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Shah M, James J, Rubaiath T, Vijay P. Orthokids Precise De-rotation Jig for Rotational Osteotomies of Humerus. Tech Hand Up Extrem Surg 2025; 29:e00507. [PMID: 39819857 DOI: 10.1097/bth.0000000000000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2025]
Abstract
Humerus de-rotational osteotomies are one of the commonly done salvage procedures in children with residual brachial plexus birth injuries. Conventionally, the degree of angular correction was measured clinically intraoperatively by the ability to reach the occiput and the belly or it can be measured by putting reference k-wires at the appropriate angles. However, accurate angular correction is essential to success, as under-correction may lead to parental dissatisfaction and over-correction may lead to loss of mid-line function. The 'Orthokids Precise De-rotation Jig' (Nebula Surgical, Rajkot, INDIA) allows the exact measurement of the rotational correction required, which will lead to improved clinical outcomes. This accurate measurement mitigates the risk of errors due to parallax or eyeballing. The jig is handy, radio-opaque, autoclavable, and can be used without extensive dissection than what is required for the plate fixation.
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Russo SA, Nice EM, Chafetz RS, Richards JG, Zlotolow DA, Kozin SH. Impact of tendon transfer on scapulothoracic and glenohumeral motion in children with brachial plexus birth injuries. J Shoulder Elbow Surg 2025; 34:e227-e238. [PMID: 39151671 DOI: 10.1016/j.jse.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 06/22/2024] [Accepted: 06/27/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Tendon transfers are often utilized to improve shoulder external rotation and abduction in children with brachial plexus birth injuries and are designed to improve glenohumeral (GH) joint motion. However, changes in scapulothoracic (ST) and GH joint function after tendon transfer are not well defined. The purpose of this study was to quantify changes in GH, ST, and humerothoracic (HT) joint function before and after tendon transfer, and we hypothesized that tendon transfers would reorient the arc of motion into more external rotation and abduction, but not increase GH motion. METHODS Motion analysis was performed in 15 children (ages 3-16) before and after transfer of teres major and/or latissimus dorsi. ST, GH, and HT joint angles were measured in a neutral, resting position and each of the modified Mallet positions. Joint angular displacements from the neutral position and the total arc of internal-external rotation for each joint were also calculated. Relevant joint angles, joint angular displacements, and internal-external rotation arcs were compared using multivariate analyses of variance with repeated measures and univariate posthoc analyses. RESULTS Glenohumeral and HT external rotation were significantly increased in all positions postoperatively. The arc of GH internal-external rotation was unchanged, but oriented in more external rotation after surgery. Only 6 patients gained active external rotation. Glenohumeral and HT internal rotation were significantly decreased after surgery, but ST internal rotation was significantly increased. Two patients had loss of midline function. In the abduction position, GH elevation joint angles were unchanged, but ST and HT elevation increased. DISCUSSION Only 4 patients gained active GH external rotation and maintained their internal rotation. Each of those patients underwent isolated tendon transfer without concomitant joint release. Seven patients maintained their preoperative internal rotation, which was attributed to increased ST internal rotation. The other half of patients lost internal rotation and gained external rotation through reorientation of the arc of rotation. Nine patients gained HT elevation, with 3 attributed to increased ST upward rotation, 5 attributed to a combination of increased ST upward rotation, and increased GH elevation, and 1 attributed to increased GH abduction contracture. These findings challenge the dogma that teres major/latissimus dorsi tendon transfers augment GH motion and highlight the importance of ST function for outcome determination.
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Affiliation(s)
- Stephanie A Russo
- Department of Orthopedic Surgery, Akron Children's Hospital, Akron, OH, USA.
| | - Emily M Nice
- Department of Research, Shriners Children's, Philadelphia, PA, USA
| | - Ross S Chafetz
- Motion Analysis Laboratory, Shriners Children's, Philadelphia, PA, USA
| | - James G Richards
- Department of Kinesiology and Applied Anatomy, University of Delaware, Newark, DE, USA
| | - Dan A Zlotolow
- Department of Orthopedic Surgery, Shriners Children's, Philadelphia, PA, USA
| | - Scott H Kozin
- Department of Orthopedic Surgery, Shriners Children's, Philadelphia, PA, USA
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Maurel N, Diop A, Lallemant-Dudek P, Fitoussi F. Upper limb kinematics in patients with neonatal brachial plexus palsy with different levels of palsy. Clin Biomech (Bristol, Avon) 2025; 122:106394. [PMID: 39642679 DOI: 10.1016/j.clinbiomech.2024.106394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 10/07/2024] [Accepted: 11/17/2024] [Indexed: 12/09/2024]
Abstract
BACKGROUND Neonatal brachial plexus palsy remains a frequent condition and most of those patients often present active and passive joint limitation depending of the extend of the palsy. The aim of this study was to compare during the Mallet score tasks the upper limb kinematics of those patients with a reference database of non-involved arms but also to characterize kinematics changes according to the extent of the palsy. METHODS Kinematic analysis was performed using an electromagnetic device. The point of achievement position and the range of motion were analyzed. The involved arm of thirty-three patients was studied. Several groups of patients were defined depending on the level of the palsy: a C5-C8 ± T1 group (fifteen patients), a C5-C6 group (five patients) and a C5-C7 group (thirteen patients). Data from non-involved arm of thirty patients were used as control. FINDINGS Many significant differences were found between the control and palsy groups and between the latter. When comparing the C5-C8 ± T1 and proximal groups, for all except the mouth task, at point of achievement the scapula was more in protraction and glenohumeral elevation was lower. Elbow flexion range of motion was different for all except the external rotation task, with a decreased flexion for mouth, neck and spine tasks and a higher flexion for elevation task. For mouth task, the C5-C8 ± T1 group had a lower supination range of motion than the proximal group. INTERPRETATION This study helps to better understand the effect of the palsy on the humerothoracic, scapulothoracic, glenohumeral and elbow kinematics.
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Affiliation(s)
- Nathalie Maurel
- Arts et Metiers Institute of Technology, EPBRO, HESAM Université, F-75013 Paris, France.
| | - Amadou Diop
- Arts et Metiers Institute of Technology, EPBRO, HESAM Université, F-75013 Paris, France.
| | - Pauline Lallemant-Dudek
- Sorbonne Université, Pediatric Physical Medicine and Rehabilitation Department, Hospital Armand Trousseau, Paris, France..
| | - Franck Fitoussi
- Sorbonne Université, Pediatric Orthopaedics Department, Hospital Armand Trousseau, Paris, France.
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Hutanu D, Corona PS, Rojas-Neira J, Nguyen TQ, Velasquez-Giron E, Soldado F. Shoulder external rotation contracture following neonatal brachial plexus injury. J Shoulder Elbow Surg 2025; 34:96-103. [PMID: 38810914 DOI: 10.1016/j.jse.2024.03.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 03/19/2024] [Accepted: 03/29/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Glenohumeral posterior external rotation contractures and scapular winging are frequently overlooked problems in residual neonatal brachial plexus injury (NBPI). Recent attention has emphasized their impact on vital functions such as feeding and hygiene. This study aims to present the epidemiology of posterior glenohumeral contractures in a significant pediatric NBPI population and explore contributing factors. METHODS We conducted a retrospective analysis of data collected from January 2019 to November 2022, involving a case series of 262 children with residual NBPI. The data included demographics, palsy level, prior surgical history, and the modified Mallet scale. Glenohumeral passive internal rotation in abduction and cross-body adduction angles were measured bilaterally. Subjects were categorized into "Belly-" (Mallet hand-to-belly <3) and "Belly+" (Mallet hand-to-belly ≥3) groups. RESULTS The median participant age was 7.9 years (range: 3.5-21 years). Extension injury patterns included Erb's palsy (56.5%), extended Erb's palsy (28.6%), and global palsy (14.9%). Contractures exceeding 10°, 20°, and 30° were prevalent in both internal rotation in abduction and cross-body adduction angles. The "Belly-" group (9.5%) demonstrated a significant reduction in both angles compared to the "Belly+" group. Weak correlations were found between internal rotation in abduction (r = 0.390, P < .0001) or cross-body adduction (r = 0.163, P = .0083) angles and Mallet hand-to-abdomen item. Glenohumeral reduction and Hoffer procedures led to a notable decrease in cross-body adduction angle, without affecting "Belly-" prevalence. Global injuries exhibited decreased angles compared to Erb's group. CONCLUSIONS External rotation glenohumeral contractures are prevalent in residual NBPI, impacting midline access. Surprisingly, the history of glenohumeral procedures or extensive injuries did not increase the likelihood of losing the ability to reach the belly. Receiver operating characteristic analysis suggests specific thresholds for maintaining this ability.
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Affiliation(s)
- Dragos Hutanu
- George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania
| | - Pablo S Corona
- Orthopedic Surgery Department, Hospital Vall Hebron, Barcelona, Spain
| | - Juliana Rojas-Neira
- Hand Surgery and Microsurgery Department, Farallones Clinic, Christus Health, Cali, Colombia.
| | | | | | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit, HM Nens "Instituto de Investigación Sanitaria HM Hospitales" Barcelona, Spain
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Alonso E, Victoria C, Touati N, Vialle R, Fitoussi F, Bachy M. Computer aided multiplanar osteotomy using patient specific instrumentation to treat cubitus varus in children. Orthop Traumatol Surg Res 2024; 110:103808. [PMID: 38159639 DOI: 10.1016/j.otsr.2023.103808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 12/13/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
Cubitus varus deformity is a common complication of supracondylar fractures in children. Anatomic correction is the key to obtaining good functional results and avoiding later symptomatic degradation. Different techniques have been described, mainly lateral closing wedge osteotomy. A medial opening wedge osteotomy seems more intuitive, allowing an anatomic reduction, but it is technically challenging. Two-plane radiographs are too simplistic to appreciate the 3D deformity. With medical imaging and image processing advances, three-dimensional (3D) virtual models of a patient's anatomy can be generated. Rapid 3D printing has allowed virtual simulations of surgical corrections to be transferred to real-world applications in the operating room, allowing more precise and accurate surgery with better 3D corrections. 3D computer modeling with the development of customized drilling and cutting guides allows complex medial opening wedge osteotomy for correction of cubitus varus deformity in immature children with best-fit plate synthesis. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Estelle Alonso
- Service de chirurgie orthopédique et réparatrice de l'enfant, Sorbonne Université, AP-HP, Hôpital Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - Christian Victoria
- Hospital for Special Surgery, Hand and Upper Extremity Service, New York, NY, USA
| | - Nizar Touati
- Service de chirurgie orthopédique et réparatrice de l'enfant, Sorbonne Université, AP-HP, Hôpital Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - Raphael Vialle
- Service de chirurgie orthopédique et réparatrice de l'enfant, Sorbonne Université, AP-HP, Hôpital Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - Franck Fitoussi
- Service de chirurgie orthopédique et réparatrice de l'enfant, Sorbonne Université, AP-HP, Hôpital Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; STREAM, CRMR Site Trousseau enfant anomalie des membres, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - Manon Bachy
- Service de chirurgie orthopédique et réparatrice de l'enfant, Sorbonne Université, AP-HP, Hôpital Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; STREAM, CRMR Site Trousseau enfant anomalie des membres, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; UMR CNRS 7052, Inserm U1271, Université de Paris, B3OA, 10, avenue de Verdun, 75010 Paris, France.
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Lovette M, Chafetz RS, Russo SA, Kozin SH, Zlotolow DA. Shoulder Motion Overestimated by Mallet Scores. J Pediatr Orthop 2024; 44:e951-e956. [PMID: 39034600 DOI: 10.1097/bpo.0000000000002775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
BACKGROUND Brachial plexus birth injuries (BPBI) occur in up 0.4 to 4.6 per 1000 live births. Weakness about the shoulder and development of glenohumeral joint contractures are common sequalae of BPBI. Shoulder function in children with BPBI is frequently assessed using the modified Mallet classification to evaluate upper extremity motion deficits. The purpose of this study was to assess the accuracy of the abduction, external rotation, and hand-to-mouth Mallet classification scores in children with BPBI using motion capture. METHODS A retrospective study of 107 children with BPBI who underwent motion capture assessment and Mallet scores on the same date were reviewed. Motion capture measurements were used to calculate humerothoracic elevation and external rotation joint angles in the abduction/hand-to-mouth and external rotation positions, respectively. The humerothoracic joint angles were converted to the corresponding Mallet scores. Discrepancies between the Mallet scores determined by clinicians and those determined by motion capture were assessed. RESULTS For abduction, 24.3% of Mallet scores were misclassified during clinical examination. Of the misclassified scores, 22 were overestimated by 1 point and 4 were underestimated by 1 point compared with motion capture. For external rotation, 72.9% of Mallet scores were misclassified during clinical examination. Only 5 patients had an HT elevation that was less than 40 degrees, with 4 of them (80%) having a Mallet hand-to-mouth score of 4. There were no differences in proportion of patients with HT elevation less than 40 degrees who had a Mallet score of 4 or a Mallet score less than 4. CONCLUSIONS There was better agreement in global abduction Mallet scores compared with external rotation and hand-to-mouth Mallet scores. This difference was likely due to the complex compensatory strategies that patients employ while performing external rotation and hand-to-mouth positions. The inaccuracy of the clinically determined Mallet scores is alarming given that they are frequently utilized to assist with surgical indications and are commonly used as outcome measures. LEVEL OF EVIDENCE Level IV Case series.
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Affiliation(s)
- Madison Lovette
- Department of Biomedical Engineering, Cleveland State University, Cleveland, OH
| | - Ross S Chafetz
- Motion Analysis Center, Shriners Hospitals for Children, Philadelphia, PA
| | - Stephanie A Russo
- Department of Orthopedic Surgery, Akron Children's Hospital, Akron, OH
| | - Scott H Kozin
- Department of Orthopedic Surgery, Shriners Hospitals for Children, Philadelphia, PA
| | - Dan A Zlotolow
- Department of Orthopedic Surgery, Shriners Hospitals for Children, Philadelphia, PA
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Millkvist H, Källströmer A, Bernspång B, Wiberg M. The impact of a soft robotic glove on activity performance and body function for brachial plexus birth injury patients-A longitudinal case series. J Hand Ther 2024:S0894-1130(24)00023-1. [PMID: 38937162 DOI: 10.1016/j.jht.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND A brachial plexus birth injury (BPBI) can cause reduced ability to use the arm and hand in daily activities due to reduced grip strength and endurance. A soft robotic glove can increase the number of activities performed and improve activity performance for patients with neurological disease. The use of a soft robotic glove for patients with BPBI has not been studied. PURPOSE To investigate if a soft robotic glove can improve activity performance and body function for patients with BPBI. STUDY DESIGN Longitudinal Case Series. METHODS A convenience sample of patients with BPBI, treated by the Brachial plexus injury service in Umeå, Sweden were studied. Eight patients used a soft robotic glove, (Carbonhand®), at home for three months. Data on activity performance and satisfaction with activity performance, active range of motion and strength were collected at baseline, and at three and four months. A patient evaluation form was filled out at three months, all patients kept a diary for three out of 12 weeks. RESULTS Six out of eight patients wanted to continue using the device and improved their self-perception of activity performance and satisfaction with the performance due to a more secure grip, compared to when not using the device. All patients had improved maximum strength and endurance in elbow flexion at three months. The device was useful as an assisting device and as a training tool. CONCLUSION A soft robotic glove (Carbonhand) may improve activity performance and perceived satisfaction and increase the number of activities that a person with BPBI can perform in everyday life. It is possible to increase strength in elbow flexion after using such a device. Due to this limited material, more research is needed.
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Affiliation(s)
- Helena Millkvist
- Hand and Plastic Surgery Clinic, University Hospital of Umeå, Umeå, Sweden; Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden; Department of Community Medicine, Umeå University, Umeå, Sweden.
| | - Anna Källströmer
- Hand and Plastic Surgery Clinic, University Hospital of Umeå, Umeå, Sweden; Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden
| | | | - Mikael Wiberg
- Hand and Plastic Surgery Clinic, University Hospital of Umeå, Umeå, Sweden; Department of Diagnostics and Intervention, Umeå University, Umeå, Sweden
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Balloufaud M, Hosni S, Bolivar J, Saguintaah M, Virassamy M, Laffont I, Coulet B, Lambert K, Delpont M. Subscapularis impairment on magnetic resonance imaging is correlated with functional limitations in neonatal brachial plexus palsy. INTERNATIONAL ORTHOPAEDICS 2024; 48:1635-1643. [PMID: 38167960 DOI: 10.1007/s00264-023-06081-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE The relationship between functional shoulder deficits in children with neonatal brachial plexus palsy (NBPP) and magnetic resonance imaging (MRI) shoulder abnormalities was evaluated. METHODS Shoulder function was assessed in 16 children (mean age: 5.8 years; range: 3-12 years) with NBPP based on shoulder rotator muscle strength, as measured using an isokinetic dynamometer and the modified Mallet score. The thickness and fatty infiltration of the subscapularis and infraspinatus muscles, and the morphology of the glenoid on MRI, were also determined. RESULTS The highest subscapularis fatty infiltration subgroup of NBPP patients promoted the highest alteration muscle thickness and modified Mallet score. CONCLUSIONS In NBPP children, subscapularis impairments play a major role in the functional limitations. This study of pediatric NBPP patients highlighted the value of adding an examination of the muscles to routine MRI assessment of bone parameters in the shoulders of NBPP children. TRIAL REGISTRATION NCT03440658.
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Affiliation(s)
- Maxime Balloufaud
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France
| | - Sarah Hosni
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - Julie Bolivar
- Pediatric Radiology, Arnaud De Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Magali Saguintaah
- Pediatric Radiology, Arnaud De Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Maxime Virassamy
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - Isabelle Laffont
- Physical Medicine and Rehabilitation Department, CHU Montpellier, University of Montpellier, Montpellier, France
- Euromov, UFR STAPS, University of Montpellier, Montpellier, France
| | - Bertrand Coulet
- Euromov, UFR STAPS, University of Montpellier, Montpellier, France
- Orthopedic Surgery, Upper Extremity, Hand and Peripheral Nerve Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Karen Lambert
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France
| | - Marion Delpont
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France.
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
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Delioğlu K, Unes S, Tuncdemir M, Ozal C, Bıyık KS, Uzumcugil A. Interrater reliability of face-to-face, tele- and video-based assessments with the modified Mallet classification in brachial plexus birth injuries. J Hand Surg Eur Vol 2024; 49:576-582. [PMID: 37684022 DOI: 10.1177/17531934231196118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
The modified Mallet classification is widely used to measure motor function in brachial plexus birth injuries. The aim of the study was to investigate agreement and reliability of this classification under three different evaluation conditions: face-to-face; live tele-assessment; and delayed video-based assessment. A total of 100 children aged 4-15 years were included. Children were assessed by two raters except for live tele-assessment, which was performed by four raters. Agreement between the three different assessment conditions for the same rater were between strong and excellent for both raters 1 and 2. The interrater reliability for raters 1 and 2 under different assessment conditions was strong to excellent. Interrater reliability among the four raters was moderate to strong in tele-assessment. The modified Mallet classification may have appropriate reliability to be used in remote medical follow-up.Level of evidence: III.
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Affiliation(s)
- Kıvanç Delioğlu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Sefa Unes
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Merve Tuncdemir
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Cemil Ozal
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Kubra Seyhan Bıyık
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Akin Uzumcugil
- Department of Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Le Roy L, van Bladel A, De Mits S, Vanden Bossche L, Van der Looven R. Three-Dimensional Upper Limb Movement Analysis in Children and Adolescents With Brachial Plexus Birth Injury: A Systematic Review. Pediatr Neurol 2024; 153:19-33. [PMID: 38309208 DOI: 10.1016/j.pediatrneurol.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 10/13/2023] [Accepted: 12/25/2023] [Indexed: 02/05/2024]
Abstract
BACKGROUND To synthesize the current evidence on clinical use of three-dimensional upper limb movement analysis (3D-ULMA) in children and adolescents with brachial plexus birth injury (BPBI). METHODS MEDLINE, Embase, and Web of Science were searched for relevant studies up to April 2022. An automatic e-mail alert was installed to ensure no eligible article was missed. Articles evaluating 3D-ULMA in children and adolescents with BPBI were included. Covidence web-based platform was used for blind screening of eligible articles. Twenty-one observational studies with a final sample size of 609, encompassing 493 BPBI cases, met the inclusion criteria. Data were extracted using a custom form to support standardized extraction conforming to the Cochrane Checklist of items. Risk of bias was assessed using the Newcastle-Ottawa Scale, the Strengthening the Reporting of Observational Studies in Epidemiology checklist, and a specifically established quality assessment form for kinematic analysis studies. RESULTS Study setups differed, including six different types of kinematic devices. Twelve studies used the (modified) Mallet positions for their 3D-ULMA. Throughout the studies, 3D-ULMA was used for various purposes. The Newcastle-Ottawa Scale scored 16 articles with five stars or more, indicating fair to moderate quality. CONCLUSIONS This systematic review summarizes the different 3D-ULMA kinematic devices, test protocols, and their clinical use for BPBI. The use of 3D-ULMA provides valuable, objective, and quantified data to clinicians with regard to movement strategies; it complements existing clinical scales and can be implemented to evaluate effectiveness of therapy interventions. Implications for future research and clinical practice are discussed.
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Affiliation(s)
- Laura Le Roy
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium.
| | - Anke van Bladel
- Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Sophie De Mits
- Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Luc Vanden Bossche
- Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ruth Van der Looven
- Child Rehabilitation, Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Ghent, Belgium
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Richardson RT, Russo SA, Chafetz RS, Warshauer S, Nice E, Richards JG, Zlotolow DA, Kozin SH. Evaluation of Upper Extremity Reachable Workspace in Children With Brachial Plexus Birth Injury. J Hand Surg Am 2024; 49:141-149. [PMID: 38099877 DOI: 10.1016/j.jhsa.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/18/2023] [Accepted: 11/13/2023] [Indexed: 02/05/2024]
Abstract
PURPOSE Brachial plexus birth injury (BPBI) results in upper extremity (UE) movement limitations. Current assessments of UE function used to inform clinical decision-making only evaluate a limited set of static postures and/or movements and have been criticized for being insensitive to certain meaningful differences in function. Reachable workspace provides a numeric and visual assessment of global UE movement ability by quantifying the regions in space that patients can reach with their hands, and it can be collected using real-time feedback to elicit a best-effort acquisition of function. This study evaluated the ability of a real-time feedback reachable workspace tool to assess UE movement in BPBI. METHODS Twenty-two children with BPBI participated. Reachable workspace data were collected with three-dimensional motion capture using real-time visual feedback to measure UE reaching ability in all regions surrounding the body. All outer, far-from-body points reached by the hand were recorded and analyzed by region. A two-way, within-subjects analysis of variance was used to assess interlimb differences in percentage workspace reached and median reach distance for each of the six regions. RESULTS The affected limb had significantly less percentage workspace reached than the unaffected limb for all six regions (mean interlimb differences by region, 5.7%-38.6%). The affected limb had significantly less median reach distance than the unaffected limb for all six regions (mean interlimb differences by region, 3.1%-36.8%). CONCLUSIONS The workspace approach was capable of detecting UE movement impairments of the BPBI-affected limb. The reported deficits in workspace on the affected limb correspond to common movement impairments in BPBI, such as limitations in shoulder elevation, external rotation, extension, and elbow extension. CLINICAL RELEVANCE The real-time feedback reachable workspace tool is sufficiently robust for assessing UE movement impairments in children with BPBI.
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Affiliation(s)
| | | | | | | | - Emily Nice
- Shriners Hospital for Children, Philadelphia, PA
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12
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Delioğlu K, Uzumcugil A, Öztürk E, Bıyık KS, Ozal C, Gunel MK. Cut-off values of internal rotation in the glenohumeral joint for functional tasks in children with brachial plexus birth injury. J Hand Surg Eur Vol 2023; 48:738-746. [PMID: 36788751 DOI: 10.1177/17531934231154362] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The aim of this study was to determine the cut-off values of the range of internal rotation motion in the isolated glenohumeral joint that is required for functional tasks in children with an upper root injury of the brachial plexus. Internal rotation motion was measured using a universal goniometer in 97 participants. The Mallet Hand to Spine and Mallet Hand to Belly tasks were assessed as functional tasks that require internal rotation of the shoulder. For the Hand to Spine task, 41° passive and 30° active internal rotation were necessary to reach the S1 level. For the Hand to Belly task, 42° passive and 29° active internal rotation were required to place the palm on the belly without wrist flexion. Of our participants, 97% could touch the belly with or without wrist flexion, but 28% could not reach S1 in the Hand to Spine task. The results of this study show the necessary amount of internal rotation of the shoulder that should be considered in treatment strategies.Level of evidence: III.
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Affiliation(s)
- Kıvanç Delioğlu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Akin Uzumcugil
- Faculty of Medicine, Department of Orthopedics and Traumatology, Hacettepe University, Ankara, Turkey
| | - Ebru Öztürk
- Faculty of Medicine, Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Kubra Seyhan Bıyık
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Cemil Ozal
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Mintaze Kerem Gunel
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
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13
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Antonacci C, Longo UG, Nazarian A, Schena E, Carnevale A. Monitoring Scapular Kinematics through Wearable Magneto-Inertial Measurement Units: State of the Art and New Frontiers. SENSORS (BASEL, SWITZERLAND) 2023; 23:6940. [PMID: 37571723 PMCID: PMC10422625 DOI: 10.3390/s23156940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023]
Abstract
Monitoring shoulder kinematics, including the scapular segment, is of great relevance in the orthopaedic field. Among wearable systems, magneto-inertial measurement units (M-IMUs) represent a valid alternative for applications in unstructured environments. The aim of this systematic literature review is to report and describe the existing methods to estimate 3D scapular movements through wearable systems integrating M-IMUs. A comprehensive search of PubMed, IEEE Xplore, and Web of Science was performed, and results were included up to May 2023. A total of 14 articles was included. The results showed high heterogeneity among studies regarding calibration procedures, tasks executed, and the population. Two different techniques were described, i.e., with the x-axis aligned with the cranial edge of the scapular spine or positioned on the flat surface of the acromion with the x-axis perpendicular to the scapular spine. Sensor placement affected the scapular motion and, also, the kinematic output. Further studies should be conducted to establish a universal protocol that reduces the variability among studies. Establishing a protocol that can be carried out without difficulty or pain by patients with shoulder musculoskeletal disorders could be of great clinical relevance for patients and clinicians to monitor 3D scapular kinematics in unstructured settings or during common clinical practice.
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Affiliation(s)
- Carla Antonacci
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo, 200, 00128 Roma, Italy; (C.A.); (A.C.)
- Unit of Measurements and Biomedical Instrumentation, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo, 21, 00128 Roma, Italy;
| | - Umile Giuseppe Longo
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo, 200, 00128 Roma, Italy; (C.A.); (A.C.)
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo, 21, 00128 Roma, Italy
| | - Ara Nazarian
- Carl J. Shapiro Department of Orthopaedic Surgery and Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 20115, USA;
| | - Emiliano Schena
- Unit of Measurements and Biomedical Instrumentation, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo, 21, 00128 Roma, Italy;
| | - Arianna Carnevale
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo, 200, 00128 Roma, Italy; (C.A.); (A.C.)
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14
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Le Hanneur M, Brahim L, Langlais T, Bouché PA, Fitoussi F. Age Influence Upon Glenohumeral Remodeling After Shoulder Axial Rebalancing Surgery in Brachial Plexus Birth Injury. J Pediatr Orthop 2023; 43:e389-e395. [PMID: 36882889 DOI: 10.1097/bpo.0000000000002380] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Shoulder rebalancing procedures have been proven to provide satisfactory functional improvements in patients with shoulder external rotation (ER) deficit due to brachial plexus birth injury (BPBI). However, the influence of age at the time of surgery on osteoarticular remodeling remains uncertain. The purposes of this retrospective case series were (1) to assess the age impact on glenohumeral remodeling and (2) to determine an age limit after which significant changes can no longer be expected. METHODS We reviewed preoperative and postoperative magnetic resonance imaging data of 49 children with BPBI who underwent a tendon transfer to reanimate active shoulder ER, with (n=41) or without (n=8) concomitant anterior shoulder release to restore passive shoulder ER, at a mean age of 72 ± 40 months (19;172). Mean radiographic follow-up was 35 ± 20 months (12;95). Univariate linear regressions were used to assess the influence of age at the time of surgery upon changes of glenoid version, glenoid shape, percentage of the humeral head anterior to the glenoid midline, and glenohumeral deformity. Beta coefficients with 95% CI were calculated. RESULTS Improvements of glenoid version, glenoid shape, percentage of the humeral head anterior and glenohumeral deformity significantly decreased by 0.19 degrees [CI=(-0.31; -0.06), P =0.0046], 0.02 grade [CI=(-0.04; -0.01), P =0.002], 0.12% [CI=(-0.21; -0.04), P =0.0076], and 0.01 grade [CI=(-0.02; -0.01), P =0.0078] per additional month of age at the time of surgery, respectively. The threshold of 5 years was identified as the age at the time of surgery after which significant remodeling no longer occurred. No significant postoperative changes were observed in patients without glenohumeral dysplasia on preoperative magnetic resonance imaging. CONCLUSION In the setting of BPBI-related glenohumeral dysplasia, the younger the surgical axial rebalancing of the shoulder, the greater the glenohumeral remodeling seems to be. Such procedure seems to be safe in patients without significant joint deformity on preoperative imaging. LEVEL OF EVIDENCE Therapeutic-Level IV.
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Affiliation(s)
- Malo Le Hanneur
- Department of Pediatric Orthopedics and Reconstruction, Armand Trousseau Hospital-Sorbonne University, Paris
- Hand to Shoulder Mediterranean Center, ELSAN, Clinique Bouchard, France
| | - Lilia Brahim
- Department of Pediatric Orthopedics and Reconstruction, Armand Trousseau Hospital-Sorbonne University, Paris
| | - Tristan Langlais
- Department of Pediatric Orthopedics and Reconstruction, Armand Trousseau Hospital-Sorbonne University, Paris
| | - Pierre-Alban Bouché
- Department of Pediatric Orthopedics and Reconstruction, Armand Trousseau Hospital-Sorbonne University, Paris
| | - Franck Fitoussi
- Department of Pediatric Orthopedics and Reconstruction, Armand Trousseau Hospital-Sorbonne University, Paris
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15
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Gundlach B, Kozin SH, Zlotolow DA, Park E. The Philadelphia Shriners Hospital Approach to Brachial Plexus Birth Injury. Semin Plast Surg 2023; 37:143-154. [PMID: 37503530 PMCID: PMC10371411 DOI: 10.1055/s-0043-1768965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
The care of children with brachial plexus birth injuries (BPBI) is a complex multidisciplinary endeavor. At the Shriners Hospital for Children in Philadelphia, we have sought to elevate the quality of care delivered to patients through outcomes research and collaboration with colleagues around the world. Our approach to the management of this challenging pathology has evolved time and again. Here, we describe our current approach to patient assessment and operative management in patients with BPBI and its many sequelae.
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Affiliation(s)
- Benjamin Gundlach
- Shriners Hospitals for Children – Philadelphia, Philadelphia, Pennsylvania
| | - Scott H. Kozin
- Shriners Hospitals for Children – Philadelphia, Philadelphia, Pennsylvania
| | - Dan A. Zlotolow
- Shriners Hospitals for Children – Philadelphia, Philadelphia, Pennsylvania
| | - Eugene Park
- Shriners Hospitals for Children – Philadelphia, Philadelphia, Pennsylvania
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16
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Zargarbashi R, Rabie H, Panjavi B, Kamran H, Mosalamiaghili S, Erfani Z, Mirghaderi SP, Salimi M. Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes. J Shoulder Elbow Surg 2023; 32:e60-e70. [PMID: 36115612 DOI: 10.1016/j.jse.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation. METHODS From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery. RESULTS The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations. CONCLUSION Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.
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Affiliation(s)
- Ramin Zargarbashi
- Pediatric Orthopaedic Surgery, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Hamid Rabie
- Orthopaedic Surgery Department, Shariati Hospital and School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Panjavi
- Pediatric Orthopaedic Surgery, Children's Medical Center, Tehran University of Medical Science, Tehran, Iran
| | - Hooman Kamran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Zohre Erfani
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Peyman Mirghaderi
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Salimi
- Bone and Joint Diseases Research Center, Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.
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17
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Grip H, Källströmer A, Öhberg F. Validity and Reliability of Wearable Motion Sensors for Clinical Assessment of Shoulder Function in Brachial Plexus Birth Injury. SENSORS (BASEL, SWITZERLAND) 2022; 22:9557. [PMID: 36502259 PMCID: PMC9736020 DOI: 10.3390/s22239557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/24/2022] [Accepted: 12/02/2022] [Indexed: 06/17/2023]
Abstract
The modified Mallet scale (MMS) is commonly used to grade shoulder function in brachial plexus birth injury (BPBI) but has limited sensitivity and cannot grade scapulothoracic and glenohumeral mobility. This study aims to evaluate if the addition of a wearable inertial movement unit (IMU) system could improve clinical assessment based on MMS. The system validity was analyzed with simultaneous measurements with the IMU system and an optical camera system in three asymptomatic individuals. Test-retest and interrater reliability were analyzed in nine asymptomatic individuals and six BPBI patients. IMUs were placed on the upper arm, forearm, scapula, and thorax. Peak angles, range of motion, and average joint angular speed in the shoulder, scapulothoracic, glenohumeral, and elbow joints were analyzed during mobility assessments and MMS tasks. In the validity tests, clusters of reflective markers were placed on the sensors. The validity was high with an error standard deviation below 3.6°. Intraclass correlation coefficients showed that 90.3% of the 69 outcome scores showed good-to-excellent test-retest reliability, and 41% of the scores gave significant differences between BPBI patients and controls with good-to-excellent test-retest reliability. The interrater reliability was moderate to excellent, implying that standardization is important if the patient is followed-up longitudinally.
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Affiliation(s)
- Helena Grip
- Department of Biomedical Engineering, Radiation Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Anna Källströmer
- Department of Surgical and Perioperative Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Fredrik Öhberg
- Department of Biomedical Engineering, Radiation Sciences, Umeå University, 901 87 Umeå, Sweden
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18
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Topley MT, Russo SA, Chafetz RS, Zlotolow DA, Kozin SH, Richards JG. Scapulothoracic and Glenohumeral Contributions to Humerothoracic Kinematics in Single Versus Double Tendon Transfers in Patients With Brachial Plexus Birth Injury. J Hand Surg Am 2022; 47:897.e1-897.e9. [PMID: 34489135 DOI: 10.1016/j.jhsa.2021.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/02/2021] [Accepted: 06/18/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Evidence suggests that patients with brachial plexus birth injury are more likely to retain midline function following a teres major tendon transfer without a concomitant latissimus dorsi transfer. Both procedures increase shoulder external rotation and abduction, but whether increased loss of midline frequency following double transfer is due to glenohumeral (GH) joint motion or scapulothoracic (ST) compensation is unknown. We hypothesized that double tendon transfers would exhibit greater GH external rotation than single tendon transfers, thus requiring greater ST rotation to internally rotate the shoulder, while GH and ST contributions to elevation remained equivalent between both groups. METHODS Twenty-six postsurgical children with C5/C6 brachial plexus birth injuries participated in this study. Thirteen patients with single tendon transfers were matched with 13 with double tendon transfer. Coordinate systems of the thorax, scapula, and humerus were measured utilizing motion capture in 6 arm positions. Joint angles were calculated by the helical (ST) and modified globe method (GH and humerothoracic [HT]). Differences between groups were compared with repeated measures of multivariate analyses of variance for each position. Pending significant multivariate analyses of variance, univariate analyses of variance determined joint differences between transfer groups. RESULTS Joint rotations from neutral were similar between groups in 5 of 6 tested positions, with double tendon transfers consistently demonstrating 15°-20˚ more internal rotation at the GH and HT joints. Still, only the internal rotation position showed statistically significant differences in GH and HT joint angles. The ST joint angles were similar in this position (45.2˚ and 48.5˚). CONCLUSIONS The arc of motion for patients with double tendon transfer was more internally rotated than in patients with single tendon transfer at the GH and HT joints for all positions. However, both groups demonstrated little active rotation from neutral. Based on this data, teres major-only tendon transfers may not reduce the risk of loss of midline function. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Matthew T Topley
- Department of Health and Rehabilitation Sciences, Temple University, Philadelphia, PA.
| | - Stephanie A Russo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center-Hamot, Erie, PA; Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA
| | - Ross S Chafetz
- Motion Analysis Laboratory, Shriners Hospital for Children, Philadelphia, PA
| | - Dan A Zlotolow
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA; Department of Orthopaedic Surgery, Temple University, Philadelphia, PA
| | - Scott H Kozin
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA; Department of Orthopaedic Surgery, Temple University, Philadelphia, PA
| | - James G Richards
- Department of Biomechanics and Movement Science, University of Delaware, Newark, DE
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19
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Abstract
BACKGROUND Brachial plexus birth injuries (BPBI) can result in lasting impairments of external rotation and cross-body adduction (CBA) that disrupt functional activities such as dressing, grooming, or throwing a ball. The purpose of this study was to compare the quantification of shoulder humerothoracic (HT) external rotation (ER), and glenohumeral (GH) CBA by 3 methods - physician visual estimate, goniometer measurement by an occupational therapist, and motion capture. METHODS Twenty-six patients with BPBI (average age of 9.9±3.2 y) participated in this study. Mallet scores and visual estimates of passive HT ER and GH CBA were recorded by a physician. The passive measures were repeated by an occupational therapist using a goniometer while motion capture measures were simultaneously collected. Active HT ER was also measured by motion capture. The passive measures were compared with analyses of variance with repeated measures, intraclass correlations, and Bland-Altman plots. External rotation Mallet scores determined by motion capture and by the physician were compared. RESULTS The measures of GH CBA were not statistically different and demonstrated good agreement, but substantial variation. For HT ER, all measures were significantly different and demonstrated poor agreement and substantial variation. When the joint angles measured by motion capture were used to determine the Mallet score, 79% of external rotation Mallet scores assigned by the physician were incorrectly categorized, with the physician always scoring the participant higher than predicted motion capture Mallet score. CONCLUSIONS Both GH CBA and HT ER measures demonstrated substantial variability between measurement types, but only HT ER joint angles were significantly different. In addition, more than three-quarters of external rotation Mallet scores were misclassified by the physician. Motion capture measurements offer the benefit of less susceptibility to patients' compensatory and/or out-of-plane movements and should be considered for clinical assessment of shoulder range of motion in children with BPBI. If motion capture is unavailable, the use of a goniometer provides more accurate clinical measures of shoulder motion than visual estimates and care should be taken to minimize and account for compensatory movement strategies. LEVEL OF EVIDENCE Level IV Case series.
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20
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Russo SA, Topley MT, Richardson RT, Richards JG, Chafetz RS, Rapp van Roden EA, Zlotolow DA, Mulcahey MJ, Kozin SH. Assessment of the relationship between Brachial Plexus Profile activity short form scores and modified Mallet scores. J Hand Ther 2022; 35:51-57. [PMID: 33308927 DOI: 10.1016/j.jht.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/19/2020] [Accepted: 10/09/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION This study aims to assess the relationship between the modified Mallet classification and the Brachial Plexus Profile activity short form (BP-PRO activity SF). The therapist or surgeon classifies upper extremity movement for the modified Mallet classification, while the BP-PRO assesses parents' perceptions of difficulty performing activities. PURPOSE To provide a deeper understanding of the relationship of functional and perceived outcome measurements. STUDY DESIGN Prospective, correlational design. METHODS Eighty children with brachial plexus birth injuries were evaluated using the modified Mallet classification, while parents simultaneously answered the BP-PRO activity SF questions. All patients had undergone one of three surgical interventions to improve shoulder function. The relationship between the two measures, patient injury levels, and surgical histories were assessed. RESULTS The average modified Mallet scores and BP-PRO activity SF scores weakly correlated (r = 0.312, P = .005) and both measures differentiated between C5-6 and C5-7 injury levels (P = .03 and P = .02, respectively). Conversely, the modified Mallet scores could differentiate between the three surgical groups (F = 8.2, P < .001), while the BP-PRO activity SF could not (P = .54). CONCLUSION The results suggest that these tools measure different aspects of patient outcomes. The Mallet classification may be more focused on shoulder motion than the BP-PRO activity SF. Additional questions that specifically require shoulder function could be incorporated into the BP-PRO activity SF to improve understanding of patient/parent perceptions of shoulder function for children with brachial plexus injuries. Clinicians should be aware of the strengths, weaknesses, and limitations of each outcome assessment tool for appropriate use and interpretation of results.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Scott H Kozin
- Shriners Hospital for Children, Philadelphia, PA, USA
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21
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Lin JS, Samora JB. Brachial Plexus Birth Injuries. Orthop Clin North Am 2022; 53:167-177. [PMID: 35365261 DOI: 10.1016/j.ocl.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Brachial plexus birth injuries (BPBIs) are typically traction type injuries to the newborn that occur during the delivery process. Although the incidence of these injuries has overall decreased from 1.5 to around 0.9 per 1000 live births in the United States over the past 2 decades, these injuries remain common, with incidence holding fairly steady from 2008 to 2014. Shoulder dystocia is the strongest identified risk factor, imparting a 100-fold greater risk. The newborn's shoulder is caught behind the mother's pubic bone, and traction performed on the child during delivery results in injury to the brachial plexus. Other risk factors associated with BPBI include macrosomia (birthweight > 4.5 kg), heavy for gestational age infants, birth hypoxia, gestational diabetes, and forceps or vacuum-assisted delivery. Breech presentation has also been described as a risk factor in the past, but there have been more recent data that challenge this association.
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Affiliation(s)
- James S Lin
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 700 Children's Drive, T2E- A2700, Columbus, OH 43205, USA
| | - Julie Balch Samora
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 700 Children's Drive, T2E- A2700, Columbus, OH 43205, USA; Department of Orthopedic Surgery, Nationwide Children's Hopsital, Columbus, OH, USA.
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22
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Nath RK, Somasundaram C. Comparing the Results of External Rotational Humeral Osteotomy in Older Children to the Mod Quad and Triangle Tilt Procedures in Adults with Obstetric Brachial Plexus Injury. EPLASTY 2022; 22:e2. [PMID: 35651582 PMCID: PMC9128834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND External Rotational Humeral osteotomy is used to address the external rotation deficit in older children with obstetric brachial plexus Injury (OBPI). Although this procedure improves the cosmetic effect of shoulder subluxation, it has no effect on the underlying structural (glenohumeral deformity and scapular elevation and rotation) and functional problems. In this study, improvements in glenohumeral joint alignment; scapular hypoplasia, elevation, and rotation (SHEAR) deformity; and upper extremity functional movements were demonstrated in adult patients with OBPI 1 year after the mod Quad and/or triangle tilt surgeries. METHODS AND PATIENTS The outcome of humeral rotational osteotomy reported in the literature was compared with the results from 43 adult patients with OBPI (21 men and 22 women; 23 right and 20 left sides) with a mean age of 21.3 years (range, 17 to 38 years) who underwent mod Quad and/or triangle tilt surgeries and had over 12 months of postoperative follow-up (mean 22.9 months; range, 12 to 50 months). RESULTS The preoperative average modified total Mallet score, including supination, was 14.6 ± 3.5 (P < 0.0001) in the 43 adult patients with OBPI in this report. This total Mallet score was significantly improved to 22 ± 3.9 (P < 0.0001) over 12 months after mod Quad and/or triangle tilt surgeries. Thirty-two (75%) of the patients showed great improvement in all upper extremity functions: shoulder abduction, external rotation, hand-to-mouth, hand-to-neck, hand-to-spine, and supination. The improvement after humeral osteotomy reported in the literature was a cosmetic effect that did not address the underlying structural and functional problems and was found to decrease the improved shoulder abduction in long-term follow-up. CONCLUSIONS Thirty-two (75%) of 43 adult patients with OBPI showed great improvement in all upper extremity functions 1 year after mod Quad and/or triangle tilt surgeries. The other 11 patients (25%) showed improvement in hand-to-mouth movement and/or supination. In contrast, humeral osteotomy, as reported in the literature, improved the cosmetic effect of shoulder subluxation but had no effect on the underlying structural and functional problems.
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23
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The outcome of soft-tissue release and tendon transfer in shoulders with brachial plexus birth palsy. JSES Int 2021; 5:905-911. [PMID: 34505104 PMCID: PMC8411056 DOI: 10.1016/j.jseint.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Shoulder involvement in brachial plexus birth palsy is common, and the adduction, internal rotation contracture deformity often requires some form of surgical treatment. There are very few long-term reports on release of contracted muscles and tendon transfers, especially in older children. We are reporting the single-center results of such a surgery with detailed outcome analysis. Methods The prospectively collected data from brachial plexus birth palsy cases who had undergone contracture release and tendon transfer were retrospectively studied and examined. The new Mallet and functional scores were compared with the original data forms and then analyzed. The radiographic evidence of glenoid dysplasia and its correlation with age and functional outcome was assessed. Results A total of 82 cases with surgery at mean age of 9.5 ± 5.09 years and a follow-up of 8 ± 3.8 (3-20) years entered the study. Of these, 56% of cases had 7 to 20 years of age at surgery. Fifty-four (66%) patients had only shoulder surgery, and 28 (34%) required additional reconstructive surgeries for hand and wrist. Moderate to severe glenohumeral dysplasia was present in 38%. The preoperative Mallet score of 10.6 ± 2.97 improved to 19.3 ± 3.39 (P < .001). Eighty-one percent of patients showed improvement in “reaching face” functions, 71% in “above head” functions, and 74% in “midline functions.” The cases with lack of improvement in midline function mostly belonged to pan-plexus injuries. Noticeable subjective and objective improvement was also observed in cases with glenohumeral dysplasia in their Mallet and functional scores (P < .001). The improvement in function and subjective satisfaction of 92% was observed irrespective of age at surgery. Conclusion Soft-tissue release and tendon transfer for brachial plexus birth palsy shoulder can improve function and limb appearance even in older children and young adults and even in the presence of glenohumeral dysplasia.
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Maurel N, Diop A, Lallemant-Dudek P, Fitoussi F. Upper limb kinematics after Latissimus Dorsi transfer in children with brachial plexus birth palsy. Clin Biomech (Bristol, Avon) 2021; 87:105413. [PMID: 34174673 DOI: 10.1016/j.clinbiomech.2021.105413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Brachial plexus birth palsy remains a frequent condition and one of its treatments is to transfer the Latissimus Dorsi tendon to the infraspinatus muscle. The aim of this study was to analyse, for the first time, the three-dimensional kinematic effects of this operation on the upper limb joints during the five Mallet tasks and their correlation with clinical parameters. METHODS Kinematic analysis was performed using an electromagnetic device. An Index of Improvement taking into account the angle in preop and postop, the reproducibility and the angle of a control group was developed. Three groups of patients were analysed: sixteen patients (mean: 10,5 years) for the reproducibility, thirty children (mean: 9,5 years) for the control group and ten patients (mean: 8 years 7 months) who were operated. FINDINGS The humerothoracic and glenohumeral external rotations improved during the external rotation, the neck and the abduction tasks and worsened during the spine task. The glenohumeral external rotation worsened during the mouth task. The Humerothoracic abduction improved during the abduction and the neck tasks. The elbow flexion improved for the neck task. Differences were observed between patients and correlations were obtained between the Index of Improvement and clinical parameters. INTERPRETATION Using kinematics allows to better analyse the evolution of joint angles after the latissimus dorsi transfer. The Index of Improvement allows to quickly analyse the effect of the operation for each angle and each patient. This effect depends on clinical parameters.
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Affiliation(s)
- Nathalie Maurel
- Arts et Metiers Institute of Technology, EPBRO, HESAM Université, 151 Boulevard de l'Hôpital, F-75013 Paris, France.
| | - Amadou Diop
- Arts et Metiers Institute of Technology, EPBRO, HESAM Université, 151 Boulevard de l'Hôpital, F-75013 Paris, France.
| | - Pauline Lallemant-Dudek
- Hôpital Trousseau, Service de Médecine Physique et de Réadaptation pédiatrique, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Faculté de Médecine Sorbonne Université, 91 Boulevard de l'Hôpital, 75013 Paris, France.
| | - Franck Fitoussi
- Hôpital Trousseau, Service de chirurgie orthopédique et reconstructrice de l'enfant, 26 Avenue du Dr Arnold Netter, 75012 Paris, France; Faculté de Médecine Sorbonne Université, 91 Boulevard de l'Hôpital, 75013 Paris, France.
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Russo SA, Richardson RT, Richards JG, Rapp van Roden EA, Chafetz RS, Topley MT, Zlotolow DA, Kozin SH. Effect of Glenohumeral Reduction Type Combined With Tendon Transfer for Brachial Plexus Injury on Objective, Functional, and Patient-Reported Outcomes. J Hand Surg Am 2021; 46:624.e1-624.e11. [PMID: 33526294 DOI: 10.1016/j.jhsa.2020.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 09/19/2020] [Accepted: 11/24/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Glenohumeral (GH) joint reductions are frequently performed during tendon transfer surgery for brachial plexus birth injuries (BPBI); however, the effect of reduction method (none required, closed, surgical) has not been assessed. This study compared objective, functional, and patient-reported outcomes between children who underwent a tendon transfer and (1) did not require GH reduction, (2) required concomitant closed GH reduction, or (3) required concomitant surgical GH reduction. METHODS Fifty-four children with BPBI who previously underwent teres major and/or latissimus dorsi transfer with or without concomitant GH reduction participated. Joint reduction method was classified as none required (n = 21), closed (n = 9), or surgical (n = 24). Motion capture was collected in a neutral position, abduction, external rotation, and internal rotation. Glenohumeral joint angles and displacements were calculated. Joint angular displacements represented the differences between the joint angles in each terminal position and the joint angles of the arm at rest in the neutral position. A hand surgeon determined modified Mallet scores. Participants' parents completed the Brachial Plexus Profile Activity Short Form (BP-PRO-SF) to assess physical activity performance. RESULTS The no-reduction group had significantly less GH elevation than the surgical-reduction group for all positions and significantly less GH elevation than the closed-reduction group for the neutral, external rotation, and internal rotation positions. There were no differences in GH rotation angles. Glenohumeral joint displacements from neutral and modified Mallet scores were similar. The no-reduction group demonstrated significantly greater BP-PRO-SF scores than the surgical-reduction group. CONCLUSIONS Patients who underwent a closed or surgical GH joint reduction consistently displayed more GH elevation. Clinically, this corresponds to an abduction contracture. Whereas increased abduction contracture provided a benefit of greater overhead motion, modified Mallet scores were similar between groups. The surgical-reduction group demonstrated lower BP-PRO-SF outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Stephanie A Russo
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center-Hamot, Erie.
| | - R Tyler Richardson
- Kinesiology Program, School of Behavioral Sciences and Education, Pennsylvania State University Harrisburg, Middletown
| | - James G Richards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE
| | | | | | | | - Dan A Zlotolow
- Upper Extremity Center of Excellence, Shriners Hospital for Children; Department of Orthopaedic Surgery, Temple University, Philadelphia
| | - Scott H Kozin
- Upper Extremity Center of Excellence, Shriners Hospital for Children; Department of Orthopaedic Surgery, Temple University, Philadelphia
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Höglund G, Grip H, Öhberg F. The importance of inertial measurement unit placement in assessing upper limb motion. Med Eng Phys 2021; 92:1-9. [PMID: 34167702 DOI: 10.1016/j.medengphy.2021.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 02/12/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
Motion analysis using inertial measurement units (IMU) has emerged as an alternative to optical motion capture. However, the validity and reliability of upper limb measurements varies significantly between studies. The objective of this study was to determine how sensor placement affects kinematic output in the assessment of motion of the arm, shoulder, and scapula. IMUs were placed proximally/distally on arms, and medially/laterally on the scapula, in a group of eleven healthy participants, while performing nine different motion tasks. Linear regressions and mixed models analysed how these different sensor placements affected the estimated joint motion by establishing the linear relationship between sensors placed on the same body segment. The placement of sensors affected the measured kinematic output considerably, most prominent affect was seen for sensor placement on scapula during flexion and abduction, and on forearm during pronation/supination. The slope of the linear regression lines was 2.5 during flexion, 2.7 during abduction, and 1.8 for forearm pronation/supination. The results of this study suggest that the forearm sensor should be placed on the dorsal side of the forearm, at the distal end; the upper arm sensor should be placed laterally, on the distal part of the arm; and the sensor on the scapula should be placed cranially, along the spine of scapula.
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Affiliation(s)
- Gustav Höglund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Helena Grip
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden.
| | - Fredrik Öhberg
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden.
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Bachy M, Lallemant P, Grimberg J, Fitoussi F. Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy. HAND SURGERY & REHABILITATION 2021; 41S:S63-S70. [PMID: 34058395 DOI: 10.1016/j.hansur.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 08/29/2018] [Accepted: 05/08/2020] [Indexed: 11/26/2022]
Abstract
Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.
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Affiliation(s)
- M Bachy
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France.
| | - P Lallemant
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| | - J Grimberg
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| | - F Fitoussi
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
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Allard R, Fitoussi F, Azarpira MR, Bachy M, Grimberg J, Le Hanneur M. Shoulder internal rotation contracture in brachial plexus birth injury: proximal or distal subscapularis release? J Shoulder Elbow Surg 2021; 30:1117-1127. [PMID: 32853791 DOI: 10.1016/j.jse.2020.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/23/2020] [Accepted: 08/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND In cases of brachial plexus birth injury with internal rotation contracture of the shoulder, the subscapularis muscle may be released proximally, from the subscapular fossa, or distally, along with periarticular soft tissues arthroscopic to the glenohumeral joint. We hypothesized that the indication for each procedure would rely primarily on patients' bone remodeling potential and periarticular soft-tissue contractures, performing proximal releases in patients aged < 4 years and periarticular distal releases in older patients. The purpose of this study was to analyze the outcomes such a strategy could provide. METHODS All patients presenting with brachial plexus birth injury-related shoulder internal rotation contractures who underwent a subscapularis release were included; in addition, to restore the joint axial balance, the infraspinatus was systematically reanimated with a tendon transfer (ie, latissimus dorsi or lower trapezius) during the same operating time. Chart review yielded preoperative and postoperative clinical and radiographic measurements, including active and passive range of motion of the shoulder in external rotation (ER) with the arm at the side of the body, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process. RESULTS Between July 2012 and January 2018, 28 children were operated on at our institution. In patients who underwent proximal subscapularis release (n = 13), significant improvements were observed regarding active shoulder ER, passive shoulder ER, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process, averaging 58° ± 32° (P < .0001), 56° ± 20° (P < .0001), 9.7 ± 3.1 points (P = .0006), 15° ± 10° (P = .0034), and 24% ± 20% (P = .0113), respectively, after a mean follow-up period of 4 years. Following distal release procedures (n = 15), these improvements averaged 26° ± 29° (P = .0024), 27° ± 28° (P = .0011), 3.3 ± 4.1 points (P = .0049), 2° ± 17° (P = .4086), and 4% ± 18% (P = .215), respectively, after a mean follow-up period of 3 years. CONCLUSION When combined with axial rebalancing of the joint, the proximal release of the subscapularis muscle appears to be sufficient to provide satisfactory functional outcomes in patients with great bone remodeling potential and supple periarticular soft tissues. In older patients, a more comprehensive release of the glenohumeral joint's arthroscopic aspect seems to provide lower but still significant clinical improvements.
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Affiliation(s)
- Romain Allard
- Department of Pediatric Orthopedics, Armand Trousseau Hospital-Sorbonne University, Paris, France
| | - Franck Fitoussi
- Department of Pediatric Orthopedics, Armand Trousseau Hospital-Sorbonne University, Paris, France
| | - Mohammad Reza Azarpira
- Department of Pediatric Orthopedics, Armand Trousseau Hospital-Sorbonne University, Paris, France
| | - Manon Bachy
- Department of Pediatric Orthopedics, Armand Trousseau Hospital-Sorbonne University, Paris, France
| | - Jean Grimberg
- Department of Pediatric Orthopedics, Armand Trousseau Hospital-Sorbonne University, Paris, France; Department of Orthopedic Surgery, Clinique Jouvenet-Ramsay-Générale de Santé, Paris, France; Institute of Research in Orthopedics and Sports Surgery (IRCOS), Paris, France
| | - Malo Le Hanneur
- Department of Pediatric Orthopedics, Armand Trousseau Hospital-Sorbonne University, Paris, France.
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Adidharma W, Lewis SP, Liu Y, Osorio MB, Steinman SE, Tse RW. Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function. Plast Reconstr Surg 2020; 146:321-331. [PMID: 32740582 DOI: 10.1097/prs.0000000000007037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach. METHODS Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05). RESULTS Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation. CONCLUSIONS Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Widya Adidharma
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Sarah P Lewis
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Yusha Liu
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Marisa B Osorio
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Suzanne E Steinman
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
| | - Raymond W Tse
- From the University of Washington School of Medicine; the Department of Rehabilitation Medicine, the Department of Orthopedics and Sports Medicine, and the Division of Plastic Surgery, Seattle Children's Hospital; and the Division of Plastic Surgery and the Department of Rehabilitation Medicine, University of Washington
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Schmieg S, Nguyen JC, Pehnke M, Yum SW, Shah AS. Team Approach: Management of Brachial Plexus Birth Injury. JBJS Rev 2020; 8:e1900200. [PMID: 32618739 DOI: 10.2106/jbjs.rvw.19.00200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Brachial plexus birth injury is an upper-extremity paralysis that occurs from a traction injury to the brachial plexus during birth. Approximately 10% to 30% of children with a brachial plexus birth injury have residual neurologic deficits with associated impact on upper-limb function.
Management of brachial plexus birth injuries with a multidisciplinary team allows optimization of functional recovery while avoiding unnecessary intervention. Early occupational therapy should be initiated with a focus on range of motion and motor learning. The need for microsurgical reconstruction of the brachial plexus can be predicted based on early physical examination findings, and reconstruction is generally performed at 3 to 9 months of age. The majority of children with residual neurologic deficits develop associated glenohumeral dysplasia. These children may require secondary procedures, including botulinum toxin injection, subscapularis and pectoralis lengthening, shoulder capsular release, shoulder tendon transfer, and humeral osteotomy.
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Affiliation(s)
- Sandra Schmieg
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Meagan Pehnke
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sabrina W Yum
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Apurva S Shah
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Ivalde FC, Marazita-Valverde J, Bataglia D. Early Complication of Humeral Derotational Osteotomy Surgery for Obstetric Brachial Plexus as Salvage for a Failed Tendon Transfer. Case Report. MÆDICA 2020; 14:418-421. [PMID: 32153676 DOI: 10.26574/maedica.2019.14.4.418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In brachial plexus injuries, external rotation in patients with a moderate to severe glenohumeral dysplasia is corrected with derotational humeral osteotomy surgery. The most frequent complications described for this procedure include keloid scar, loss of external rotation secondary to bone remodelling, loss of internal rotation, prominence of osteosynthesis, fracture distal to the plate transient ulnar paraesthesia and radial nerve palsy (1), and delayed union and non-union. Rarely, treating complications associated with derotational humeral osteotomy may require revision of osteosynthesis (2). The literature that investigates the effectiveness of derotational humeral osteotomy as a procedure to rescue dorsal infraspinatus tendon transfer is limited. This article is the first communication of a pediatric patient with an obstetric brachial plexus injury receiving a derotational osteotomy as a procedure to salvage a failed rescue Latissimus dorsi tendon transfer with a complication. This case report was performed according to the principles of the Declaration of Helsinki. Written informed consent for participation in this case report was obtained from the patient's parents.
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Affiliation(s)
- Flavio César Ivalde
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Orthopedics, University of Buenos Aires School of Medicine, Argentina
| | - José Marazita-Valverde
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Orthopedics, University of Buenos Aires School of Medicine, Argentina
| | - Danilo Bataglia
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Physiotherapy, University of Buenos Aires School of Medicine, Argentina
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Russo SA, Zlotolow DA, Chafetz RS, Rodriguez LM, Kelly D, Linamen H, Richards JG, Lubahn JD, Kozin SH. Efficacy of 3 therapeutic taping configurations for children with brachial plexus birth palsy. J Hand Ther 2019; 31:357-370. [PMID: 28454773 DOI: 10.1016/j.jht.2017.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 12/10/2016] [Accepted: 03/20/2017] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Cross-sectional clinical measurement study. INTRODUCTION Scapular winging is a frequent complaint among children with brachial plexus birth palsy (BPBP). Therapeutic taping for scapular stabilization has been reported to decrease scapular winging. PURPOSE OF THE STUDY This study aimed to determine which therapeutic taping construct was most effective for children with BPBP. METHODS Twenty-eight children with BPBP participated in motion capture assessment with 4 taping conditions: (1) no tape, (2) facilitation of rhomboid major and rhomboid minor, (3) facilitation of middle and lower trapezius, and (4) facilitation of rhomboid major, rhomboid minor, and middle and lower trapezius (combination of both 2 and 3, referred to as combined taping). The participants held their arms in 4 positions: (1) neutral with arms by their sides, (2) hand to mouth, (3) hand to belly, and (4) maximum crossbody adduction (CBA). The scapulothoracic, glenohumeral and humerothoracic (HT) joint angles and joint angular displacements were compared using multivariate analyses of variance with Bonferroni corrections. RESULTS Scapular winging was significantly decreased in both the trapezius and combined taping conditions in all positions compared with no tape. Rhomboids taping had no effect. Combined taping reduced HT CBA in the CBA position. CONCLUSIONS Rhomboid taping cannot be recommended for treatment of children with BPBP. Both trapezius and combined taping approaches reduced scapular winging, but HT CBA was limited with combined taping. Therefore, therapeutic taping of middle and lower trapezius was the most effective configuration for scapular stabilization in children with BPBP. Resting posture improved, but performance of the positions was not significantly improved. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Stephanie A Russo
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center - Hamot, Erie, PA, USA.
| | - Dan A Zlotolow
- Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Ross S Chafetz
- Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Luisa M Rodriguez
- Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Devin Kelly
- Movement Analysis Laboratory, Shriners Hospital for Children, Erie, PA, USA
| | - Holly Linamen
- Department of Physical and Occupational Therapy, Shriners Hospital for Children, Erie, PA, USA
| | - James G Richards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - John D Lubahn
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center - Hamot, Erie, PA, USA
| | - Scott H Kozin
- Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA
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Ivalde FC, Miguens GN, Socolovsky M. Using the main elbow flexion skin crease as an intraoperative parameter to determine the degree of exorotation needed for humeral derotational osteotomies in upper-type brachial plexus patients. J Orthop Surg (Hong Kong) 2019; 26:2309499018792712. [PMID: 30111242 DOI: 10.1177/2309499018792712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
UNLABELLED Even though one of the surgical techniques most frequently used to correct external rotation deformity of the shoulder in brachial plexus patients is a humeral derotational osteotomy, few intraoperative parameters has yet been identified to determine the appropriate degree of rotation. We present in this technical note our initial experience using the main elbow flexion skin crease to quantify the correct rotation of the humerus in four young, male patients with upper-type brachial plexus injuries. All patients had a functional elbow and a stable shoulder, but also an external rotation deficit. Via a deltopectoral approach, we used the main elbow flexion crease as an intraoperative surgical parameter to determine the degree of external rotation of the humerus required to achieve a better positioning of the hand in space. After surgery, increased elbow flexion range and enhanced hand-to-face movement was observed, while internal rotation was preserved for performing midline activities. Moreover, all patients exhibited increased active elbow flexion and osteotomy consolidation, with mean elbow flexion increasing from 66.3° to 97.5° pre to postoperatively, and a mean 56.3° of internal rotation correction ultimately achieved. We propose that the main elbow flexion crease is a useful intraoperative parameter to determine the degree of intraoperative external rotation necessary to restore the plane of hand-face movements in upper-type palsies. LEVEL OF EVIDENCE IV; case series.
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Affiliation(s)
- Flavio César Ivalde
- 1 Peripheral Nerve & Brachial Plexus Surgery Program, Department of Orthopedics, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gustavo Nizzo Miguens
- 1 Peripheral Nerve & Brachial Plexus Surgery Program, Department of Orthopedics, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Mariano Socolovsky
- 2 Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
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Nicholson TA, Elder A, Gallen K, Namdari S. Rotational Osteotomy of the Humeral Shaft for Malunion in Osteogenesis Imperfecta: A Case Report. JBJS Case Connect 2019; 9:e0161. [PMID: 31373913 DOI: 10.2106/jbjs.cc.18.00161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report a case of an adult with osteogenesis imperfecta, who underwent humeral shaft osteotomy to correct an internal rotation deformity results from a humeral shaft malunion. The patient incurred a temporary radial nerve palsy. CONCLUSIONS Humeral shaft malunion can be successfully treated with rotational osteotomy of the humerus through an anterior approach; however, the risk of radial nerve palsy exists and may be minimized by a posterior approach.
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Affiliation(s)
- Thema A Nicholson
- Department of Orthopaedic Surgery, Rothman Institute-Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexandra Elder
- Sidney Kimmel Medical College-Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kate Gallen
- Department of Orthopaedic Surgery, Rothman Institute-Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Surena Namdari
- Department of Orthopaedic Surgery, Rothman Institute-Thomas Jefferson University, Philadelphia, Pennsylvania
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35
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Rehabilitation of Neonatal Brachial Plexus Palsy: Integrative Literature Review. J Clin Med 2019; 8:jcm8070980. [PMID: 31284431 PMCID: PMC6679188 DOI: 10.3390/jcm8070980] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 11/24/2022] Open
Abstract
This integrative literature review has been carried out with the aim of analyzing the scientific literature aimed at identifying and describing existing rehabilitation treatments/therapies for neonatal brachial plexus palsy (NBPP). NBPP is a frequent consequence of difficult birthing, and it impairs the function of the brachial plexus in newborns. This is why knowledge on rehabilitation strategies deserves special attention. The data collection was carried out in January 2019, in the EBSCOhost and BVS (Biblioteca Virtual em Saúde) platforms, in the CINAHL Complete, MEDLINE Complete, LILACS and PubMed databases. Thirteen articles were included in this integrative literature review, based on a literature search spanning title, abstract and full text, and considering the inclusion criteria. Two main treatments/therapies for NBPP rehabilitation were identified: conservative treatment and surgical treatment. Conservative treatment includes teamwork done by physiatrists, physiotherapists and occupational therapists. These professionals use rehabilitation techniques and resources in a complementary way, such as electrostimulation, botulinum toxin injection, immobilizing splints, and constraint induced movement therapy of the non-injured limb. Professionals and family members work jointly. Surgical treatment includes primary surgeries, indicated for children who do not present any type of spontaneous rehabilitation in the first three months of life; and secondary surgeries, recommended in children who after primary surgery have some limitation of injured limb function, or in children who have had some spontaneous recovery, yet still have significant functional deficits. Treatment options for NBPP are defined by clinical evaluation/type of injury, but regardless of the type of injury, it is unanimous that conservative treatment is always started as early as possible. It should be noted that there was no evidence in the literature of other types of rehabilitation and techniques used in clinical practice, such as preventive positioning of contractures and deformities, hydrotherapy/aquatic therapy, among others, so we consider there is a need for further studies at this level in this area.
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Abstract
BACKGROUND In children with brachial plexus birth palsy (BPBP) undergoing tendon transfers to augment shoulder external rotation, it is unclear whether transfer of the latissimus dorsi with its combined latissimus dorsi and teres major (cLT) versus isolated teres major (iTM) tendon transfer yield different outcomes. METHODS Records of patients with BPBP who underwent shoulder tendon transfers to augment external rotation were retrospectively reviewed. Transfer type (cLT or iTM) was considered indiscriminate by virtue of surgeon preference. Modified Mallet Scale (mMS) and Active Movement Scale scores were recorded. Patients with <12 months' follow-up, C7 or lower palsy, humeral osteotomy, shoulder procedure(s) within 8 months, microsurgery within 1 year, or recurrent glenohumeral subluxation confirmed by postoperative imaging were excluded. Matched cohorts were identified within each tendon transfer group to yield similar preoperative shoulder function and glenohumeral alignment status. Outcomes for all tendon transfers as well as differences between cLT and iTM cohorts were analyzed. RESULTS Among 121 cLT and 34 iTM transfers, 49 cLT and 14 iTM met the inclusion criteria. Subsequent matching of cohorts yielded 28 patients (14 cLT and 14 iTM). Average age at time of transfer was 3.0±1.4 years. Follow-up averaged 4.1±3.1 years. There were no statistically significant preoperative differences between cohorts, thus matching criteria were validated. Regardless of tendon(s) transferred, mMS external rotation improved (2.2 to 3.5, P<0.001), whereas mMS internal rotation decreased (3.8 to 3.2, P<0.001). When comparing matched cohorts, cLT transfer produced a greater mMS external rotation improvement than iTM (2.1 vs. 1.5, respectively; P=0.025). Loss of midline function (defined as mMS external rotation <3) occurred in 5 (35.7%) cLT and 2 (14.3%) iTM patients. CONCLUSIONS Both cLT or iTM transfer are effective at augmenting shoulder external rotation in children with C5-C6 BPBP. Furthermore, cLT transfers may yield a larger improvement in external rotation in certain patients. However, both techniques slightly decrease shoulder internal rotation. Given that more total cLT patients lost midline function among matched cohorts, iTM transfer may still be considered when limited midline function is a concern. LEVEL OF EVIDENCE Level III.
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Abstract
BACKGROUND Loss of midline function impairs the child's ability to perform certain activities of daily living such as dressing, buttoning, and perineal care. The purpose of this study was to assess brachial plexus birth palsy (BPBP) patients with loss of midline function with respect to etiology and treatment. METHODS A retrospective review of all BPBP patients with loss of midline function was performed. The modified Mallet scale was used with internal rotation assessed via hand on spine and hand to belly. Demographics, extent of BPBP, prior surgical intervention, procedure(s) performed to correct the loss of midline function, complications, and outcomes were assessed. RESULTS In total, 20 patients were identified with loss of midline function as defined by the inability to reach midline and touch their umbilicus. Nineteen patients had previously undergone tendon transfers about the shoulder with or without arthroscopic capsular release to improve external rotation. After the initial surgery, modified Mallet scores improved 1 grade for abduction, hand to mouth, hand to neck, and external rotation without altering the hand to spine category. However, the internal rotation category (hand to umbilicus) decreased from an average 2.71 preoperatively to an average 2.15 postoperatively. Nine patients underwent a derotational humeral osteotomy to improve midline function. The average correction of internal rotation was 47.8 degrees (range, 20 to 85 degrees). After this surgery, modified Mallet scores remained unchanged for hand to spine; however, the scores improved back to 2.7 for the internal rotation category. Two complications were noted including 1 plate fracture and 1 fracture through a screw hole. CONCLUSIONS BPBP patients who undergo surgical procedures to improve shoulder external rotation and/or obtain joint reduction may inadvertently lose midline function. Derotational humeral osteotomy can effectively restore midline function, which is needed to perform activities of daily living. Surgical procedures to improve external rotation should be performed in a manner that minimizes limitation of midline functions. LEVEL OF EVIDENCE Level III-therapeutic.
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Motion Necessary to Achieve Mallet Internal Rotation Positions in Children With Brachial Plexus Birth Palsy. J Pediatr Orthop 2019; 39:14-21. [PMID: 28834853 DOI: 10.1097/bpo.0000000000001010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Upper extremity function in children with brachial plexus birth palsy (BPBP) is assessed with clinical tests such as the Mallet classification, which uses a hand to spine position to assess shoulder internal rotation, or the modified Mallet classification, which adds an additional internal rotation task (hand to belly). Children with BPBP frequently have difficulty performing the hand to spine task. This study compared scapulothoracic and glenohumeral (GH) parameters associated with successful completion of the hand to spine and hand to belly modified Mallet positions. METHODS Motion capture measurement of 32 children with BPBP was performed in hand on spine, internal rotation (hand to belly), hand to mouth, and maximal humerothoracic extension positions. Modified Mallet scores were determined by a hand surgeon. RESULTS Children with better hand to spine performance demonstrated significantly greater GH extension and a nonsignificant trend toward increased GH internal rotation compared with children with scores <3. Children with better internal rotation position performance demonstrated significantly greater GH internal rotation and no significant difference in GH extension. Hand on spine and internal rotation Mallet scores moderately correlated (Pearson r=0.469); however, 54% of children who could place their palms flat on their bellies could not reach behind their backs. CONCLUSIONS Successfully reaching behind one's back requires both internal rotation and extension, representing a multiplanar motion. The hand to belly performance is less affected by extension and should be considered for internal rotation assessment, particularly for children undergoing surgical intervention that may affect internal rotation. LEVEL OF EVIDENCE Level II.
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Scapular Stabilization Limits Glenohumeral Stretching in Children With Brachial Plexus Injuries. J Hand Surg Am 2019; 44:63.e1-63.e9. [PMID: 29934088 DOI: 10.1016/j.jhsa.2018.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 03/14/2018] [Accepted: 04/20/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify the effects of scapular stabilization on scapulothoracic and glenohumeral (GH) stretching. METHODS Motion capture data during external rotation and abduction with and without scapular stabilization were collected and analyzed for 26 children with brachial plexus birth palsy. These positions were performed by an experienced occupational therapist and by the child's caretaker. Scapulothoracic and GH joint angular displacements were compared between stretches with no stabilization, stabilization performed by the therapist, and stabilization performed by the caretaker. The relationship between the age and ability of the therapist and caretaker to perform the stretches with scapular stabilization was also assessed. RESULTS During external rotation there were no significant differences in either the scapulothoracic or GH joint during stabilization by either the therapist or the caretaker. During abduction, both scapulothoracic and GH joint angular displacements were statistically different. Scapulothoracic upward rotation angular displacement significantly decreased with scapular stabilization by the therapist and caretaker. Glenohumeral elevation angular displacement significantly decreased with scapular stabilization performed by the therapist and caretaker. There were only weak correlations between age and the differences in scapulothoracic and GH joint angular displacement performed by both the therapist and the caretaker. CONCLUSIONS The findings of this study indicate that scapular stabilization may be detrimental to passive stretching of the GH joint in children, as demonstrated by a reduced stretch. Based on the findings of this study, we have changed our practice to recommend passive stretches without scapular stabilization for children aged 5 years and older with brachial plexus birth palsy. In infants and children aged less than 5 years, we now recommend stretching with and without scapular stabilization until the effect of scapular stabilization is objectively assessed in these age groups. LEVEL OF EVIDENCE/TYPE OF STUDY Therapeutic IV.
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Pondaag W, Malessy MJ. Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey. J Orthop Res 2018; 36:2533-2541. [PMID: 29566312 PMCID: PMC6175006 DOI: 10.1002/jor.23901] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 03/18/2018] [Indexed: 02/04/2023]
Abstract
There is no consensus regarding strategies to optimally treat children with a brachial plexus birth injury (BPBI). Comparison of outcome data presented by different centers is impossible due to the use of (1) many different outcome measures to evaluate results; (2) different follow-up periods after interventions; and (3) different patient ages at the time of assessment. The goal of iPluto (international PLexus oUtcome sTudy grOup) was to define a standardized dataset which should be minimally collected to evaluate upper limb function in children with BPBI. This dataset must enable comparison of the treatment results of different centers if prospectively used. Three rounds of internet surveys were used to reach consensus on the dataset. A Delphi-derived technique was applied using a nine point Likert scale. Consensus was defined as having attained a rating of 7/8/9 by > = 75% of the participants. A total of 59 participants from five continents participated in the Second and Third Rounds of the survey. Consensus was reached regarding four elements: (1) evaluation should take place at the age of 1/3/5/7 years; range of motion in degrees should be measured for (2) passive joint movement; (3) active range of motion; and (4) the Mallet score should be determined. Consensus on how to asses and report outcome for BPBI was only reached on motor items from the "Body Function and Structure" domain. Consensus regarding additional ICF domains to obtain a more elaborate set of outcome items, should be addressed in future research. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:2533-2541, 2018.
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Affiliation(s)
- Willem Pondaag
- Department of NeurosurgeryLeiden University Medical CenterLeidenThe Netherlands
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Long-term results of latissimus dorsi transfer for internal rotation contracture of the shoulder in patients with obstetric brachial plexus injury. JSES OPEN ACCESS 2018; 2:159-164. [PMID: 30675588 PMCID: PMC6334879 DOI: 10.1016/j.jses.2018.05.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background This study evaluated the long-term outcome of patients with obstetric brachial plexus injury who underwent transfer of the latissimus/teres major tendon to restore shoulder external rotation and determined whether loss of internal rotation would affect their quality of life. Methods All patients with a history of obstetric brachial plexus injury who underwent latissimus dorsi transfer for internal rotation contracture were included. Results from 3 clinic visits (preoperative, and short-term and long-term postoperatively) were recorded. Quality of life was evaluated with a questionnaire. Internal rotation impairment was evaluated using the Activities of Daily Living which require active Internal Rotation scoring system. Results The study included 45 patients. At a mean 5 months postoperatively, shoulder motion was significantly improved in abduction and external rotation. This was associated with a significant loss of active internal rotation. These results deteriorated over time (at a mean 7.64 years postoperatively), especially in internal rotation (from being able to reach the sacrum to only being able to reach the trochanter) and in external rotation with the arm abducted. This decrease in function led 10 patients (22%) to undergo revision surgery. The mean score on the activities of daily living which require active internal rotation (ADLIR) at the last follow-up was 53. Conclusion Although the short-tem results of latissimus dorsi transfer and subscapularis release are encouraging, these gains deteriorated over a longitudinal follow-up period. Abduction is maintained over the long-term, but external rotation deteriorates. Internal rotation deteriorated over a long-term longitudinal follow-up, leading to functional impairment.
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Greenhill DA, Trionfo A, Ramsey FV, Kozin SH, Zlotolow DA. Postoperative Loss of Midline Function in Brachial Plexus Birth Palsy. J Hand Surg Am 2018; 43:565.e1-565.e10. [PMID: 29223630 DOI: 10.1016/j.jhsa.2017.10.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/15/2017] [Accepted: 10/25/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To identify the rate of and predictive variables for functionally limited shoulder internal rotation in postoperative patients with brachial plexus birth palsy. METHODS Records of patients with brachial plexus birth palsy who had surgery on the affected upper extremity during a 10-year period were retrospectively reviewed. Patient demographics, physical examinations, and all upper extremity procedures were recorded. Loss of midline function (LOM) was defined as a Modified Mallet Scale or Active Movement Scale (AMS) internal rotation score <3. Exclusion criteria were <1-year follow-up after the most recent procedure, insufficient documentation, or preexisting LOM. Multivariable logistic regression was performed on 3 different scenarios of candidate variables to identify those associated with LOM. All scenarios included each procedure as a candidate variable. Scenario A additionally analyzed preprocedural AMS scores. Scenario B additionally analyzed preprocedural Modified Mallet Scale scores. Scenario C isolated the surgical pathway without preprocedural examination scores. RESULTS Among 172 included patients, 34 (19.8%) developed LOM. Predictive variables associated with LOM included severity of initial palsy (C5-7, odds ratio 3.6; C5-T1, odds ratio 4.9), poor recovery of upper trunk motor function before the patient's first surgery (specifically Modified Mallet Scale abduction < 4, AMS elbow flexion < 3, and AMS wrist extension < 3), and patients who ultimately required surgical glenohumeral reduction (odds ratio 3.6). Age, number of procedures, closed shoulder reduction with casting, shoulder tendon transfers, and external rotation humeral osteotomies were not predictive of LOM. CONCLUSIONS Approximately 1 in every 5 patients with brachial plexus birth palsy will develop LOM after entering a surgical algorithm designed to improve shoulder external rotation. Patients with a more severe initial palsy (C5-7 or global), poor spontaneous recovery of upper trunk motor function (elbow flexion or wrist extension) before their first procedure, and those who ultimately require surgical glenohumeral joint reduction should be counseled as having a higher odds of LOM development. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Dustin A Greenhill
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA
| | - Arianna Trionfo
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA.
| | - Frederick V Ramsey
- Department of Clinical Sciences, Temple University School of Medicine, Philadelphia, PA
| | - Scott H Kozin
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA
| | - Dan A Zlotolow
- Department of Orthopaedic Surgery, Shriners Hospital for Children, Philadelphia, PA
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External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial Plexus Birth Palsy. J Pediatr Orthop 2018; 38:32-37. [PMID: 26886458 DOI: 10.1097/bpo.0000000000000735] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success. METHODS Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation. RESULTS Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures. CONCLUSIONS Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention. LEVEL OF EVIDENCE Level IV-therapeutic.
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Abstract
BACKGROUND The Mallet scale, Active Movement Scale (AMS), and Toronto Test are validated for use in children with brachial plexus birth palsy (BPBP). However, the inability to compare these evaluation systems has led to difficulty gauging treatment efficacy and interpreting available literature in which multiple scoring systems are reported. Given the critical importance of physical examination, we compared 3 scoring systems to clarify statistical relationships between current validated evaluation methods. METHODS The medical records of children with BPBP treated at a single institution over a 14-year period were retrospectively reviewed. Modified Mallet, AMS, and Toronto scores were recorded throughout the entire period. Data were included if at least 2 complete scoring systems were documented during the same examination session. Spearman correlation coefficients were calculated for all composite and subscore combinations. A concordance table was constructed for select variables found to be highly correlated. RESULTS Total single-session score combinations were as follows: 157 Mallet and AMS, 325 AMS and Toronto, and 143 Mallet and Toronto. Composite AMS and Toronto scores were found to have a strong correlation (r=0.928, P<0.001). A concordance table comparing these variables revealed that a Toronto score of 3.5 is concordant to an AMS score of 45. Modified Mallet scores had only a moderate correlation with composite AMS (r=0.512, P<0.001) and Toronto (r=0.458, P<0.001) scores. Specifically regarding the modified Mallet score, maneuvers requiring external rotation had stronger correlations with the composite modified Mallet score than maneuvers highlighting internal rotation. CONCLUSIONS Modified Mallet scores do not correlate well with AMS or Toronto scores and should be utilized separately when managing children with BPBP. Similarly, AMS and Toronto scores are inadequate to guide clinical decisions for which the literature cites Mallet scores as outcome measures, and vice versa. Lastly, Mallet scores should incorporate an isolated internal rotation component to adequately assess midline function. LEVEL OF EVIDENCE Diagnostic level III.
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Remodeling after arthroscopic reduction of glenohumeral joint in adduction internal rotation shoulder deformity in obstetric brachial plexus palsy. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abzug JM, Kozin SH, Waters PM. Open Glenohumeral Joint Reduction and Latissimus Dorsi and Teres Major Tendon Transfers for Infants and Children Following Brachial Plexus Birth Palsy. Tech Hand Up Extrem Surg 2017; 21:30-36. [PMID: 28448306 DOI: 10.1097/bth.0000000000000150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Glenohumeral dysplasia can occur in brachial plexus birth palsy due to an imbalance of muscle forces. Most commonly this occurs in C5-C6 injuries where the shoulder external rotators are weak compared with the shoulder internal rotators. Treatment of the dysplasia with open reduction of the glenohumeral joint in combination with rebalancing the muscles can improve the development of the joint. Furthermore, the tendon transfer can improve shoulder function by decreasing the internal rotation forces about the shoulder while increasing the external rotation forces. This paper describes the indications, contraindications, and technique of performing an open glenohumeral joint reduction and latissimus dorsi and teres major tendon transfers for brachial plexus birth palsy.
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Affiliation(s)
- Joshua M Abzug
- *Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD †Shriners Hospital for Children, Philadelphia, PA ‡Children's Hospital Boston, Boston, MA
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Triplanar Humeral Osteotomy for Restoration of Midline Function in Patients With Brachial Plexus Birth Palsy. Tech Hand Up Extrem Surg 2017; 21:48-54. [PMID: 28394871 DOI: 10.1097/bth.0000000000000156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Brachial plexus birth palsy resolves spontaneously in a majority of patients, however, others may have serious permanent dysfunction. Although nerve transfers or grafts are early options for treatment, many children have residual deficits or present too late for such procedures. In these patients, rotational osteotomy of the humerus may restore improved function and motion. Unfortunately, traditional humeral osteotomies only provide correction in a single plane, therefore appropriate correction of the typical residual deformity is incomplete. Here, we describe a novel technique for obtaining a calculated correction in 3 planes using a single osteotomy of the humerus on the basis of a mathematical equation. Nine patients are described here with an average of 35.4 months follow-up. Corrections were obtained in adduction, extension, and either internal or external rotation depending on the initial deformity and Modified Mallet scores were collected for each patient. There was 1 case of transient radial nerve palsy with no long-term complications overall.
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Nicholson KF, Richardson RT, Rapp EA, Quinton RG, Anzilotti KF, Richards JG. Validation of a mathematical approach to estimate dynamic scapular orientation. J Biomech 2017; 54:101-105. [DOI: 10.1016/j.jbiomech.2017.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 01/13/2017] [Accepted: 01/17/2017] [Indexed: 11/29/2022]
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Mahon J, Malone A, Kiernan D, Meldrum D. Reliability of 3D upper limb motion analysis in children with obstetric brachial plexus palsy. Physiol Meas 2017; 38:524-538. [PMID: 28140349 DOI: 10.1088/1361-6579/aa5c13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Kinematics, measured by 3D upper limb motion analysis (3D-ULMA), can potentially increase understanding of movement patterns by quantifying individual joint contributions. Reliability in children with obstetric brachial plexus palsy (OBPP) has not been established. OBJECTIVE This study aimed to determine between session reliability and measurement errors of 3D-ULMA using the acromion method (AM) in children with OBPP. APPROACH Ten participants (mean 10 years, range 7-15 years, Narakas classification I-III) completed 3D-ULMA on two occasions, mean interval of 8.6 d (±2.8 d). Kinematic data were captured by a 4-CODA cx1 optoelectronic tracking system. Participants performed three trials of the modified Mallet scale tasks. Local coordinate systems, segment and joint rotations were defined as recommended by the International Society of Biomechanics. The intraclass correlation coefficient (ICC 2,K) and standard error of measurement (SEM) were calculated for task duration, range and joint angle at point of task achievement (PTA). MAIN RESULTS Results indicated poor reliability for spatiotemporal parameters and range. Moderate to excellent reliability at PTA was observed in 19/60 variables (ICC: 0.77-0.98; SEM: 3.5°-10.4°). The Abduction Task had the highest (ICC: 0.79-0.98; SEM: 3.5°-10.3°) with External Rotation the lowest reliability. Glenohumeral and thoracohumeral elevation had the most consistent reliability. Scapular protraction/retraction had consistently poor reliability (ICC: 0-0.72; SEM: 3.5°-10.2°) with axial rotation also poor (ICC: 0.00-0.91; SEM: 6.3°-32.8°). This study determined inconsistent test-retest reliability of 3D-ULMA, using AM, to track dynamic performance of functional tasks in children with OBPP. It is the first study to outline measurement error in this population. This information permits more reliable interpretation of future studies of kinematic patterns in children with OBPP.
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Affiliation(s)
- Judy Mahon
- Gait Analysis Laboratory, Central Remedial Clinic, Vernon Ave., Clontarf, Dublin 3, Ireland
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Russo SA, Rodriguez LM, Kozin SH, Zlotolow DA, Chafetz RS, Killelea CM, Nicholson KF, Richards JG. Therapeutic Taping for Scapular Stabilization in Children With Brachial Plexus Birth Palsy. Am J Occup Ther 2016; 70:7005220030p1-7005220030p11. [DOI: 10.5014/ajot.2016.018903] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abstract
OBJECTIVE. In this study, we aimed to assess whether therapeutic taping for scapular stabilization affected scapulothoracic, glenohumeral, and humerothoracic joint function in children with brachial plexus birth palsy and scapular winging.
METHOD. Motion capture data were collected with and without therapeutic taping to assist the middle and lower trapezius in seven positions for 26 children. Data were compared with one-way multivariate analyses of variance.
RESULTS. With therapeutic taping, scapular winging decreased considerably in all positions except abduction. Additionally, there were increased glenohumeral cross-body adduction and internal rotation angles in four positions. The only change in humerothoracic function was an increase of 3° of external rotation in the external rotation position.
CONCLUSION. Therapeutic taping for scapular stabilization resulted in a small but statistically significant decrease in scapular winging. Overall performance of positions was largely unchanged. The increased glenohumeral joint angles with therapeutic taping may be beneficial for joint development; however, the long-term impact remains unknown.
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Affiliation(s)
- Stephanie A. Russo
- Stephanie A. Russo, MD, PhD, is Resident Physician, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center—Hamot, Erie, PA;
| | - Luisa M. Rodriguez
- Luisa M. Rodriguez, OTR/L, is Occupational Therapist, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA
| | - Scott H. Kozin
- Scott H. Kozin, MD, is Chief of Staff and Hand Surgeon, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA, and Department of Orthopaedic Surgery, Temple University, Philadelphia, PA
| | - Dan A. Zlotolow
- Dan A. Zlotolow, MD, is Hand Surgeon, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA, and Department of Orthopaedic Surgery, Temple University, Philadelphia, PA
| | - Ross S. Chafetz
- Ross S. Chafetz, DPT, PhD, is Motion Analysis Laboratory Physical Therapist, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA
| | - Carolyn M. Killelea
- Carolyn M. Killelea, PhD, is Motion Analysis Laboratory Engineer, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA
| | - Kristen F. Nicholson
- Kristen F. Nicholson, PhD, is Motion Analysis Laboratory Biomechanist, Gait Analysis Laboratory, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - James G. Richards
- James G. Richards, PhD, is Distinguished Professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark
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