Faculty Bibliography

The management of children with brachial plexus birth injuries is complex and requires a multidisciplinary approach. In the following article, we describe our approach to evaluation and management at Nicklaus Children's Hospital. It is our aim is to elucidate nuances in management.

Eponyms, while inherently flawed, remain a constant in medical vernacular, especially in orthopaedic surgery. It is essential to understand how these eponyms came to be named and for whom they were named after in order to know the correct usage and definition of these eponyms. In this first part, we describe the history of eponym usage in paediatric hip radiography; who, when, what, where, and how. We hope to provide a historical perspective of interest, resolve any controversies in semantic definitions, and create a comprehensive library of eponymous terms related to paediatric hip radiography.

BACKGROUND:Children with suspected fractures are typically evaluated with multiple x-rays. This approach can add time, discomfort, and radiation exposure without clinical benefit. The purpose of this study was to determine whether a focused radiographic protocol could reduce the number of x-rays performed without missing any fractures. METHODS:Pediatric patients presenting at 2 sites within an academic medical center [urgent care (UC) and the emergency department(ED)] for a suspected fracture were identified. There were 495 patients (UC, 409; ED, 86) over a 3-month period. A retrospective chart review was performed to characterize the standard x-rays performed. Using this data, a simplified protocol was developed and distributed. Subsequently, 333 patients (UC, 259; ED, 74) were evaluated over the same period 1-year later. The main outcome measures included the final diagnosis, the total number of x-rays, the number of anatomic areas imaged, visit length, and the time for additional trips to radiology. Charts were reviewed to identify any missed injuries. Welch 2-sample t tests and Fisher exact tests were used for statistical analysis. RESULTS:After implementing the radiographic protocol, there was a significant reduction in the number of x-ray views, 3.4 versus 5.1 (P<0.001). There was a decrease in imaging of multiple anatomic areas with the largest reduction occurring in patients presenting with elbow injuries (9% vs. 44%, P<0.001). No difference was found in the rate of patients sent back to radiology (6% vs. 7%, P=0.67). However, among patients presenting with outside imaging, significantly fewer were sent to radiology for additional x-rays (29% vs. 50%, P<0.01). CONCLUSION/CONCLUSIONS:A simple radiographic protocol for evaluating pediatric patients with suspected fractures safely led to a decrease in the overall number of x-rays without missing any injuries. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

We report the results of ten consecutive patients who had correction of an elbow flexion contracture of greater than 30° in brachial plexus birth injury using a modified Outerbridge-Kashiwagi procedure. All patients had minimum 23-month follow-up. Pre- and post-operative elbow range of motion and DASH scores were recorded in all patients. The operative technique for the procedure and post-operative course is discussed. Surgery was supplemented by botulinum toxin injection into the biceps brachii muscle in most cases. The average age at surgery was 14 years 10 months. The initial plexus lesion was global in eight patients and upper in two. Pre-operative flexion contractures averaged 51° (range 35 to 60) and post-operative averaged 21° (range 15 to 30). Of these patients, one had no change in active flexion, four had loss of active flexion, and five had gain of active flexion. All ten patients were satisfied with their results and stated that they would recommend the procedure to other patients. Level of evidence: IV.

BACKGROUND:Most brachial plexus birth injuries (BPBI) are caused by traction on the brachial plexus during a difficult delivery. Fortunately, the possibility of complete recovery from such an incident is relatively high, with only 10% to 30% of patients having prolonged and persistent disability. These patients have muscle imbalances and co-contractions typically localized around the shoulder and elbow. These imbalances and co-contractures cause abnormal motor performances and bone/joint deformities. Typically, physical/occupational therapies are the conventional therapeutic modalities but are often times inadequate. Botulinum toxin A (BTX-A) injections into targeted muscles have been used to combat the muscular imbalances and co-contractions. METHODS:With compliance to PRISMA guidelines, a systematic review was performed to identify studies published between 2000 and 2017 that used BTX-A to treat neonatal brachial plexus palsies. RESULTS:Ten studies were included, involving 325 patients. Three groups of indications for the use of BTX-A were identified: (1) internal rotation/adduction contracture of the shoulder; (2) elbow flexion lag/elbow extension lag; and (3) forearm pronation contracture. CONCLUSIONS:The included studies show an overall beneficial effect of BTX-A in treating co-contractures seen in patients with BPBI. Specifically, BTX-A is shown to reduce internal rotation/adduction contractures of the shoulder, elbow flexion/extension contractures, and forearm pronation contractures. These beneficial effects are blunted when used in older patients. Nevertheless, BTX-A is a useful treatment for BPBI with a relatively low-risk profile.

Brachial plexus birth injuries are rare, with treatment and follow-up often required from infancy until skeletal maturity. We review complications that may occur related to primary nerve surgery or secondary musculoskeletal procedures, and discuss how these may be avoided.

Background and Objective(s): Patients with brachial plexus birth palsy may develop significant elbow flexion contractures greater than 30 degrees that limit function and present issues with body image. In later childhood, serial casting is ineffective due to permanent bony changes in the elbow joint. This paper reports a permanent and effective treatment of elbow flexion contractures in adolescent patients utilizing distal humeral arthrolysis along with radical anterior release, a modified Outerbridge-Kashiwagi procedure. The operative technique for the procedure and postop course is discussed. Study Design: The paper reports the results of the 12 consecutive patients who had correction of an elbow flexion contracture of greater than 30 degrees using a modified Outerbridge- Kashiwagi procedure. All patients had minimum 1 year follow- up, ranging from 14 months to 5 years. Pre and postoperative elbow range of motion were measured with a goniometer. 10 of the 12 patients also had pre- and postoperative DASH scores. At the last followup, patients were asked if they were satisfied with the operation and would they recommend it to others. The operative technique for the procedure and postop course is discussed. Study Participants & Setting: The group consisted of 6 males and 6 females who presented to our Brachial Plexus Program. The average age at surgery was 14 years 8 months, ranging from 11 years 11 months to 17 years 6 months. The initial plexus lesion was global in 10 patients and Erb's palsy in 2. Materials/Methods: Each patient had operative correction of their flexion contracture, utilizing a modified distal humeral arthrolysis, combined with an anterior approach that consisted of soft tissue release and median nerve neurolysis. Post-operatively, the patients were immobilized in a well padded plaster cast in gravity extension for 2 weeks. Then each had serial casting for 4 weeks using a long arm drop out casting technique. Patients were instructed in home exercise program, consisting of range of motion and strengthening exercises. Night splinting in full extension was recommended for a year. Results: Pre-operative flexion contractures averaged 49.6 degrees (-35 to -60). Post-operative flexion contractures averaged -21.1 degrees (-15 to -27). Average pre-op active elbow flexion was 130.8 degrees (130 to 150). Average post-op active flexion was 124.2 (90 to 140). Of these patients, 4 had no change in active flexion, 4 had loss of flexion, and 4 had gain of some flexion. All twelve patients were pleased with their results and stated that they would recommend the procedure. Of the 10 patients with recorded DASH scores, the average pre-op was 37.4, and the average post-op was 13.7. No patient showed a worse post-operative DASH score. All twelve patients were satisfied with their result and would recommend it to other patients. Conclusions/Significance: These are the preliminary results of a novel approach to significant problem of form and body image referable to the elbow. The modified Outerbridge- Kashiwagi procedure, as developed by the authors, provided significant, permanent gains in elbow extension

Peripheral nerve injuries of the lower extremity (LE) are frequently encountered in orthopaedic practice. They can be traumatic or iatrogenic. Proper and timely diagnosis and treatment are the keys to optimizing outcomes. This paper reviews and discusses the basic anatomy and physiology of nerve injury and the current literature on the incidence, pathogenesis, diagnosis, management and outcomes of sciatic, femoral, peroneal, and tibial nerve injuries. The purpose of this review is to suggest a protocol for evaluation and management of LE nerve injuries.