Upper extremity spasticity in children with cerebral palsy: a randomized, double-blind, placebo-controlled study of the short-term outcomes of treatment with botulinum A toxin.

PURPOSE: Botulinum A toxin (BoNT-A) injections are used widely to manage lower extremity spasticity in children with cerebral palsy. However, their use in the upper extremity is less well defined. This randomized, double-blind, placebo-controlled clinical trial evaluated the safety and efficacy of upper extremity intramuscular injections of BoNT-A in a cross-section of children with varying levels of function. METHODS: Upper extremity function of study participants (N = 73; M:F = 47:26; age range, 3-18 y) was evaluated using the House Classification system (scores, 0-8, where a higher score indicates higher functional ability). Three groups of children were identified based on their House scores: 0-2 (n = 10), 3-5 (n = 54), and 6-8 (n = 9). Following randomization, children received a BoNT-A or placebo injection at baseline. Injections were administered at 8 and 20 weeks if clinically indicated. Occupational therapists evaluated study participants at screening, at baseline, and at 4, 8, 14, 20, and 26 weeks. Physician evaluations occurred at baseline and at 8, 20, and 26 weeks. The Melbourne Assessment of Unilateral Upper Limb Function evaluated the quality of upper extremity function before and after injections and served as the primary outcome variable. RESULTS: The majority of study participants underwent 3 injection sessions. Muscles injected were individualized based on each child's particular spasticity pattern. A statistically higher percentage of children receiving BoNT-A injections showed an improvement in the Melbourne assessment at 26 weeks compared with the children receiving placebo. The range, frequency, and severity of postinjection adverse events were similar in both groups. CONCLUSIONS: Children receiving BoNT-A injections demonstrated clinically meaningful short-term improvements in upper extremity function. Injections were well tolerated and safe. In contrast to other studies, study participants underwent multiple injection sessions based on their individual spasticity patterns.

Quantification of upper extremity function and range of motion in children with cerebral palsy.

This study evaluated the hypothesis that upper extremity function and range of motion can be quantified reliably in children with cerebral palsy (CP) in a busy clinical setting. The specific aim was to determine the inter- and intrarater reliability of a modified House Functional Classification (MHC) system to evaluate upper extremity function and a standardized instrument to document upper extremity range of motion (Upper Extremity Rating Scale [UERS]). Sixty-five children with CP (43 males, 22 females, mean age 9y 2mo, SD 4y 1mo) with spasticity involving the upper extremity (quadriplegia n=22; hemiplegia n=36; diplegia n=7; Gross Motor Functional Classification System Levels I n=41, II n=6, III n=3, IV n=5, V n=10) were evaluated independently by occupational therapists and orthopedic surgeons using both instruments at several visits. Inter- and intrarater reliability were determined for both instruments by calculating measures of agreement (weighted kappa values and intraclass correlation coefficients [ICCs]). Interrater agreement (ICC=0.94) and intrarater agreement (ICC=0.96) on the MHC were good to excellent. Similarly, inter-rater agreement (kappa 0.66-0.81) and intrarater agreement (kappa 0.64-0.88) on the UERS was either good or excellent. The MHC and the UERS provide standardized, reliable, reproducible, and efficient instruments that can be used by occupational therapists and orthopedic surgeons to evaluate the upper extremities of children with CP.

PIP Fracture/Dislocation Treatment Technique: Use of a Hemi-Hamate Resurfacing Arthroplasty.

The nature of injury following a PIP fracture dislocation is determined by the direction of force transmission and the position of the joint at the time of impact. Dorsal dislocations with palmar lip fractures are the most frequently encountered and can be classified based on stability. The degree of stability is directly determined by the amount of middle phalangeal palmar lip involvement; the larger the palmar lip fracture, the more unstable the joint becomes. When there is persistent instability or greater than 30 degrees of flexion is required to maintain reduction, treatment must be aimed at reconstituting the cup shaped geometry and buttressing effect of the volar lip of the middle phalanx if stability is to be restored. The use of a hemi-hamate autograft to reconstruct the base of the middle phalanx is a new technique that restores joint congruity and stability while allowing for early motion. This operative technique replaces the damaged palmar lip of the middle phalanx with a size-matched portion of the hamate obtained from its distal dorsal articular surface between the 4th and 5th metacarpals. By restoring both articular congruity and osseous stability the advantage of this procedure is that it allows more immediate rehabilitation with a potential for earlier motion, less stiffness and possibly less post-traumatic arthritis.

Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft.

PURPOSE: This retrospective study was designed to evaluate the clinical and radiographic results of a hemi-hamate autograft for the treatment of comminuted dorsal proximal interphalangeal (PIP) joint fracture/dislocations. METHODS: Thirteen consecutive patients underwent hemi-hamate autograft for the treatment of an unstable dorsal PIP fracture dislocation. The fractured middle phalangeal base was debrided and the defect was replaced using a size-matched portion of the dorsal/distal hamate osteoarticular surface and was secured with miniscrews. The average middle phalangeal volar lip involvement on initial radiographs was 60% (range, 40% to 80%). The average time to surgery was 45 days (range, 2-175 d). Range of motion, stability, and grip strength were measured at a mean follow-up evaluation of 16 months. Radiographs were evaluated for union, graft incorporation, and/or collapse. Subjective data, satisfaction, and return to work were obtained on 12 of the 13 patients at a mean follow-up evaluation of 17 months. RESULTS: The average arc of motion at the PIP joint was 85 degrees (range, 65 degrees to 100 degrees ). The distal interphalangeal (DIP) joint average arc of motion was 60 degrees (range, 35 degrees to 80 degrees ). Average grip strength was 80% of the uninjured side. Bony union was achieved in all patients. One graft showed ulnar collapse but graft resorption was not noted. Except for 2 patients with recurrent dorsal subluxation there were no complications. The average pain level was 1.3 (as rated on a visual analog scale of 0-10). Eleven of 12 patients were very satisfied with their function and one was somewhat satisfied; one patient was lost to follow-up. CONCLUSIONS: When greater than 50% of the volar base of the middle phalanx is fractured in a PIP fracture/dislocation or the joint remains unstable despite a lesser degree of involvement, a hemi-hamate autograft should be considered. This procedure reconstructs the cup-shaped contour of the middle phalangeal articular surface and facilitates a stable, functional arc of motion at the PIP joint. Additionally, in our experience the procedure renders minimal disability and has a low complication rate.