Investigating the effect of anatomical variations in the response of the neonatal brachial plexus to applied force: Use of a two-dimensional finite element model.

The brachial plexus is a set of nerves that innervate the upper extremity and may become injured during the birthing process through an injury known as Neonatal Brachial Plexus Palsy. Studying the mechanisms of these injuries on infant cadavers is challenging due to the justifiable sensitivity surrounding testing. Thus, these specimens are generally unavailable to be used to investigate variations in brachial plexus injury mechanisms. Finite Element Models are an alternative way to investigate the response of the neonatal brachial plexus to loading. Finite Element Models allow a virtual representation of the neonatal brachial plexus to be developed and analyzed with dimensions and mechanical properties determined from experimental studies. Using ABAQUS software, a two-dimensional brachial plexus model was created to analyze how stresses and strains develop within the brachial plexus. The main objectives of this study were (1) to develop a model of the brachial plexus and validate it against previous literature, and (2) to analyze the effect of stress on the nerve roots based on variations in the angles between the nerve roots and the spinal cord. The predicted stress for C5 and C6 was calculated as 0.246 MPa and 0.250 MPa, respectively. C5 and C6 nerve roots experience the highest stress and the largest displacement in comparison to the lower nerve roots, which correlates with clinical patterns of injury. Even small (+/- 3 and 6 degrees) variations in nerve root angle significantly impacted the stress at the proximal nerve root. This model is the first step towards developing a complete three-dimensional model of the neonatal brachial plexus to provide the opportunity to more accurately assess the effect of the birth process on the stretch within the brachial plexus and the impact of biological variations in structure and properties on the risk of Neonatal Brachial Plexus Palsy.

Simulation of the Childbirth Process in LS-DYNA.

Childbirth or labor, as the final phase of a pregnancy, is a biomechanical process that delivers the fetus from the uterus. It mainly involves two important biological structures in the mother, the uterus-generating the pushing force on the fetus-and the pelvis (bony pelvis and pelvic floor muscles)-resisting the movement of the fetus. The existing computational models developed in this field that simulate the childbirth process have focused on either the uterine expulsion force or the resistive structures of the pelvis, not both. An FEM model including both structures as a system was developed in this paper to simulate the fetus delivery process in LS-DYNA. Uterine active contraction was driven by contractile fiber elements using the Hill material model. The passive portion of the uterus and pelvic floor muscles were modeled with Neo Hookean and Mooney-Rivlin materials, respectively. The bony pelvis was modeled as a rigid body. The fetus was divided into three components: the head, neck, and body. Three uterine active contraction cycles were modeled. The model system was validated based on multiple outputs from the model, including the stress distribution within the uterus, the maximum Von Mises and principal stress on the pelvic floor muscles, the duration of the second stage of the labor, and the movement of the fetus. The developed model system can be applied to investigate the effects of pathomechanics related to labor, such as pelvic floor disorders and brachial plexus injury.

Studying the Effects of Shoulder Dystocia and Neonate-Focused Delivery Maneuvers on Brachial Plexus Strain: A Computational Study.

The purpose of this computational study was to investigate the effects of neonate-focused clinical delivery maneuvers on brachial plexus (BP) during shoulder dystocia. During shoulder dystocia, the anterior shoulder of the neonate is obstructed behind the symphysis pubis of the maternal pelvis, postdelivery of the neonate's head. This is managed by a series of clinical delivery maneuvers. The goal of this study was to simulate these delivery maneuvers and study their effects on neonatal BP strain. Using madymo models of a maternal pelvis and a 90th-percentile neonate, various delivery maneuvers and positions were simulated including the lithotomy position alone of the maternal pelvis, delivery with the application of various suprapubic pressures (SPPs), neonate in an oblique position, and during posterior arm delivery maneuver. The resulting BP strain (%) along with the required maternal delivery force was reported in these independently simulated scenarios. The lithotomy position alone served as the baseline. Each of the successive maneuvers reported a decrease in the required delivery force and resulting neonatal BP strain. As the applied SPP force increased (three scenarios simulated), the required maternal delivery force and neonatal BP strain decreased. A further decrease in both delivery force and neonatal BP strain was observed in the oblique position, with the lowest delivery force and neonatal BP strain reported during the posterior arm delivery maneuver. Data obtained from the improved computational models in this study enhance our understanding of the effects of clinical maneuvers on neonatal BP strain during complicated birthing scenarios such as shoulder dystocia.

How to Build Your Mentoring Tree-Insight Gained From a 36-Year Career in Biomedical Engineering.

Mentoring is often viewed as a unidirectional relationship, with the senior, more seasoned individual imparting knowledge, guidance, and experience to more junior individuals. But this structure limits our ability to recognize that the mentoring relationship can bring benefits and opportunities for growth to the mentor as well. On the occasion of receiving the 2022 Robert M. Nerem Education and Mentorship Medal, I have had the opportunity to reflect on the mentoring that I have been lucky enough to participate in-both as mentor and mentee-during my academic career. This paper discusses some of those insights and presents the concept of a mentoring tree-through which we can identify multiple mentors and mentees, each of whom can provide mutual support and insight as we progress through our careers. Each individual who is part of our mentoring tree can play a role at different times and with different challenges within our professional path. This everchanging and growing structure provides continuous mentoring without overtaxing any single relationship.

A Computational Procedure to Derive the Curve of Carus for Childbirth Computational Modeling.

Computational modeling serves an important role in childbirth-related research. Prescribed fetal descent trajectory is a key characteristic in childbirth simulations. Two major types of fully prescribed fetal descent trajectories can be identified in the literature: straight descent trajectories and curve of Carus. The straight descent trajectory has the advantage of being simpler and can serve as a reasonable approximation for relatively small fetal movements during labor, but it cannot be used to simulate the entire childbirth process. The curve of Carus is the well-recognized fetal descent trajectory with physiological significance. However, no detailed procedure to geometrically define the curve of Carus can be found in existing computational studies. This status of curve of Carus simulation in the literature hinders the direct comparison of results across different studies and the advancement of computational techniques built upon previous research. The goals of this study are: (1) propose a universal approach to derive the curve of Carus for the second stage of labor, from the point when the fetal head engages the pelvis to the point when the fetal head is fully delivered; and (2) demonstrate its utility when considering various fetal head sizes. The current study provides a detailed formulation of the curve of Carus, considering geometries of both the mother and the fetus. The maternal geometries were obtained from MRI data, and the fetal head geometries were based on laser scanning of a replica of a real fetal head.

Interactive Digital Experience as an Alternative Laboratory (IDEAL): Creative Investigation of Forensic Biomechanics.

An Interactive Digital Experience as an Alternative Laboratory (IDEAL) was developed and implemented in a flipped biomechanics classroom. The IDEAL challenge problem was created to more closely simulate a real-world scenario than typical homework or challenge problems. It added a more involved story, specific characters, simple interaction, and student-led inquiry into a challenge problem. Students analyzed musculoskeletal biomechanics data to conduct a forensic biomechanics investigation of an individual who suffered a fracture. Students ultimately approached the IDEAL problem with a greater appreciation and enjoyment than previous open-ended challenge problems-those that were assigned in a traditional problem-statement manner-throughout the semester. Students who were more fully engaged in the IDEAL challenge problem, as evidenced by the fact that they requested all of the evidence on their own, also performed better on the final report grade. This signals improved learning with respect to biomechanical analysis when the students were creatively participating in the storyline surrounding the forensic investigation.

Forces Involved with Labor and Delivery-A Biomechanical Perspective.

Childbirth is a primarily biomechanical process of physiology, and one that engineers have recently begun to address in a broader fashion. Computational models are being developed to address the biomechanical effects of parturition on both maternal and fetal tissues. Experimental research is being conducted to understand how maternal tissues adapt to intrauterine forces near the onset of labor. All of this research requires an understanding of the forces that are developed through maternal efforts-both uterine contractions and semi-voluntary pushing-and that can be applied by the clinician to assist with the delivery. This work reviews the current state of knowledge regarding forces of labor and delivery, with a focus on macro-level biomechanics.

Childbirth Computational Models: Characteristics and Applications.

The biomechanical process of childbirth is necessary to usher in new lives-but it can also result in trauma. This physically intense process can put both the mother and the child at risk of injuries and complications that have life-long impact. Computational models, as a powerful tool to simulate and explore complex phenomena, have been used to improve our understanding of childbirth processes and related injuries since the 1990s. The goal of this paper is to review and summarize the breadth and current state of the computational models of childbirth in the literature-focusing on those that investigate the mechanical process and effects. We first summarize the state of critical characteristics that have been included in computational models of childbirth (i.e., maternal anatomy, fetal anatomy, cardinal movements, and maternal soft tissue mechanical behavior). We then delve into the findings of the past studies of birth processes and mechanical injuries in an effort to bridge the gap between the theoretical, numerical assessment and the empirical, clinical observations and practices. These findings are from applications of childbirth computational models in four areas: (1) the process of childbirth itself, (2) maternal injuries, (3) fetal injuries, and (4) protective measures employed by clinicians during delivery. Finally, we identify some of the challenges that computational models still face and suggest future directions through which more biofidelic simulations of childbirth might be achieved, with the goal that advancing models may provide more efficient and accurate, patient-specific assessment to support future clinical decision-making.

Design as a Feature of Biomedical Engineering Education-Satisfying ABET and Preparing Students to Address Clinical Needs.

Design is an important aspect of biomedical engineering education. It prepares students to work as part of a team to develop systems that address medical and health-related needs-and it is required to be part of an accredited undergraduate engineering program. This work looks at the history of design requirements in the U.S. and the current state of biomedical engineering curricula with respect to design. As a growing number of programs have expanded their design program beyond the capstone project, some examples of innovative programs are described. There is no single way to address design education within an undergraduate biomedical engineering program. However, intentional development of this component of the curriculum can enhance the impact on student learning and outcomes.

Herbert R. Lissner: The Father of Impact Biomechanics.

Professor Herbert R. Lissner was a pioneer in impact biomechanics, having initiated research on the injury mechanisms, mechanical response, and human tolerance of the human brain to blunt impact 80 years ago-in 1939. This paper summarizes the contributions made by Professor Lissner in head injury as well as in the many areas of impact biomechanics in which he was involved. In 1977, the Bioengineering Division of ASME established the H. R. Lissner Award to recognize outstanding career achievements in the area of biomechanics. In 1987, this award was converted to a society-wide Medal, and to date it has been awarded to 44 exemplary researchers and educators. The lead author of this paper was Professor Lissner's first and only Ph.D. student, and he offers a unique insight into his research and contributions.

Engineering and women's health: a slow start, but gaining momentum.

While biomedical engineers have participated in research studies that focus on understanding aspects particular to women's health since the 1950s, the depth and breadth of the research have increased significantly in the last 15-20 years. It has been increasingly clear that engineers can lend important knowledge and analysis to address questions that are key to understanding physiology and pathophysiology related to women's health. This historical survey identifies some of the earliest contributions of engineers to exploring aspects of women's health, from the behaviour of key tissues, to issues of reproduction and breast cancer. In addition, some of the more recent work in each area is identified and areas deserving additional attention are described. The interdisciplinary nature of this area of engineering, along with the growing interest within the field of biomedical engineering, promise to bring exciting new discoveries and expand knowledge that will positively impact women's health in the near future.

Maternal Endogenous Forces and Shoulder Dystocia.

Childbirth is a complicated biomechanical process that many take for granted. However, the delivery forces generated by a mother (uterine contractions and maternal pushing) are strong and have a significant effect on the body and tissues of the fetus, especially during the second stage of labor. Although most infants are born without negative, force-related outcomes, in some infants the normal forces of labor cause an injury that can have either temporary or permanent sequelae. The biomechanical situation is further complicated when an infant's shoulder impacts the maternal pelvis, which provides increased resistance and creates added stresses within the neonatal body and tissues.

Transcranial sonothrombolysis using high-intensity focused ultrasound: impact of increasing output power on clot fragmentation.

BACKGROUND: The primary goal of this study was to investigate the relationship between increasing output power levels and clot fragmentation during high-intensity focused ultrasound (HIFU)-induced thrombolysis. METHODS: A HIFU headsystem, designed for brain applications in humans, was used for this project. A human calvarium was mounted inside the water-filled hemispheric transducer. Artificial thrombi were placed inside the skull and located at the natural focus point of the transducer. Clots were exposed to a range of acoustic output power levels from 0 to 400 W. The other HIFU operating parameters remained constant. To assess clot fragmentation, three filters of different mesh pore sizes were used. To assess sonothrombolysis efficacy, the clot weight loss was measured. RESULTS: No evidence of increasing clot fragmentation was found with increasing acoustic intensities in the majority of the study groups of less than 400 W. Increasing clot lysis could be observed with increasing acoustic output powers. CONCLUSION: Transcranial sonothrombolysis could be achieved in vitro within seconds in the absence of tPA and without producing relevant clot fragmentation, using acoustic output powers of <400 W.

Effect of clinician-applied maneuvers on brachial plexus stretch during a shoulder dystocia event: investigation using a computer simulation model.

OBJECTIVE: The objective of the study was to determine how standard shoulder dystocia maneuvers affect delivery force and brachial plexus stretch. STUDY DESIGN: A 3-dimensional computer model of shoulder dystocia was developed, including both a fetus and a maternal pelvis. Application of suprapubic pressure, rotation of the infant's shoulders, and delivery of the posterior arm following shoulder dystocia were each modeled, and delivery force and brachial plexus stretch were predicted. RESULTS: Compared with lithotomy alone, all maneuvers reduced both the required delivery force and brachial plexus stretch. The greatest effect was seen with delivery of the posterior arm, which showed a 71% decrease in anterior nerve stretch (3.9% vs 13.5%) and an 80% decrease in delivery force. CONCLUSION: The standard maneuvers met the objective of reducing the necessary delivery force compared with the lithotomy position alone. Brachial plexus stretch is also reduced when these maneuvers are used rather than continuing the delivery in lithotomy position.

The effect of yield damage on the viscoelastic properties of cortical bone tissue as measured by dynamic mechanical analysis.

We have previously shown, using Dynamic Mechanical Analysis (DMA), that the presence of a defect in cortical bone tissue affects the apparent viscoelastic properties of that bone. However, mechanically induced damage is more complex than a machined defect making it difficult to predict its effect on bone viscoelasticity. We performed DMA measurements before and after introduction of yield damage into cortical bone beams from sheep radii. The specimens were placed in a DMA machine and baseline measurements of storage modulus (E1) and loss factor (tandelta) were performed using a 3-point bending configuration for a frequency range of 1-10 Hz. Measurements were done in all four bending directions (cranial, caudal, medial, and lateral) in random order. After subjecting the specimens to monotonic yield damage in a servohydraulic testing machine with the load applied to the cranial surface, oscillatory tests were repeated. To supplement results from the current experiment, additional analyses were performed on data from experiments where bone was either cut or fatigue-loaded between viscoelasticity measurements. Introduction of mechanical damage increased tan delta and frequency sensitivity of E1, consistent with the assertion that increased energy dissipation in damaged bone might contribute to its increased resistance to fatigue and fracture.

The high frequency properties of brain tissue.

Computer modeling is becoming increasingly important in the realm of brain biomechanics and injury. New computer simulations range from modeling of brain surgery, a low frequency, high strain event, to predicting injury as a result of an impact to the head, a high frequency event with varying strain magnitudes. This range of modeling efforts requires characterization of the tissue over as wide a frequency and strain range as possible. Research done to date has concentrated on the low frequency properties of the tissue. Complex compression and complex shear moduli have been measured at frequencies up to 350 Hz. Impact modeling requires use of frequency data at significantly higher frequencies than these. The "wave-in-a-tube" ultrasonic method was applied to brain tissue to determine mechanical properties at frequencies between 100 kHz and 10 MHz. Of these properties, only complex bulk modulus |K*| is fairly invariant (2133 MPa) with respect to frequency. Complex shear and complex Young's moduli vary with frequency and approach an asymptotic upper limit. Some variation in complex Poisson's ratio was also observed.

Prediction of brachial plexus stretching during shoulder dystocia using a computer simulation model.

OBJECTIVE: The purpose was to study the impact of maternal endogenous and clinician-applied exogenous delivery forces on brachial plexus stretching during a shoulder dystocia event. STUDY DESIGN: A computer software crash dummy model (MADYMO, version 5.4, TNO Automotive, Delft, The Netherlands) was modified on the basis of established maternal pelvis and fetal anatomic specifications. The brachial plexus was modeled as a spring, with mechanical properties that were based on previously reported experimental data. Increasing amounts of endogenous or exogenous loading forces were applied until delivery of the anterior fetal shoulder occurred. Brachial plexus deformation was assessed as percent stretch in the nerve (Change in length/Original length x 100). RESULTS: With lithotomy positioning, both maternal endogenous and clinician-applied exogenous delivery forces were associated with brachial plexus stretching (15.7% vs 14.0%, respectively). McRoberts positioning reduced needed loading forces for delivery and resulted in 53% less brachial plexus stretch (6.6%). Downward lateral displacement of the fetal head was associated with a 30% increase in brachial plexus stretch (18.2%) compared with axial positioning of the head (14.0%). CONCLUSION: Brachial plexus stretch varied as a result of the load required for delivery, the source of the applied force, pelvic orientation, and fetal head positioning. Maternally derived and clinician-applied delivery forces can both lead to brachial plexus deformation when shoulder dystocia is encountered. The McRoberts maneuver can reduce brachial plexus stretching. Management of fetal head position may also be important in reducing unnecessary brachial plexus stretch.

Cement pressurization after provisional repair of femoral cortical defects.

Cortical defects are common and problematic in cemented revision hip arthroplasty. Extruded cement can cause thermal injury, pain, and impingement. Decreased cement pressure limits bony interdigitation and leads to loosening. Historically, surgeons have used a finger to contain cement and improve pressure, and decrease porosity, but, with large or multiple defects, fingers are ineffective. Novel solutions--such as wrapping foil suture packaging or half a syringe barrel around the defects--have been previously published. In the study reported here, we used modern cementing techniques, continuous pressure monitoring, and porosity calculations to analyze the utility of the 3 provisional defect-fixation techniques. The foil and the hemisyringe worked as well as a finger (P > .05). All 3 techniques enhanced pressurization and maintained the porosity reduction. Although manually pressurizing cement and feeling resistance provide the surgeon with more tactile feedback, using the gun and a proximal adapter was more effective in improving pressure. Using these provisional defect-fixation techniques as well as a cement gun and proximal adapter can improve cement pressure and decrease porosity. These techniques are particularly useful with large or multiple cortical defects encountered in revision arthroplasty or total hip arthroplasty after open reduction.

Defining forces that are associated with shoulder dystocia: the use of a mathematic dynamic computer model.

OBJECTIVE: A computer model was modified to study the impact of maternal endogenous and clinician-applied exogenous delivery loads on the contact force between the anterior fetal shoulder and the maternal symphysis pubis. STUDY DESIGN: Varying endogenous and exogenous loads were applied, and the contact force was determined. Experiments also examined the effect of pelvic orientation and the direction of load application on contact force behind the symphysis pubis. RESULTS: Exogenous loading forces (50-100 N) resulted in anterior shoulder contact forces of 107 to 127 N, with delivery accomplished at 100 N of applied load. Higher contact forces (147-272 N) were noted for endogenously applied loads (100-400 N), with delivery occurring at 400 N of maternal force. Pelvic rotation from lithotomy to McRoberts' positioning resulted in reduced contact forces. Downward lateral flexion of the fetal head led to little difference in contact force but required 30% more exogenous load to achieve delivery. CONCLUSION: Compared with clinician-applied exogenous force, larger maternally derived endogenous forces are needed to clear the impacted anterior fetal shoulder. This is associated with >2 times more contact force by the obstructing symphysis pubis. McRoberts' positioning reduces shoulder-symphysis pubis contact force. Lateral flexion of the fetal head results in the larger forces that are needed for delivery but has little effect on contact force. Model refinements are needed to examine delivery forces and brachial plexus stretching more specifically.

Assessment of bone quantity and 'quality' by ultrasound attenuation and velocity in the heel.

OBJECTIVE: To determine if ultrasound measurements in the heel are related to bone quality in addition to quantity. DESIGN: In situ and in vitro experiments on cadaver heels. BACKGROUND: It has been suggested, but not demonstrated, that clinical ultrasound - used to screen for osteoporosis in clinical trials - provides a measure of 'bone quality' as distinct from bone quantity. METHODS: Ultrasound transmission velocity (UTV) and the slope of the linear dependence of broadband ultrasound attenuation on frequency (BUA) were measured in situ in 32 heels of 16 cadavers and in vitro in cores of calcaneal trabecular bone. RESULTS: After adjusting for Young's modulus, in situ UTV explains 33% (P = 0.03) and in situ BUA explains none of the remaining variance in density (r(2) = 0.02, P = 0.60). After adjusting for density, in situ BUA explains 29% (P = 0.04) and in situ UTV explains none of the remaining variance in Young's modulus (r(2) = 0.01, P = 0.79). By comparison, in vitro BUA explains 58% (P = 0.001) of the remaining variance in Young's modulus, after adjusting for density. CONCLUSIONS: In situ BUA reflects 'bone quality' independently of bone quantity, whereas in situ UTV reflects bone quantity independently of 'bone quality'.