Limited glenohumeral cross-body adduction in children with brachial plexus birth palsy: a contributor to scapular winging.

BACKGROUND: Approximately 1 of every 1000 live births results in life-long impairments because of a brachial plexus injury. The long-term sequelae of persistent injuries include glenohumeral joint dysplasia and glenohumeral internal rotation and adduction contractures. Scapular winging is also common, and patients and their families often express concern regarding this observed scapular winging. It is difficult for clinicians to adequately address these concerns without a satisfying explanation for why scapular winging occurs in children with brachial plexus birth palsy. This study examined our proposed theory that a glenohumeral cross-body abduction contracture leads to the appearance of scapular winging in children with residual brachial plexus birth palsy. METHODS: Sixteen children with brachial plexus injuries were enrolled in this study. Three-dimensional locations of markers placed on the thorax, scapula, and humerus were recorded in the hand to mouth Mallet position. The unaffected limbs served as a control. Scapulothoracic and glenohumeral cross-body adduction angles were compared between the affected and unaffected limbs. RESULTS: The affected limbs demonstrated significantly greater scapulothoracic and significantly smaller glenohumeral cross-body adduction angles than the unaffected limbs. The affected limbs also exhibited a significantly lower glenohumeral cross-body adduction to scapulothoracic cross-body adduction ratio. CONCLUSIONS: The results of this study support the theory that brachial plexus injuries can lead to a glenohumeral cross-body abduction contracture. Affected children demonstrated increased scapulothoracic cross-body adduction that is likely a compensatory mechanism because of decreased glenohumeral cross-body adduction. These findings are unique and better define the etiology of scapular winging in children with brachial plexus injuries. This information can be relayed to patients and their families when explaining the appearance of scapular winging. LEVEL OF EVIDENCE: Level II.

Developing a pollicization outcomes measure.

PURPOSE: To evaluate which objective criteria correlated with subjective impressions of outcome following index finger pollicization for thumb hypoplasia. METHODS: Forty-two pollicizations in 35 patients were assessed by a comprehensive subjective and objective measurement analysis. In the subjective measures, the surgeon, therapist, and caregiver rated how the pollicized digit "looks like a thumb" and "works like a thumb." The caregiver also completed a subjective questionnaire. For objective results, we measured appearance, strength, range of motion, stability, and ability to pick up objects. The subjective results were then correlated with objective data via a linear regression analysis. RESULTS: When combining the total subjective score for "looks like a thumb," "works like a thumb," and the caregiver questionnaire, we found significant correlation scores for palmar abduction, lateral pinch, tip pinch, and picking up a bead, a die, and a table tennis ball. The strongest correlations were found with composite flexion, metacarpophalangeal (MCP) joint range of motion, interphalangeal (IP) joint range of motion, and the sticker test. Three of these 4 items (sticker test and MCP joint and IP arcs of motion) also correlated best with children who preferred using their thumbs for small object acquisition instead of scissor pinch. CONCLUSIONS: Composite flexion, MCP and IP joint arcs of motion, and the sticker test correlated the strongest with the subjective criteria. These parameters appear to be the most critical measures that impress a good outcome following pollicization. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Biceps-to-triceps transfer for elbow extension in persons with tetraplegia.

PURPOSE: Restoration of elbow extension via tendon transfer is an integral part of upper extremity surgical reconstruction in persons with tetraplegia. The purpose of this investigation was to assess patient satisfaction and elbow extension strength after biceps-to-triceps transfers. METHODS: This is a retrospective chart review of biceps-to-triceps transfers in patients with spinal cord injury. Forty-five patients (77 arms) with spinal cord injury underwent biceps-to-triceps transfer. A total of 40 patients (68 arms) were available for follow-up. The average age at surgery was 17.3 years (range, 6.4-21.7 y).The biceps tendon was transferred around the medial aspect of the arm. The preoperative elbow extension strength was 0/5 (54 arms), 1/5 (10 arms), or 2/5 (4 arms). We also used the Canadian Occupational Performance Measure to measure patient-perceived outcome in a subset of 8 subjects. RESULTS: Stringent manual muscle testing (MMT) for elbow extension revealed a statistically significant increase in muscle strength after surgery (p < .001). Forty-two arms were able to extend completely against gravity (MMT 3/5 or greater). Nine arms had a mild extension lag against gravity (MMT of 3/5). Therefore, 75% (51/68) of arms were able to function overhead. Seventeen arms had MMT scores less than 3/5. The top 5 goals of the 8 patients with completed preoperative and postoperative Canadian Occupational Performance Measure results were analyzed. After transfer, all 8 patients reported improved performance of and/or satisfaction with at least one goal. Performance and satisfaction were greatly improved (at least 4 points) for activities of living such as dressing, grooming, reaching for objects, recreational activities, wheelchair propulsion, and transfers. CONCLUSIONS: Based on these results, we believe the biceps-to-triceps transfer is a reliable technique for restoration of elbow extension in persons with tetraplegia. Overhead function is obtainable in most cases with careful surgical technique and meticulous postoperative therapy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Shoulder function after medial approach and derotational humeral osteotomy in patients with brachial plexus birth palsy.

BACKGROUND: The purpose of this study was to assess outcome after rotational humeral osteotomies, using a medial approach, in children with brachial plexus birth palsy. METHODS: A retrospective review of children with brachial plexus birth palsy who underwent external rotational humeral osteotomies, using a medial approach, for the treatment of internal rotation contractures was performed. Presurgical and postsurgical range of motion, standard Mallet, and modified Mallet scores were recorded. The traditional Mallet score was modified to include a sixth subscale that further evaluated internal rotation. This was assessed by having the patients' attempts to place their palm flat on their naval. RESULTS: Twenty-three children underwent external rotational humeral osteotomies. The mean rotational correction achieved during the procedure was 43.2+/-11.6 degrees (range: 20-70 degrees). The mean preoperative standard aggregate Mallet score was 13.8+/-2.8 and the mean postoperative score was 16.1+/-2.5 (P=0.002). When the additional internal rotation scale was added into the score, the mean preoperative aggregate score was 18.0+/-2.1 and the mean postoperative score was 19.5+/-2.8 (P=0.032). Further analysis revealed a statistically significant improvement (P<0.05) in external rotation, hand to neck, and hand to mouth functions. Internal rotation was decreased as represented by statistically significant decreases in hand to spine and hand to belly (P<0.05). CONCLUSIONS: Rotational humeral osteotomies can be performed safely and effectively using a medial approach. These osteotomies significantly improve activities associated with external rotation. However, the degree of external rotation must be carefully balanced against the loss of internal rotation, which would impede midline function. The addition of a sixth subscale to the Mallet score that assesses hand to belly provides more clinically relevant information regarding midline function than hand to spine. LEVEL OF EVIDENCE: This is a Level IV study.