Search

Background: Limb length discrepancy (LLD) is a frequent observation in children with birth brachial plexus palsy (BBPP) and a common concern among parents. A common assumption is that the LLD decreases if the child is using the involved limb more. However, there is no literature evidence for this assumption. The present study was conducted to assess the correlation between the functional status of the involved limb and the LLD in children with BBPP. Methods: One hundred consecutive patients (age > 5 years) with unilateral BBPP seen at our institute underwent measurements of limb lengths to assess the LLD. The arm, forearm and hand segments were measured separately. The functional status of the involved limb was assessed using modified House’s Scoring system (Scores 0–10). The correlation between limb length and functional status was assessed using the one-way Analysis of Variance (ANOVA) test. Post-hoc analyses were performed as required. Results: A length difference was observed in 98% of the limbs with brachial plexus lesions. The average absolute LLD was 4.6 cm with a standard deviation of 2.5 cm. We found a statistically significant difference in LLD among the patients with a House score of Conclusions: LLD was seen in most of the patients with BBPP. The functional status of the involved upper limb in BBPP was found to be significantly associated with LLD. Though causation cannot be assumed. We found that children using the involved limb independently tend to have the least LLD. Level of Evidence: Level IV (Therapeutic)

Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatment is to achieve a satisfactory grasp enabling the use of the hand for daily activities. The aim of this study is to report the outcomes of the transfer of brachioradialis (BR) to flexor pollicis longus (FPL) and biceps to the flexor digitorum profundus (FDP) for an isolated lower BPI. Methods: This is a retrospective study of all patients with an isolated lower BPI who underwent a BR to FPL and biceps to FDP transfer for restoration of digital flexion over a 1-year period from May 2019 to June 2020. Patient demographic and injury data were collected at the presentation. Outcomes data included the ability to grasp and perform activities of daily living and DASH score. Results: The study included three patients (all men) with an average age of 30.3 years. All sustained an isolated lower BPI following a road traffic accident and tendon transfers were performed at a mean of 9.3 months after the initial injury. At a mean of 1-year follow-up, all three recovered grade M4 motor power of digital flexion, achieved good grasp function with pulp-to-palm distance of Conclusions: BR to FPL for thumb flexion and biceps to FDP using fascia lata graft to restore finger flexion is simple and effective surgeries in patients with isolated lower BPI. Level of Evidence: Level V (Therapeutic)

Motor deficit in patients with extended upper brachial plexus palsy is variable. A patient with only thumb and finger extensors may seem to have active wrist extension because of them secondarily acting at wrist and causing wrist extension. To determine the presence of wrist extensors, it is important to block the wrist extension caused by the finger and thumb extensors. Conventional muscle testing is often ineffective in these patients as they learn a variety of trick movements over the time. We describe a simple clinical test to reveal the strength of the wrist extensors only by negating the effect of digital extensors on the wrist. If wrist extensors are absent, a nerve or tendon transfer can be done to address this deficit and improve the functional outcome. Level of Evidence: Level V (Diagnostic)

Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexus injury (BPI). This internally rotated posture of the limb becomes more apparent and functionally limiting once the patient recovers elbow flexion resulting in the hand striking the abdomen on attempted flexion (‘tummy flexion’). This precludes hand-to-mouth reach, resulting in an inability to eat with the involved hand. The aim of this study is to present the outcomes of an external rotation osteotomy of the humerus in adult BPI. Methods: All BPI patients who underwent an external rotation osteotomy of the humerus at our institution over a 5-year period from January 2015 to December 2020 were included in this study. Data with regard to the age, gender, type of BPI, time from injury to nerve surgery and from nerve surgery till external rotation osteotomy, degree of pre- and postoperative external rotation, time to union, patient satisfaction and complications were recorded. Results: The study included 19 patients (18 men and one woman) with an average age of 30 years (range 20–58). The average time interval from the injury to the nerve surgery was 3.8 months, and between the nerve surgery and the external rotation osteotomy was 29.5 months. No patient had any preoperative external rotation and all attained a resting posture of 15°–20° of external rotation, were able to reach the mid-line of the body, and none complained of loss of internal rotation. There was an implant failure in one patient that was managed with splinting till union and removal of implants later. Conclusions: External rotation osteotomy of the humerus is a simple and effective procedure to place the limb in a better aesthetic and functional position. Level of Evidence: Level IV (Therapeutic)

The usual recommendation in posterior interosseous nerve (PIN) palsy is to use the flexor carpi radialis instead of the flexor carpi ulnaris (FCU) for restoration of digital extension. The use of FCU takes away the only remaining ulnar deviator of the wrist. Although preserving the FCU prevents severe radial deviation deformity, we found that some patients still develop a radial deviation deformity, especially during wrist extension. We have used a brachioradialis (BR) to extensor carpi ulnaris (ECU) transfer to prevent the development of a radial deviation deformity and find that it restores the normal radio-ulnar balance of the wrist by providing a dynamic ulnar stabiliser. It is a simple addition to the standard two tendon transfers for PIN palsy with minimal donor morbidity. We have used this triple transfer for PIN palsy in seven patients with satisfactory results and no complications. Level of Evidence: Level V (Therapeutic)

Background: The presence of a separate compartment for the extensor pollicis brevis tendon (EPB) has an implication in the treatment outcome for de Quervain disease. The EPB entrapment test, proposed by Alexander and colleagues, claims to correlate with the presence of a separate compartment for EPB. The purpose of our study is to evaluate the reliability of the EPB entrapment test in predicting a separate compartment for EPB in patients with de Quervain disease. Methods: This was a prospective observational study involving 50 consecutive patients who underwent de Quervain release by a single surgeon. Preoperatively, EPB entrapment test was performed by the operating surgeon. The outcome of the test was recorded and the presence of a separate compartment for the EPB was determined during surgery. Sensitivity, specificity, positive predictive value and negative predictive value of the EPB entrapment test was determined. Results: EPB entrapment test was positive in 28 of 50 patients. In 21 of them, a separate compartment for the EPB was noted. The positive predictive value of the test was found to be 75.8%. The test had a false positive rate of 26.9%, a false negative rate of 12.5%, sensitivity of 87.5% and specificity of 73%. There is a significant association between a positive EPB entrapment test and the presence of a separate compartment for the EPB (p value Conclusions: The EPB entrapment test is a reliable clinical test to look for the presence of a separate compartment for EPB. Considering the response of pain on both extension and abduction of the thumb further improves the sensitivity of the test. Hence, we suggest including this response also as a positive test. Level of Evidence: Level II (Diagnostic)

The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral nerve injuries of the upper extremity. Nerve transfers offer faster reinnervation of a denervated muscle by taking advantage of a donor nerve, branch or fascicle close to the recipient muscle. A number of considerations in respect of donor selection for nerve transfers underlie their success. In this review article, we discuss the principles of donor selection for nerve transfers, the different options available and our considerations in choosing a suitable transfer in reanimating the elbow and the shoulder. We feel this will help nerve surgeons navigate the controversies in the selection of donor nerves and make appropriate treatment decisions for their patients. Level of Evidence: V (Therapeutic)

Kienbock’s disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from ‘doing nothing’ to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This ‘black hole’ in the literature presents difficulties to surgeons treating the condition and even patient’s confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim to preserve the lunate while once the lunate is collapsed its removal is performed. The lunate preserving operations basically are either decreasing the load on the lunate to possibly permit its revascularization or are the procedures which are aimed at augmenting the vascularity of the lunate. Radius shortening osteotomy is the most popular treatment in the early stages especially in the patients’ with negative ulnar variance and the proximal row carpectomy is most popular in the advanced stages of the disease. Authors present their algorithm of management of Kienbock’s disease and discuss the various treatment options described in the literature in an attempt to find the apt in 2020.

Soft tissue loss over the dorsum of the finger could potentially expose critical structures like extensor tendon, bone, and joint. These exposed structures often require flap coverage. Local flap is one of the available options to cover most small-sized defects on the dorsum of fingers. One of the primary requisites for any flap used on the dorsum of the finger, especially over a joint, is to enable the full range of motion of the finger. Even though skin over the dorsum of the fingers can be pinched easily in extension, with full flexion such suppleness is not demonstrated.

Flexor tendon injuries have constituted a large portion of the literature in hand surgery over many years. Yet many controversies remain and the techniques of surgery and therapy are still evolving. The anatomical and finer technical considerations involved in treating these injuries have been put forth and discussed in detail including the rehabilitation following the flexor tendon repair. The authors consider, recognition and mastery of these facts form the foundation for a successful flexor tendon repair. The trend is now towards multiple strand core sutures followed by early active mobilization. However, the rehabilitation process appears to be one of the major determinant of the success following a flexor tendon repair. Early mobilization is essential for all the flexor tendon repairs as it is proved to improve the quality of the repaired tendon. The art of achieving the harmony between a stronger repair and unhindered gliding of the repair site through the narrow flexor tendon sheath simultaneously can be mastered with practice added to the knowledge of the basic principles.