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Outcome after tendon transfers to restore wrist extension in children with brachial plexus birth injuries

Ruchelsman, David E; Ramos, Lorna E; Price, Andrew E; Grossman, Leslie Agatha; Valencia, Herbert; Grossman, John A I
Children with brachial plexus birth injuries often require tendon transfer to restore active wrist extension and maximize hand function. The purpose of this study is to assess the clinical results in children with brachial plexus birth injuries after tendon transfer to reconstruct active wrist extension. Over a 10-year period, 21 children (11 male, 10 female) underwent tendon transfer to reconstruct active wrist extension by a single surgeon. Eight patients had C5/C6/C7 injury and 13 patients had global palsy (C5-T1). The average age at surgery was 5.5 years (range, 3 to 8 y). Restoration of wrist extension was measured according to the functional scale of Duclos and Gilbert. The mean duration of follow-up was 36 months (minimum follow-up of 1 y). At latest follow-up, 14 (66%) children (C5/C6/C7, n=8; global, n=6) demonstrated active wrist extension >/=30 degrees. Within the global injury subcohort, 3 patients demonstrated static extension of the wrist. Four failures occurred in the global palsy group. Children with absent active wrist extension after a brachial plexus birth injury can benefit from a tendon transfer. The more severe global palsy cases have a worse outcome
PMID: 21572285
ISSN: 1539-2570
CID: 132591

Hypoplasia of the trapezius and history of ipsilateral transient neonatal brachial plexus palsy

Min, William; Price, Andrew E; Alfonso, Israel; Ramos, Lorna; Grossman, John A I
We present two children with hypoplasia of the left trapezius muscle and a history of ipsilateral transient neonatal brachial plexus palsy without documented trapezius weakness. Magnetic resonance imaging in these patients with unilateral left hypoplasia of the trapezius revealed decreased muscles in the left side of the neck and left supraclavicular region on coronal views, decreased muscle mass between the left splenius capitis muscle and the subcutaneous tissue at the level of the neck on axial views, and decreased size of the left paraspinal region on sagittal views. Three possibilities can explain the association of hypoplasia of the trapezius and obstetric brachial plexus palsy: increased vulnerability of the brachial plexus to stretch injury during delivery because of intrauterine trapezius weakness, a casual association of these two conditions, or an erroneous diagnosis of brachial plexus palsy in patients with trapezial weakness. Careful documentation of neck and shoulder movements can distinguish among shoulder weakness because of trapezius hypoplasia, brachial plexus palsy, or brachial plexus palsy with trapezius hypoplasia. Hence, we recommend precise documentation of neck movements in the initial description of patients with suspected neonatal brachial plexus palsy
PMID: 21310341
ISSN: 1873-5150
CID: 123210

Glenohumeral deformity in children with brachial plexus birth injuries

Ruchelsman, David E; Grossman, John A I; Price, Andrew E
Shoulder deformity remains the most common musculo-skeletal sequela following a brachial plexus birth injury. The natural history of untreated glenohumeral deformity is one of progression in this unique patient population. In infants and young children with persistent neurological deficits, shoulder dysfunction becomes a major source of morbidity, as these children have extreme difficulty placing the hand in space. The functional limitations due to muscle denervation and the resultant periarticular soft tissue contractures and progressive osseous deformities have been well-characterized. Increasing attention is being given to the glenohumeral dysplasia (GHD) and the associated prevalence of early posterior dislocation of the shoulder in infants with brachial plexus birth injuries. GHD represents a spectrum of findings, including glenoid and humeral head articular incongruities and dysplasia, subluxation, and frank dislocation. This article presents our comprehensive, temporally-based management strategies for the glenohumeral joint deformities in these children utilizing soft tissue and bony reconstructive procedures
PMID: 21332437
ISSN: 1936-9727
CID: 128794

Persistent Posterior Interosseous Nerve Palsy Associated with a Chronic Type I Monteggia Fracture-Dislocation in a Child: A Case Report and Review of the Literature

Ruchelsman, David E; Pasqualetto, Michele; Price, Andrew E; Grossman, John A I
We present a rare case of persistent complete posterior interosseous nerve palsy associated with a chronic type I Monteggia elbow fracture-dislocation consisting of anterior dislocation of the radial head and malunion of the ulna in an 8-year-old child requiring surgical treatment. Posterior interosseous nerve neuropraxia following acute Monteggia injury patterns about the elbow has been described and is thought to be secondary to traction or direct trauma. The condition typically resolves following successful closed reduction of the radial head. This report describes combined treatment of the nerve and skeletal injury for the chronic type I Monteggia injury. The literature is reviewed, and diagnostic challenges with and treatment options for chronic Monteggia fracture-dislocations in children are discussed
PMCID:2686791
PMID: 19052821
ISSN: 1558-9447
CID: 91483

Brachial plexus birth palsy: an overview of early treatment considerations

Ruchelsman, David E; Pettrone, Sarah; Price, Andrew E; Grossman, John A I
Since the description by Smellie in 1764, in a French midwifery text, that first suggested an obstetric origin for upper limb birth palsy, great strides have been made in both diagnosis and early and late treatment. This report presents an overview of selected aspects of this complex and extensive subject. Early treatment options are reviewed in the context of the present controversies regarding the natural history and the indications for and timing of microsurgical intervention in infants with brachial plexus birth injuries
PMID: 19302062
ISSN: 1936-9719
CID: 99290

Cortical dysplasia and obstetrical brachial plexus palsy [Case Report]

Alfonso, Israel; Alfonso, Daniel T; Price, Andrew E; Grossman, John A I
We report 2 patients with obstetrical brachial plexus palsy, ipsilateral leg weakness, and contralateral motor cortical dysplasia. To our knowledge, this is the first description of such an association. In both cases, the diagnosis of obstetrical brachial plexus palsy was established clinically shortly after birth and later confirmed neurophysiologically. Motor cortex dysplasia was diagnosed by magnetic resonance imaging (MRI). The association of obstetrical brachial plexus palsy and contralateral motor cortex dysplasia, a condition known to produce congenital hemiparesis, raises the possibility that the cortical dysplasia was a predisposing factor for obstetrical brachial plexus palsy in these cases
PMID: 19073856
ISSN: 1708-8283
CID: 91482

Entrapment neuropathy contributing to dysfunction after brachial plexus birth injuries [Letter]

Price, Andrew E; Beric, Aleksandar; Yaylali, Ilker; Grossman, John A I
PMID: 17717479
ISSN: 0271-6798
CID: 95128

Botulinum toxin type A as an adjunct to the surgical treatment of the medial rotation deformity of the shoulder in birth injuries of the brachial plexus

Price, A E; Ditaranto, P; Yaylali, I; Tidwell, M A; Grossman, J A I
We retrospectively reviewed 26 patients who underwent reconstruction of the shoulder for a medial rotation contracture after birth injury of the brachial plexus. Of these, 13 patients with a mean age of 5.8 years (2.8 to 12.9) received an injection of botulinum toxin type A into the pectoralis major as a surgical adjunct. They were matched with 13 patients with a mean age of 4.0 years (1.9 to 7.2) who underwent an identical operation before the introduction of botulinum toxin therapy to our unit. Pre-operatively, there was no significant difference (p = 0.093) in the modified Gilbert shoulder scores for the two groups. Post-operatively, the patients who received the botulinum toxin had significantly better Gilbert shoulder scores (p = 0.012) at a mean follow-up of three years (1.5 to 9.8). It appears that botulinum toxin type A produces benefits which are sustained beyond the period for which the toxin is recognised to be active. We suggest that by temporarily weakening some of the power of medial rotation, afferent signals to the brain are reduced and cortical recruitment for the injured nerves is improved
PMID: 17356143
ISSN: 0301-620x
CID: 71310

Is arthroscopic release indicated? [Letter]

Price, Andrew E; Tidwell, Michael A; Grossman, John A I
PMID: 17272473
ISSN: 0021-9355
CID: 71307

Fetal deformations: a risk factor for obstetrical brachial plexus palsy?

Alfonso, Israel; Diaz-Arca, Gemma; Alfonso, Daniel T; Shuhaiber, Hans H; Papazian, Oscar; Price, Andrew E; Grossman, John A I
The purpose of this report is to discuss the association of brachial plexus palsy and congenital deformations. We reviewed all charts of patients less than 1 year of age with obstetrical brachial plexus palsy evaluated by one of the authors (IA) between January 1998 and October 2005 at Miami Children's Hospital Brachial Plexus Center. Of 158 patients with obstetrical brachial plexus palsy, 7 had deformations (4.4%). Deformations were present in 32% of patients delivered by cesarean section, but in only 2% of patients delivered vaginally. The deformations were ipsilateral, involving the chest in two patients, distal arms in two patients, proximal arm in one patient, ear in one patient, and the leg in one patient. All patients with deformations had unilateral Erb's palsies. None had a history of maternal uterine malformation. Two presumptive mechanisms of injury, one causing the deformation (compressive forces) and one causing brachial plexus palsy at the time of delivery (traction forces), were present in all cases. The higher incidence of deformation in patients with obstetrical brachial plexus palsy born by cesarean sections and the presence of two presumptive mechanisms in all of the cases presented here raises the possibility that fetal deformations are a risk factor for obstetrical brachial plexus palsy
PMID: 16996396
ISSN: 0887-8994
CID: 72449