The Effects of Radial Longitudinal Deficiency on Long-Term Use of the Thumb in Pediatric Patients Following Index Pollicization.

PURPOSE: To assess the effect of radial longitudinal deficiency on the function of pollicized digits as determined by the Thumb Grasp and Pinch (T-GAP) assessment. METHODS: We retrospectively evaluated 25 hands with thumb hypoplasia that underwent index finger pollicization. Patients were followed for an average of 10.4 years. Hands were divided by severity into two groups: no or mild radial longitudinal deficiency (RLD) (Group 1 = 16) and moderate to severe RLD (Group 2 = 9). We collected demographic information and completed physical examination measures, including hand strength, elbow, wrist, and hand range of motion, the Kapandji opposition score, active grasp span, and T-GAP total score. RESULTS: Patients with moderate to severe forms of RLD had stiffer long fingers, lower Kapandji opposition scores, and limited active and passive range of motion for elbow flexion, wrist ulnar deviation, and pollicized thumb interphalangeal flexion. They had shorter forearms, decreased active grasp span, and fewer thumb creases at the interphalangeal thumb joint. In addition, the T-GAP total score was significantly lower when comparing the two groups. Children with mild dysplasia were able to achieve 32% of age-matched normal grasp strength. Patients with more severe radial dysplasia averaged 17% less grasp strength compared with children with mild dysplasia. Patients with moderate to severe RLD also had lower T-GAP total scores and strength measurements if they had limited wrist ulnar deviation. CONCLUSIONS: Individuals with moderate to severe RLD have unique anatomical factors that affect outcomes after pollicization. These individuals use their thumbs for fewer activities, have weaker grasp, and retain more primitive grasp patterns compared with those who have milder forms of RLD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The Green Transfer-Long-Term Results.

PURPOSE: The purpose of this study was to determine the long-term results of the Green transfer (flexor carpi ulnaris to extensor carpi radialis brevis) for patient-reported outcomes, wrist position, and range of motion. METHODS: We re-examined 13 patients from a previous prospective study involving surgery for hemiplegia that included a Green transfer. The average follow-up was 8 years with the range from 5 to 11 years. The wrist range of motion and the postoperative position of the wrists were measured. The surgical outcomes were measured via the Pediatric Orthopedic Data Collection Instrument, the Shriner's Hospital Upper Extremity Evaluation, Pediatric Quality of Life, and visual analog score for appearance from the patient and the parent. RESULTS: At this follow-up, only 7 of the 13 patients had a wrist position near neutral with the ability to flex and extend the wrist. Wrist range of motion was improved in four, decreased in four, and stayed the same in five patients. In contrast to these positional wrist results, statistically significant improvements were noted in several aspects of the Pediatric Orthopedic Data Collection Instrument, visual analog scores, and Shriner's Hospital Upper Extremity Evaluation scores. CONCLUSIONS: Long-term follow-up of the flexor carpi ulnaris to extensor carpi radialis brevis tendon transfer in hemiplegic patients reveals the results to be variable but favorable from a patient-reported outcome standpoint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Abductor Pollicis Longus Tendon Abnormalities and Release in Children With Congenital Clasped Thumb.

BACKGROUND: Congenital clasped thumb is associated with deficient thumb extensor tendons. Reconstruction includes tendon transfer. Here, we describe a variant of the abductor pollicis longus (APL) tendon, not previously reported, contributing to the flexion deformity. The purpose of this study is to report examples of and offer surgical repair techniques for APL variants identified in patients with clasped thumb. METHODS: We reviewed records of 11 consecutive patients undergoing reconstruction for clasped thumb. Surgical anatomy of the APL tendon was evaluated in all patients, followed by release of aberrant APL attachments. Participants were invited to return for an in-person assessment with a certified hand therapist. Data were collected regarding intraoperative findings, surgical techniques for reconstruction, postoperative thumb motion, and patient and caregiver satisfaction. RESULTS: Eleven children (12 thumbs) underwent aberrant APL release and rerouting between 2019 and 2021. Preoperatively, all thumbs were passively correctible to 0° of extension. In all patients, the APL was found to terminate palmar to the metacarpophalangeal (MCP) joint, creating an MCP flexion moment when tensioned. The average age at surgery was 7 years (range: 1-15 years), and the average follow-up was 14.2 months (range: 1-21 months). The mean postoperative thumb radial abduction was 55° (range: 20°-75°). CONCLUSIONS: When reconstructing clasped thumbs, surgeons should explore the presence of APL abnormalities. Release and centralization of the APL can improve thumb position and function. This technique may avoid the need for extra-anatomical tendon transfer in patients with clasped thumb.

Inter- and Intrarater Reliability of the Thumb Grasp and Pinch Assessment for Children Following Index Pollicization for Congenital Thumb Hypoplasia.

PURPOSE: The Thumb Grasp and Pinch (T-GAP) assessment quantifies functional hand use in children with congenital thumb hypoplasia by categorizing grasp and thumb use patterns during assessment activities that encourage a variety of grasp and pinch styles. This study aims to demonstrate interrater and intrarater reliability results of the T-GAP. METHODS: A retrospective review was performed of children who had undergone index finger pollicization for congenital thumb hypoplasia and subsequent evaluation with videotaping of the T-GAP assessment. Following a training period, 4 occupational therapists scored 11 T-GAP videos on 2 separate occasions, separated by at least 2 weeks. Intraclass correlation coefficients (ICCs), standard error of measurements, minimum detectable change (MDC), and Pearson correlation coefficients were calculated. RESULTS: The T-GAP raw scores were 16 to 55, demonstrating a range of mild to severe hand grasp differences. The ICCs for the interrater reliability trials were 0.887 and 0.901. Intrarater ICCs were all above 0.88. The MDC for each trial was 8.1 and 6.7 points. Pearson correlation coefficients calculated for each rater and each pair of raters were above 0.8 in all cases. CONCLUSIONS: Interrater and intrarater reliability testing results for the T-GAP were excellent in all cases; this strongly suggests that results from T-GAP assessments are reliable. The high ICCs suggest that raters can classify and score children's hand function consistently. CLINICAL RELEVANCE: This study, in conjunction with previous work, suggests that the T-GAP may be an ideal approach to assessing the outcomes of pollicization and provide a means of ongoing assessment of children's grip and pinch function.

A New, Direct Measure of Thumb Use in Children After Index Pollicization for Congenital Thumb Hypoplasia.

PURPOSE: After index pollicization for congenital thumb hypoplasia, time-based hand dexterity tests do not indicate whether the new thumb is being used by a child. The Thumb Grasp and Pinch assessment (T-GAP) is a new outcome measure that classifies grasp and pinch styles to quantify use of the new thumb. The goal of this study was to establish concurrent validity and construct validity in the T-GAP. METHODS: Data from children treated with index finger pollicization for congenital thumb hypoplasia were retrospectively reviewed. Measures of strength, range of motion, and scores on the Box and Blocks Test (BBT), 9-Hole Peg Test (NHPT), Functional Dexterity Test (FDT), and Task 7 (Heavy Objects) from the Jebsen-Taylor Test (JTT7) were recorded. Patients also completed the T-GAP consisting of 9 age-appropriate tasks, during which grasp patterns were classified. Spearman correlation coefficients were calculated comparing the T-GAP score with scores on the BBT, NHPT, FDT, and JTT7. RESULTS: We evaluated 21 thumbs in 21 children an average of 71.7 months after pollicization surgery (range, 9-175 months). The T-GAP score was significantly correlated with BBT, NHPT, FDT, and JTT7 (R = 0.69, -0.60,-0.59, and -0.60, respectively). The T-GAP score was significantly correlated with tripod pinch, key pinch, and grip strength (R = 0.77, 0.75, and 0.71, respectively) and with opposition and grasp span (R = 0.50 and 0.52, respectively). The T-GAP was the only functional measure correlated with parent and patient satisfaction with thumb function. CONCLUSIONS: Concurrent validity was supported by significant correlations between T-GAP score for all 4 dexterity measures. Construct validity was supported by significant correlations between strength and range of motion of the thumb and T-GAP score. CLINICAL RELEVANCE: This evaluation may help surgeons and therapists better understand results after pollicization and determine whether the new thumb is being incorporated into daily activities.

Change in Hand Function and Dexterity with Age after Index Pollicization for Congenital Thumb Hypoplasia.

BACKGROUND: Little is known about how performance on strength, range of motion, and dexterity measures changes as children with index finger pollicization mature. The authors reviewed performance in range of motion, strength, and dexterity over a 7-year period and report outcomes over time. METHODS: Data from children treated with index finger pollicization for congenital thumb hypoplasia from 2007 to 2014 were reviewed retrospectively. Children were followed for an average of 3.9 years (range, 1 to 7 years) during the study period. Standardized assessments included range of motion, grip, key pinch and tripod pinch strength, the Box and Block Test, the Nine Hole Peg Test, and the Functional Dexterity Test. Average score by age and average yearly change were calculated for each assessment, and scores were plotted against published age-matched scores of normal children when available. RESULTS: Twenty-three patients with 29 affected thumbs were included. Distal grasp span increased 0.17 inch and Kapandji opposition improved 0.26 point with each year of age; however, proximal web-space size did not increase over time. Grip strength improved an average of 2.69 kg/year, and tripod and key pinch improved 0.58 kg and 0.67 kg with each year of age. Box and Block Test scores improved an average of 4.11 blocks/year. Scores on the Nine Hole Peg Test improved 3.83 seconds/year, and scores on the Functional Dexterity Test improved 0.026 peg/second each year. CONCLUSIONS: Children with pollicized thumbs improve in dexterity and strength with growth. Web-space size did not change with age; therefore, the thumb should be carefully positioned at the time of surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Effect of Treatment on Stereognosis in Children With Hemiplegic Cerebral Palsy.

PURPOSE: To determine if rehabilitation alone or combined with surgery or botulinum toxin injection improved stereognosis in children with hemiplegic cerebral palsy. METHODS: Inclusion criteria were children with spastic hemiplegic cerebral palsy who had stereognosis testing 2 separate times with documentation of intervening treatment. Sixty-three children were included, 30 girls and 33 boys at an average age of 9.1 years (range, 4.4-16.0 years). Twelve standardized objects were used for manual identification. Baseline and postintervention stereognosis results were recorded for the hemiplegic and the dominant limb of each patient. The patients were separated into 3 groups based on intervening treatment: surgery with rehabilitation (27 patients), botulinum toxin injection with rehabilitation (19 subjects), and rehabilitation alone (7 subjects). Results were also analyzed by patient age group. RESULTS: Baseline testing of the hemiplegic limb revealed that 27 patients (43%) exhibited severe stereognosis impairment (0-4 objects identified correctly), 18 (28%) were moderately impaired (5-8 objects), 13 (21%) were mildly impaired (9-11 objects), and 5 (8%) had intact stereognosis (12 objects). There was no statistically significant difference in change in stereognosis scores postintervention among the 3 different treatment groups or between patients who had surgery and those who did not have surgery. There was no statistically significant difference in stereognosis function or postintervention change based on patient age at time of testing. CONCLUSIONS: In this study, 92% of children with spastic hemiplegic cerebral palsy had stereognosis impairment with a wide spectrum of severity. After operative or nonoperative treatment interventions, stereognosis as a secondary outcome measure was not changed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Affected and contralateral hand strength and dexterity measures in children with hemiplegic cerebral palsy.

PURPOSE: To determine how the affected hemiplegic hand and contralateral dominant hand in children with hemiplegic cerebral palsy compare with age-matched norms for grip strength, pinch strength, and dexterity. METHODS: We enrolled 37 children with hemiplegic cerebral palsy (26 boys; average age, 9.8 y). Grip and pinch strength and Box and Blocks Test for dexterity were measured in both hands. Affected and contralateral hands results were analyzed and compared with each other and with norms for age and sex. RESULTS: Affected hands had significantly less grip and pinch strength than the contralateral hands. Subjects transported significantly fewer blocks in one minute with the Box and Blocks Test (mean, 10.8 blocks) with the affected hand than the contralateral hand. Compared with normative values, affected-side grip and pinch strengths were significantly less, whereas contralateral hand grip and pinch strengths were similar. Dexterity in both affected and contralateral hands was significantly less than normative values. Decreased dexterity in the contralateral hand was correlated with decreased nonverbal intelligence quotient. CONCLUSIONS: Dexterity of the contralateral hand is diminished in children with hemiplegia. Assessment of the contralateral hand may reveal opportunities for therapeutic intervention that improve fine motor function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Correlation of motor function and stereognosis impairment in upper limb cerebral palsy.

PURPOSE: To correlate motor function, as measured by the Jebsen-Taylor test, and sensory function, as measured by the 12-object stereognosis testing, in the hands of children with spastic hemiplegia due to cerebral palsy. METHODS: A chart review identified children with hemiplegic and triplegic cerebral palsy with stereognosis and Jebsen-Taylor testing between 1997 and 2008. Forty-one children were included in the study, including 22 girls and 19 boys, with an average age of 8.7 years (range, 6-16 years). The right side is affected in 23 children; 34 children have hemiplegic cerebral palsy, and 7 have triplegic cerebral palsy. The initial Jebsen-Taylor and stereognosis test results were recorded for each subject, as well as age, diagnosis, affected side, and prior treatment with hand therapy, botulinum toxin injection, or surgery. Descriptive statistics, chi-square analysis, paired t-tests, and correlation measurements were used for analysis of the data. RESULTS: Statistically significant inverse correlations exist between the cards, small objects, checkers, light objects, and heavy objects on the Jebsen-Taylor subtests, as correlated with the stereognosis scores in the affected hand (p < or = 0.04). The stereognosis scores for the patients who were not able to complete the Jebsen-Taylor test with the affected hand were significantly lower than those who were able to complete the Jebsen-Taylor test with the affected hand (p = .04). The stereognosis scores were significantly lower for the affected side as compared with the contralateral side. The Jebsen-Taylor total test times were significantly longer for the affected side as compared with the contralateral side (p < .001). CONCLUSIONS: In children with hemiplegic and triplegic cerebral palsy, the impairment of stereognosis is correlated with impairment in motor function, and the inability to complete the Jebsen-Taylor test with the affected hand is associated with impaired stereognosis function. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The Unilateral Below Elbow Test: a function test for children with unilateral congenital below elbow deficiency.

The Unilateral Below Elbow Test (UBET) was developed to evaluate function in bimanual activities for both the prosthesis wearer and non-wearer. Nine tasks were chosen for each of four age-specific categories defined by development stages of hand function (2-4y, 5-7y, 8-10y, and 11-21y). Two scales, Completion of Task and Method of Use, were designed to rate performance. To measure reliability, four occupational therapists scored samples of videotaped UBET performances. For Completion of Task, an interval scale, agreement in scoring was measured with interclass correlation coefficients (ICC; n=9; five females, four males). For Method of Use, a nominal scale, chance-adjusted association was calculated with Cohen's kappa coefficients (interobserver n=198; 111 females, 87 males; intraobserver n=93; 56 females, 37 males). For Completion of Task, the average ICC was 0.87 for the prosthesis-on condition, and 0.85 for the prosthesis-off condition. ICCs exceeded 0.80 for eight out of nine tasks for the two older age groups, but for only five out of nine tasks in the younger age groups. Higher inter- and intraobserver kappa coefficients for Method of Use resulted when scoring children with their prostheses on versus off. The oldest age group had lower kappa values than the other three groups. The UBET is recommended for the functional evaluation of Completion of Task in children with unilateral congenital below elbow deficiency with and without their prostheses. Method of Use scoring can evaluate individuals for directed therapy interventions or prosthetic training.

Pediatric unilateral below-elbow amputees: retrospective analysis of 34 patients given multiple prosthetic options.

Thirty-four unilateral below-elbow amputees from the Shriners Hospitals for Children/Twin Cities were retrospectively analyzed in long-term follow-up. All of these patients were provided with a variety of prosthetic options, including a "passive" cosmetic upper extremity device. Most of the patients were also fitted with conventional prostheses using a body-powered voluntary closing terminal device (97%) as well as myoelectric prostheses (82%). These patients were considered consistent prosthetic users by the clinic team. The average follow-up was 14 years, with many of the patients being followed up throughout their entire childhood. All patients were sent questionnaires, and the authors carried out patient interviews and chart review. Final analysis indicated that 15 patients (44%) selected a simple cosmetic "passive hand" as their prosthesis of choice. In long-term follow-up 14 patients (41%) continued as multiple users. Fourteen patients (41%) selected the conventional prosthesis using a voluntary closing terminal device as the prosthesis of choice. Only five patients (15%) selected the myoelectric device as their primary prosthesis. The authors conclude that successful unilateral pediatric amputees may choose multiple prostheses on the basis of function and that frequently the most functional prosthesis selected in the long term is the simplest in design. The authors believe strongly that unilateral pediatric amputees should be offered a variety of prosthetic options to help with normal activities of daily living.