Challenges in Management of Proximal Humerus Diaphyseal Fracture in a Patient with Brachial Plexus Birth Injury: A Case Report.

CASE: Two-and-a-half-month-old boy, a known case of brachial plexus birth injury, sustained proximal humeral diaphyseal fracture. Fracture healed in varus malunion and failed to remodel subsequently. Challenges were faced in the course of the management because of progression of the deformity. Finally, the fracture united after rigid internal fixation performed at 2.5 years. CONCLUSION: Neuromuscular imbalance can lead to angular deformity at fracture site and cause unpredictable remodeling, as in our case. Conservative management may fail to achieve union with satisfactory alignment. Rigid internal fixation should be considered in such cases to achieve union.

Brachial Plexus Birth Injury due to Proximal Humeral Physeal Separation: A Case Report.

CASE: A 9-day-old male neonate presented with swelling over his left shoulder and reduced movements of the left upper extremity since birth. Radiographs raised a suspicion of a shoulder dislocation. Ultrasonography confirmed the diagnosis of proximal humeral physeal separation. Magnetic resonance imaging (MRI) revealed edema of the infraclavicular part of the brachial plexus. Conservative management was followed, and the injury remodeled completely at 2 years. CONCLUSION: Neonatal proximal humeral physeal separation poses a diagnostic challenge. Ultrasonography is helpful for diagnosis. MRI is indicated when concurrent brachial plexus birth injury is suspected. Conservative management yields good outcome in the absence of entrapped nerves and tendons.

Hip Spica Table: A Technical Note.

Introduction: Hip spica is a widely used treatment modality in the management of various paediatric orthopaedic conditions. A standardized hip spica table is not universally available and various centerres have devised their own designs. In collaboration with the local engineering team, we have designed a light weight yet sturdy, economical and portable hip spica table. Materials and Methods: Components of the spica table and their measurements are described. Technique of mounting and unmounting the patient off the table has been discussed. We have applied the hip spica using the current design in 141 children between 2009 and 2023. The same table has been used for the children aged 6 months to 10 years. We have not experienced any table breakage during spica application. The acrylic sheet was changed only once during the study period due to attrition. Conclusion: Our design has been used successfully at our center for more than 14 years. It is simple, economical, portable and durable. It can be used in dedicated pediatric orthopedic centers and can be carried easily to the field hospitals. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00935-1.

Clinical Diagnosis of the Infantile Shoulder Subluxation in Residual Brachial Plexus Birth Injury and Its Correlation With Ultrasound Diagnosis.

INTRODUCTION AND AIMS OF STUDY: Timely detection of shoulder subluxation in infants with brachial plexus birth injury (BPBI) is essential to prevent the progression of glenohumeral deformity. Shoulder ultrasonography (USG) is routinely used to detect an infantile subluxation/dislocation, but its use is limited because of the paucity of expert radiologists in developing countries. The aim of this study was to determine the clinical examination predictors to determine shoulder subluxation in patients with BPBI correlating with ultrasound confirmation. METHODS: We prospectively studied children who presented to our hospital between 2017 and 2021 diagnosed as brachial plexus birth injury. In patients developing internal rotation contracture of the shoulder, we looked for 3 standard clinical signs: reduced passive external rotation <60 degrees, deep anterior crease (DAC) and relatively short arm segment. Shoulder subluxation was defined as USG measurement of alpha angle>30 degrees and ossific nuclei of the humerus lying behind the dorsal scapular line. Sensitivity and specificity were used to assess their efficacy in clinical diagnosis of shoulder subluxation in different groups. The predicted probability of shoulder subluxation from each prediction rule was compared with actual distributions based on USG confirmation. RESULTS: Of the 58 BPBI infants who developed PER<60 degrees at the shoulder, 41 had USG confirmed shoulder subluxation. The 2 independent predictors of shoulder subluxation (PER<45 degrees and DAC) were identified in the current patient population based on data analysis. The presence of short arm segment is a very specific marker of shoulder subluxation but not sensitive. The predicted probability of shoulder subluxation from the prediction rule combining all the 3 markers were similar to the actual distributions in the current patient population. CONCLUSIONS: PER<45 degrees and presence of deep anterior crease are clinical markers indicating shoulder dislocation in patients with BPBI developing reduced external rotation at the shoulder. On the basis of the proposed clinical diagnosis algorithm, the above markers along with the selective use of USG can help in early detection and treatment of infantile shoulder dislocation.

Closed Reduction Technique for Severely Displaced Radial Neck Fractures in Children.

Background: The described technique is useful for achieving closed reduction of severely displaced (i.e., Judet Type-III and IV) pediatric radial neck fractures. It is widely agreed that radial neck fractures with angulation of >30° should be reduced. Various maneuvers have been described, but none uniformly achieves complete reduction in severely displaced radial neck fractures (Types III and IV)1-4. The aim of the present technique is to achieve closed reduction in these severely displaced radial neck fractures without surgical instrumentation. Description: A stepwise approach is described. First, the radial head is viewed in profile under an image intensifier so that it appears rectangular. Varus stress is applied at the medial aspect of the elbow by the assistant, and thumb pressure is applied at the radial head along the posterolateral aspect of the elbow. This results in partial reduction of the radial head. The elbow is then simultaneously flexed and pronated with continuous pressure over the radial head. This final step anatomically reduces the radial head, and hyperpronating the forearm locks it in the corrected position. Alternatives: Operative alternatives to this technique include intra-focal pin-assisted reduction to achieve closed reduction, the Métaizeau technique of achieving indirect closed reduction of the fracture with the aid of a TENS (Titanium Elastic Nailing System) nail, and open reduction5. Nonoperative techniques have also been described for use with Judet Type-II and III fractures, but not with the severely displaced types described in the present article. Rationale: This technique takes into consideration the anatomy of the capsule and lateral collateral ligament complex. The biomechanical ligamentotaxis helps in achieving anatomic reduction of the radial head. Placing the forearm in pronation tightens the annular and lateral collateral ligaments and prevents redisplacement. There are potential complications with operative treatment, including the risk of nerve injury with percutaneous reduction techniques and the risks of osteonecrosis, premature epiphyseal fusion, and heterotopic ossification with open reduction. These complications can be avoided by the use of the presently described technique. Expected Outcomes: This technique provided satisfactory clinical outcomes in our previous study6, with none of the 10 patients showing signs of growth disturbance, loss of reduction, or reported complications at 12 months. Terminal restriction of supination was observed in 1 patient. No patient had osteonecrosis or elbow deformity. No patient required conversion to an implant-assisted or open reduction procedure. Important Tips: The steps need to be followed sequentially as described in order to achieve an anatomical reduction.After achieving the reduction, it is necessary to keep the forearm in pronation to maintain the reduction with the aid of the lateral ligament complex.This technique may not work in complex fractures with elbow dislocation because of the lack of ligamentous integrity.In the final step, the elbow is pronated and flexed simultaneously, with sustained pressure over the radial head in order to obtain further correction. This is the most critical step of the technique because anatomic reduction of the partially reduced fracture is achieved at this time. Acronyms and Abbreviations: Percut. = percutaneousAP = anteroposteriorCR = closed reductionORIF = open reduction and internal fixation.

Hip Spica Stroller: A Technical Note.

Background: Care of the child after hip-spica application is the most challenging issue faced by parents. Reduced mobility and recumbency can cause respiratory problems, skin irritation and discomfort for the child. Parents need to lift the child in a spica to make him upright and to mobilize. To improve the comfort of the family in post spica care, we have designed a 'Hip Spica Stroller' which is low profile, comfortable, easy to construct and relatively inexpensive. This manuscript discusses our early experience with this hip-spica stroller use. Methods: A sturdy, relatively lightweight and portable stroller was designed in collaboration with local mechanical engineering team. The stroller allowed safe upright placement of the child with spica and their easy mobility. From the second post-operative day, children were mobilised in the stroller. We looked for development of any complications related to the stroller such as spica breakage, skin irritation or excoriation development. Parents were also inquired about their feedback and satisfaction with the device upon spica removal. Results: We used the spica stroller in nine patients after Developmental Dysplasia Hip (DDH) treatment and in eight patients post shaft femur fracture treatment. None of the patients experienced any stroller-related complications. All the patients maintained the joint reduction and the fractured bone fragment alignment. High satisfaction rates were reported by parents. Conclusion: Hip Spica Stroller is an innovative and easy-to-make device which would enhance the post spica care. It can aid alleviating the fear of parents for their child's hip-spica treatment. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00568-2.

Modified Velpeau Sling Application for the Treatment of Fractures Around Shoulder in Infants.

BACKGROUND: Fractures around the shoulder region in infants are treated by arm-chest bandaging, adhesive strapping, or sling application. These conventional treatment methods are associated with issues like skin irritation, excoriation, movement of bone fragments causing muscle spasm, and difficulty in nursing care. We describe the technique of modified Velpeau sling application and reviewed its efficacy at a long-term follow-up. METHODS: A retrospective study was conducted with 19 infants who presented between 2009 and 2018 to a tertiary care center in western India with either clavicle or humerus fracture. Inclusion criteria was any infant with humerus or clavicle fracture that underwent modified Velpeau sling application and had a minimum follow-up of 2 years. Patients were followed at weekly intervals until sling discontinuation based on the fracture healing. At further follow-up, children were assessed for the presence of angular or rotational malalignment and limb length discrepancy. Functional outcome was measured by the Paediatric Adolescent Shoulder Survey at the final follow-up. RESULTS: Seven clavicle and 12 humerus fractures were treated with this technique. The mean age at presentation was 50 days (range, 1 d to 7 mo). The average follow-up was 6 years (range, 2 to 10 y). Two infants had underlying osteogenesis imperfecta. Infants without underlying pathology had no angular/rotational malalignment or limb length discrepancy, while both infants with underlying osteogenesis imperfecta had a varus alignment and shortening of the humerus. Infants without underlying pathology demonstrated good functional outcomes measured by the Paediatric Adolescent Shoulder Survey questionnaire, while those with pathology had functional limitations. CONCLUSIONS: The modified Velpeau method is an effective way of treating fractures around the shoulder region in infants without underlying pathology. Several advantages such as accessibility of sling material, easy application, inexpensive material, and absence of skin-related complications make this an effective treatment. LEVEL OF EVIDENCE: Level IV-therapeutic study.