Failed peripheral nerve reconstruction with processed nerve allografts in three patients

Non peer reviewe

Patterns of genetic structuring in the coral Pocillopora damicornis on reefs in East Africa

Studies of population genetic structures provide an indication of direction and magnitude of larval transport and hence are an important component in the assessment of the ability of reefs to recover from severe disturbance. This paper reports data on population genetic structures in the coral Pocillopora damicornis from 26 reefs in Kenya and Tanzania. Gene flow among reefs was found to be variable, with a significant overall genetic subdivision (FST = 0.023 +/- 0.004 SE; p < 0.001), however, only 34% of all pairwise population comparisons showed significant differentiation. Panmixia could not be rejected between reefs separated by as much as 697 km, while other sites, separated by only a single kilometre, were found to be significantly differentiated. An analysis of molecular variance indicated that population genetic differentiation was significant only at the smaller spatial scale (< 10 km), whereas panmixia could not be rejected between groups of samples separated by over 100 km. Estimates of contemporary gene flow showed similar results, with numbers of first generation migrants within each population ranging from 0 to 4 (~5% of the total number of colonies sampled) and likely dispersal distances ranging between 5 and 500 km. This study showed that population differentiation in P. damicornis varied over spatial scales and that this variability occurred at both evolutionary and ecological time scales. This paradox is discussed in light of stochastic recruitment and small scale population structures found in other species of coral. The study also identifies potential source reefs, such as those within Mnemba Conservation area near Zanzibar and genetically isolated reefs such as those within Malindi Marine National Park and Reserve in northern Kenya

Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures

Background and purpose - Controversy exists regarding the optimal treatment for displaced medial epicondyle fractures. We compared the results of nonoperative and operative treatment and calculated the incidence of medial epicondyle fractures in the pediatric census population. Patients and methods - 112 children under 16 years old who sustained > 2 mm displaced fracture of the medial epicondyle were treated in our institution between 2014 and 2019. 80/83 patients with 81 non-incarcerated fractures were available for minimum 1-year follow-up. 41 fractures were treated with immobilization only, 40 by open reduction and internal fixation, according to the preference of the attending surgeon. Outcome was assessed at mean 2.6 years (1-6) from injury with different patient-reported outcome measures. Elbow stability, range of motion, grip strength, and distal sensation were registered in 74/80 patients. Incidence was calculated for 7- to 15-year-olds. Results - Nonoperatively treated children had less pain according to the PedsQL Pediatric Pain Questionnaire (3 vs. 15, p = 0.01) with better cosmetic outcome (VAS 95 vs. 87, p = 0.007). There was no statistically significant difference between the groups in respect of QuickDASH, PedsQL generic core scale, Mayo Elbow Performance Score, grip strength, carrying angle, elbow stability, or range of motion (p > 0.05). All 41 nonoperatively treated children returned to pre-injury sports; of the surgically treated 6/40 had to down-scale their sporting activities. The incidence of displaced (> 2 mm) fractures of the medial epicondyle in children aged 7-15 years was >= 3:100,000. Interpretation - Displaced fractures of the medial humeral epicondyle in children heal well with 3-4 weeks' immobilization. Open reduction and screw fixation does not improve outcome.Peer reviewe

Clinical significance of cervical MRI in brachial plexus birth injury

Background and purpose - Patient selection for nerve surgery in brachial plexus birth injury (BPBI) is difficult. Decision to operate is mostly based on clinical findings. We assessed whether MRI improves patient selection. Patients and methods - 157 BPBI patients were enrolled for a prospective study during 2007-2015. BPBI was classified at birth as global plexus injury (GP) or upper plexus injury (UP). The global plexus injury was subdivided into flail upper extremity (FUE) and complete plexus involvement (CP). Patients were seen at set intervals. MRI was scheduled for patients that had either GP at 1 month of age or UP with no antigravity biceps function by 3 months of age. Type (total or partial avulsion, thinned root), number and location of root injuries and pseudomeningoceles (PMC) were registered. Position of humeral head (normal, subluxated, dislocated) and glenoid shape (normal, posteriorly rounded, pseudoglenoid) were recorded. Outcome was assessed at median 4.5 years (1.6-8.6) of age. Results - Cervical MRI was performed on 34/157 patients at median 3.9 months (0.3-14). Total root avulsions (n = 1-3) were detected on MRI in 12 patients (8 FUE, 4 CP). Reconstructive surgery was performed on 10/12 with total avulsions on MRI, and on all 10 with FUE at birth. Sensitivity and specificity of MRI in detecting total root avulsions was 0.88 and 1 respectively. Posterior shoulder subluxation/dislocation was seen in 15/34 patients (3.2-7.7 months of age). Interpretation - Root avulsion(s) on MRI and flail upper extremity at birth are both good indicators for nerve surgery in brachial plexus birth injury. Shoulder pathology develops very early in permanent BPBI.Peer reviewe

Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury : An observational study

Objective To study the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI). Design Retrospective observational study. Setting Helsinki University Women's Hospital, Finland. Sample Deliveries with SD. Methods Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010-2014 were considered the pre-training period and years 2015-2019 were considered the post-training period. Main outcome measures The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed. Results During the study period, 113 085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p < 0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p < 0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p < 0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm. Conclusions Systematic simulation-based training of midwives and doctors can translate into improved individual and team performance and can significantly reduce the incidence of permanent BPBI.Peer reviewe

Olkahermopunoksen syntymävaurio

Olkahermopunoksen syntymävaurio johtuu synnytyksessä hermojuuriin kohdistuvasta liian kovasta venytyksestä. Suurin osa vaurioista paranee muutamassa kuukaudessa itsestään, mutta pahimmillaan yläraaja voi jäädä täysin toimimattomaksi. Lähete yliopistosairaalaan tehdään, mikäli vastasyntyneen yläraaja on täysin veltto tai lapsen yläraajan toiminta ei ole toipunut täysin normaaliksi kuukaudessa. Päivittäinen liikeharjoittelu aloitetaan kaikissa tapauksissa jo synnytyslaitoksella. Noin puolet pysyvän vaurion saaneista lapsista hyötyy botuliinitoksiiniruiskeista tai leikkaushoidosta.publishedVersio

Casting versus flexible intramedullary nailing in displaced forearm shaft fractures in children aged 7-12 years: a study protocol for a randomised controlled trial

Introduction The forearm is the most common fracture location in children, with an increasing incidence. Displaced forearm shaft fractures have traditionally been treated with closed reduction and cast immobilisation. Diaphyseal fractures in children have poor remodelling capacity. Malunion can cause permanent cosmetic and functional disability. Internal fixation with flexible intramedullary nails has gained increasing popularity, without evidence of a better outcome compared with closed reduction and cast immobilisation.Method and analysis This is a multicentre, randomised superiority trial comparing closed reduction and cast immobilisation to flexible intramedullary nails in children aged 7-12 years with >10 degrees of angulation and/or >10 mm of shortening in displaced both bone forearm shaft fractures (AO-paediatric classification: 22D/2.1-5.2). A total of 78 patients with minimum 2 years of expected growth left are randomised in 1:1 ratio to either treatment group. The study has a parallel non-randomised patient preference arm. Both treatments are performed under general anaesthesia. In the cast group a long arm cast is applied for 6 weeks. The flexible intramedullary nail group is immobilised in a collar and cuff sling for 4 weeks. Data are collected at baseline and at each follow-up until 1 year.Primary outcome is (1) PROMIS paediatric upper extremity and (2) forearm pronation-supination range of motion at 1-year follow-up. Secondary outcomes are Quick DASH, Paediatric Pain Questionnaire, Cosmetic Visual Analogue Scale, wrist and elbow range of motion as well as any complications and costs of treatment. We hypothesise that flexible intramedullary nailing results in a superior outcome.Ethics and dissemination We have received ethical board approval (number: 78/1801/2020) and permissions to conduct the study from all five participating university hospitals. Informed consent is obtained from the parent(s). Results will be disseminated in peer-reviewed publications

Cast immobilisation in situ versus open reduction and internal fixation of displaced medial epicondyle fractures in children between 7 and 16 years old. A study protocol for a randomised controlled trial

Introduction Medial epicondyle fracture of the humerus is a common injury in childhood. There is uniform agreement that minimally displaced fractures (dislocation 2 mm dislocation without joint incarceration or ulnar nerve dysfunction. We hypothesise that there is no difference in treatment outcomes between nonoperative and operative treatment.Methods and analysis This is a multicentre, controlled, prospective, randomised noninferiority study comparing operative treatment to non-operative treatment of >2 mm dislocated paediatric medial epicondyle fractures without joint incarceration or ulnar nerve dysfunction. A total of 120 patients will be randomised in 1:1 ratio to either operative or nonoperative treatment. The study will have a parallel nonrandomised patient preference arm. Operative treatment will be open reduction and internal fixation. Nonoperative treatment will be upper limb immobilisation in long arm cast for 4 weeks. Data will be collected at baseline and at each follow-up up to 2 years. Quick-DASH is used as primary outcome measure. Secondary outcomes are patient-reported pain, differences in range of motion, Pediatric Quality of Life Inventory, cosmetic visual analogue scale and Mayo Elbow Performance Score.Ethics and dissemination Ethical approval has been obtained from Helsinki University Hospital (HUS) ethical board HUS/1443/2019. Each study centre has obtained their own permission for the study. A written authorisation from legal guardian will be acquired and the child will be informed about the trial. Results of the trial will be disseminated as published articles in peer-reviewed journals.</div

Improving Shoulder Function in Brachial Plexus Birth Injury

HUS, New Children’s Hospital is the only treatment center for permanent brachial plexus birth injury (BPBI) for the 1.7 million residents of the region of Uusimaa, Finland. The hospital serves as a tertiary treatment center for a population of 2.2 million. The aims of this study are: to calculate the annual incidence of permanent BPBI in the region of the hospital district of Helsinki and Uusimaa in 1995-2019, to analyze whether cervical magnetic resonance imaging (MRI) is reliable in detecting root avulsions, to assess if shoulder dysplasia can be prevented by a protocol including early range of motion (ROM) exercises, ultrasound (US) screening, and Botulinum toxin A (BTX) injections in combination with spica bracing, and to develop a new neurotization technique to restore active shoulder external rotation (ER) in adduction. 431 children with BPBI were referred to our brachial plexus clinic between 1995 and 2019. The injury was permanent in 258 children. Of these, 179 children were born in our primary catchment area, with 437454 births during the 25-year-long study period. Cervical MRI was done to 34 children born between 2007 and 2013 who were clinically potential candidates for plexus surgery. Root avulsion in MRI served as one indication to recommend plexus repair. Our shoulder protocol to prevent shoulder dysplasia, including ROM exercises, US screening, BTX injections, and shoulder ER spica bracing, was developed between 2000 and 2009. The risk for permanent BPBI in the hospital district of Helsinki and Uusimaa from vaginal births varied annually between 0.1 and 0.9 per 1000, with a decreasing tendency. MRI was a reliable imaging modality with both high sensitivity (0.88) and specificity (1.00) for avulsion injuries. Posterior shoulder subluxation, as a result of advancing shoulder dysplasia, was verified by imaging in 48% (114/237) of children with permanent injury. Mean age at detection dropped from 5 years (range 0.3-8.6) in children born before 2000 to 4.9 months (range 1.1-12) in children born 2010 or later. Active shoulder ER in adduction had improved by mean 57° (range 40-95°) in 12/14 children, active ER in abduction by mean 56° (range 30-85) and active abduction mean 27° (range 10-60°) in all 14 patients 4 years (range 2-5) after specific neurotization of the infraspinatus muscle with the spinal accessory nerve (SAN). The annual incidence of permanent BPBI shows marked variation with a decreasing trend. MRI has both high sensitivity and specificity for detecting root avulsion injuries. Half of all children with permanent BPBI develop shoulder dysplasia during the first year, which can be reliably detected with US. ROM exercises, BTX injections and spica bracing seem beneficial in preventing and treating shoulder dysplasia in children 6-12 months old. Active ER in adduction can be reliably restored and maintained by neurotizing the infraspinatus muscle with SAN.Obstetrisk brachialplexus skada (OPB) uppkommer i 0.2-3 av 1000 födslar och associeras oftast med vaginal förlossning. Till riskfaktorer för OBP räknas makrosomi (födselvikt >4.5kg), övervikt hos den gravida, Typ II diabetes samt avvikande foster presentation vid förlossningen. Skadans svårighetsgrad definieras av hur många av nerverna som drabbats, samt till vilken grad. En fjärdedel av skadorna är permanenta. De mildare, icke permanenta skadorna, läks helt under det första levnadsåret. Diagnosen är klinisk, och skadans svårighetsgrad kan vidare undersökas med hjälp av elektroneuromyografi, datortomografi med intratekalt kontrastmedel, eller magnet resonanstomografi (MRT). Vården av bestående OBP i Helsingfors och Nylands sjukvårdsdistrikt (HUS) är centrerad till HUS barnkirurgiska enhet, Nya barnsjukhuset. Enheten ansvar även för vården av barn med bestående OBP födda i HUS tertiärvårds område. Studiens huvudsyften är att reda ut incidensen för bestående OBP i Helsingfors och Nylands sjukvårdsdistrikt, reda ut om MRT är en pålitlig modalitet för påvisning av nervrots avulsion, reda ut om dysplastiska förändringar i axelleden kan reduceras med hjälp av daglig rörelseträning, ultraljuds (UL) screening, i kombination med Botulinum toxin A (BTX) injektioner och immobilisation i skena, samt utveckla en ny operationsteknik för att förbättra aktiv utåtrotation (UR) i axelleden. Studien omfattar barn födda mellan 1995 och 2019 med bestående OBP som vårdats på HUS enhet Nya Barnsjukhuset. Under studiens gång vårdades 258 barn med bestående skada på enheten. Under samma period föddes 437 454 barn i Helsingfors och Nylands sjukvårdsdistrikt, 179 av dem fick bestående OBP. Innan år 2000 fanns ingen regelbunden uppföljning av axelleden. Vårt nuvarande protokoll utvecklades mellan 2000-2010, och har varit i regelbundet bruk sedan 2010. Protokollet består av daglig rörelseträning, regelbunden UL screening under det första levnadsåret, och om dysplastiska förändringar, eller ledkontrakturer uppstår, behandling med BTX samt immobilisation av axelleden i UR-skena. Vi fann att förekomsten av bestående OBP har under de senaste åren minskat i Helsingfors och Nylands sjukvårdsdistrikt till nuvarande 0.3 per 1000 levande födda. MRT har både hög sensitivitet (0.9) och specificitet (1.0) för detektion av avulsionsskador hos barn med OBP. Ca hälften (48%) av barnen med en permanent skada utvecklar dysplastiska förändringar i axelleden under det första året. Vi fann att dessa kan upptäckas pålitligt mha regelbunden UL screening, och svårighetsgraden minskas genom regelbunden rörelseträning samt BTX i kombination med immobilisation i UR-skena. Aktiv UR kan återfås och bibehållas genom neurotisation av infraspinatus muskeln med AN