While there are many proposed surgical treatment options for the correction of swan-neck deformities, none are perfect. We describe a partial flexor digitorum superficialis tenodesis that combines both a static volar plate with a dynamic oblique retinacular ligament vector reconstruction. This is performed through a single, short mid-lateral incision and requires no tendon grafts. The protected early active exercises are encouraged postoperatively, and our long-term results have been promising. The technique was designed for children with cerebral palsy, but the indications have since expanded.Level of Evidence: Level V (Therapeutic)

Radial tunnel syndrome (RTS) is an uncommon controversial entity thought to cause chronic lateral proximal forearm pain due to compression of the deep branch of the radial nerve, without paralysis or sensory changes. Diagnostic confusion for pain conditions in this region results from inconsistent definitions, terminology, tests, and descriptions in the literature of RTS and "tennis elbow," or lateral epicondylitis. A case of bilateral RTS with signs discordant with traditionally used clinical diagnostic tests was successfully relieved with surgical decompression and led us to perform a comprehensive critical review of the condition. We delineate the controversy surrounding its diagnosis and aim to facilitate appropriate management and identify other areas for further study in this controversial condition. Clinical validity and evidence of anatomical rationale for the traditionally used Maudsley's provocative test is unclear in diagnosis of RTS or in chronic lateral elbow pain, if at all. Neither imaging nor electrophysiological studies contribute to a clinical diagnosis which is supported by short-term improvement after an injection with long-acting local anesthetic and corticosteroid. Accurate diagnosis and treatment of RTS can significantly improve quality of life, but validity and evidence for traditional clinical tests and definitions must be clarified.

Background: Surgical intervention for improvement of upper limb function in children with cerebral palsy is reported to be of benefit where careful patient selection is taken into consideration. Currently there are no clinical guidelines to help determine selection of individuals best suited for operative management, nor does research exist that identifies characteristics of the patient cohort currently being selected as appropriate for surgery. The aim of this study is to determine the current trends in selection, assessment and management of patients with cerebral palsy undergoing upper limb surgery. Methods: This retrospective study included data from 102 individuals with cerebral palsy who had undergone upper limb surgical management during a 10-year time period at the Royal Children’s Hospital, Melbourne, Australia. There were 138 separate surgical events involving 579 procedures during this period. Data regarding the characteristics of the individuals and their perioperative assessment was collected and analysed. Results: The cohort was 56.9% male, the median age at time of surgery was 14.2 years old. Motor involvement was 51.0% bilateral and 49.0% unilateral and 96.0% of individuals had a spastic component. The most common surgical goal was position care (50.4% of cases), followed by activity and participation (47.9% of cases). Preoperative outcome measures were used in 69.6% of cases. Conclusions: Currently, individuals are selected for surgery using variable preoperative assessment. Selection has great potential to differ between clinicians. These compounding issues provide rationale for initiating further research into understanding the characteristics of this patient group and promoting better standardisation of perioperative assessment.

Sialorrhea is a common problem in children with disability, often negatively affecting socialization, self-esteem, and burden of care. Saliva control surgery is an available option to manage this problem, particularly when other conservative methods have failed. As little is known about the long-term impact of surgery, we followed up 62 patients who had combined bilateral submandibular duct translocation and bilateral sublingual gland excision at our pediatric hospital between 1994 and 2014. Eligible individuals were identified through a search of ICD procedure codes. When families of patients were contacted successfully, they were invited to complete a 14-item questionnaire designed specifically for this study. The results indicated that long-term outcomes of surgery were very good; 13/62 (21%) individuals no longer had a drooling problem and another 30 (48%) experienced only mild to moderate drooling. Although 84% families reported some or major improvement in drooling, 9 families reported that they would not go through the experience again because of a difficult recovery period, lack of effectiveness of the intervention, changes in saliva consistency that caused coughing and gagging, and dental decay. None of the collected variables were predictive of good or poor outcome. The study indicated that surgical intervention is effective in the long term in the majority of cases and can be recommended to other families who attend our saliva control clinic.

An acutely blue finger may cause concern, with both ischaemic and non-ischaemic aetiologies. Achenbach syndrome is a rare condition involving spontaneous haematoma of the finger. We present a case with distinct histological findings and a family history.

A 7-year-old Palestinian female born with Harlequin ichthyosis was referred for management of severe flexion contractures of the fingers, adduction contractures of both thumbs and pseudosyndactyly causing significant functional impairment. The contractures affected the metacarpophalangeal joints and interphalangeal joints of all fingers and the thumb of both hands. The eyelid deformities were assessed by an ophthalmologist. The patient was also commenced on Acitretin several months prior to the surgical procedure. Retinoid therapy in ichthyosis has been shown to reduce thickness of scaling, increase the ability to sweat and to improve ectropion. Topical therapy included 8-hourly bathing in dilute salt and sodium hypochlorite followed by the application of soft white paraffin ointment. The left hand (Fig. 1) and upper lid were selected for the first procedure. Infection, uncertainty of graft take in this rare condition, possible poor donor site healing, failure to achieve worthwhile contracture correction and contracture recurrence were particularly discussed with her guardian. A large ellipse of full-thickness skin was harvested from the patient’s left lower abdomen and was fenestrated. The donor site was closed primarily. The thinnest skin was used by the ophthalmologist as an inlay graft following a generous transverse release of the left upper lid. The first web space was transversely incised, exposing the underlying subcutaneous tissues. The neurovascular bundles were identified and preserved. Skin graft was fashioned to resurface the first web space defect and secured with absorbable sutures. The second and third web spaces were similarly released. The release was extended over the volar surfaces of the index and middle fingers to correct the contractures. The extent of ulnar-sided volar release was limited by the availability of full-thickness graft and poorer potential to correct the more severely contracted and less functionally important little finger. After the defects were fully covered, axial Kirschner wires were placed through the interphalangeal and metacarpophalangeal joints of the thumb, index and middle fingers, holding them in extension (Fig. 2). Following thorough lavage of the graft beds, a dressing of tulle gras and silver impregnated hydrogel was applied and secured with gauze, bandages and an above-elbow clam shell cast. As there was minimal post-operative discomfort, she was discharged on day 1 and returned for a dressing change under

Medical Journal of AustraliaVolume 206, Issue 11 p. 477-477 Medical Education High-pressure injection injury: benign appearance belies potentially devastating consequences Anna T Ryan, Corresponding Author Anna T Ryan annatr@unimelb.edu.au University of Melbourne, Melbourne, VICCorrespondence: annatr@unimelb.edu.auSearch for more papers by this authorBruce R Johnstone, Bruce R Johnstone Royal Children's Hospital Melbourne, Melbourne, VICSearch for more papers by this author Anna T Ryan, Corresponding Author Anna T Ryan annatr@unimelb.edu.au University of Melbourne, Melbourne, VICCorrespondence: annatr@unimelb.edu.auSearch for more papers by this authorBruce R Johnstone, Bruce R Johnstone Royal Children's Hospital Melbourne, Melbourne, VICSearch for more papers by this author First published: 19 June 2017 https://doi.org/10.5694/mja16.00664Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume206, Issue11June 2017Pages 477-477 RelatedInformation

BACKGROUND:We report a variant of paediatric trigger thumb which is locked in extension rather than flexion.METHODS:Eleven children with 14 trigger thumbs (three bilateral) locked in extension were reviewed retrospectively over a 12-year period. The number of flexed trigger thumbs encountered over this period was established from the operating room database.RESULTS:All children were treated with release of the A1 pulley. Nine children achieved a full range of motion at the interphalangeal joint. One child with bilateral extended trigger thumbs required bilateral dorsal capsulotomy and another child developed temporary mild triggering in flexion.CONCLUSIONS:Approximately 1% of trigger thumbs treated operatively at this institution presented as the extended variant. Trigger thumb locked in extension should be considered in a child presenting with inability to flex the thumb.

Background: The authors evaluated long-term shoulder function in patients with neonatal brachial plexus palsy undergoing suprascapular nerve reconstruction with cervical root grafting or spinal accessory nerve transfer. Methods: A retrospective review was performed on all infants presenting with neonatal brachial plexus palsy between 1994 and 2010. Functional outcomes were compared by type of suprascapular nerve reconstruction. Results: Seventy-four patients met the inclusion criteria (46 transfers, 28 grafts). Both groups presented with an active movement scale score of 2.0 for shoulder abduction and 0.0 for external rotation. Postoperative follow-up was 9.0 years for the graft group and 6.7 years for the transfer group. Both groups achieved an active movement scale score of 5.0 for shoulder abduction at 12, 24, and 36 months postoperatively. Active movement scale scores for shoulder external rotation were 1.0, 2.0, and 2.5 for the graft group versus 2.0, 2.0, and 3.0 for the transfer group at 12, 24, and 36 months postoperatively. None of these differences reached statistical significance. Composite Mallet scores were 13.0 for the graft group versus 15.0 for the transfer group at 3 years (p = 0.06) and 13.0 for the graft group versus 16.0 for the transfer group at 5 years postoperatively (p = 0.07). Secondary shoulder surgery was performed on 57.1 percent (16 of 28) of patients with grafts compared with 26.1 percent (12 of 46) of patients with transfers (OR, 3.17; p = 0.02). Conclusion: Suprascapular nerve reconstruction by cervical root grafting results in poorer shoulder function and a two-fold increase in secondary shoulder surgery compared with spinal accessory nerve transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

ANZ Journal of SurgeryVolume 83, Issue 3 p. 192-193 LETTERS TO THE EDITOR Poly Implant Prothèse silicone breast implant rupture, gel bleed and fatigue in a ‘blinded’ patient Bruce Johnstone MBBS, FRACS, Bruce Johnstone MBBS, FRACS 7th Floor, 766 Elizabeth Street, Melbourne, Victoria, AustraliaSearch for more papers by this authorKatrina Read MBBS, FRACS, Katrina Read MBBS, FRACS 7th Floor, 766 Elizabeth Street, Melbourne, Victoria, AustraliaSearch for more papers by this authorWendy Dick RN, Div1, Wendy Dick RN, Div1 7th Floor, 766 Elizabeth Street, Melbourne, Victoria, AustraliaSearch for more papers by this author Bruce Johnstone MBBS, FRACS, Bruce Johnstone MBBS, FRACS 7th Floor, 766 Elizabeth Street, Melbourne, Victoria, AustraliaSearch for more papers by this authorKatrina Read MBBS, FRACS, Katrina Read MBBS, FRACS 7th Floor, 766 Elizabeth Street, Melbourne, Victoria, AustraliaSearch for more papers by this authorWendy Dick RN, Div1, Wendy Dick RN, Div1 7th Floor, 766 Elizabeth Street, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 06 March 2013 https://doi.org/10.1111/ans.12057Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume83, Issue3March 2013Pages 192-193 RelatedInformation

Lipoblastoma is a rare benign neoplasm of infancy and childhood with the potential for locally invasive, rapid growth. It has an excellent prognosis, and does not metastasise. An important differential diagnosis for these rapidly-enlarging tumours is liposarcoma. Ultrasound, magnetic resonance imaging, fine needle aspiration, and cytogenetics are important diagnostic tools for this rare tumour. We present two cases of lipoblastoma of the hand that were excised within a three month period with no evidence of recurrence at 14, and 12, months respectively.

Background:  Lawn mowers cause severe injuries that are particularly devastating to children. This study analyses the patterns and trends in lawn mower injuries involving children referred to Victoria’s principal children’s hospital.

Purpose To retrospectively compare the long-term results of cemented and uncemented surface replacement arthroplasties of the proximal interphalangeal (PIP) joint in a single surgeon's experience.Methods A cemented prosthesis was used on 18 patients for 27 PIP joints between February 1997 and September 2000. An uncemented prosthesis was used on 18 patients for 21 PIP joints between September 2000 and June 2003. The preoperative and postoperative pain score (0-10) during activities of daily living and the active range of motion for each digit as well as radiographs were assessed. Patients with less than 2 year of follow-up were excluded unless the short follow-up was due to prosthesis removal. Mean follow-up was 5 years.Results Data were available for 28 patients who collectively received 24 cemented implants and 19 uncemented implants. The average length of follow-up was 4 years for the uncemented group and 6 years for the cemented group. The average pain score decreased by 5.5 units after the operation, and the average arc of motion increased by 13 degrees after the operation. No evidence was found for any association between implant type and postoperative pain and motion measurements. Very strong evidence was found for an association between implant type and subsidence, with 1 cemented implant subsiding compared with 13 uncemented implants. There was no evidence for an association between implant type and joint failure.Conclusions There was no difference in the postoperative pain scores or the postoperative arc of motion for the cemented versus the uncemented group. There were significantly more cases with radiologic evidence of loosening in the uncemented group (p < .001). Revision rate was higher in the uncemented group (26%) compared with that of the cemented group (8%), but this was not a significant difference (risk difference, -0.18; 95% confidence interval, -0.040 to 0.05).

Carpal tunnel syndrome in children is uncommon. Mucopolysaccharidosis is the most common cause of carpal tunnel syndrome in this age group. With new treatment modalities available for mucopolysaccaridoses, the prognosis of the disease has greatly improved. The musculoskeletal manifestations including carpal tunnel syndrome now assume more importance. Early diagnosis and treatment of carpal tunnel syndrome in these children are important to achieve a good outcome. The authors present their experience in the management of children with mucopolysaccharidosis and carpal tunnel syndrome.

Many surgical procedures require intraoperative stimulation of peripheral nerves. Using a pair of conventional bipolar forceps and an anesthetic impulse generator (Stimlocator, Model SL3, B. Braun Australia Pty Ltd, Australia), we have developed a simple, effective, and inexpensive alternative to standard nerve stimulation devices that enables the accurate localization of motor fascicles intraoperatively. Bipolar forceps provide better control than a monopolar electrode, as the current generated across the nerve fibers generates an action potential that is then propagated down the axon. This inexpensive and reusable device is routinely used at Royal Children's Hospital, Melbourne, and its efficacy and ease of use has been demonstrated over a long period.

Purpose To evaluate children with obstetric brachial plexus palsy treated with botulinum toxin A (Botox)injections to assist with the management of contracted muscles and joints as well as co‐contraction. Methods Since September 2004, 20 children have been treated. The median age at treatment was 2.1 years (range 7 months to 11 years). As experience was gained, the total dose of Botox increased from 4 to 10 units per kg. Results 12 patients were treated primarily for restriction of passive external rotation at the shoulder at an average age of 24 months (range 7 to 42 months). This group had the most impressive gains which became apparent within a week of injection. There was a high level of parental satisfaction with an improvement in passive range and increased ease of physiotherapy. Six had excellent and 4 had good results. The two patients who had little improvement had clear indications for surgery. Seven (58%) of these 12 patients went on to have a repeat injection , in 2 cases with a higher dose, aiming to achieve further gains. Five patients were treated for co‐contraction of the latissimus dorsi and/or teres major were aged 8 months and from 8 to 11 years. They reported minor gains.All five patients who had triceps injections had improved elbow flexion. One patient had an over active biceps injected with minor benefit. Conclusion It is hoped that persistent physiotherapy assisted by botulinum toxin A injections targeting internal rotators can reduce gleno‐humoral joint dysplasia, posterior subluxation and the need for open procedures. Shoulder subluxation identified by ultrasound should be further imaged with CT or MRI and be considered for an open procedure.

Parental questionnaires are inexpensive alternatives to standardized testing for outcome measurement. The Parent Report of Children's Abilities has previously been revised (PARCA‐R) and validated for use with very‐preterm infants at 2 years of age. This study revalidated the PARCA‐R for assessing cognition in a larger and more inclusive sample of preterm infants. One hundred and sixty‐four children (82 males, 82 females) of <32 weeks' gestation (median 29wks, interquartile range [IQR] 28‐30wks); and median birthweight 1200g (IQR 925‐1463g) were evaluated using the Mental Development Index (MDI) of the Bayley Scales of Infant Development ‐ 2nd edition (BSID‐II) at 2 years' corrected age. Parents completed the PARCA‐R questionnaire. Significant correlations between PARCA‐R Parent Report Composite (PRC) scores and MDI scores (r=0.77, 95% confidence interval [CI] 0.69‐0.82, p<0.01) demonstrated concurrent validity. A receiver operating characteristic‐determined PRC cut‐off of <44 had optimal discriminatory power (area under curve 0.92) for identifying MDI <70, with 85% sensitivity (95% CI 0.58‐0.96), 87% specificity (95% CI 0.81‐0.92), 98% negative predictive value (95% CI 0.95‐1), and 37% positive predictive value (95% CI 0.22‐0.54). The PARCA‐R has good concurrent validity and diagnostic utility for identifying cognitive delay in very‐preterm infants at 2 years of age. It is useful for outcome measurement, developmental screening, and facilitating parental involvement at folow‐up.

Purpose To evaluate patients with cerebral palsy treated with botulinum toxin A injections to assist with the management of contracted muscles and joints as well as co‐contraction.Methods Since 1998, 40 limbs have been treated. The average age was 14 years (range 4 to 33 years) and the average dose given was 107 units (range 50 to 200 units). Digital flexors were injected in 26 limbs, elbow flexors in 18, wrist flexors in 17, thumb adductors in 13, pronator teres in 9, intrinsics in 3, shoulder abductors in 2 and ECU in one limb. All patients were injected under a general anaesthetic, allowing for an assessment of fixed contractures. Padded plaster casts were applied, putting the injected muscles on full stretch before the reversal of anaesthesia and were maintained for approximately 3 weeks. Thermoplastic splits were then wore 23 hrs per day for a further three weeks. Splints were serially modified to achieve progressively more extension as the flexion contractures were corrected. Simultaneous surgical procedures such as tendon lengthening and transfers were performed in 14 limbs.Results The results in the elbow flexors were disappointing. The finger, thumb and wrist flexors have responded extremely well, despite fixed flexion deformities being documented under anaesthesia in the majority of patients.Conclusion It is estimated that the muscle bellies have been elongated by 3 to 4 cm either by the lengthening of, or addition to the sarcomeres.The results in these patients are vastly superior to that which could be obtained surgically.