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.

Treatment Options for Bifid Ulna Deformity Following Galeazzi-equivalent Injury in Adolescents.

A Galeazzi-equivalent lesion occurs in children and adolescents following a traumatic distal radius fracture when the strong radioulnar ligaments and relative weakness of the ulnar physis result in an avulsion-type Salter-Harris III fracture of the distal ulna. In unreduced fractures, the osteogenic nature of the torn periosteal sleeve may result in the formation of a bifid distal ulna. We describe two cases of bifid distal ulna that developed after missed Galeazzi-equivalent lesions. The first case was treated with resection of the volar limb and reduction of the ulnar fracture, whereas the second case was treated with simple resection of the dorsal limb. Negative ulnar variance developed in both cases. Level of Evidence: Level V (Case report).

Nerve Transfer of Brachialis Branch to Anterior Interosseus Nerve Using In Situ Lateral Antebrachial Cutaneous Nerve Graft in Tetraplegia.

PURPOSE: Reconstruction of finger motion is a therapeutic goal in tetraplegic patients. Although nerve transfer of the brachialis branch of the musculocutaneous nerve to the anterior interosseus nerve has been previously described, this results in unreliable reinnervation because the donor nerve is proximal to the target muscle. We describe an alternative technique in which nerve transfer is performed using the lateral antebrachial cutaneous nerve as a vascular in situ nerve graft. The clinical results are reported. METHODS: Nine upper limbs of 6 patients (mean age 25 years) with tetraplegia were subjected to brachialis-to-anterior interosseus nerve transfer using the lateral antebrachial cutaneous nerve as a vascular in situ nerve graft, at a mean of 6 months after injury. Additional supinator branch transfer to the posterior interosseous nerve was performed for 6 upper limbs and to the flexor digitorum superficialis motor branch for 1 upper limb. RESULTS: At a mean of 2 years of follow-up, thumb and finger flexion strength scored M3-M4 in 5 of the 9 limbs according to the Medical Research Council scale. Key pinch and grip pinch averaged 0.6 kg (range, 0-1.0 kg) and 2.2 kg (range, 0-8 kg), respectively. No donor-site deficit was observed. CONCLUSIONS: Brachialis-to-anterior interosseus nerve transfer with an in situ lateral antebrachial cutaneous nerve graft can be used to reconstruct thumb and finger flexion in tetraplegic patients. Combined with supinator-to- posterior interosseous nerve transfer, simultaneous active extension of the fingers can be achieved. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

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.

Appearance of congenital hand anomalies.

BACKGROUND AND OBJECTIVE: Impact of appearance of congenital hand anomalies has not previously been reported. The purpose of this study was to describe the common perception about how different congenitally malformed hands look. METHODS: We developed a questionnaire in a game format to evaluate the appearance of different hands. Altogether 1450 (954 females) 4- to 84-year-old residents (296 children) of two European and one Asian (n = 102) country were asked to rate the appearance of different looking hands on a five-point pictorial Likert-type scale. Standardized photographs of the dorsal aspect of 17 different congenitally malformed non-operated hands and a normal hand were presented to respondents. Significance of age, gender, nationality, and profession of the respondents was assessed. RESULTS: The respondents' ranking order of the hands was nearly consistent. The normal hand (mean = 4.43, standard deviation = 0.85, Md = 5) and clinodactyly (mean = 4.37, standard deviation = 0.86, Md = 5) were perceived to have the best appearance. Symbrachydactyly (mean = 1.42, standard deviation = 0.68, Md = 1) and radial club hand (mean = 1.40, standard deviation = 0.68, Md = 1) received the lowest scores. Adults rated the appearance of hands higher than children regarding 14 hands, females higher than men regarding 15 hands, and Europeans higher than Asians in 4 hands (p < 0.05, respectively). Europeans rated four-finger hand (mean = 3.21, standard deviation = 1.18, Md = 3) better looking than six-finger hand (mean = 2.92, standard deviation = 1.18, Md = 3, p < 0.005), whereas Asians gave higher scores to six-finger hand (mean = 2.66, standard deviation = 1.26, Md = 3) compared to four-finger hand (mean = 2.51, standard deviation = 1.14, Md = 2). Medical doctors and nurses gave higher scores compared to the other profession groups, school children, and high school students in five hands (p < 0.05). CONCLUSIONS: A normal hand is perceived distinctly better looking than most congenitally different hands. Different malformations' appearance was ranked very coherently in the same order despite of participants' age, gender, nationality, or profession. Asians seem to prefer an additional digit to a four-finger hand.

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.

9 years' follow-up of 168 pin-fixed supracondylar humerus fractures in children.

Background and purpose - The long-term outcome of pin-fixed supracondylar humerus fractures (SCHF) in children is not well known. We assessed the 7- to 12-year outcome in 168 children. Patients and methods - During 2002-2006, 210 domestic children (age 7 (1-14) years) with SCHF (Gartland III 79%, Gartland II 19%, and flexion type 2%) were pin fixed in Helsinki. 36 (17%) patients had a nerve palsy. Radiographic alignment was regarded as satisfactory in 81% of patients (Baumann angle (BA) within ±10˚ of normal range and whose anterior humeral line (AHL) crossed the capitulum). After a mean follow-up of 9 (7-12) years, 168 (80%) patients answered a questionnaire regarding elbow appearance (scale 0-10), function (scale 0-10), and pain (scale 0-10), and symmetry of range of motion (ROM) and carrying angle (CA). 65 (31%) patients also attended a clinical follow-up examination. Results - Mean subjective score for appearance was 8.7 (2-10) and for function 9.0 (2-10) (n = 168). Elbow ROM asymmetry was experienced by 28% and elbow CA asymmetry by 17% of the patients. Elbow pain was reported by 14%, and was more common in children with nerve injuries. Long-term outcome was good or excellent in 60/65 and CA in 56/65 of the follow-up visit patients using Flynn's criteria. BA exceeding normal values by 10˚ was associated with lower subjective outcome; AHL crossing point with the capitulum was not associated with outcome. Interpretation - Long-term subjective outcome is satisfactory with few exceptions if elbow ROM and CA are restored within 10° of the uninjured elbow. Radiographs at fracture union have little prognostic value. Nerve injuries can cause long-term pain.

Outcome after pin fixation of supracondylar humerus fractures in children: postoperative radiographic examinations are unnecessary.

Background and purpose - The quality of pin fixation of displaced supracondylar humerus fractures in children has not been assessed, and the clinical value of radiographic examinations after pin fixation is unclear. We evaluated pin configuration, quality of osteosynthesis, and outcome in 264 supracondylar fractures. The clinical significance of postoperative radiographs was analyzed. Patients and methods - 252 Gartland-III and 12 flexion-type supracondylar humerus fractures were pin-fixed in the periods 2002-2006 and 2012-2014. During 2012-2014, staff were intructed that postoperative radiographs should not be taken. Quality of reduction was assessed by measuring Baumann and lateral capitellohumeral angles (LCHA) and also by recording the crossing point of the anterior humeral line (AHL) with bony capitellum. Rotatory alignment was registered as normal or abnormal. Pin configuration and quality of osteosynthesis were evaluated. The clinical significance of postoperative radiographs was analyzed. Results - Postoperatively, Baumann angle was normal in 66% of the fractures, AHL crossed the capitellum in 84%, and no malrotation was evident in 85% of the fractures. Crossed pins were used in 89% of the cases. 2 or more pins fixed both fracture fragments in 66%. Radiographic examinations were inadequate for assessment of LCHA in 13%, of Bauman angle in 8%, of AHL in 2%, of rotation in 1%, and of pin fixation in 2% of the cases. Postoperative radiographs did not give useful information except in 1 patient who had corrective osteotomy. All 94 patients with follow-up (97%) who were treated during 2012-2014 were satisfied with the outcome. Interpretation - Despite pin fixation being deemed unsatisfactory in one-third of the cases, significant malunion was rare. Postoperative radiography did not alter management or outcome.

Free Vascularized Fibular Graft is Reliable in Upper Extremity Long-Bone Reconstruction with Good Long-Term Outcomes.

Background Free vascularized fibular graft is useful in upper extremity long-bone reconstruction. The authors studied the reliability and long-term outcomes of this technique. Methods The authors included 20 patients with a minimum follow-up of 24 months in this study, and retrospectively reviewed patients' hospital records and used a preinformation form, the Disabilities of the Arm, Shoulder and Hand (DASH), the Lower Extremity Functional Scale (LEFS), and the 15D health-related quality of life (HRQoL) instrument to perform a cross-sectional assessment. Results A total of 9 adults and 11 children underwent vascularized fibular transfer for radical tumor resection (n = 13), infection (n = 1), injury (n = 3), or secondary pseudoarthrosis (n = 3) in various locations of the upper extremity. The median follow-up period was 6 years. Six reoperations proved necessary: one early reanastomosis and five revisions with cancellous bone grafting to enhance union. Altogether, 19 of the 20 grafts survived: one graft failed due to infection. One arm was amputated due to tumor recurrence. The median duration of bone union was 12 months. One graft never achieved distal union, whereas another developed nonunion after a stress fracture. Ten patients completed the questionnaires, with a median of 15.3 years postoperatively. The results revealed functional capabilities ranging from no restrictions to significantly impaired, and an HRQoL comparable to that of an age-standardized general population. Conclusion The free vascularized fibular graft is viable in different age groups to reconstruct upper extremity long-bone defects in cases of radical bone resection, extensive injury, and diaphyseal pseudoarthrosis. The long-term outcomes support the use of this technique.

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.

Pediatric distal humeral fractures and complications of treatment in Finland: a review of compensation claims from 1990 through 2010.

BACKGROUND: The distal part of the humerus is the second most common fracture location in children. Complications are more common than with other pediatric fractures and are mostly related to inappropriate diagnosis and treatment. METHODS: On the basis of data from 1990 through 2010 in the national registry of inpatient care treatment in Finland, we calculated the number of children less than seventeen years of age who were treated under anesthesia for a distal humeral fracture (reduction with or without internal fixation) and the number of treatment institutions. We analyzed compensation claims concerning the treatment of these fractures that were received by the Patient Insurance Centre. The risk of a complication of treatment and the number of avoidable complications of treatment were assessed. RESULTS: A total of 7909 children underwent a procedure under anesthesia to treat a distal humeral fracture. Claims were filed for 117 patients (118 fractures, including seventy-four supracondylar, nineteen epicondylar, nineteen condylar, and six T-type), and compensation was granted for eighty-three (71%) of the patients. Deformity (forty-nine), delayed treatment (twenty), nerve injury (seventeen), and infection (seven) were the most common reasons for compensation. On reevaluation of the claims, ninety patients were assessed as having had complications of treatment. In our opinion, complications could have been avoided for eighty-six (96%) of these patients. CONCLUSIONS: We believe that improving the quality of primary assessment and operative technique would decrease the number of complications in the treatment of pediatric distal humeral fractures. Centralizing operative treatment to tertiary hospitals should be considered.