The construct validity and internal consistency of QuickDASH in pediatric patients with upper extremity fractures.

BACKGROUND AND PURPOSE: Investigation of treatment options in the pediatric population necessitates the use of valid patient-reported outcome measures (PROMs). We aimed to assess the construct validity and internal consistency of the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) in the pediatric population with upper extremity fractures treated both operatively and conservatively. PATIENTS AND METHODS: QuickDASH, along with several reference PROMs and objective outcome measures, was obtained from 148 5- to 18-year-old patients with a humeral medial epicondyle fracture or a fracture of the distal forearm in a cross-sectional setting with a single follow-up visit. Spearman's rank correlation and linear regression models were used to assess convergent validity, exploratory factor analysis (EFA) to assess structural validity, and Cronbach's alpha to investigate internal consistency. RESULTS: The direction and magnitude of correlation showed by QuickDASH with reference outcome measures was consistent and demonstrated good convergent validity. EFA indicated a 3-factor model with poor fit indices and structural validity remained questionable. Construct validity was considered acceptable overall. QuickDASH demonstrated good internal consistency with an acceptable Cronbach's alpha (α = 0.75). CONCLUSION: QuickDASH demonstrated acceptable construct validity and good internal consistency and is thus a valid instrument, with some limitations, to assess disability and quality of life in pediatric patients with upper extremity fractures.

Ethnic background as a risk factor for permanent brachial plexus birth injury: A population-based study.

INTRODUCTION: Brachial plexus birth injury is the most common birth injury causing permanent disability in Finland. This study aimed to assess risk factors of a permanent brachial plexus birth injury and calculate the incidence. MATERIAL AND METHODS: This is a retrospective population-based study including all deliveries between 2006 and 2022 in Southern Finland. The number of children born, obstetric data, and migrant status were gathered from the registries of the Finnish Institute for Health and Welfare, and Statistics Finland. Race of the mothers of children with a permanent brachial plexus birth injury was recorded. The severity of permanent brachial plexus birth injury was assessed using the 3-month Toronto test score. A lower score was indicative of a more severe injury (scored 0-10). RESULTS: One hundred of the 298 428 children born during the 17-year study period sustained a permanent brachial plexus birth injury (0.34 per 1000). Mothers of children with a permanent brachial plexus birth injury had a higher body mass index (29 vs. 24 kg/m2) and their pregnancies were more often complicated by diabetes (28% vs. 12%), shoulder dystocia (58% vs. 0.3%), and/or assisted deliveries (45% vs. 10%) compared with all other mothers (p < 0.001). Thirty two of the 52 725 children born to migrant mothers had a permanent brachial plexus birth injury (0.61 per 1000). The incidence of permanent brachial plexus birth injury was 5.7 times higher among children of Black migrants from Africa (18/11 738, 1.53 per 1000) compared with children of native mothers (0.27 per 1000). Black mothers had a higher body mass index at the start of pregnancy (29 vs. 26 kg/m2, p = 0.02) compared with Caucasians. Children of Black mothers had a more severe injury compared with all others (p = 0.007) with a mean 3-month Toronto test score of 4.2 (range 0.0-6.5, SD ±1.6) vs. 5.6 (range 0.0-9.3, SD ±2.2). CONCLUSIONS: Shoulder dystocia and assisted delivery are the most important risk factors for a permanent brachial plexus birth injury. Black race was associated with a higher rate and a more severe permanent brachial plexus birth injury.

Activity-restriction only as treatment yields positive outcomes in pediatric spinal compression fractures: a prospective study of 47 patients at medium-term follow-up.

BACKGROUND AND PURPOSE: We aimed to evaluate the clinical outcomes, radiographic results, and health-related quality of life in pediatric AO type A1 spinal compression fractures treated with activity-restriction only. PATIENTS AND METHODS: All children between 2014 and 2020 with an AO type A1 spinal compression fracture treated with activity-restriction only identified from an institutional fracture registry were invited to a prospective outcomes study. Clinical findings and spinal radiographs were assessed at median 3 years, interquartile range (IQR) 1-4 follow-up from injury. Oswestry Disability Index, Pediatric Quality of Life Inventory Generic Core Scale (PedsQL), and PedsQL Pediatric Pain Questionnaire were compared with reference values. 63 children were identified, of whom 47 agreed to participate. 8 were polytrauma patients. RESULTS: Age at injury was median 11 (IQR 9-14) years. The number of injured vertebrae was median 2 (IQR 1-3). 82% (94 of 115) were thoracic vertebrae fractures and 70% (33 of 47) of the patients had thoracic vertebrae fractures only. At follow-up all but 2 fractures showed radiographic remodeling. There was no difference from the published reference values in the patient-reported outcome measures. A lower PedsQL physical functioning score was associated with higher patient-reported pain (P = 0.03). At follow-up 12 patients had hyperkyphosis (median difference from the reference values 4°, IQR 3-6, 95% confidence interval [CI] 3-6) and 5 hypolordosis (median difference from reference 8°, IQR 4-11, CI 4-14). None of the patients had surgery for deformity during follow-up. CONCLUSION: Clinical, radiographic, and health-related quality of life outcomes were good after activity-restriction treatment in pediatric A1 spinal compression fractures.

Permanent Brachial Plexus Birth Injury: Helsinki Shoulder Protocol.

Passive shoulder exercises from birth and ultrasound screening from 3 to 12 months. Botox is given to shoulder internal rotators and a bracing commenced, if alpha-angle exceeds 30°, or passive shoulder external rotation is below 70 degrees. Plexus reconstruction is recommended to children with root avulsion(s) on magnetic resonance imaging or 3-month Toronto Test Score < 3.5. Specific neurotization is recommended to children without avulsions, but lack of progress in healing. Shoulder dysplasia was diagnosed in 49% of 270 patients with permanent brachial plexus birth injury in our catchment area from 1995 to 2021. The age at detection of shoulder dysplasia dropped from mean 5.4 years in children born before 2000 to mean 3.9 months in children born after 2009. Botox was given to 57% of the patients born after 2009. Rate of shoulder relocation decreased from 28 to 7% while mean active shoulder external rotation in adduction increased from 2 to 46°.

The Risk of Nerve Injury in Pediatric Forearm Fractures.

UPDATE: This article was updated on July 19, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 1080, in the last sentence of the Results section of the Abstract, the text that had read "0.05% (4 of 777)" now reads "0.5% (4 of 777)." BACKGROUND: The risk of fracture-related nerve injury associated with forearm fractures in children is unknown. The purposes of the present study were to calculate the risk of fracture-related nerve injury and to report the institutional rate of complications of surgical treatment of pediatric forearm fractures. METHODS: Four thousand, eight hundred and sixty-eight forearm fractures (ICD-10 codes S52.0 to S52.7) that had been treated in our tertiary level pediatric hospital between 2014 and 2021 were identified in our institutional fracture registry. Of these, 3,029 fractures occurred in boys and 53 were open fractures. Sex, age at injury, trauma mechanism and energy, fracture type, treatment method, and cause and type of nerve injury were assessed in 43 patients with 44 registered nerve injuries. Patients with nerve injuries were reevaluated to calculate the recovery time. Univariable and multivariable regression analyses were performed to determine the risk of nerve injury. RESULTS: The risk of a fracture-related nerve injury was 0.7% (33 of 4,868). Only 2 injuries were permanent; thus, the risk of permanent nerve injury associated with a forearm fracture was 0.04% (2 of 4,868). The ulnar nerve was affected in 19 cases; the median nerve, in 8; and the radial nerve, in 7. In cases of open fracture, the risk of nerve injury was 17% (9 of 53). Open fractures had an OR of 33.73 (95% CI, 14.97 to 70.68) on univariate analysis and an OR of 10.73 (95% CI 4.50 to 24.22) on multivariate analysis with adjustment for female sex and both-bone diaphyseal fracture. Both-bone diaphyseal fracture (ICD-10 code S52.4) had an OR of 9.01 (95% CI, 4.86 to 17.37) on univariate analysis and an OR of 9.98 (95% CI 5.32 to 19.47) on multivariate analysis with adjustment for age and female sex. Overall, 777 fractures were internally fixed. The risk of nerve injury as a complication of internal fixation was 1.3% (10 of 777). Four of these iatrogenic injuries (including 2 involving the median nerve, 1 involving the ulnar nerve, and 1 involving the radial nerve) were permanent; thus, the risk of permanent nerve injury as a complication of internal fixation was 0.5% (4 of 777). CONCLUSIONS: Nerve injury following a pediatric forearm fracture is rare and has an excellent potential for spontaneous recovery. In the present study, all of the permanent nerve injuries occurred in association with open fractures or as a complication of internal fixation. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Early disc degeneration in radiotherapy-treated childhood brain tumor survivors.

BACKGROUND: Childhood brain tumor (BT) survivors have an increased risk of treatment-related late effects, which can reduce health-related quality of life and increase morbidity. This study aimed to investigate lumbar disc degeneration in magnetic resonance imaging (MRI) in adult survivors of radiotherapy-treated childhood BT compared to age and sex-matched population controls. METHODS: In this cross-sectional comparative study, 127 survivors were identified from hospital registries. After a mean follow-up of 20.7 years (range 5-33.1), 67 survivors (mean age 28.4, range 16.2-43.5) were investigated with MRI and compared to 75 sex-matched population-based controls. Evaluated MRI phenotypes included Pfirrmann grading, , intervertebral disc protrusions, extrusions, and high-intensity-zone-lesions (HIZ). Groups were also compared for known risk factors of lumbar intervertebral disc (IVD) degeneration. RESULTS: Childhood BT survivors had higher Pfirrmann grades than controls at all lumbar levels (all p < 0.001). Lumbar disc protrusions at L4-5 (p = 0.02) and extrusions at L3-4 (p = 0.04), L4-5 (p = 0.004), and L5-S1 (p = 0.01) were significantly more common in the BT group compared to the control. The survivor cohort also had significantly more HIZ-lesons than the controls (n=13 and n=1, p=0.003). Age at diagnosis was associated with lower degree of IVD degeneration (p < 0.01). Blood pressure correlated with IVD degeneration (P < 0.05). CONCLUSIONS: Signs of early disc degeneration related to tumor treatment can be seen in the IVDs of survivors. Disc degeneration was more severe in children treated in adolescence.

Factors affecting hand cosmesis and the aesthetic impact of surgery on congenital hand differences in Finland.

We assessed the appearance and cosmetic impact of surgery in congenitally different hands in Finland. A questionnaire was sent to 1165 respondents (786 female) with a mean age of 33 years (range 3-84). Participants were shown nine image pairs and seven pairs of pre- and postoperative images twice in a random order and asked to choose the more cosmetically pleasing one. We found that the appearance and number of fingers had an important aesthetic role, with higher number and more normal appearing digits consistently scoring higher than its counterpart (range 59-99%). Postoperative appearances were perceived as better than preoperative ones in syndactyly (98%), thumb duplication (92%), cleft hand (93%) and radial dysplasia (99%). Toe transfer and pollicization had little impact on cosmesis. This study demonstrated that surgery could improve cosmesis in congenitally different hands and overall, most respondents prefer an appearance that is as close as possible to normality. Level of evidence: IV.

Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study.

OBJECTIVE: To study the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI). DESIGN: Retrospective observational study. SETTING: Helsinki University Women's Hospital, Finland. SAMPLE: Deliveries with SD. METHODS: Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010-2014 were considered the pre-training period and years 2015-2019 were considered the post-training period. MAIN OUTCOME MEASURES: The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed. RESULTS: During the study period, 113 085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p < 0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p < 0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p < 0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm. CONCLUSIONS: Systematic simulation-based training of midwives and doctors can translate into improved individual and team performance and can significantly reduce the incidence of permanent BPBI.

A protocol-based treatment plan to improve shoulder function in children with brachial plexus birth injury: a comparative study.

Children with permanent brachial plexus birth injury have a high risk of developing posterior shoulder subluxation. In 2010, we implemented a protocol to reduce the incidence of this deformity, including early passive exercises, ultrasound screening, botulinum toxin-A injections, shoulder splinting and targeted surgeries. Two-hundred and thirty-seven consecutive children treated at our institution, with a mean follow-up of 11 years (range 1 to 17) were compared in three groups: children born from 1995 to 1999 (n = 53), 2000-2009 (n = 109) and 2010-2019 (n = 75). Posterior shoulder subluxation developed in 48% of all patients but the mean age at detection of shoulder subluxation decreased from 5 years to 4.9 months. Need for shoulder relocation surgery also decreased from 28% to 7%. Mean active shoulder external rotation in adduction improved from 2° to 46°. In conclusion, our established protocol has the potential to reduce the incidence of posterior shoulder subluxation in children with brachial plexus birth injury.Level of evidence: II.

Casting versus flexible intramedullary nailing in displaced forearm shaft fractures in children aged 7-12 years: a study protocol for a randomised controlled trial.

INTRODUCTION: The forearm is the most common fracture location in children, with an increasing incidence. Displaced forearm shaft fractures have traditionally been treated with closed reduction and cast immobilisation. Diaphyseal fractures in children have poor remodelling capacity. Malunion can cause permanent cosmetic and functional disability. Internal fixation with flexible intramedullary nails has gained increasing popularity, without evidence of a better outcome compared with closed reduction and cast immobilisation. METHOD AND ANALYSIS: This is a multicentre, randomised superiority trial comparing closed reduction and cast immobilisation to flexible intramedullary nails in children aged 7-12 years with >10° of angulation and/or >10 mm of shortening in displaced both bone forearm shaft fractures (AO-paediatric classification: 22D/2.1-5.2). A total of 78 patients with minimum 2 years of expected growth left are randomised in 1:1 ratio to either treatment group. The study has a parallel non-randomised patient preference arm. Both treatments are performed under general anaesthesia. In the cast group a long arm cast is applied for 6 weeks. The flexible intramedullary nail group is immobilised in a collar and cuff sling for 4 weeks. Data are collected at baseline and at each follow-up until 1 year.Primary outcome is (1) PROMIS paediatric upper extremity and (2) forearm pronation-supination range of motion at 1-year follow-up. Secondary outcomes are Quick DASH, Paediatric Pain Questionnaire, Cosmetic Visual Analogue Scale, wrist and elbow range of motion as well as any complications and costs of treatment.We hypothesise that flexible intramedullary nailing results in a superior outcome. ETHICS AND DISSEMINATION: We have received ethical board approval (number: 78/1801/2020) and permissions to conduct the study from all five participating university hospitals. Informed consent is obtained from the parent(s). Results will be disseminated in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT04664517.

Cast immobilisation in situ versus open reduction and internal fixation of displaced medial epicondyle fractures in children between 7 and 16 years old. A study protocol for a randomised controlled trial.

INTRODUCTION: Medial epicondyle fracture of the humerus is a common injury in childhood. There is uniform agreement that minimally displaced fractures (dislocation ≤2 mm) can be treated nonoperatively with immobilisation. Open fractures, fractures with joint incarceration or ulnar nerve dysfunction require surgery. There is no common consensus in treatment of closed medial epicondyle fractures with >2 mm dislocation without joint incarceration or ulnar nerve dysfunction. We hypothesise that there is no difference in treatment outcomes between nonoperative and operative treatment. METHODS AND ANALYSIS: This is a multicentre, controlled, prospective, randomised noninferiority study comparing operative treatment to non-operative treatment of >2 mm dislocated paediatric medial epicondyle fractures without joint incarceration or ulnar nerve dysfunction. A total of 120 patients will be randomised in 1:1 ratio to either operative or nonoperative treatment. The study will have a parallel nonrandomised patient preference arm. Operative treatment will be open reduction and internal fixation. Nonoperative treatment will be upper limb immobilisation in long arm cast for 4 weeks. Data will be collected at baseline and at each follow-up up to 2 years. Quick-DASH is used as primary outcome measure. Secondary outcomes are patient-reported pain, differences in range of motion, Pediatric Quality of Life Inventory, cosmetic visual analogue scale and Mayo Elbow Performance Score. ETHICS AND DISSEMINATION: Ethical approval has been obtained from Helsinki University Hospital (HUS) ethical board HUS/1443/2019. Each study centre has obtained their own permission for the study. A written authorisation from legal guardian will be acquired and the child will be informed about the trial. Results of the trial will be disseminated as published articles in peer-reviewed journals. TRIAL REGISTRATION: The trial has been registered at clinicaltrials.gov with registration number NCT04531085.

Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures.

Background and purpose - Controversy exists regarding the optimal treatment for displaced medial epicondyle fractures. We compared the results of nonoperative and operative treatment and calculated the incidence of medial epicondyle fractures in the pediatric census population.Patients and methods - 112 children under 16 years old who sustained > 2 mm displaced fracture of the medial epicondyle were treated in our institution between 2014 and 2019. 80/83 patients with 81 non-incarcerated fractures were available for minimum 1-year follow-up. 41 fractures were treated with immobilization only, 40 by open reduction and internal fixation, according to the preference of the attending surgeon. Outcome was assessed at mean 2.6 years (1-6) from injury with different patient-reported outcome measures. Elbow stability, range of motion, grip strength, and distal sensation were registered in 74/80 patients. Incidence was calculated for 7- to 15-year-olds.Results - Nonoperatively treated children had less pain according to the PedsQL Pediatric Pain Questionnaire (3 vs. 15, p = 0.01) with better cosmetic outcome (VAS 95 vs. 87, p = 0.007). There was no statistically significant difference between the groups in respect of QuickDASH, PedsQL generic core scale, Mayo Elbow Performance Score, grip strength, carrying angle, elbow stability, or range of motion (p > 0.05). All 41 nonoperatively treated children returned to pre-injury sports; of the surgically treated 6/40 had to down-scale their sporting activities. The incidence of displaced (> 2 mm) fractures of the medial epicondyle in children aged 7-15 years was ≥ 3:100,000.Interpretation - Displaced fractures of the medial humeral epicondyle in children heal well with 3-4 weeks' immobilization. Open reduction and screw fixation does not improve outcome.

New Simple Technique for Syndactyly Release.

Can good functional and cosmetic result be achieved in syndactyly separation using a straight midline incision with a hexagonal dorsal skin flap? METHODS: We performed 39 web reconstructions at a median of 20 months of age (11-43 months) to 26 consecutive children (21 male) with 30 simple, 4 complex, and 5 complicated syndactylies. Eighteen of the simple syndactylies were incomplete, ending at the proximal interphalangeal joint in 15 and at the distal interphalangeal joint in 3. Inguinal skin grafts were used in 2 children with either complex or complicated syndactyly. Operation time was recorded. Complications were registered. Height of the new web spaces was calculated. Parents' satisfaction on both functional and cosmetic outcome was assessed using a Visual Analog Scale from 0 to 100. RESULTS: Duration of one web reconstruction ranged from 50 to 95 minutes in simple incomplete, 56 to 135 in simple complete, 116 to 151 in complex, and 72 to 123 in complicated syndactylies. One child had a self-induced bilateral postoperative infection that lead to web creep. Two patients developed hypertrophic scars, which responded well to silicone treatment. Mean cosmetic and functional Visual Analog Scale scores were 87 (45-100) and 92 (63-100), respectively, at a mean follow-up of 1.3 years (range, 0.5-3.7). CONCLUSION: Web reconstruction using a hexagonal dorsal skin flap and straight midline incisions with closure at mid-lateral lines is safe, with good cosmetic and functional outcome in our short-term follow-up.

Mid-Term Outcome after Selective Neurotization of the Infraspinatus Muscle in Patients with Brachial Plexus Birth Injury.

Active shoulder external rotation in adduction can be restored by selective neurotization of the infraspinatus muscle with the spinal accessory nerve in select patients with brachial plexus birth injury. Does the improved shoulder external rotation stand the test of time? METHODS: Fourteen consecutive brachial plexus birth injury patients with active shoulder external rotation in adduction of ≤ 0 degrees and active shoulder elevation ≥ 90 degrees underwent selective neurotization of the infraspinatus muscle at mean 2 years of age between 2012 and 2016. All 14 patients had congruent shoulders joints with passive external rotation in adduction of 30 degrees. Pre-and postoperative electromyography was done to seven patients. Shoulder function and the subjective outcome was assessed after a mean follow-up of 3.8 years. RESULTS: Shoulder external rotation in adduction improved by a mean 57 degrees in the 12 children who did not develop shoulder internal rotation contracture. Shoulder external rotation in abduction and shoulder abduction increased in all 14 patients. Reinnervation of the supraspinatus muscle was evident in all seven children who underwent postoperative EMG. Thirteen patients' parents were satisfied with the outcome. CONCLUSIONS: Functionally significant shoulder external rotation can be restored and maintained by reinnervation of the infraspinatus muscle in brachial plexus birth injury patients with congruent shoulder joints, if internal rotation contracture does not develop.

Clinical significance of cervical MRI in brachial plexus birth injury.

Background and purpose - Patient selection for nerve surgery in brachial plexus birth injury (BPBI) is difficult. Decision to operate is mostly based on clinical findings. We assessed whether MRI improves patient selection. Patients and methods - 157 BPBI patients were enrolled for a prospective study during 2007-2015. BPBI was classified at birth as global plexus injury (GP) or upper plexus injury (UP). The global plexus injury was subdivided into flail upper extremity (FUE) and complete plexus involvement (CP). Patients were seen at set intervals. MRI was scheduled for patients that had either GP at 1 month of age or UP with no antigravity biceps function by 3 months of age. Type (total or partial avulsion, thinned root), number and location of root injuries and pseudomeningoceles (PMC) were registered. Position of humeral head (normal, subluxated, dislocated) and glenoid shape (normal, posteriorly rounded, pseudoglenoid) were recorded. Outcome was assessed at median 4.5 years (1.6-8.6) of age. Results - Cervical MRI was performed on 34/157 patients at median 3.9 months (0.3-14). Total root avulsions (n = 1-3) were detected on MRI in 12 patients (8 FUE, 4 CP). Reconstructive surgery was performed on 10/12 with total avulsions on MRI, and on all 10 with FUE at birth. Sensitivity and specificity of MRI in detecting total root avulsions was 0.88 and 1 respectively. Posterior shoulder subluxation/dislocation was seen in 15/34 patients (3.2-7.7 months of age). Interpretation - Root avulsion(s) on MRI and flail upper extremity at birth are both good indicators for nerve surgery in brachial plexus birth injury. Shoulder pathology develops very early in permanent BPBI.

Selective Neurotization of the Infraspinatus Muscle in Brachial Plexus Birth Injury Patients Using the Accessory Nerve.

The authors present a new technique to improve active shoulder external rotation in patients with brachial plexus birth injury. Eight brachial plexus birth injury patients (aged 1.5 to 4.7 years) lacking active external rotation in adduction (<10 degrees) with congruent glenohumeral joints and no significant internal rotation contracture (passive external rotation >45 degrees) underwent neurotization of the infraspinatus branch of the suprascapular nerve with the spinal accessory nerve. Active and passive range of shoulder motion was measured postoperatively (3, 6, and 12 months). Parents' satisfaction was assessed. At 1-year follow-up, mean improvement for active external rotation was 47 degrees (range, 20 to 85 degrees) in adduction and 49 degrees (range, 5 to 85 degrees) in abduction. All but one patient's parents were satisfied. Functionally significant active external rotation can be restored in brachial plexus birth injury by direct neurotization of the infraspinatus muscle.