve SSEP monitoring.

Botulinum toxin for treatment of cocontractions related to obstetrical brachial plexopathy

Botulinum toxin type A was recently introduced for treatment of biceps - triceps muscle cocontraction, which compromises elbow function in children with obstetrical brachial plexopathy. This is our preliminary experience with this new approach. Eight children were treated with 2 - 3 U/kg of botulinum toxin injected in the triceps (4 patients) and biceps (4 patients) muscle, divided in 2 or 3 sites. All patients submitted to triceps injections showed a long-lasting improvement of active elbow flexion and none required new injections, after a follow-up of 3 to 18 months. Three of the patients submitted to biceps injections showed some improvement of elbow extension, but none developed anti-gravitational strength for elbow extension and the effect lasted only three to five months. One patient showed no response to triceps injections. Our data suggest that botulinum toxin can be useful in some children that have persistent disability secondary to obstetrical brachial plexopathy.