Introduction: This study aims to explore the types of surgeries performed for radial polydactyly, complications and their associations with Wassel–Flatt classification types using a multi-centre prospective paediatric hand surgery registry. Methods: Patients with radial polydactyly in the Congenital Upper Limb Differences (CoULD) Registry who underwent surgery were reviewed for Wassel–Flatt classification, types of surgeries performed and complications. Results: A total of 247 extremities with radial polydactyly in 230 patients underwent surgical treatment at an average age of 1.4 years (ranging from 24 days to 8.4 years) for the index operation. The most common primary procedure was excision of the radial thumb with reconstruction of the dominant ulnar thumb (87%), followed by simple excision (7%). Thumbs classified as the hypoplastic subtype were more likely to undergo simple excision. The most common ancillary procedure was ligament reconstruction. Fifteen patients (7%) experienced 17 total complications including five thumbs requiring revision at an average of 3.6 years (range 2.5–4.3 years) after the first surgery. Conclusions: Excision of the radial thumb with reconstruction of the ulnar thumb is the most common procedure for patients undergoing surgical treatment for radial polydactyly, followed by simple excision of a hypoplastic polydactylous digit. Surgical complication rates for radial polydactyly surgery are low (7%) with a 2% reoperation rate at the 3 year follow-up. Level of Evidence: IV

Background:Pediatric hand fractures are common, yet disparities in their management and outcomes remain underexplored. The purpose of this study is to investigate the influence of socioeconomic status (SES) and health insurance status on time-to-presentation, treatment, and outcomes for pediatric hand fractures. Methods:We conducted a retrospective cohort study of pediatric patients who presented with hand fractures between January 2021 and December 2022, identified through electronic health records. Patient demographics, date of presentation, treatment (operative vs non-operative), and outcomes were assessed. Multivariable regression analyses were used to evaluate delayed presentation (>8 days from the initial injury, defined as 75th percentile of days to presentation) and need for operative intervention based on sociodemographics, Child Opportunity Index (COI) level (a proxy for SES), and fracture characteristics. Results:We included 300 patients (median age: 14 years [interquartile range: 13-16]; 76.7% male). Of these, 63 patients (21.0%) experienced delayed presentation, and 38 patients (12.7%) underwent operative intervention. forty-fiveIn total 145, patients (48.3%) had private insurance and 155 (51.7%) had public insurance. The multivariable analysis showed no statistically significant differences in delayed presentation based on sex, race, primary language, or type of insurance. However, patients living in neighborhoods with very low to moderate COI were found to have a significant delay in time to presentation compared to those with high to very high COI. Conclusions:In this retrospective cohort of pediatric patients with hand fractures, those with lower COI were more likely to experience delayed presentation. No significant differences in time to presentation and intervention type (operative vs non-operative) were observed based on sex, insurance type, primary language, or race/ethnicity. These findings underscore the importance of socioeconomic measures such as COI as separate from race and ethnicity data and highlight the need for focused interventions to ensure equitable care for all pediatric patients. Key Concepts:(1)Pediatric patients from low or very low Child Opportunity Index scores are more likely to have a delayed presentation after finger and hand fractures.(2)The observed difference is independent of race, ethnicity, language, and insurance.(3)Care pathways are needed to improve access for these underserved patients with acute injuries. Level of Evidence:IV, Case series.

This cross-sectional study assesses overall health-related quality of life among children in North America who have brachial plexus birth injury.

Case: A 3-year-old previously healthy girl presented with persistent leg pain following conservative treatment of a nondisplaced distal femur fracture and was found to have symptomatic scurvy and multinutrient deficiency secondary to food selectivity. Following nutritional repletion and iron supplementation, the patient experienced full resolution of symptoms with return to normal activities without residual musculoskeletal complaints. Conclusion: This case demonstrates the importance of considering systemic and nutritional conditions, particularly vitamin C deficiency (scurvy), when evaluating patients with persistent musculoskeletal complaints. Early recognition may enable timely medical treatment of these often-reversible conditions.

Pediatric finger fractures are among the most common injuries of the hand. Although most can be treated nonsurgically with good results, a small subset benefits from intervention. The purpose of this review was to provide an update on potentially problematic pediatric phalanx fractures. We will review common finger fractures unique to pediatric patients, classifications, surgical indications, and treatment options for chronic presentations.

Patient navigators attend visits with health care teams for the administrative aspects of patients' health-related social needs. We describe an innovative patient navigator intervention in an orthopedic clinic focused on brachial plexus birth injury, a diagnosis that disproportionately affects medically underserved and underresourced children, and present policy implications of this intervention.

This chapter aims to provide a comprehensive review of the techniques and challenges associated with applying upper extremity casts in pediatric patients. The chapter, along with its accompanying figures and video clips, serves as an introductory guide to pediatric orthopaedic cast application for trainees. Generally, casts are used to preserve appropriate alignment rather than to create improved alignment. In cases of nondisplaced fractures or those with acceptable alignment, the role of the cast is to maintain that alignment until healing occurs. For fractures with unacceptable alignment, reducing them to an acceptable position is necessary while the cast is utilized to maintain proper alignment. For challenging fractures that are difficult to keep aligned, have displaced intraarticular components, or are length-unstable, surgical intervention is recommended, followed by casting for immobilization after surgery. This chapter reviews the indications, application, techniques, and pitfalls of short arm, thumb spica, mitten, ulnar gutter, long arm, and hanging arm casts. Key Concepts:(1)The cast index is a valuable measure that impacts the rates of loss of reduction in distal radius fractures.(2)Molds are important not only for maintaining fracture reduction but also for keeping the cast in position and preventing slippage.(3)Along with using a cast saw to split fiberglass casts, a cast splitter should be employed to ensure proper bivalving.

Demographic, radiological and surgical characteristics of IPMN patients.

While brachial plexus birth injury is a relatively common condition with an incidence of approximately 1.5 in 1,000 live births, pediatric nonobstetric brachial plexus injuries are more rare. Among nonobstetric causes of brachial plexus dysfunction, trauma is the most common, while other etiologies include thoracic outlet syndrome, acute flaccid myelitis, Parsonage-Turner syndrome, and various oncologic etiologies. The presentation and pattern of injury of each patient is unique despite having the commonality of a brachial plexus injury. As such, treatment algorithms can be complex, and outcomes unpredictable. The aim of this review is to provide a basis of information on which a clinician can appropriately manage pediatric or adolescent patients with brachial plexus injuries of various etiologies.

CASE:We present a unique case of bilateral ulnar longitudinal deficiency (ULD) with concurrent postaxial polydactyly (PAPD) in a 2-month-old boy, an association that has not previously been described. CONCLUSION:ULD, a rare musculoskeletal anomaly, often manifests with complex digital abnormalities. ULD may be associated with other musculoskeletal differences and congenital heart anomalies, necessitating comprehensive evaluation. Considering the Sonic hedgehog-Patched-Gli pathway's role in limb development, we discuss potential genetic mechanisms underlying this dual anomaly. This case broadens our understanding of ULD phenotypes and underscores the need for continued investigation regarding the genetic pathways underlying congenital upper limb differences.

Diagnostic performance of serum protein panels.

The purpose of this investigation was to investigate short finger and cleft type symbrachydactyly to identify the defining features of these two subtypes. This retrospective study extracted data from the Congenital Upper Limb Differences (CoULD) Registry. Five paediatric hand surgeons reviewed photographs and radiographic imaging to evaluate the characteristics of each subtype and the reliability of diagnosis and evaluated the recorded diagnosis in the registry. Final analysis included 50 short finger and 54 cleft type symbrachydactyly. Key characteristic patterns were identified for each type, with further subdivision of subtypes with notable hypoplasia of the index or ring fingers or all digits. Consensus was obtained (inter-rater reliability 78%) and reliably applied for these unique subclassifications. While no clear trend in increasing severity was identified for these two subgroups of symbrachydactyly, this re-classification exercise provides clearer definition of the different subtypes and may give insight into the developmental biology of these conditions, predict future clinical function and guide surgical outcomes. Level of evidence: IV

Case: We present a unique case of bilateral ulnar longitudinal deficiency (ULD) with concurrent postaxial polydactyly (PAPD) in a 2-month-old boy, an association that has not previously been described. Conclusion: ULD, a rare musculoskeletal anomaly, often manifests with complex digital abnormalities. ULD may be associated with other musculoskeletal differences and congenital heart anomalies, necessitating comprehensive evaluation. Considering the Sonic hedgehog-Patched-Gli pathway's role in limb development, we discuss potential genetic mechanisms underlying this dual anomaly. This case broadens our understanding of ULD phenotypes and underscores the need for continued investigation regarding the genetic pathways underlying congenital upper limb differences.

List of extra miRNA classifiers.

Normalized signal intensity variations obtained on the antibody microarray.

PURPOSE:The Narakas classification describes brachial plexus birth injury (BPBI) according to nerve root injury by the pattern of motor weakness on clinical examination. However, it is unknown whether the classification truly corresponds to the described nerve roots. The distribution of nerve root injuries on magnetic resonance imaging (MRI) in infants with BPBI was compared with the clinical classification. METHODS:Infants with BPBI were prospectively enrolled at three children's hospitals, and the Narakas group was determined by physical examination. Infants underwent MRI prior to age 16 weeks. Neuroradiologists determined the injury severity (intact, rupture, avulsion) at each nerve root on MRI. The nerve root findings on MRI were compared with the expected nerve root injuries, based on the clinical Narakas classification. RESULTS:Sixty-eight infants completed the MRI revealing 19 distinct patterns of nerve injury. The nerve root injury findings on MRI did not always correspond with the nerve roots involvement expected based on the Narakas classification. In Narakas 1 patients, 23% had injury to C5-C6 only, and 55% had additional injuries to C7, C8, and/or T1. In Narakas 2 patients, only 26% had an injury specifically to C5-C7 only. In the Narakas 3 and 4 groups, 43% had a C5-T1 global injury as expected by the Narakas classification. The mean number of nerve roots affected, and mean avulsions increased with higher Narakas grades. The most commonly injured and avulsed nerve roots were C6 (n = 60) and C8 (n = 15), respectively. CONCLUSIONS:In 68 infants, 19 different patterns of injury were identified, suggesting that the pathoanatomy of BPBI is more nuanced than classically described. For Narakas 1 and 2 infants, the nerve root injury on MRI was often more extensive than expected based on clinical examination. Our results suggest the Narakas classification may not precisely correspond with the injury at the root level, as seen on MRI. TYPE OF STUDY/LEVEL OF EVIDENCE:Diagnostic II.

Normalized miRNA profiling data.

Patient demographics and clinical characteristics.

Diagnostic performance of serum miRNA panels.