Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction: early experience.

BACKGROUND: Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting. METHODS: A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting. RESULTS: Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion. CONCLUSION: Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.

Evaluating the feasibility of implementing the Sup-ER protocol for infants with brachial plexus birth injury.

BACKGROUND: The Sup-ER protocol involves a repositioning program for infants with brachial plexus birth injury to position the shoulder in external rotation (ER) to address progressive loss in passive range of motion (PROM). The British Columbia Children's Hospital (BCCH) eligibility criteria for this protocol are infants aged 4-8 weeks with decreased shoulder ER PROM and/or Active Movement Scale (AMS) shoulder ER and/or supination scores ≤2. The resources needed to implement this protocol in large clinics have not been studied. PURPOSE: This study aims to evaluate the BCCH criteria that are used to identify appropriate candidates for the Sup-ER protocol. STUDY DESIGN: A retrospective cohort study was conducted to identify the percentage of infants who would have been recommended the Sup-ER protocol based on their PROM and AMS scores between 4 and 8 weeks of age. METHODS: A sensitivity and specificity evaluation was used to describe the BCCH criteria's ability to identify infants in this historical cohort who went on to have incomplete shoulder function (ie, true positive) vs infants who had functional shoulder outcome at 9 months of age (ie, false positive). RESULTS: At a mean of 5.8 weeks (95% confidence interval [CI] 5.3, 6.3), 46 of the 87 (53%) infants satisfied the BCCH Sup-ER protocol criteria. Forty-four (51%) were female, half (n = 45) were left side affected, and 88% had upper plexus injury. The BCCH Sup-ER protocol criteria had sensitivity of 100% and specificity of 71% to identify infants with incomplete shoulder function. Removing the AMS supination ≤2 score criterion from the criteria improves the specificity to 84%, while sensitivity remains high (97%). CONCLUSIONS: Modifying the BCCH criteria to all infants aged 4-8 weeks with AMS shoulder ER ≤2 and/or decreased shoulder ER PROM improves the precision of identifying infants who would benefit from the Sup-ER protocol.

Prevalence and predictors of elbow flexion contractures during early childhood following brachial plexus birth injury.

BACKGROUND: Elbow flexion contracture development in school-age children with a brachial plexus birth injury (BPBI) is common. Reports indicate onset between 2 and 4 years; however, little is known about early childhood prevalence, development, and trajectory of these contractures. PURPOSE: To determine the prevalence and predictors of BPBI elbow flexion contractures during early childhood. STUDY DESIGN: A retrospective cross-sectional study. METHODS: Demographic, diagnostic, treatment, and elbow contracture data were collected for children with a BPBI <4 years between 2015 and 2019 from a prospectively collected database. Spinal root motor contributions and injury were determined using Active Movement Scale (AMS) scores at 6 weeks of age and used to predict contracture development. RESULTS: Of the 171 children that met inclusion criteria, 87% (n = 149) had upper plexus injuries. The mean age at the time of evaluation for an elbow contracture was 21.4 ± 12.7 months. The prevalence of elbow flexion contractures was 22% (n = 38), with mean onset at 13.4 ± 11.0 months. Mean contracture degree was -10.8 ± -6.9 degrees with 76% (n = 29) <-10 degrees. AMS shoulder abduction, flexion, and external rotation; elbow flexion; forearm supination; and wrist extension scores at a mean 2.3 ± 1.4 months were significantly lower in children who developed elbow flexion contractures (p < 0.001). Logistic regression found that low AMS elbow flexion with high elbow extension scores were a significant (p < 0.003) predictor of elbow contracture development. CONCLUSIONS: The prevalence of elbow flexion contractures in early childhood is greater than previously understood. These findings indicate that C5-C6 injury affecting elbow flexion with relative preservation of elbow extension is a predictor of contracture development. Further research is needed to investigate the nature and sequelae of C5-C6 injury and its effects on elbow flexion contracture development.

Long-Term Hand Function Outcomes of the Surgical Management of Complete Brachial Plexus Birth Injury.

PURPOSE: Hand function outcomes of primary nerve reconstruction for total brachial plexus birth injury (BPBI) are confounded by nerve roots left in continuity, inclusion of secondary procedures, and no assessment of the ability to perform activities of daily living. The purpose of this study was to evaluate the long-term hand function outcomes in a cohort of patients with a complete BPBI who had no nerve root in continuity prior to primary nerve reconstruction targeting the lower trunk. METHODS: This single-center retrospective case series of complete BPBI included patients who underwent primary nerve reconstruction. The outcomes were assessed using the active movement scale (AMS) and brachial plexus outcome measure preoperatively and at the age of 4 and 8 years. RESULTS: Fifty patients with a complete BPBI, of whom 82% (41/50) had an avulsion of C8-T1, underwent primary nerve reconstruction at a mean age of 4.1 months. Compared with the preoperative AMS scores, a statistically significant increase of AMS scores was observed at 4 and 8 years of age for all movements except forearm pronation. Between 4 and 8 years of age, there was a statistically significant improvement of external rotation of the shoulder and elbow flexion as well as diminution of thumb flexion. In the brachial plexus outcome measure assessment, there were 83% (24/29) at 4 years and 81% (21/26) at 8 years who had sufficient functional movement to perform wrist, finger, and thumb activities. CONCLUSIONS: Functional hand outcome was restored to sufficiently perform bimanual activity tasks in 81% (21/26) of patients with a complete BPBI at 8 years of age. This affirmed that primary nerve reconstruction reinnervating the lower trunk can result in a functional extremity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Evaluation of a Pediatric Facial Paralysis Education and Family Support Day.

INTRODUCTION: Facial paralysis impairs the mimetic functions of the facial musculature. In pediatric patients, free functioning muscle transfer neurotized with an intact contralateral facial nerve is the gold standard for smile reanimation. In response to requests from families of children with facial paralysis, the Division of Plastic and Reconstructive Surgery at the Hospital for Sick Children hosted an inaugural "Facial Paralysis Family Day." The objective was to create an opportunity for families to meet, exchange stories, and build support networks. METHODS: This study was a quality improvement project to conduct a needs assessment and evaluate the feasibility and satisfaction of implementing a family support intervention for individuals living with facial paralysis. RESULTS: The needs assessment demonstrated that families were most interested in advances in medicine, therapy and coping sessions and meeting other families. The post-event evaluation questionnaire indicated that attendees enjoyed the event, would attend again and found it highly valuable connecting and networking other families. It also indicated that key needs identified were addressed, with excellent ratings for the presentation discussing advances in medicine (100% rated "good" or "very good"), the therapy sessions (92% rated "good" or "very good") and the presentations by patients and their families (100% rated "good" or "very good.") DISCUSSION:: Two areas of improvement highlighted were elaborating further on medical advances and facilitating interactions between families. Overall, this event was well regarded and will likely be repeated at our institution and serve as a valuable resource for other hospitals planning to organize a similar event.

Management of congenital melanocytic nevi in the plastic surgery clinic: Families' expectations and their persistent concern about malignancy.

BACKGROUND: Children with congenital melanocytic nevi (CMN) were historically managed with surgical removal to lower the risk of malignant transformation. The evolving literature over the last decade has indicated a significantly lower risk than previously estimated. Indications for excision currently revolve around aesthetic and psychosocial concerns. This study describes and evaluates the perspectives and expectations of patients and families referred to a pediatric plastic surgery clinic on CMN management. METHOD: A two-part questionnaire was administered before and after an initial clinic appointment to evaluate patient and family concerns of lesion growth, risk of malignancy, treatment expectations, and stigmatization. RESULTS: Thirty questionnaires were completed for 11 male and 19 female patients, mean age 9.2 years (1-25). Referring doctors (majority dermatologists) were rarely concerned about malignancy (8%), but parents listed it as a top reason for wanting the CMN removed (37%) and the most common expectation for the visit followed by information about surgical options and outcome. Before the clinic, 93% were at least "slightly" worried about CMN growth and 96% about malignancy, whereas 63% and 72%, respectively, after the clinic. CONCLUSIONS: Families want information about surgical excision and are concerned about malignancy, indicating lingering misinformation or misconception about melanoma risk. For the majority, CMN removal remains at least slightly important, presumably for aesthetic reasons and remaining concern about malignancy. Involved health care professionals should assure reliable and coherent patient information about MM risk, indications for surgery and expected outcome to best support families' decision-making.

Sensory Outcome in Children Following Microsurgery for Brachial Plexus Birth Injury.

PURPOSE: Studies are limited on sensory outcome in children with brachial plexus birth injury (BPBI). The purpose of this research was to evaluate the sensory function of the hand in children with BPBI who had microsurgical reconstruction of the brachial plexus. METHODS: The sensory thresholds of children with upper and total plexus injury were evaluated with the Weinstein Enhanced Sensory Test and a test of stereognosis. RESULTS: A total of 63 children participated (aged 10.92 ± 3.29 years), 24 (38%) of whom had abnormal sensory thresholds in the affected hand. Only 4 children had loss of protective sensation or higher thresholds. These 4 measurements were all identified in the territory of the superficial branch of the radial nerve. Twelve children with upper plexus (43%) and 12 (34%) with total plexus injury had sensory impairment in the affected hand. These proportions were not statistically different. Of all children evaluated, 18 (29%) had a lower stereognosis score in the affected hand compared with the unaffected hand. The proportions of children with impairment in stereognosis in the upper plexus group (n = 5; 18%) versus the total plexus group (n = 13; 37%) were not statistically different. Age at the time of assessment, sex, upper versus total plexus injury, number of root avulsions, subjective report of altered sensation, and Faces Pain Scale-Revised score were not related to sensory impairment in the affected hand. CONCLUSIONS: Sensory recovery in BPBI after microsurgical reconstruction in children with total plexus injury who had reconstruction of the lower trunk had the potential to achieve sensory recovery similar to their upper plexus counterparts. A large proportion of children achieve normal sensory outcome, and those who had deficits had mild impairments. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Comparing Cephalic Index and Midsagittal Vector Analysis in Assessing Morphology in Sagittal Synostosis: A CT-Based Morphometric Analysis.

INTRODUCTION: Assessment of cranial dysmorphism in sagittal synostosis is often subjective but objective measures can be applied. These include cephalic index (CI) and midsagittal vector analysis (MSVA). OBJECTIVE: To assess discriminant validity, construct validity, and responsiveness of CI and MSVA measured from computed tomography (CT) in patients with sagittal synostosis. METHODS: Patients with nonsyndromic isolated sagittal synostosis with complete preoperative (n = 30) and postoperative (n = 13) CT data were included. Age-matched control group (n = 24) comprised of normocephalic patients who underwent CT for reasons related to trauma. OUTCOME MEASURES: Retrospective CT evaluation of CI and MSVA was conducted and correlated with a dysmorphism numeric rating scale (D-NRS) that measured surgeon-rated severity of sagittal synostosis. Responsiveness of CI and MSVA was evaluated using dysmorphism global rating of change (D-GRC). RESULTS: Thirty patients with sagittal synostosis were demographically similar to 24 normocephalic patients. The difference in CI and MSVA was statistically significant between normocephalic and scaphocephalic patients. Cephalic index had a good correlation with D-NRS (r = -0.665, ρ = -0.667), but not with MSVA (r = 0.250, ρ = 0.203). Change in CI (r = 0.738, ρ = 0.657) was well correlated with D-GRC, but not with MSVA (r = -0.409, ρ = -0.301). CONCLUSION: Cephalic index appears to quantify the severity of sagittal synostosis better than MSVA. Cephalic index also has better responsiveness than MSVA to measure a reduction in severity of disease; however, MSVA is a better descriptive craniometric measurement. Midsagittal vector analysis was able to quantify the shift in morphology in sagittal synostosis following surgical treatment.

Evaluation of pain in pediatric upper extremity conditions.

STUDY DESIGN: Narrative Review. INTRODUCTION: Hand surgeons and therapists play an important role in the early identification of children at risk of developing chronic or recurrent pain after an upper extremity injury. Early identification of children at risk of developing a pain syndrome is critical because their physical, psychological, and/or social functioning may decline quickly without proper management due to the multidimensional nature of pain. PURPOSE OF THE STUDY: This article outlines one approach to evaluating upper extremity pain in children to help identify those with, or at risk of, chronic pain. METHODS: An assessment framework that recognizes the biological, sensory, emotional, and psychosocial components of pain is described. RESULTS: The key components of a screening evaluation include obtaining a detailed history and a thorough physical examination that involves: systematic upper extremity mapping of sensory thresholds, mapping of sensory disturbances, and screening of self-reported pain intensity, location, descriptors, and interference. DISCUSSION AND CONCLUSION: The evaluation approach described will enable hand therapists to identify children with upper extremity pain that are at risk of developing a chronic pain and make an early referral to a multidisciplinary pain team that provides education, pharmacological pain management, physical rehabilitation, and psychological treatments.

Forearm Pronation Osteotomy for Supination Contracture Secondary to Obstetrical Brachial Plexus Palsy: A Retrospective Cohort Study.

BACKGROUND: Obstetrical brachial plexus palsy can lead to fixed forearm supination contracture. Fixed supination may lead to functional deficits as the affected hand cannot be positioned optimally for activities on a desk such as writing and typing, or for using tools including utensils, which require a neutral or pronated forearm. Forearm pronation osteotomy has been used to address this problem, although the functional benefit over nonoperative management has not been clearly defined. Potentially deleterious consequences on hand function that requires supination or fine motor skills are also uncertain. METHODS: Patients with fixed forearm supination contracture were selected from our institutional brachial plexus database. Those who underwent both bone forearm rotational osteotomy were analyzed for age at time of surgery, preoperative forearm resting position, active and passive supination and pronation, and preoperative function assessed by the brachial plexus outcome measure (BPOM) and active movement scale (AMS). Preoperative results were compared with values obtained at follow-up at least 12 months postoperatively. A matched cohort of children with fixed forearm supination contracture that were treated nonoperatively and followed for at least 12 months, was also selected. For this group, forearm resting position, movement, AMS, and BPOM scores were analyzed at a baseline clinic visit and the most recent follow-up. Changes in forearm resting position, AMS, and BPOM activity scale scores were then compared between groups. RESULTS: Records were obtained for 14 cases and 10 controls. Study groups were similar with respect to resting forearm position, hand function, and time from initial to final evaluation. Groups differed with respect to age and active supination. We observed a statistically significant change in resting position among operative patients compared with their preoperative status and compared with controls. Hand-specific AMS score did not change significantly in the operative group as compared with controls. The BPOM score for drums, reflective of function in neutral rotation to mild pronation, improved in the operated patients as compared with controls. There was no loss of plate holding ability (reflective of supination function, putty (grasp), or bead placement (fine motor) among the operated patients as compared with controls. CONCLUSIONS: By pronating resting forearm position by about 90 degrees to near neutral, osteotomy resulted in improved neutral to mild pronation-dependent function without loss of supination-dependent function or hand motor skills. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

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.

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.

Establishing expert consensus on the evaluation of pediatric upper extremity function.

STUDY DESIGN: Consensus statement. INTRODUCTION: There is a lack of consensus in the literature on the measures of pediatric upper extremity (UE) function for musculoskeletal conditions. PURPOSE: To establish expert consensus on utility, satisfaction and importance of functional outcome measures in children with UE musculoskeletal conditions, across International Classification of Functioning, Disability and Health (ICF) domains. METHODS: Using Delphi Consensus Methodology, expert panelists completed three rounds of questionnaires. RESULTS: Agreement on Body Functions and Structure, Activity, and Participation outcome measures was determined (α, ICC range = 0.86-0.96). Mean satisfaction of measures in the respective domains was between 6.93 and 7.94. The Activity domain had lowest satisfaction, however there was consensus it was the most important. DISCUSSION: Consensus on relative importance, but low satisfaction in the Activity domain suggests a need for better outcomes in this domain. CONCLUSIONS: Findings report the status of outcome measure utility and use in pediatric UE function. LEVEL OF EVIDENCE: 5.

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.

The incidence of idiopathic musculoskeletal pain in children with upper extremity injuries.

INTRODUCTION: Children with upper extremity injuries may report persistent pain beyond the period of acute injury. In the published literature, it is unclear whether these children develop idiopathic musculoskeletal pain (IMP) such as complex regional pain syndrome (CRPS). The purpose of this study was to determine the incidence rate of IMP after upper extremity injury in school-aged children over a 5-year period and to describe the characteristics of these children. METHODS: A retrospective case series was conducted of all children aged 8-18 years with an upper extremity injury who attended the outpatient hand clinic in a tertiary care pediatric hospital. RESULTS: A reported incidence rate of IMP was 1.9% over a 5-year period in the 879 children reviewed. Girls were more likely to have IMP. The categorical distribution of the type, etiology and anatomical location of injury was proportionately different for those with IMP compared to those without documentation of IMP. In comparison, a higher percentage of children with IMP reported disproportionate pain and hypersensitivity or neuropathic pain symptoms compared to the children who had pain from a known etiology. CONCLUSION: The incidence rate of IMP after upper extremity injury in school-aged children is low. Some common characteristics of this population that may help clinicians identify these children and make timely referrals for treatment include female gender, disproportionate pain, previously seen by multiple specialists, generalized injury in the hand, unspecific etiology or type of injury and unremarkable x-rays.

Patient reported outcomes in brachial plexus birth injury: results from the iPLUTO world-wide consensus survey.

PURPOSE: Brachial plexus birth injuries (BPBI) can have lifelong effects on the development and functional use of the upper extremity. Currently there is no agreement with regards to what patient-reported outcome (PRO) measures should be used. Therefore, the ability to compare the effects of treatment between individuals and institutions is challenging. This study aimed to achieve consensus among clinicians on the use of PRO measures within this patient group to allow for improved comparison of treatments and outcomes in the future. MATERIALS AND METHODS: Online, a 3 round Delphi survey was completed by 35 international multi-disciplinary specialist centers. RESULTS: All respondents (100%) agreed that PRO measures are useful for clinical evaluation and patient treatment. None of the outcome measures scored >75% agreement for ability to assess responsiveness and current state in children with BPBI as most outcome measures were judged as not specific for BPBI. Additionally, participant centers were asked their perspective on the best available PRO option for each of the 3 categories: functional use of the upper limb, quality of life and pain. This resulted in endorsement by the participant centers of the Brachial Plexus Outcome Measure - Self-Evaluation, the Pediatric Quality of Life Inventory, and Visual Analogue Scale/Brief Pain Inventory respectively. CONCLUSION: International specialists in BPBI agree that PRO measures are important to use both clinically and in research in children aged 5 years and above.

Patient-reported outcome measures were judged as useful both in clinic and in research for brachial plexus birth injury (BPBI), according to a panel of specialized centers.Currently available outcome measures were judged as not specific for BPBI.The panel endorsed the following measures as best available: the Brachial Plexus Outcome Measure ­ Self-Evaluation scale for functional evaluation, the Pediatric Quality of Life Inventory for disease-related quality of life and the Faces Pain Scale - Revised/Visual Analogue Scale/Brief Pain Inventory for pain.

Evaluation of Long-Term Surgical and Patient-Reported Outcomes after Pediatric Facial Reanimation.

BACKGROUND: Outcomes of pediatric facial reanimation beyond 10 years are not known. This cross-sectional study evaluated long-term surgical and patient-reported outcomes of adults who underwent smile reconstruction as children with either a cross-face nerve graft (CFNG) or masseter nerve transfer at least 10 years previously. METHODS: Commissure excursion was quantified with FACE-Gram software at 3 time points: preoperatively, early postoperatively within 2 years, and at long-term follow-up. Patient-reported outcomes were evaluated with validated questionnaires (Facial Clinimetric Evaluation Scale, FACE-Q 1.0) and thematic analysis of semistructured interviews. Results are reported as median (interquartile range [IQR]). RESULTS: A total of 42 patients were included (26 women and 16 men). Median long-term follow-up was 19.3 years (IQR, 8.8 years) for CFNG and 17.6 years (IQR, 5.8 years) for masseter nerve transfer. For both groups, commissure excursion increased significantly from preoperative to early postoperative time points and remained stable at long-term follow-up (P < 0.0001). Commissure excursion at long-term follow-up between the 2 groups was not significantly different (CFNG, 5.0 mm [IQR, 9.4 mm]; masseter nerve transfer, 8.4 mm [IQR, 4.1 mm]); P > 0.05). For patient-reported outcomes, median Facial Clinimetric Evaluation Scale score was 72 of 100, and 95% of respondents agreed with the statement "I am pleased with the result" on the FACE-Q 1.0. Overall quality of life was rated at 7 of 10 or greater by 97% of participants, and all participants would recommend the surgery to other children. CONCLUSIONS: Pediatric facial reanimation with CFNG or masseter nerve transfer reliably improves commissure excursion with longevity beyond 10 years. Adult patients report overall high satisfaction and social functioning.

Comparison of Surgical Wait Times and Procedure Length in the Management of Postaxial Polydactyly Using Local or General Anesthesia.

Introduction: For infants with ulnar polydactyly, surgical removal of the supernumerary digit can be performed under general or local anesthetic. This study evaluated the wait times, surgical duration, and sedation times associated with performing the procedure under local versus general anesthetic in infants with ulnar polydactyly. Methods: The databases of three surgeons at our institution were reviewed for children less than 2 years of age who underwent surgery for non-syndromic ulnar polydactyly. Data collection included patient demographics, wait times, duration of surgery and sedation and complications. Results: The study included children (n = 55) who received treatment under local (n = 22) or general (n = 33) anesthesia. The wait times for the local anesthetic group were significantly shorter than the general anesthetic group (p < 0.05) for: referral to first consultation appointment; referral to surgery date, and decision date to surgery date. The duration of surgery (17.9 ± 6.9 vs 36.6 ± 20.2 min) and sedation time (26.3 ± 11.1 vs 74.8 ± 29.1 min) were significantly shorter in the local anaesthetic group (p < 0.05). There were no differences in complication rates between the groups. Conclusion: In this single-institution retrospective analysis, treatment of non-syndromic ulnar polydactyly with local anesthetic and bottle sedation was associated with shorter wait times, and duration of surgery and sedation. Level of Evidence: III, retrospective chart review and quality improvement initiative.

Introduction : Chez les nourrissons présentant une polydactylie cubitale, il est possible de procéder à l'ablation chirurgicale du doigt excédentaire sous anesthésie locale ou générale. La présente étude visait à évaluer les temps d'attente, la durée de l'opération et la durée de la sédation associés à l'intervention lorsqu'elle était effectuée sous anesthésie locale ou générale chez les nourrissons présentant une polydactylie cubitale. méthodes : Les chercheurs ont fouillé les bases de données de trois chirurgiens de leur établissement pour en extraire les cas d'enfants de moins de deux ans ayant subi une opération de la polydactylie cubitale non syndromique. La collecte de données incluait les caractéristiques des patients, les temps d'attente, la durée de l'opération et de la sédation et les complications. Résultats : La présente étude incluait des enfants (n=55) qui avaient été traités sous anesthésie locale (n=22) ou générale (n=33). Le temps d'attente du groupe sous anesthésie locale était beaucoup plus court que celui du groupe sous anesthésie générale (p<0,05) pour ce qui est de la période entre l'orientation et la première consultation, l'orientation et la date de l'opération, ainsi que la date de la décision et la date de l'opération. La durée de l'opération (17,9 ± 6,9 minutes par rapport à 36,6 ± 20,2 minutes) et de la sédation (26,3 ± 11,1 minutes par rapport à 74,8 ± 29,1 minutes) était beaucoup plus courte dans le groupe sous anesthésie locale (p<0,05). Il n'y avait pas de différence entre les groupes à l'égard des taux de complications. Conclusion : Dans cette analyse rétrospective mono-institutionnelle, le traitement de la polydactylie cubitale non syndromique accompagné d'une anesthésie locale et d'une sédation par bonbonne était associé à une diminution du temps d'attente ainsi que de la durée d'opération et de sédation.

Elucidating children's understanding of brachial plexus birth injury.

Facilitating children's understanding of their medical condition can improve health outcomes and psychosocial well-being. To inform how medical information is delivered, an interpretive qualitative approach was used to explore children's understanding of their brachial plexus birth injury. In-depth interviews of children with brachial plexus birth injuries (n = 8) and their caregivers (n = 10) were conducted individually and as a child-caregiver dyad. Thematic analysis of interview data found that children primarily understood their injury through lived experiences of functional and psychosocial concerns related to movement and appearance of the affected limb, rather than medical information. Children's ability to learn about diagnostic and prognostic information was influenced by age, emotional readiness, and background knowledge. In receiving information about their medical condition, children needed greater support in understanding their prognosis and its implications on their future. These narratives indicate the importance of addressing the primary functional and psychosocial concerns to contextualize medical information and ascertain the emotional readiness of children with brachial plexus birth injuries in information delivery approaches.

Intersection of physical and mental health of youth with brachial plexus birth injuries: A qualitative study.

Introduction: Youth with brachial plexus birth injuries (BPBI) have an increased risk of mental health issues such as depression, anxiety, and diminished self-confidence. Despite this evidence, current standards of care focus on physical interventions. Evaluation of psychological and emotional concerns is rarely prioritized in clinical settings. Therefore, mental health needs are unmet and poorly understood. Methods: An interpretivist qualitative approach was used to understand the perspectives of youth with BPBI and their caregivers on the barriers and facilitators of addressing mental health concerns, to inform practice guidelines, and promote meaningful participation within this population. Results: A purposeful sample of nine youth with BPBI between 10 to 20 years and eight caregivers participated in in-depth interviews. The interviews were semi-structured and an average of 60 min (35-85 min) long. Three themes emerged from these data: (i) physical disability identity and mental health; (ii) pursuit of "normal" body image; and (iii) paradox of advocacy. Findings illuminated the intersection of physical and mental health in these youth and provides actionable practice recommendations. Areas of need were identified including mental health support around the challenges of advocacy, body image, surgery, and preparation for the 'aging out' process for youth and their families. Conclusions: The well-being of youth with BPBI is a result of the intersection between their physical and mental health. Further research on optimizing mental health resources within physical health settings is needed to better support the holistic needs of these youth and their families.