Serial casting for elbow flexion contractures in neonatal brachial plexus palsy

Elbow flexion contractures in neonatal brachial plexus palsy: A one-year comparison of dynamic orthosis and serial casting

OBJECTIVE

Elbow flexion contractures are common complications of neonatal brachial plexus palsy, but evidence on how to treat these contractures is weak. This study compared the treatment of elbow flexion contractures using a dynamic orthosis or serial circular casting.

METHODS

A randomized controlled trial was conducted with one-year follow-up. Children with an elbow flexion contracture of ≥30° were treated with either a night-worn dynamic orthosis for one year or serial casting for four weeks followed by night splinting. For pragmatic reasons, some participants were included in an open part of this study, this group was also analyzed separately. Degree of contracture and goal attainment scaling was evaluated at baseline and after 8, 20 and 54 weeks.

RESULTS

55 patients were analyzed in this trial, 32 of whom were randomized to treatment. At one-year follow-up of the randomized group, both dynamic splinting (median -8.5°, interquartile range [IQR] -13.5, -5) and serial casting (median -11.0°, IQR -16, -5) resulted in significant reduction of contracture (P < 0.001). The reduction was significantly greater with serial casting in the first 20 weeks, but not at one-year follow-up (P = 0.683). In the entire cohort, the individual functional goals had been reached in 24 out of 32 cases (80%) of dynamic splinting and 18 out of 23 cases (82%) of serial casting, respectively.

CONCLUSION

The dynamic night orthosis is comparable to serial casting for treating elbow flexion contractures in children with brachial plexus birth injury. We recommend selecting one of these treatment modalities in close consultation with parents and patients.

Shared decision making in youth with brachial plexus birth injuries and their families: A qualitative study

OBJECTIVE

The objective of this study is to elucidate the decision-making experiences of youth with brachial plexus birth injuries who face preference-sensitive decisions regarding treatment options for a persistent elbow contracture.

METHODS

Transcripts, research-created drawings, and field notes from in-depth interviews with 5 young adults and 14 youth-parent dyads, and 15 participant observation sessions of families and clinicians in the clinic setting were deductively and inductively coded and thematically analyzed.

RESULTS

Youth's shared decision making was influenced by relational processes with their clinicians and parents. Youth's trust in their clinicians' recommendations for pursuing treatment and pressure from their parents to pursue or continue rehabilitation treatment affected how their voices were expressed and heard. Parental emotional adjustment to the birth injury played a role in parental perceptions of what was deemed their youth's best interest in the shared decision.

CONCLUSIONS

The decision-making experiences of youth with brachial plexus birth injury illustrate the complexity of paediatric preference-sensitive decisions and the significance of social and emotional factors on these shared decisions.

PRACTICE IMPLICATIONS

Opportunity for youth to express their voice without external pressure during shared decision making is needed to make well-informed decisions based on their own values. Interventions such as decision coaching and decision support tools may help youth and parents to formally identify and discuss these relational processes.

Developing a decision aid for youth with brachial plexus birth injuries facing treatment decisions for an elbow flexion contracture

BACKGROUND

A common sequela of brachial plexus birth injury (BPBI) is an elbow flexion contracture. Youth with BPBI and their families face rehabilitation or surgical decisions that ideally entail careful deliberation of the risks and benefits of treatment within the context of the child's and family's functional and appearance-related goals.

OBJECTIVE

To develop a patient decision aid (PtDA) following International Patient Decision Aid Standards to help these youth and their families make treatment decisions.

DESIGN

Mixed-methods study.

SETTING

Brachial plexus clinic in a pediatric tertiary care center.

PARTICIPANTS

Five young adults (21-24 years), 14 youth (8-19 years) and their parents, 15 families (children 2-16 years), and 19 clinicians from a brachial plexus clinic participated in the PtDA development. Seventeen other youth (8-18 years) facing treatment decisions regarding their elbow contracture field tested the PtDA prototype.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

In-depth interviews and participant observation to conduct a decisional needs assessment of young adults, youth, parents, and health care professionals involved in these shared decisions. Cognitive interviews to field test the PtDA prototype.

RESULTS

Evidence from previously conducted knowledge synthesis and the youth-focused decisional needs assessment qualitative data informed the development of new PtDA prototype, which included a questionnaire-based values clarification method for youth to rate what matters most to them regarding their elbow function, appearance, psychosocial impact, and treatment options. The majority (90%) of youth >11 years who field tested the PtDA prototype understood its content, whereas only 29% of those between 8 and 11 years demonstrated independent comprehension. The majority (69%) responded that they would prefer to use the PtDA on their own either at home or in the clinic waiting room.

CONCLUSIONS

This new PtDA can be used to help youth with BPBI and their families to make a personal value-based informed decision regarding treatment options for their elbow flexion contracture.

Corrective Procedure for Flexion Contracture of the Elbow in Neonatal Palsy Sequelae: Long-term Follow-up

BACKGROUND

Aim of this paper is to validate a procedure for correcting elbow flexion contracture in patients suffering from brachial plexus neonatal palsy sequelae during their teens. Elbow flexion contracture represents an unsolved problem in the natural history of obstetric brachial plexus palsy (OBPP) because of the consistent deformity recurrence. Following a previous paper, in which an original technique was proposed in a small sample of patients, the authors show the possible correction of the deformity in a larger group of patients.

METHODS

The procedure includes a combination of a posterior approach to the elbow with olecranon tip section and an anterior one with capsulotomy and soft tissue release to improve elbow range of motion. A series of 26 patients, who underwent the procedure, were checked out in medium and long term. Collected data were age, type of brachial plexus palsy, length of hospitalization, duration of surgery, preoperative and postoperative elbow range of motion, preoperative and postoperative DASH scores and satisfaction scores. Explaining further details about the procedure, the Authors report their results, including a statistical analysis.

RESULTS

At the final follow-up, the mean increase of elbow extension was about 22°. Functional outcomes were successful as well, with a mean increase of 10 points of DASH score. Over 75% of patients were fully satisfied with their outcome.

CONCLUSIONS

The outcome has confirmed the good efficacy of the procedure in increasing elbow extension but also in improving cosmetic appearance in adolescents suffering from flexed elbow in OBPP sequelae.

Effectiveness of non-surgical and surgical interventions for elbow flexion contractures in brachial plexus birth injury: A systematic review

PURPOSE

To conduct a systematic review of studies on non-surgical and surgical interventions for elbow flexion contractures secondary to brachial plexus birth injury (BPBI).

METHODS

MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched for randomized controlled trials, observational studies, and case series studies on treatment of elbow flexion contractures secondary to BPBI. Study quality was evaluated using the Effective Public Health Practice Project tool.

RESULTS

Of the 950 records found, 132 full text articles were reviewed, and 3 cohort studies and 8 case series were included. The overall methodological quality of included studies was weak. The weak quality evidence demonstrated that significant gains in elbow extension passive range of motion (ROM) can be achieved with serial casting (range: 15 to 34.5 degrees) or elbow release surgery (range: 28.4 to 30.0 degrees). At best, a reduction to an elbow contracture between -15.0 and -18.8 degrees (casting) and -8.0 and -43.6 (elbow release surgery) can be achieved. Insufficient outcomes on elbow flexion ROM and strength were found in both non-surgical and surgical studies.

CONCLUSION

The quality of evidence on the effectiveness of interventions for an elbow flexion contracture secondary to BPBI is weak. In the context of insufficient evidence on the risks of pursuing such interventions, it is prudent to attempt non-surgical interventions prior to surgery.

LEVEL OF EVIDENCE

III - systematic review of level IV studies.

Prevalence and etiology of elbow flexion contractures in brachial plexus birth injury: A scoping review

PURPOSE

To synthesize the evidence on the prevalence and etiology of elbow flexion contractures secondary to brachial plexus birth injury (BPBI).

METHODS

Using Arksey and O'Malley's scoping review framework, MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched, followed by a comprehensive grey literature search. Articles and abstracts of studies of all level of evidence on the prevalence, natural history, clinical presentation, etiology, and treatment of elbow flexion contractures in BPBI were included.

RESULTS

Of the 884 records found, 130 full text articles were reviewed, and 57 records were included. The median prevalence of elbow flexion contracture in BPBI was 48%. The magnitude of the contractures was between 5 and 90 degrees. Contractures > 30 degrees were found in 21% to 36% of children. With recent clinical and lab studies, there is stronger evidence that the contractures are largely due to the effects of denervation causing failure in the growth of the affected flexor muscles, while muscle imbalance, splint positioning, and postural preferences play a smaller role.

CONCLUSION

The etiology of elbow flexion contractures is multifaceted. The contribution of growth impairment in the affected muscles offers greater understanding as to why maintaining passive range of motion in these contractures can be difficult.