Current Concept in the Management of Brachial Plexus Birth Palsy

Most infants with brachial plexus birth palsy with signs of recovery in the first 6 weeks of life will improve spontaneously to have a normal function. However, infants who fail to recover in the first 3 months of life carry the risk of long-term disability. Panplexopathy and Horner’s syndrome carry worst prognosis. Plastic neural reconstruction is indicated for the failure of return of function by 3–6 months. There is no consensus about the ideal timing of intervention, and subject is still open to debate. With microsurgical reconstruction, there is improvement in outcome in a high percentage of patients. However, any of these reconstructions is not strong enough to provide a normal function. Limited shoulder abduction and external rotation are the main elements of limitations in residual brachial plexus birth palsy children. Infants with internal contracture can be benefited with Botulinum toxin injection. Internal rotation contracture release and shoulder-rebalancing surgeries for residual brachial plexus birth palsy patients in the form of tendon transfers for congruent glenohumeral joint clearly benefit patients. Patients with noncongruent glenohumeral joint would need a derotational humeral/glenoid anteversion osteotomy. All the mentioned procedures will substantially improve but not normalize the function in children

Defining and Differentiating Congenital Vertical Talus and Congenital Oblique Talus

Background:. Congenital vertical talus (CVT) and congenital oblique talus (COT) are rocker-bottom foot deformities that have similar names and no objective definitions. This has led to confusion for practitioners, as well as scientific challenges for researchers. Our goal was to provide objective radiographic criteria to define and differentiate CVT and COT. Methods:. We evaluated 62 pairs of maximum dorsiflexion and plantar flexion lateral radiographs of infant feet that had been clinically diagnosed with CVT. The dorsiflexion tibiotalar angle, the plantar flexion talus-first metatarsal angle, and the plantar flexion foot center of rotation of angulation (foot-CORA) were measured using transparent overlay tools. Freehand measurements were made on a subset of 10 pairs of radiographs to confirm clinical applicability. Nine contralateral pairs of radiographs of normal feet were measured for comparison. Results:. Specific values for the radiographic measurements were identified that, together, reliably differentiated the shapes of rocker-bottom feet with CVT, COT, and flexible flatfoot with a short tendo-Achilles (FFF-STA), as well as the shape of the normal foot. More severe and rigid rocker-bottom foot deformities were diagnosed with CVT. Less severe and more flexible deformities were diagnosed with COT. Conclusions:. CVT, COT, FFF-STA, and normal feet can be reliably differentiated using 2 angular measurements and 1 bone position measurement on dorsiflexion and plantar flexion lateral radiographs. Our data indicated that the differentiation of CVT and COT is based primarily on the rigidity of the navicular dislocation rather than the verticality of the talus. The data further supported the proposition that COT is a foot deformity along a spectrum of valgus/eversion deformities of the hindfoot that requires early treatment. Application of these diagnostic criteria should lead to clinical studies that identify a specific treatment, treatment outcome, and prognosis for each deformity. Level of Evidence:. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence

Multilevel orthopedic surgery for crouch gait in cerebral palsy: An evaluation using functional mobility and energy cost

Background: The evidence for the effectiveness of orthopaedic surgery to correct crouch gait in cerebral diplegic is insufficient. The crouch gait is defined as walking with knee flexion and ankle dorsiflexion through out the stance phase. Severe crouch gait in patients with spastic diplegia causes excessive loading of the patellofemoral joint and may result in anterior knee pain, gait deterioration, and progressive loss of function. We retrospectively evaluated the effect of surgery on the mobility and energy consumption at one year or more with the help of validated scales and scores. Materials and Methods: 18 consecutive patients with mean age of 14.6 years with cerebral diplegia with crouched gait were operated for multilevel orthopaedic surgery. Decisions for surgery were made with the observations on gait analysis and physical examination. The surgical intervention consisted of lengthening of short muscle-tendon units, shortening of long muscles and correction of osseous deformities. The paired samples t test was used to compare values of physical examination findings, walking speed and physiological cost index. Two paired sample Wilcoxon signed rank test was used to compare functional walking scales. Results: After surgery, improvements in functional mobility, walking speed and physiological cost index were found. No patient was able to walk 500 meters before surgery while all were able to walk after surgery. The improvements that were noted at one year were maintained at two years. Conclusions: Multilevel orthopedic surgery for older children and adolescents with crouch gait is effective for improving function and independence