Evaluation of Upper Extremity Reachable Workspace in Children With Brachial Plexus Birth Injury.

PURPOSE: Brachial plexus birth injury (BPBI) results in upper extremity (UE) movement limitations. Current assessments of UE function used to inform clinical decision-making only evaluate a limited set of static postures and/or movements and have been criticized for being insensitive to certain meaningful differences in function. Reachable workspace provides a numeric and visual assessment of global UE movement ability by quantifying the regions in space that patients can reach with their hands, and it can be collected using real-time feedback to elicit a best-effort acquisition of function. This study evaluated the ability of a real-time feedback reachable workspace tool to assess UE movement in BPBI. METHODS: Twenty-two children with BPBI participated. Reachable workspace data were collected with three-dimensional motion capture using real-time visual feedback to measure UE reaching ability in all regions surrounding the body. All outer, far-from-body points reached by the hand were recorded and analyzed by region. A two-way, within-subjects analysis of variance was used to assess interlimb differences in percentage workspace reached and median reach distance for each of the six regions. RESULTS: The affected limb had significantly less percentage workspace reached than the unaffected limb for all six regions (mean interlimb differences by region, 5.7%-38.6%). The affected limb had significantly less median reach distance than the unaffected limb for all six regions (mean interlimb differences by region, 3.1%-36.8%). CONCLUSIONS: The workspace approach was capable of detecting UE movement impairments of the BPBI-affected limb. The reported deficits in workspace on the affected limb correspond to common movement impairments in BPBI, such as limitations in shoulder elevation, external rotation, extension, and elbow extension. CLINICAL RELEVANCE: The real-time feedback reachable workspace tool is sufficiently robust for assessing UE movement impairments in children with BPBI.

Early Results of 3-Dimensional Planning and Customized Cutting Guides for the Treatment of Severe Madelung Defofrmity.

PURPOSE: Surgical treatment of Madelung deformity can present challenges due to a need for multiplanar correction. Developing customized cutting guides for osteotomies may improve surgical outcomes by enhancing the surgeon's understanding and surgical correction. METHODS: All patients who underwent forearm osteotomies for Madelung deformity using computed tomography planning with 3-dimensional-printed customized cutting guides were retrospectively reviewed (n = 8). Seven patients underwent a double osteotomy of the radius, and 1 underwent a single osteotomy. RESULTS: Ulnar tilt was improved in all cases. Correction of deformity was significant on anteroposterior but not on lateral views. The mean preoperative and postoperative radial bow was measured in 2 planes, with an average preoperative bow of 32° (± 21°) on anteroposterior radiographs and 36° (± 17°) on lateral radiographs, and an average bow of 10° (± 6°) on anteroposterior radiographs and 7° (± 6°) on lateral films after surgery. The predicted radial bow was calculated to be 9.1° (± 8°). CONCLUSIONS: Three-dimensional planning allows predictable deformity correction across multiple but not all parameters. Future studies comparing clinical and radiographic outcomes of guided versus nonguided osteotomies are required to justify the additional expense and preoperative planning efforts. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Adolescent Wrist Pain.

Adolescence is a difficult time, both physically and emotionally. Rapid growth coupled with physical changes in the background of high levels of activity can be overwhelming. Meanwhile, unfamiliar life stressors coupled with undeveloped compensatory mechanisms can lead to overwhelming anxiety and emotional distress. Emotional factors can make injuries and overuse syndromes feel more catastrophic. Occasionally, an adolescent's emotional distress can manifest physically, without antecedent injury or physiologic cause. Understanding the psychological milieu is as important as understanding the disease processes that can affect adolescents if one hopes to manage these patients effectively.

Nerve Transfers for Restoration of Elbow Flexion in Patients With Acute Flaccid Myelitis.

PURPOSE: The purpose of this study was to evaluate short- to midterm outcomes of patients with acute flaccid myelitis who underwent nerve transfers for restoration of elbow flexion. METHODS: Patients with a minimum of 10 months of follow up after undergoing nerve transfers to restore elbow flexion were clinically assessed using the Active Movement Scale (AMS). They were evaluated for any postoperative complications, particularly weakness in the distribution of the donor nerve(s). Fifteen of 25 consecutive patients who were treated using this surgical technique were included in the final analysis. RESULTS: All patients exhibited poor elbow flexion preoperatively (AMS 0 to 3). At a mean follow up of 17.3 months, 80% (15/25) of patients achieved excellent elbow flexion (AMS 6 or 7); 9 of these 15 had full active range of motion. Two patients achieved good elbow flexion (AMS 5) with antigravity movement to less than 50% of the passive range of motion. No cases of superficial or deep infection were reported, and all patients maintained identical motor function, relative to preoperative status, of the muscles innervated by the donor nerves. CONCLUSIONS: Nerve transfer surgery has shown promising short- to midterm results for recovery of nerve and muscle function, particularly for the restoration of elbow flexion. We recommend this treatment option for patients not demonstrating clinical improvement after 6 to 9 months of incomplete recovery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Scapulothoracic and Glenohumeral Contributions to Humerothoracic Kinematics in Single Versus Double Tendon Transfers in Patients With Brachial Plexus Birth Injury.

PURPOSE: Evidence suggests that patients with brachial plexus birth injury are more likely to retain midline function following a teres major tendon transfer without a concomitant latissimus dorsi transfer. Both procedures increase shoulder external rotation and abduction, but whether increased loss of midline frequency following double transfer is due to glenohumeral (GH) joint motion or scapulothoracic (ST) compensation is unknown. We hypothesized that double tendon transfers would exhibit greater GH external rotation than single tendon transfers, thus requiring greater ST rotation to internally rotate the shoulder, while GH and ST contributions to elevation remained equivalent between both groups. METHODS: Twenty-six postsurgical children with C5/C6 brachial plexus birth injuries participated in this study. Thirteen patients with single tendon transfers were matched with 13 with double tendon transfer. Coordinate systems of the thorax, scapula, and humerus were measured utilizing motion capture in 6 arm positions. Joint angles were calculated by the helical (ST) and modified globe method (GH and humerothoracic [HT]). Differences between groups were compared with repeated measures of multivariate analyses of variance for each position. Pending significant multivariate analyses of variance, univariate analyses of variance determined joint differences between transfer groups. RESULTS: Joint rotations from neutral were similar between groups in 5 of 6 tested positions, with double tendon transfers consistently demonstrating 15°-20˚ more internal rotation at the GH and HT joints. Still, only the internal rotation position showed statistically significant differences in GH and HT joint angles. The ST joint angles were similar in this position (45.2˚ and 48.5˚). CONCLUSIONS: The arc of motion for patients with double tendon transfer was more internally rotated than in patients with single tendon transfer at the GH and HT joints for all positions. However, both groups demonstrated little active rotation from neutral. Based on this data, teres major-only tendon transfers may not reduce the risk of loss of midline function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The One-Bone Forearm in Children: Surgical Technique and a Retrospective Review of Outcomes.

PURPOSE: The purpose of this study was to describe a technique of end-to-end rigid fixation of the distal radius to the proximal ulna. The shortening and radioulnar overlap in this technique yield a high union rate, large corrections, and few complications. METHODS: This retrospective chart review from 2 centers was undertaken in 39 patients (40 forearms) who underwent one-bone forearm operations between 2005 and 2019. There were 25 male and 14 female patients, with a mean age at surgery of 9.7 years (range 3 to 19 years; SD, 4.5 years). The diagnoses included brachial plexus birth injury, spinal cord injury, arthrogryposis multiplex congenita, cerebral palsy, ulnar deficiency with focal indentation, multiple hereditary exostosis, acute flaccid myelitis, and tumor. RESULTS: The average follow-up was 33.5 months (1.2-110.1 months; SD, 27.1 months). The 36 forearms in supination had an average supination contracture of 93° (range, 15° to 120°; SD, 15.4°). The 4 pronated arms had an average pronation contracture of 80° (range, 50° to 120°; SD, 29.2°). The average postoperative position was 22.8° of pronation (range, -15° to 45°; SD, 12.9°). The average correction obtained with our technique was 113° (range, 20° to 145°; SD, 22.9°). Radiographic union was demonstrated in 32 (80%) of the one-bone forearms by 10 weeks, 39 (97.5%) by 16 weeks, and 40 (100%) by 24 weeks. One patient had peri-implant fractures prior to union. No forearms required reoperation for nonunion. CONCLUSIONS: One-bone forearm performed with this technique allows reliable healing and a large degree of correction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Comparison of Shoulder Motion Measurements by Visual Estimate, Goniometer and Motion Capture.

BACKGROUND: Brachial plexus birth injuries (BPBI) can result in lasting impairments of external rotation and cross-body adduction (CBA) that disrupt functional activities such as dressing, grooming, or throwing a ball. The purpose of this study was to compare the quantification of shoulder humerothoracic (HT) external rotation (ER), and glenohumeral (GH) CBA by 3 methods - physician visual estimate, goniometer measurement by an occupational therapist, and motion capture. METHODS: Twenty-six patients with BPBI (average age of 9.9±3.2 y) participated in this study. Mallet scores and visual estimates of passive HT ER and GH CBA were recorded by a physician. The passive measures were repeated by an occupational therapist using a goniometer while motion capture measures were simultaneously collected. Active HT ER was also measured by motion capture. The passive measures were compared with analyses of variance with repeated measures, intraclass correlations, and Bland-Altman plots. External rotation Mallet scores determined by motion capture and by the physician were compared. RESULTS: The measures of GH CBA were not statistically different and demonstrated good agreement, but substantial variation. For HT ER, all measures were significantly different and demonstrated poor agreement and substantial variation. When the joint angles measured by motion capture were used to determine the Mallet score, 79% of external rotation Mallet scores assigned by the physician were incorrectly categorized, with the physician always scoring the participant higher than predicted motion capture Mallet score. CONCLUSIONS: Both GH CBA and HT ER measures demonstrated substantial variability between measurement types, but only HT ER joint angles were significantly different. In addition, more than three-quarters of external rotation Mallet scores were misclassified by the physician. Motion capture measurements offer the benefit of less susceptibility to patients' compensatory and/or out-of-plane movements and should be considered for clinical assessment of shoulder range of motion in children with BPBI. If motion capture is unavailable, the use of a goniometer provides more accurate clinical measures of shoulder motion than visual estimates and care should be taken to minimize and account for compensatory movement strategies. LEVEL OF EVIDENCE: Level IV Case series.

Combined clinic and home-based therapeutic approach for the treatment of bilateral radial deficiency for a young child with Holt-Oram syndrome: A case report.

BACKGROUND: Holt-Oram syndrome (HOS) is a rare, genetic condition characterized by the combination of congenital heart defect and hypoplasia in one or both upper extremities. Children with HOS commonly present with varied joint and limb involvement including radial longitudinal deficiency impacting hand function. Evidence-based guidelines regarding orthotic wear and therapeutic techniques are lacking. PURPOSE: The aim of this case report was to present the results of a long-term occupational therapy program for a patient with HOS pre and postpollicization. STUDY DESIGN: Case report. METHODS: A 4-month-old patient with bilateral radial longitudinal deficiencies began outpatient occupational therapy for custom orthosis fabrication and treatment which included long term clinic and home-based intervention. Techniques included passive range of motion, orthosis wear, therapeutic taping, and modified constraint induced movement therapy. Longitudinal assessment of musculoskeletal alignment and functional hand use was performed using goniometry for passive and active range of motion, the Assisting Hand Assessment (AHA), and The Thumb Grasp and Pinch Assessment (T-GAP). RESULTS: Improvement in passive and active range of motion was achieved as well as improved activity level function as measured by the AHA and T-GAP postpollicization and intervention. CONCLUSIONS: A combined clinic and home-based therapeutic approach can be effective for children with HOS to improve alignment and function pre and postpollicization to further enhance hand function. Comprehensive, long-term assessment is necessary to fully evaluate and communicate improvement.

Assessment of the relationship between Brachial Plexus Profile activity short form scores and modified Mallet scores.

INTRODUCTION: This study aims to assess the relationship between the modified Mallet classification and the Brachial Plexus Profile activity short form (BP-PRO activity SF). The therapist or surgeon classifies upper extremity movement for the modified Mallet classification, while the BP-PRO assesses parents' perceptions of difficulty performing activities. PURPOSE: To provide a deeper understanding of the relationship of functional and perceived outcome measurements. STUDY DESIGN: Prospective, correlational design. METHODS: Eighty children with brachial plexus birth injuries were evaluated using the modified Mallet classification, while parents simultaneously answered the BP-PRO activity SF questions. All patients had undergone one of three surgical interventions to improve shoulder function. The relationship between the two measures, patient injury levels, and surgical histories were assessed. RESULTS: The average modified Mallet scores and BP-PRO activity SF scores weakly correlated (r = 0.312, P = .005) and both measures differentiated between C5-6 and C5-7 injury levels (P = .03 and P = .02, respectively). Conversely, the modified Mallet scores could differentiate between the three surgical groups (F = 8.2, P < .001), while the BP-PRO activity SF could not (P = .54). CONCLUSION: The results suggest that these tools measure different aspects of patient outcomes. The Mallet classification may be more focused on shoulder motion than the BP-PRO activity SF. Additional questions that specifically require shoulder function could be incorporated into the BP-PRO activity SF to improve understanding of patient/parent perceptions of shoulder function for children with brachial plexus injuries. Clinicians should be aware of the strengths, weaknesses, and limitations of each outcome assessment tool for appropriate use and interpretation of results.

Outcomes of Osteochondral Autograft Transplantation in Pediatric Patients With Osteochondritis Dissecans of the Capitellum.

PURPOSE: To assess the outcomes of osteochondral autograft transplantations in the treatment of osteochondritis dissecans of the capitellum in the pediatric population. METHODS: Between 2011 and 2016, 15 patients who had undergone osteochondral autograft transplantation at a mean age of 13.7 years at surgery were identified. The donor site was from the superolateral, non-weight-bearing surface of the lateral femoral condyle of the ipsilateral knee. RESULTS: Mean follow-up was 29.5 months, with no patients lost to follow-up. Mean arc of motion increased significantly from 121.9° preoperatively to 139.1° postoperatively. All 9 elite athletes returned to sports at an elite level: 7 returned to the same level of competition in the same sport, 1 retired from gymnastics due to multiple injuries but began diving at an elite level, and 1 retired from baseball unrelated to elbow symptoms but continued hockey at the same level. Of the 4 recreational athletes, all returned to sport. There were no intraoperative complications. The symptoms resolved completely in all but 2 patients, who improved over their preoperative condition. The donor site knee pain resolved in all patients at an average of 2.3 months. Postoperative imaging demonstrated the healing and incorporation of the plug in all patients. CONCLUSIONS: In the treatment of osteochondritis dissecans of the capitellum, osteochondral autograft transplantation demonstrates excellent clinical and radiographic outcomes, with minimal short-term donor site morbidity and a high level of return to the sport. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effect of Glenohumeral Reduction Type Combined With Tendon Transfer for Brachial Plexus Injury on Objective, Functional, and Patient-Reported Outcomes.

PURPOSE: Glenohumeral (GH) joint reductions are frequently performed during tendon transfer surgery for brachial plexus birth injuries (BPBI); however, the effect of reduction method (none required, closed, surgical) has not been assessed. This study compared objective, functional, and patient-reported outcomes between children who underwent a tendon transfer and (1) did not require GH reduction, (2) required concomitant closed GH reduction, or (3) required concomitant surgical GH reduction. METHODS: Fifty-four children with BPBI who previously underwent teres major and/or latissimus dorsi transfer with or without concomitant GH reduction participated. Joint reduction method was classified as none required (n = 21), closed (n = 9), or surgical (n = 24). Motion capture was collected in a neutral position, abduction, external rotation, and internal rotation. Glenohumeral joint angles and displacements were calculated. Joint angular displacements represented the differences between the joint angles in each terminal position and the joint angles of the arm at rest in the neutral position. A hand surgeon determined modified Mallet scores. Participants' parents completed the Brachial Plexus Profile Activity Short Form (BP-PRO-SF) to assess physical activity performance. RESULTS: The no-reduction group had significantly less GH elevation than the surgical-reduction group for all positions and significantly less GH elevation than the closed-reduction group for the neutral, external rotation, and internal rotation positions. There were no differences in GH rotation angles. Glenohumeral joint displacements from neutral and modified Mallet scores were similar. The no-reduction group demonstrated significantly greater BP-PRO-SF scores than the surgical-reduction group. CONCLUSIONS: Patients who underwent a closed or surgical GH joint reduction consistently displayed more GH elevation. Clinically, this corresponds to an abduction contracture. Whereas increased abduction contracture provided a benefit of greater overhead motion, modified Mallet scores were similar between groups. The surgical-reduction group demonstrated lower BP-PRO-SF outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Long Thoracic Nerve Transfer for Children With Brachial Plexus Injuries.

INTRODUCTION: The transfer of intraplexal and extraplexal nerves for restoration of function in children with traumatic and birth brachial plexus palsies has become well accepted. Little has been written about using the long thoracic nerve (LTN) as a donor in reanimation of the upper extremity. The authors present a case series of nerve transfers using the LTN as a donor in brachial plexus injury. METHODS: A retrospective chart review was performed over a 10-year period at a single institution. The primary outcome measure was the active movement scale. RESULTS: Fourteen patients were included in the study: 10 birth injury patients and 4 blunt trauma patients. Average follow-up time was 21.3 and 10.75 months, respectively. The best outcomes were seen when the LTN was used for reinnervation of the obturator nerve in free functioning muscle transfers. The next most successful recipients were the musculocutaneous and axillary nerves. Outcomes were poor in transfers to the posterior interosseous fascicles of the radial nerve and the radial nerve branches to the triceps. DISCUSSION: The LTN may be a potential nerve donor for musculocutaneous or axillary nerve reinnervation in patients with brachial plexus injuries when other donors are not available during a primary plexus reconstruction. However, the best use may be for delayed neurotization of a free functioning muscle transfer after the initial plexus reconstruction has failed and no other donors are available. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Early results of nerve transfers for restoring function in severe cases of acute flaccid myelitis.

OBJECTIVE: To describe early functional outcomes of nerve transfer surgery in a relatively large cohort of patients with acute flaccid myelitis (AFM). METHODS: A retrospective case analysis was made of patients with AFM treated with nerve transfer surgery between 2007 and 2018. Surgical criteria were persistent motor deficits after 6 months from onset and available donor nerves. Thirty-two patients with AFM were evaluated; 16 underwent nerve transfer surgeries. Motor function was evaluated by a licensed occupational therapist using the Active Movement Scale preoperatively and during follow-up examinations. Patients with 6 or more months of follow-up were included in the analysis. Patients with procedures other than nerve transfers were excluded. RESULTS: Sixteen patients with AFM had nerve transfers, with a male predominance (75%) and median age of 2.5 years (range = 4 months-12 years). Eleven patients had a minimum 6 months of follow-up. Nerve transfers to restore elbow function had 87% excellent recovery for elbow flexion and 67% for elbow extension. Finger and thumb extension were full against gravity in 1 patient (100%). Shoulder external rotation was excellent in 50% of patients and shoulder abduction in only 20%. Nine of 10 patients (90%) had resolution of shoulder pseudosubluxation following nerve transfer to the suprascapular nerve. INTERPRETATION: Patients with AFM with persistent motor deficits 6 to 9 months after onset benefit from nerve transfer surgery. Restoration of elbow function was more reliable than restoration of shoulder function. We recommend early referral of patients with incomplete recovery to a center experienced in nerve transfers for timely evaluation and treatment. ANN NEUROL 2019;86:607-615.

Bipolar Latissimus Dorsi Transfer for Arthrogryposis Multiplex Congenita: Minimum 10-Month Follow-Up.

PURPOSE: To examine the outcomes of patients who have undergone bipolar latissimus dorsi transfer for loss of elbow flexion in arthrogryposis multiplex congenita (AMC). METHODS: This study retrospectively evaluated 6 cases (5 patients) of bipolar latissimus dorsi transfer performed to restore active elbow flexion in pediatric patients with AMC. Elbow range of motion and strength were evaluated before and after surgery. Functional outcomes were evaluated by the patients' ability to perform activities of daily living. Complications and patient satisfaction were also evaluated at final follow-up. RESULTS: The patients were a mean age of 7.8 ± 3 years. The mean follow-up was 30.2 months (range, 10-44 months). At most recent follow-up, all cases reported improved function of the surgical extremity when performing activities of daily living and overall satisfaction. The postoperative active range of motion was 76° ± 14°. All cases had active elbow flexion against gravity. One patient was noted to have decreased muscle activation of the transfer 6 months after surgery, but strength improved by the 10-month follow-up. No other complications were noted. CONCLUSIONS: We recommend bipolar latissimus dorsi transfer as a reliable option to restore functional elbow flexion in patients with AMC. Meticulous pedicle handling and assessment of the latissimus dorsi viability is paramount. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

What's New in Congenital Hand Surgery.

BACKGROUND: Congenital conditions of the hand and upper extremity are a frequent source of consultation among pediatric orthopaedists and hand surgeons. Advances in the fields of molecular biology and genetics have helped to better understand some of these conditions and redefine previous classification systems. New outcome measurement tools have been used to assess surgical results and have brought into focus a different aspect of the patients' experience. METHODS: We searched PubMed database for papers related to the treatment of congenital hand anomalies published from January 1, 2015 to October 31, 2018. The search was limited to English articles yielding 207 papers. Three pediatric hand surgeons selected the articles based upon the criteria that the topic was germane, the article fell under the subheadings within the manuscript, and the conclusions were meaningful. RESULTS: A total of 40 papers were selected for review, based upon their quality and new findings. Research articles with significant findings were included for syndactyly, symbrachydactyly, cleft hand, polydactyly, radial longitudinal deficiency, congenital radio-ulnar synostosis, and macrodactyly. CONCLUSIONS: Our knowledge of the embryology and pathophysiology of congenital upper extremity conditions continues to evolve. Functional assessments combined with patient and parent-reported outcomes have our understanding of the results following surgical procedures. Further research and standardization of our scientific data will provide better answers and higher quality of evidence. LEVEL OF EVIDENCE: Level V-literature review and expert opinion.

Ulnar focal cortical indentation: a progressive, deforming variant of focal fibrocartilaginous dysplasia.

BACKGROUND: Focal fibrocartilaginous dysplasia is a rare growth disturbance of bone resulting in deformity. In the ulna, focal fibrocartilaginous dysplasia is particularly rare, and the characteristic fibroligamentous tether can result in progressive deformity with progressive dislocation of the radial head. The fibroligamentous tether is similar in appearance and function to the Vickers ligament seen in Madelung deformity. The imaging features of ulnar focal fibrocartilaginous dysplasia include a unilateral angular deformity in the ulna with a radiolucent cortical defect and surrounding sclerosis, with secondary radial bowing or radial head dislocation. Focal fibrocartilaginous dysplasia of the ulna has been described using the term ulnar focal cortical indentation. OBJECTIVE: To review the clinical and radiologic features of four cases of ulnar focal cortical indentation occurring in pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed picture archiving and communication system and electronic medical record imaging findings with surgical correlation of ulnar focal cortical indentation at two large specialty pediatric hospitals. RESULTS: Ulnar focal cortical indentation lesions typically arise in the ulnar metaphysis and result in angular forearm deformities with progressive radial deformity including radial head dislocation. Early surgical intervention prevents progression of the deformity and retains range of motion. CONCLUSION: Ulnar focal cortical indentation, although rare, is likely a progressive form of focal fibrocartilaginous dysplasia resulting in significant deformity and disability. Early recognition of the characteristic imaging features is important for early surgical intervention to preserve range of motion and prevent radial head dislocation.

A Cadaveric Study on the Accuracy of an Individualized Guiding Template to Assist Scaphoid Fixation Using Computed Tomography and 3-Dimensional Printing.

PURPOSE: The aim of this study was to evaluate the feasibility and accuracy of scaphoid screw guidewire placement using a computer-assisted-designed, and 3-dimensional-printed, surgical guiding template in cadaver wrists. METHODS: Computed tomography (CT) scans of 12 fresh-frozen cadaver wrists were performed and the data imported into a surgical planning system. A 3-dimensional skin surface template block with a guiding hole was generated from the CT data to allow a screw guidewire to be placed in the central third of the scaphoid. This 3-dimensional model was printed and then put back onto the wrist. A screw guidewire was inserted through the palmar guide hole into the intact scaphoid and then a postprocedure CT scan was obtained. These postprocedure data were introduced into the surgical planning system. Angular and linear deviation between the preprocedural simulation and the image of the guidewire was measured in the system to assess accuracy. RESULTS: Mean angular deviation was 3.85° ± 1.32° (range, 1.56°-5.35°) and linear deviations of the 12 specimens were less than 1.1 mm. No specimen required a repeat drilling to the scaphoid. All the screw guidewires were considered to be centrally placed in the scaphoid based on our criterion of central placement of the scaphoid screw. CONCLUSIONS: The use of a computer-assisted 3-dimensional-printed surgical guide template to assist screw guidewire placement into an intact scaphoid, mimicking a nondisplaced scaphoid fracture, showed acceptable accuracy in cadaver wrists. CLINICAL RELEVANCE: Our technique may provide a simple and effective method for the guidance of screw guidewire insertion in a nondisplaced scaphoid fracture surgery.

Scapular Stabilization Limits Glenohumeral Stretching in Children With Brachial Plexus Injuries.

PURPOSE: To quantify the effects of scapular stabilization on scapulothoracic and glenohumeral (GH) stretching. METHODS: Motion capture data during external rotation and abduction with and without scapular stabilization were collected and analyzed for 26 children with brachial plexus birth palsy. These positions were performed by an experienced occupational therapist and by the child's caretaker. Scapulothoracic and GH joint angular displacements were compared between stretches with no stabilization, stabilization performed by the therapist, and stabilization performed by the caretaker. The relationship between the age and ability of the therapist and caretaker to perform the stretches with scapular stabilization was also assessed. RESULTS: During external rotation there were no significant differences in either the scapulothoracic or GH joint during stabilization by either the therapist or the caretaker. During abduction, both scapulothoracic and GH joint angular displacements were statistically different. Scapulothoracic upward rotation angular displacement significantly decreased with scapular stabilization by the therapist and caretaker. Glenohumeral elevation angular displacement significantly decreased with scapular stabilization performed by the therapist and caretaker. There were only weak correlations between age and the differences in scapulothoracic and GH joint angular displacement performed by both the therapist and the caretaker. CONCLUSIONS: The findings of this study indicate that scapular stabilization may be detrimental to passive stretching of the GH joint in children, as demonstrated by a reduced stretch. Based on the findings of this study, we have changed our practice to recommend passive stretches without scapular stabilization for children aged 5 years and older with brachial plexus birth palsy. In infants and children aged less than 5 years, we now recommend stretching with and without scapular stabilization until the effect of scapular stabilization is objectively assessed in these age groups. LEVEL OF EVIDENCE/TYPE OF STUDY: Therapeutic IV.

Suprascapular Ligament Release From an Anterior Approach: An Anatomic Feasibility Study.

PURPOSE: The results of spinal accessory to suprascapular nerve transfers have been less reliable than other nerve transfers in the upper limb, possibly owing to compression of the nerve by the suprascapular ligament. The posterior approach has been advocated to allow for release of the ligament. The purpose of this study was to determine whether a ligament release is possible from the anterior approach. METHODS: Nine fresh-frozen cadavers were dissected to determine whether the ligament could be approached and released from the anterior approach. Complete ligament release was demonstrated by subluxation of the nerve out of the suprascapular notch. RESULTS: Ligament release was achieved in all specimens, although in one, confirmation of complete release required a posterior approach. CONCLUSIONS: Release of the suprascapular ligament to eliminate a potential source of compression of the suprascapular nerve during spinal accessory to suprascapular nerve transfer is possible through an anterior approach. CLINICAL RELEVANCE: Release of the suprascapular ligament through an anterior approach allows this procedure to be performed through the same approach as brachial plexus exploration and spinal accessory nerve to suprascapular nerve transfer. This method could reduce surgical time and patient repositioning and avoid additional incisions.

Motion Necessary to Achieve Mallet Internal Rotation Positions in Children With Brachial Plexus Birth Palsy.

BACKGROUND: Upper extremity function in children with brachial plexus birth palsy (BPBP) is assessed with clinical tests such as the Mallet classification, which uses a hand to spine position to assess shoulder internal rotation, or the modified Mallet classification, which adds an additional internal rotation task (hand to belly). Children with BPBP frequently have difficulty performing the hand to spine task. This study compared scapulothoracic and glenohumeral (GH) parameters associated with successful completion of the hand to spine and hand to belly modified Mallet positions. METHODS: Motion capture measurement of 32 children with BPBP was performed in hand on spine, internal rotation (hand to belly), hand to mouth, and maximal humerothoracic extension positions. Modified Mallet scores were determined by a hand surgeon. RESULTS: Children with better hand to spine performance demonstrated significantly greater GH extension and a nonsignificant trend toward increased GH internal rotation compared with children with scores <3. Children with better internal rotation position performance demonstrated significantly greater GH internal rotation and no significant difference in GH extension. Hand on spine and internal rotation Mallet scores moderately correlated (Pearson r=0.469); however, 54% of children who could place their palms flat on their bellies could not reach behind their backs. CONCLUSIONS: Successfully reaching behind one's back requires both internal rotation and extension, representing a multiplanar motion. The hand to belly performance is less affected by extension and should be considered for internal rotation assessment, particularly for children undergoing surgical intervention that may affect internal rotation. LEVEL OF EVIDENCE: Level II.