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Classification of limb anomalies in oral-facial-digital syndromes. A classification of limb anomalies in oral-facial-digital (OFD) syndromes is offered to help differentiate between the various types of OFD syndromes. A clinical case is presented with clinical features consistent with both OFD syndrome type I (Papillon Leage-Psaume syndrome) and type VI (Váradi syndrome). The final diagnosis as a new mutation of type I syndrome was established after reviewing the radiological findings in the hands.
Unilateral hypertrophy of the upper extremity due to aberrant muscles. We present a case of congenital unilateral hypertrophy of an upper extremity due to aberrant muscles. Reviewing the previous Japanese reports, we discuss the clinical features and the pathogenetic factors of this rare anomaly.
Functional motor innervation of brachial plexus roots. An intraoperative electrophysiological study. The electrophysiological properties of the normal brachial plexus and functional motor innervation were examined during the operation of transfer of contralateral C7 transfer from the healthy side. Different roots of the brachial plexus were stimulated and maximum amplitudes were recorded. The results showed that functional motor innervation of brachial plexus roots were: C5 mainly forms the axillary nerve to innervate the deltoid muscle; C6 mainly forms the musculocutaneous nerve to innervate biceps; C7 mainly forms the radial nerve to innervate triceps; C8 mainly forms the median nerve to innervate flexor digitorum superficialis and profundus; and T1 mainly forms the ulnar nerve to innervate the intrinsic muscles of the hand.
Transposition of the bicipital tuberosity for treatment of fixed supination contracture in obstetric brachial plexus lesions. In nine patients with obstetric brachial plexus lesions (Klumpke type), an impingement of the bicipital tuberosity on the ulna was the main cause for the forearm and hand to be fixed in supination. A surgical technique using reinsertion of the biceps tendon on the bicipital tuberosity is described in detail. It has substantially improved all patients. After a mean follow-up of 29.4 months the hand was in a more functional position than preoperatively in all patients. In seven cases pronation could be increased by contraction of the biceps muscle. By relaxing the biceps muscle and by contraction of the supinator muscle a limited active supination was possible in six cases.
Closure of fasciotomy wounds. A technical modification. The closure of fasciotomy wounds creates problems for patient and surgeon alike. Split thickness skin grafting results in unsightly and insensate wounds and often requires general anaesthesia and prolonged inpatient care. We describe an improvement of a previously reported technique which is as effective as proprietary medical devices currently available. The technique may also be applied to the delayed primary closure of traumatic wounds.
Grip and pinch strength variations in different types of workers. We measured grip and pinch strengths in non-manual, light manual and heavy manual workers using a Jamar dynamometer and a pinch measuring device. Heavy manual workers had the strongest grips with the least difference between sides. Office workers had the weakest grips and the greatest difference between sides. Light manual workers were between these two groups. Consequently, the occupation of the patient must be taken into account when using grip and pinch strength measurements to assess the need for rehabilitation and in medicolegal reports.
Passive axial rotation of the metacarpophalangeal joint. We measured passive axial rotation at the metacarpophalangeal (MCP) joints of the index, long, ring and small fingers of both hands in 100 healthy subjects using a magnetic position and orientation system called an Isotrak. Large degrees of passive rotation were found, with the ring and small finger MCP joints displaying significantly greater ranges of supination than the other two joints. Supination ranges were also found to be significantly greater than the pronation values in each joint. These results support present anatomical understanding that, during prehensile activities, axial rotation of the MCP joints occurs to allow the hand to adapt to an object being held.
Variations of the flexor digitorum superficialis tendon of the little finger. Seventy cadaveric hands were dissected to study variations of the flexor digitorum superficialis tendon (FDS) to the little finger. Anatomical variations were present in 13% of hands and 10% of the hands showed an anatomical variation that would preclude independent FDS function in the little finger. The distance of the decussation from the metacarpophalangeal joint was measured. A ratio of this distance to proximal phalangeal length was calculated. The ratio indicated that decussation position was independent of phalangeal size.
Results of dynamic splintage following extensor tendon repair. We report a prospective study of dynamic splintage following extensor tendon repair. Eighty-four patients with 101 extensor tendon injuries were studied. Using Dargan's evaluation system, there were 97% excellent results for the thumb and 93% excellent and good results for the fingers. The average total active motions were 107 degrees for thumbs and 245 degrees for fingers. Over 80% of patients regained good power grip. Patients with associated digital fractures or with ragged lacerations had poorer results. Overall, we found that dynamic splintage was a satisfactory method after extensor repair.
Does sympathetic blockade prevent the physiologic changes associated with tourniquet use in children? This study investigated a means of controlling the altered physiologic effects that occur when tourniquet inflation time is > or = 50 min during orthopaedic surgery in children. Forty patients were assigned randomly, 20 in each group. Both groups received inhalational anesthesia for induction. The control group had nitrous/narcotic with inhalation anesthesia for maintenance. The other group received a sympathetic blockade with 0.5% epidural bupivacaine, which was confirmed with the use of thermography technique and supplemented with 0.5-1% isoflurane. Duration of surgery and length of tourniquet inflation time were equal in the two groups. There was a significant difference in physiologic changes related to the tourniquet inflation time. The group with sympathetic blockade had only minor changes in blood pressure, pulse rate, and temperature compared with the control group.
Humerus shaft fractures in young children: accident or abuse? We performed a retrospective review of 34 humerus shaft fractures (HSFs) in children younger than 3 years to determine the frequency of child abuse in young children with this injury. Data were obtained from hospital records (including previous and subsequent emergency, clinic, and inpatient notes), radiographs, and county childprotective services. Cases were reviewed independently by four physicians and were classified as probable abuse, probable not abuse, and indeterminate. Only 18% were classified as probable abuse. The history and findings other than the fracture itself were critical in establishing cause. Neither age nor fracture pattern is pathognomonic of abuse, but suspicion should remain high. A detailed history, complete physical examination, and appropriate radiographic investigation are required in every case either to make the diagnosis of abuse or to avoid the trauma of a false accusation.
Management of pulseless pink hand in pediatric supracondylar fractures of humerus. Thirteen (3.2%) of 410 patients seen in British Columbia's Children's Hospital in Vancouver from January 1984 to September 1992 with supracondylar fractures did so with an absence of a radial pulse in an otherwise well perfused hand. A combination of segmental pressure monitoring, color-flow duplex scanning, and magnetic resonance angiography (MRA) appears to be a valid, noninvasive, and safe technique in evaluating patency of the brachial artery and collateral circulation across the elbow. Based on this study, early revascularization of a pulseless otherwise well-perfused hand in children with type 3 supracondylar fractures, although technically feasible and safe, has a high rate of asymptomatic reocclusion and residual stenoses of the brachial artery. Therefore a period of close observation with frequent neurovascular checks should be completed before more invasive correction of this problem is contemplated.
Osteochondral lesions in the radiocapitellar joint in the skeletally immature: radiographic, MRI, and arthroscopic findings in 13 consecutive cases. Radiography, magnetic resonance imaging (MRI), and arthroscopy were performed in 13 consecutive cases of osteochondral lesions of the radiocapitellar joint in 12 patients aged 11-16 years. Nine patients had a high activity level, and two patients had a significant trauma before the onset of symptoms. Symptoms were limited range of motion, pain, and catchings or lockings. Clinical findings were decreased range of motion and lateral elbow tenderness. Radiography revealed loose body, flattening of the humeral capitellum, or subchondral cysts (or a combination of these) in all cases but three. There was a good correlation between MRI and arthroscopic examination. Nine lesions were located in the humeral capitellum, one lesion in the radial head, and in three cases, lesions were found in both sites. Loose-body removal, shaving, or subchondral drilling (or a combination of these) was performed in 11 cases. All surgically treated patients improved in the short run. Awareness of the typical clinical and radiologic picture will allow identification of the cases suitable for arthroscopy and surgical treatment. In these cases, MRI can be omitted.
Compartment syndrome associated with bupivacaine and fentanyl epidural analgesia in pediatric orthopaedics. Two patients had a compartment syndrome after surgery at a remote site performed under a continuous lumbar infusion of a mixture of narcotic (fentanyl) and local anesthetic (bupivacaine 0.1%). Each patient had inadvertent excessive pressure applied to the limb distally and had no perception of pain in the presence of this analgesic combination. After the relief of this pressure from a sling or traction apparatus, each child had signs of a compartment syndrome, and this sensation of pathologic pain was not masked by the epidural infusion. A discussion of the literature questions the benefits of bupivacaine local anesthetic as a routine addition to epidural analgesia for orthopaedic surgery.
Fractures of the capitellum in adolescents. Fractures of the capitellum are rare in children. The treatment of these injuries has been controversial. At a major pediatric trauma center, seven capitellar fractures were seen in children between 1988 and 1994. The average age of the children was 14.7 years (range, 11-17). Six of these fractures were type I injuries, with large anterosuperior fragments that required operative reduction and internal fixation in five cases. Internal fixation methods used were K wires in three patients, Herbert screws in one patient, and cannulated screws in one patient. The remaining type I fracture was treated with a closed reduction. The seventh fracture was a type II fracture, treated nonoperatively. Five children did well with their respective treatments, but one required reoperation to remove an exostosis block to flexion. Accurate open reduction and internal fixation for the displaced capitellar fracture in children is an effective treatment to restore normal elbow function.
Brachialis muscle entrapment in displaced supracondylar humerus fractures: a technique of closed reduction and report of initial results. A retrospective review was conducted of 152 extension-type supracondylar humerus fractures in 151 children. Ninety-two (61%) of 152 of these fractures were displaced (Gartland type III). Initial irreducibility was present in 20 of the 92 displaced fractures. Brachialis muscle interposition was diagnosed by physical examination or intraoperative findings in 18 (90%) of the 20 initially irreducible fractures. Sixteen of the fractures with brachialis muscle interposition underwent an attempt at freeing the impaled proximal fragment by the described "milking maneuver." The maneuver was successful in 15 of the 16 patients and was followed by closed reduction and percutaneous pinning. Three of the remaining four cases required open reduction and pinning. We identify the incidence of initial irreducibility in displaced supracondylar humerus fractures, describe clinical findings suggestive of brachialis entrapment, and demonstrate the milking maneuver to be a valuable technique in the treatment of displaced supracondylar fractures with brachialis interposition.
Factors affecting fracture position at cast removal after pediatric forearm fracture. The outcome of a pediatric forearm fracture is related to the angulation of that fracture at the time of union. We discuss the factors affecting the position of the fracture at union. Three hundred forty-six children with 369 reductions of forearm fractures were reviewed retrospectively. Quality of reduction at the time of operation and loss of reduction during the period of cast immobilization were assessed using axis deviation. Loss of reduction had a greater influence on the final position of the fracture at union than did the position of the fracture at initial reduction. To ensure a satisfactory outcome, all pediatric forearm fractures should be monitored with radiologic review and remanipulation if their axis deviation is > 5 in younger patients or > 3 in patients with fractures close to or after growth-plate closure. Right forearm fractures in boys were identified as a subgroup at greater risk for redisplacement.
Long-term outcome of sacroiliac disruptions in children. We retrospectively evaluated the outcome of sacroiliac-joint disruption in 18 children, ranging in age from 2 to 16 years. Ten patients were treated with bedrest; eight were treated surgically. Follow-up was performed at an average of 14 years (range, 8-23); three patients had daily back pain, and six had occasional back pain. Six patients had limited lumbosacral motion, but only two were symptomatic. The sacroiliac joint was fused in nine patients and irregular in four. Fracture reduction had been incomplete in nine patients, of whom five had a vertical shear injury. All developed complete or incomplete fusion of the sacroiliac joint, but we could not find a clear relationship between the often impressive radiographic changes and symptoms. Nine patients had a leg-length discrepancy of > 1 cm; three patients had pelvic asymmetry. Disabling long-term symptoms persisted from incomplete neurologic recovery in six patients.
Surgical treatment of displaced olecranon fractures in children. Thirty-five children who had fractures of the olecranon were reviewed. Age at the time of injury ranged from 0 years 2 months to 15 years 4 months. Fractures were retrospectively classified as type I or II according to the amount of displacement apparent on the initial radiographs. Type I fractures were those with < 3 mm of displacement, and type II were those with displacement of > or = 3 mm. Type I fractures (n = 23) were treated with closed methods, and splint or cast immobilization was maintained for an average of 3 weeks. All 23 type I fractures had satisfactory results on follow-up. Type II fractures (n = 12) were treated with open reduction and internal fixation. Greater intraarticular displacement was often seen intraoperatively than had been appreciated radiographically. Ten of 12 patients with type II fractures were available for follow-up; all had satisfactory results. Restoration of the articular surface in children with olecranon fractures optimizes joint function and growth potential. The amount of fracture may be more than is apparent on plain radiographs.