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1.
JBJS Rev ; 11(7)2023 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-37411042

RESUMO

¼ Pediatric hand and upper limb differences include a wide range of conditions that may be genetic, part of a syndrome, or arise from birth trauma or an unknown cause.¼ Because of the variety of conditions and complexity of care requiring professionals from multiple disciplines, the Pediatric Hand Team is similar in purpose to the coordinated multidisciplinary care provided by Craniofacial Panels for children with craniofacial anomalies. Pediatric hand surgeons are trained to lead and coordinate the care of children with these differences, and the Pediatric Hand Team includes occupational and/or certified hand therapists, child life specialists, geneticists and genetic counselors, prosthetists and orthotists, pediatric physical medicine and rehabilitation physicians, pediatric orthopaedic surgeons, pediatric anesthesiologists, and social workers and psychologists. The Team must also have access to pediatric imaging, including ultrasound and magnetic resonance imaging.¼ Treatment of hand differences may include observation, splinting/bracing, therapy, reconstructive surgery, or a combination of these, and indications vary with development, age, associated conditions, and child and family preference. Children who have challenges coping with the stigma of their difference may benefit from programs such as Hand Camp and the Lucky Fin Project.¼ Multiple online and print resources are available to support the Pediatric Hand Team and the child's family and other caregivers.¼ A well-coordinated team-based approach meets the physical and psychosocial needs of the child with hand and upper limb differences from birth to adulthood.


Assuntos
Adaptação Psicológica , Cirurgiões , Criança , Humanos , Extremidade Superior
2.
J Hand Surg Am ; 48(1): 37-45, 2023 01.
Artigo em Inglês | MEDLINE | ID: mdl-34953599

RESUMO

PURPOSE: Forearm supination contractures occur in 7% of children with brachial plexus birth injuries (BPBI). Biceps rerouting is proposed when pronation has deteriorated but is passively correctable to at least 0° (neutral). The purpose of this investigation was to evaluate long-term outcomes of biceps rerouting for this indication, including magnitude and maintenance of correction, complications, and subsequent osteotomy. METHODS: We conducted a retrospective review of all children with BPBI and forearm supination contractures treated with biceps rerouting alone, for the above indications, from 1993 to 2017 with at least 2 years follow-up. Demographic information, BPBI characteristics, surgical details, and ranges of motion were obtained from medical records. Pre- and postoperative active pronation (AP) and supination (AS), elbow flexion contracture, and arc of forearm rotation (Arc) were analyzed using linear mixed-effect models. RESULTS: Twenty-five children (13 females; 13 left forearms; 15 global BPBI) underwent biceps rerouting at age 7 ± 3 years and were followed for 6 ± 3 years. Before surgery, the mean AP and AS were 6° ± 29° and 62° ± 27°, respectively. At the final follow-up, the mean AP, AS, and Arc were 39° ± 36°, 18° ± 34°, and 57° ± 42°, respectively. AP was significantly improved and AS was significantly decreased by 2 years after surgery and at the final follow-up. Neither Arc nor elbow flexion contracture changed significantly. Two of 25 (8%) children underwent subsequent forearm osteotomy. CONCLUSIONS: Biceps rerouting in children with BPBI improves the forearm position when pronation is deteriorating by shifting the arc from supination to pronation without decreasing the arc of motion or worsening elbow flexion contractures. There is a low risk of complications and a limited need for subsequent forearm osteotomy. These results are maintained over time. When performed before passive pronation is reduced beyond neutral, this procedure may prevent severe supination contractures and reduce the need for forearm osteotomy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.


Assuntos
Traumatismos do Nascimento , Plexo Braquial , Contratura , Feminino , Humanos , Criança , Pré-Escolar , Supinação , Contratura/cirurgia , Contratura/complicações , Músculo Esquelético/cirurgia , Antebraço/cirurgia , Pronação , Traumatismos do Nascimento/complicações , Traumatismos do Nascimento/cirurgia
3.
J Perinatol ; 43(5): 578-583, 2023 05.
Artigo em Inglês | MEDLINE | ID: mdl-36585508

RESUMO

OBJECTIVES: To determine the prevalence of perinatal factors associated with brachial plexus birth injury (BPBI) in affected infants and their relationship with BPBI severity. STUDY DESIGN: Retrospective study of BPBI infants prospectively enrolled in a multicenter registry. The prevalence of perinatal factors was calculated. Infants were stratified by injury severity and groups were compared to determine the association of severity and perinatal factors. RESULTS: Seven-hundred-ninety-six BPBI infants had a mean 4.2 ± 1.6 perinatal factors. Nearly all (795/796) reported at least one factor, including shoulder dystocia(96%), no clavicle fracture (91%), difficult delivery(84%), parity >1(61%) and birthweight >4000 g(55%). Ten-percent (74/778) had Horner's syndrome and 28%(222/796) underwent nerve surgery. Birth asphyxia and NICU admission were significantly associated with injury severity. CONCLUSIONS: NICU admission and asphyxia were associated with BPBI severity. An improved understanding of the relationship between perinatal factors and BPBI severity may be used to guide early referral to BPBI providers and support prevention efforts.


Assuntos
Traumatismos do Nascimento , Plexo Braquial , Gravidez , Feminino , Lactente , Humanos , Estudos Retrospectivos , Traumatismos do Nascimento/epidemiologia , Prevalência , Asfixia , Plexo Braquial/lesões
4.
J Hand Surg Am ; 45(12): 1186.e1-1186.e6, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32753228

RESUMO

PURPOSE: Shoulder internal rotation contractures (IRC) are common sequela of brachial plexus birth injuries (BPBI). Botulinum toxin A (BTX-A) injection into targeted muscles has been described to facilitate functional improvement at the shoulder joint and prevent glenohumeral dysplasia. The purpose of this study was to assess the outcomes of BTX-A injections on shoulder IRC in children with BPBI. METHODS: We conducted a retrospective analysis of 47 children with shoulder IRC due to BPBI, who were treated with BTX-A. Shoulder passive external rotation in adduction and Active Movement Scale external rotation scores were recorded before and after BTX-A injection. We also recorded the number of children who underwent secondary surgical balancing procedures to improve shoulder motion after BTX-A injection. RESULTS: Mean age at the time of injection was 12 months (range, 5-23 months). Subjects demonstrated a significant increase in passive external rotation of 46° (range, 10° to 90) at 4 months; an average improvement of 18° (range, -30° to 80°) persisted at 11 months after injection. A total of 28 patients (60%) underwent subsequent external rotation tendon transfer. At 5-year follow-up, 7 patients (15%) had adequate functional shoulder range of motion and did not undergo external rotation tendon transfer. CONCLUSIONS: Botulinum toxin A injections result in improvement in IRC due to BPBI, which is sustained beyond the expected half-life of 3 months. As many as 15% of patients who have this treatment avoid external rotation tendon transfer. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.


Assuntos
Traumatismos do Nascimento , Toxinas Botulínicas , Neuropatias do Plexo Braquial , Plexo Braquial , Contratura , Articulação do Ombro , Traumatismos do Nascimento/complicações , Traumatismos do Nascimento/tratamento farmacológico , Toxinas Botulínicas/uso terapêutico , Plexo Braquial/lesões , Neuropatias do Plexo Braquial/tratamento farmacológico , Contratura/tratamento farmacológico , Contratura/etiologia , Humanos , Lactente , Amplitude de Movimento Articular , Estudos Retrospectivos , Rotação , Ombro
5.
J Bone Joint Surg Am ; 102(4): 298-308, 2020 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-31725125

RESUMO

BACKGROUND: Shoulder external rotation recovery in brachial plexus birth injury is often limited. Nerve grafting to the suprascapular nerve and transfer of the spinal accessory nerve to the suprascapular nerve are commonly performed to restore shoulder external rotation, but the optimal surgical technique has not been clearly demonstrated. We investigated whether there was a difference between nerve grafting and nerve transfer in terms of shoulder external rotation recovery or secondary shoulder procedures. METHODS: This is a multicenter, retrospective cohort study of 145 infants with brachial plexus birth injury who underwent reconstruction with nerve grafting to the suprascapular nerve (n = 59) or spinal accessory nerve to suprascapular nerve transfer (n = 86) with a minimum follow-up of 18 months (median, 25.7 months [interquartile range, 22.0, 31.2 months]). The primary outcome was the Active Movement Scale (AMS) score for shoulder external rotation at 18 to 36 months. The secondary outcome was secondary shoulder surgery. Two-sample Wilcoxon and t tests were used to analyze continuous variables, and the Fisher exact test was used to analyze categorical variables. The Kaplan-Meier method was used to estimate the cumulative risk of subsequent shoulder procedures, and the proportional hazards model was used to estimate hazard ratios (HRs). RESULTS: The grafting and transfer groups were similar in Narakas type, preoperative AMS scores, and shoulder subluxation. The mean postoperative shoulder external rotation AMS scores were 2.70 in the grafting group and 3.21 in the transfer group, with no difference in shoulder external rotation recovery between the groups (difference, 0.51 [95% confidence interval (CI), -0.31 to 1.33]). A greater proportion of the transfer group (24%) achieved an AMS score of >5 for shoulder external rotation compared with the grafting group (5%) (odds ratio, 5.9 [95% CI, 1.3 to 27.4]). Forty percent of the transfer group underwent a secondary shoulder surgical procedure compared with 53% of the grafting group; this was a significantly lower subsequent surgery rate (HR, 0.58 [95% CI, 0.35 to 0.95]). CONCLUSIONS: Shoulder external rotation recovery in brachial plexus birth injury remains disappointing regardless of surgical technique, with a mean postoperative AMS score of 3, 17% of infants achieving an AMS score of >5, and a high frequency of secondary shoulder procedures in this study. Spinal accessory nerve to suprascapular nerve transfers were associated with a higher proportion of infants achieving functional shoulder external rotation (AMS score of >5) and fewer secondary shoulder procedures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Nervo Acessório/cirurgia , Plexo Braquial/cirurgia , Paralisia do Plexo Braquial Neonatal/cirurgia , Transferência de Nervo , Nervos Espinhais/transplante , Estudos de Coortes , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos
6.
Plast Reconstr Surg ; 143(5): 1017e-1026e, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31033825

RESUMO

BACKGROUND: Infants with brachial plexus birth injury who do not recover motor function spontaneously in a timely manner are candidates for brachial plexus reconstruction with nerve autograft. Outcomes of this intervention are incompletely understood. The authors present the long-term outcomes of brachial plexus reconstruction with sural nerve autograft in infants with brachial plexus birth injury. METHODS: The authors retrospectively reviewed all infants with brachial plexus birth injury who underwent brachial plexus reconstruction with sural nerve autograft between 1992 and 2014 with a minimum 2-year follow-up. The authors used Active Movement Scale scores to determine the presence and timing of shoulder, elbow, and wrist recovery. They assessed recovery of hand function in infants with global brachial plexus birth injury with the Raimondi scale. The number and type of secondary reconstructive procedures were identified. RESULTS: Forty-three infants who underwent brachial plexus reconstruction at age 7 ± 2 months old were followed for 7 ± 5 years. Most infants recovered antigravity elbow flexion (91 percent) and shoulder abduction (67 percent), but fewer recovered antigravity shoulder external rotation (19 percent) and wrist extension (37 percent). Mean postoperative times until observed antigravity motor strength (Active Movement Scale score >5) at the shoulder, elbow, and wrist were all greater than 12 months; evidence of initial motor recovery (Active Movement Scale score >2) was observed earlier. The mean Raimondi score in infants with global brachial plexus birth injury was 2.2 (range, 0 to 5) at final follow-up. Thirty-three children underwent 2 ± 1.2 secondary reconstructive procedures. CONCLUSIONS: Brachial plexus reconstruction with sural nerve autograft reliably results in recovery of shoulder abduction and elbow flexion, but recovery of shoulder external rotation and wrist extension is less predictable, and recovery often takes more than 1 year. Secondary procedures are often performed to optimize function. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Traumatismos do Nascimento/complicações , Neuropatias do Plexo Braquial/cirurgia , Procedimentos Neurocirúrgicos/métodos , Procedimentos de Cirurgia Plástica/métodos , Nervo Sural/transplante , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/etiologia , Articulação do Cotovelo/inervação , Articulação do Cotovelo/fisiologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Amplitude de Movimento Articular , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Articulação do Ombro/inervação , Articulação do Ombro/fisiologia , Transplante Autólogo/métodos , Resultado do Tratamento , Articulação do Punho/inervação , Articulação do Punho/fisiologia
7.
J Hand Surg Am ; 39(5): 895-901, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24594270

RESUMO

PURPOSE: To assess recurrence and complications in children with radial longitudinal deficiency treated with or without external fixator soft tissue distraction prior to centralization. METHODS: Thirteen upper extremities treated with centralization alone were compared with 13 treated with ring fixator distraction followed by centralization. Resting wrist position between the 2 groups was compared before surgery, approximately 2 years after surgery (midterm), and at final follow-up, which was at a mean of 10 years for the centralization-alone group and 6 years for the distraction group. Radiographs were reviewed for hand-forearm angle, hand-forearm position, volar carpal subluxation, ulnar length, and physeal integrity. RESULTS: The clinical resting wrist position was improved significantly after surgery and at final follow-up in both groups, but recurrence was worse at final follow-up in the distraction group patients. Radiographically, in the centralization alone group, the hand-forearm angle improved from 53° before surgery to 13° at midterm but worsened to 27° at final follow-up. In the distraction group, the hand-forearm angle improved from 53° before surgery to 21° at midterm but worsened to 36° at final follow-up. The hand-forearm position improved between preoperative and final assessment in both groups, but at final follow-up, the centralization-alone group had a significantly better position. Volar subluxation was 4 mm improved in the centralization alone group and 2 mm worse in the distraction group at final follow-up. CONCLUSIONS: Centralization, with or without distraction with an external fixator, resulted in improved alignment of the wrist. Distraction facilitated centralization, but it did not prevent deformity recurrence and was associated with a worse final radial deviation and volar subluxation position compared with wrists treated with centralization alone. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.


Assuntos
Deformidades Congênitas da Mão/cirurgia , Rádio (Anatomia)/anormalidades , Articulação do Punho/anormalidades , Criança , Pré-Escolar , Fixadores Externos , Feminino , Humanos , Lactente , Masculino , Recidiva , Estudos Retrospectivos , Resultado do Tratamento
8.
J Hand Surg Am ; 39(2): 226-36, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24359797

RESUMO

PURPOSE: To evaluate the implications of the transverse bone in cleft hand by assessing outcomes after reconstruction in comparison with a control group. METHODS: This study is a retrospective review of 23 hands in 18 patients following surgical reconstruction of the cleft hand. Eleven hands had a transverse bone component, and 12 hands (control group) did not. Patients and their families were contacted to assess overall satisfaction following reconstruction. Clinical and radiographic records were reviewed to assess aesthetic and functional outcomes, the need for additional surgery, and radiographic divergence angles. RESULTS: There was no difference in aesthetic or functional subjective outcomes. There was no statistically significant difference in any objective outcome measure between the two groups. The use of the cleft for pinch was more dependent on the status of the index finger and the preoperative thumb-index webspace rather than the presence of a transverse bone. Eleven (4 transverse and 7 control) hands required additional surgery to address abnormal function or posture of the index and ring fingers. Preoperative radiographic divergence angles were larger in the transverse bone group than in the control group, whereas postoperative divergence angles were nearly equivalent. CONCLUSIONS: Similar outcomes between the two groups demonstrate that the presence of a transverse bone in cleft hand was not associated with worse outcomes following cleft reconstruction. Preoperative narrowing of the thumb webspace and postoperative index finger metacarpophalangeal joint abnormality are associated with worse functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic Level III.


Assuntos
Estética , Falanges dos Dedos da Mão/anormalidades , Falanges dos Dedos da Mão/cirurgia , Deformidades Congênitas da Mão/diagnóstico por imagem , Deformidades Congênitas da Mão/cirurgia , Ossos Metacarpais/anormalidades , Ossos Metacarpais/cirurgia , Complicações Pós-Operatórias/etiologia , Transplante Ósseo/métodos , Pré-Escolar , Estudos de Coortes , Feminino , Falanges dos Dedos da Mão/diagnóstico por imagem , Dedos/anormalidades , Força da Mão/fisiologia , Humanos , Lactente , Masculino , Ossos Metacarpais/diagnóstico por imagem , Osteotomia/métodos , Satisfação do Paciente , Força de Pinça/fisiologia , Complicações Pós-Operatórias/diagnóstico por imagem , Radiografia , Reoperação , Estudos Retrospectivos
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