Purpose Accurate classification of brachial plexus birth injury (BPBI) is critical for predicting outcomes and guiding early intervention. In 1987, Narakas introduced the first widely adopted system. Over time, misquotations and reinterpretations have obscured the work, conflating group definitions, exaggerating recovery rates, and misrepresenting prognosis. Methods This manuscript revisits Narakas’ original classification, traces misquotations, and clarifies their impact on management. We aim to provide the original publication as a reliable reference for contemporary care of BPBI. Results Group 1 involves Sunderland grade 1−2 injuries to C5 and/or C6, with 93% achieving full spontaneous recovery. Group 2 includes Sunderland grade 2−3 injuries to C5−6 and grade 1−2 to C7. Groups 1 and 2 present similarly, with slightly weaker elbow extension in group 2. The key differentiator is slower recovery of the upper trunk, not C7 involvement. Only 22% fully recovered. Group 3 involves Sunderland grades 4−5 for C5−C6, grade 3 for C7, and grades 1−2 for C8−T1. Five percent achieved a full recovery, and 15% had a satisfactory outcome. Group 4 involves Sunderland grade 5 injuries to C5−C7 with avulsion of C8. No patients achieved full or good shoulder recovery, 35% had fair elbow recovery, and hand/wrist recovery was poor. Conclusions BPBI is complex, with extensive sequelae if mismanaged. Narakas’ work provides critical guidance for prognosis and treatment. Misquotations have propagated inaccurate expectations and hindered care. Reprinting and disseminating the original classification and associated group outcomes clarifies prognosis, informs clinical decisions, and supports improved care. Our table and commentary provide an accessible reference to optimize BPBI care. Level of evidence IV.

Outcomes after brachial plexus birth injury (BPBI) vary widely, highlighting the need for rehabilitation strategies that reliably enhance functional recovery. We hypothesized that a coordinated, interdisciplinary rehabilitation network involving surgeons and occupational therapists improves functional outcomes after spinal accessory to suprascapular nerve (SAN-SSN) transfer. We compared outcomes from two academic centers with similar surgical indications and techniques but distinct rehabilitation models. We reviewed 25 infants who underwent SAN-SSN transfer from 2022 to 2024. Institution A used a coordinated multidisciplinary rehabilitation model in which the surgeon partnered directly with specialized therapists. Patients at institution B self-selected therapy sites. Pre- and postoperative external rotation Active Movement Scale (AMS) scores were collected and analyzed. Both cohorts showed significant improvement in external rotation (ER) (P < 0.05). Median postoperative AMS scores were higher at institution A (7; interquartile range [IQR] 5.5–7) than at institution B (4; IQR 3–5). Functional recovery (AMS ≥ 6) occurred in 72.7

Purpose:We aimed to examine and compare socioeconomic characteristics of infants with brachial plexus birth injury (BPBI) at two high-volume, distinct healthcare systems in the United States. Methods:All patients diagnosed with non-transient BPBI presenting between November 2021-November 2023 at either institution, New York City ("NY") or Los Angeles ("LA"), were included. To stratify based on socioeconomic background, Area Deprivation Index (ADI) and Child Opportunity Index (COI) were utilized. ADIs were presented in national percentiles (1-100 %) or state-normed deciles (1-10), with higher rankings indicating greater disadvantage. COI scores and quintiles were assigned using nationally-normed ZIP code-level data, with lower COI signifying lower childhood opportunity. Continuous variables underwent two-tailed, unpaired Mann-Whitney U and t-tests. Categorical variables underwent chi-square tests. The significance level was set at p < 0.05. Results:When comparing the LA (n = 92) and NY (n = 107) cohorts, the mean ADI scores were not significantly different: 24.5 % (SD 21.1) and 25.4 % (SD 13.5) respectively (p = 0.713). When comparing the COI scores, overall mean COI was significantly greater in LA (34.2, SD 26.9) compared to NY (17.3, SD 25.6; p < 0.001). While a significantly higher number of patients from NY than LA fell into categories of very low or low in education, social and economic, and overall COI, the distributions of these categories were more evenly spread across the LA cohort. Conclusion:Our findings underscore the importance of considering regional differences in patient populations when patients present with BPBI, as addressing such disparities may increase equitable access to treatment and optimize functional outcomes. Given the time-sensitive nature of BPBI care and implications of long-term disability if left under-treated, it is essential to allocate resources towards effectively treating BPBI in affected demographics, especially those experiencing resource deficits. By acknowledging geographic-specific differences in resource access among BPBI populations, physicians can develop targeted strategies to ensure equitable BPBI care.

Background: Glenohumeral dysplasia (GHD) is a well-documented sequelae following brachial plexus birth injury (BPBI). Despite its morbidity, the precise incidence of infantile GHD varies widely in the literature. Methods: This prospective cohort study included consecutive patients diagnosed with a non-transient BPBI between November 2021-November 2023. Patients were enrolled into the study from a specialized, high-volume brachial plexus clinic. A diagnosis of GHD was made by an alpha angle measurement on ultrasonography greater than 30° in the setting of abnormal shoulder function, as indicated by Active Movement Scale (AMS) scores for shoulder abduction, shoulder flexion, and external rotation. Results: Forty-two infants with a diagnosis of non-transient BPBI were initially seen at a mean age of 1.6 months. During continuous follow-up, 50% (n=21) of patients were diagnosed with GHD with a mean alpha angle of 35° (SD 8) and at a mean age of 3.2 (SD 1.4) months. At the time of diagnosis, infants had a median AMS score of 4 (interquartile [IQR] 3, 5) for shoulder abduction, 5 (IQR 3, 5) for shoulder flexion, and 4 (IQR 2, 5) for external rotation. The presence of upper extremity fracture was significant when comparing BPBI patients with GHD and those without, though the relative risk was not significant. Conclusions: This study demonstrates a high incidence of GHD in a prospective evaluation of infants with BPBI using serial ultrasonography. Those caring for BPBIs should be aware of such a common sequela and initiate early screening and management protocols to prevent and treat the deformity.

Supracondylar humerus (SCH) fractures account for approximately 30

BACKGROUND AND OBJECTIVES:Despite the high morbidity associated with glenohumeral dysplasia (GHD) in children with brachial plexus birth injuries, the progression of this condition often remains unnoticed, even after correcting for the underlying brachial plexus birth injuries. GHD, driven by a multifactorial process involving disruptions in both direct and indirect neural regulation of bony and muscular structures, can lead to intermittent or permanent shoulder mobility imbalances, significantly impacting the quality of life of those affected. Recent research efforts are increasingly directed toward identifying the root causes, managing the deformity, and determining effective treatment options for correcting GHD. METHODS:A comprehensive search strategy was used by the authors to identify relevant literature relating to the progression, pathoanatomy, clinical presentation, and management of GHD following brachial plexus birth injuries across various search engines, such as PubMed, Scopus, and Embase. Considering the topic's interdisciplinary nature, articles were retrieved from both neurosurgical and orthopaedic journals to enrich the review. RESULTS:Given the challenges in managing patients with brachial plexus birth injuries, a multidisciplinary care team consisting of certified occupational hand therapists, neurosurgeons, plastic surgeons, and orthopedic surgeons, specializing in brachial plexus injuries should be advocated for. The aim of this collaborative effort is to correct brachial plexus birth injuries and prevent the persistence of GHD. CONCLUSION:As research continues to focus on understanding the complexities of this condition, the aim of this review article is to summarize the current literature on the course of brachial plexus birth injury and the development of GHD. By doing so, we hope to provide neurosurgeons with the necessary knowledge and essential tools needed to identify and effectively treat GHD during management of brachial plexus birth injuries.

Background Brachial plexus birth injury (BPBI) is common and while most recover, 8-36% of patients experience permanent impairment. Typically, adolescents with untreated BPBI lack active and passive external shoulder rotation (ER) and overhead shoulder function. Limited shoulder function is due to 1) nonoperative BPBI 2) untreated BPBI or 3) unrecognized glenohumeral joint dysplasia. We describe a technique for achieving reanimation in adolescents who did not receive timely/effective BPBI care, a postoperative rehabilitation protocol, and results from a series of eight patients who underwent shoulder reanimation. Methods A comprehensive shoulder reanimation approach is performed. Anteriorly, the pectoralis minor, major, and anterior capsule necessitate release. In severe dysplasia, a coracoidectomy, posterior glenoid osteotomy, and/or subscapularis slide may be necessary. Acromial dysplasia is also common, frequently necessitating osteoplasty. The deltoid is usually nonfunctional, and we use a bipolar latissimus muscle transfer for reanimating abduction and forward flexion. To assist with ease of rehabilitation we will often transfer the tendon of the teres major. Levator scapulae transfer to the supraspinatus is often performed to assist with the initiation of abduction. For external rotation, the ipsilateral lower trapezius is used. Finally, ipsilateral rhomboid advancement and contralateral lower trapezius muscle transfer is performed for dynamic scapular stabilization. After surgery, all patients participated in our rigorous postoperative rehabilitation protocol. Results Eight patients (13.8±5.6 years, 35±24 weeks follow-up) were included. All patients participated in our rehabilitation protocol. Preoperatively, patients generally achieved 0° ER from neutral and in maximum abduction. Postoperatively, patients achieved an average of 71° (30-90°) ER from neutral and an average of 82° (65-90°) ER in maximum abduction. Preoperatively, patients generally had 0-20° of abduction, which they achieved through scapulothoracic motion. Postoperatively, patients could achieve an average of 115° (90-180°) of abduction. Preoperatively, patients had 0-20° of FF that was mediated through scapulothoracic motion. Postoperatively, patients’ FF increased to an average of 91° (20-170°). Conclusion This technique is intended to restore a congruent glenohumeral joint and reanimate structures allowing for abduction, FF, and ER. While we advocate for early treatment of BPBI, applying this technique to undertreated/untreated adolescent patients paired with our rehabilitation protocol results in significant functional improvement, allowing for an improved quality of life.

We report a case of an isolated congenital absence of the right fifth metacarpal with ring and little finger syndactyly in a 6-year-old girl without other ipsilateral limb anomalies or phenotypic disorders. The patient underwent amputation of the hypoplastic right little finger with reconstruction of the ulnar collateral ligament of the ring finger metacarpophalangeal joint as well as hypothenar muscle transfer. She has returned to normal childhood activities without limitation at 3 months after surgery. Absence of the fifth metacarpal is a rare congenital anomaly without clear recommendations regarding reconstructive options. This case discussion supplements the current literature by describing an unusual presentation of this hand anomaly while supporting individualized management to maximize functional and cosmetic results.

Background:Brachial plexus birth injury (BPBI) encompasses a spectrum of upper extremity paralysis cases following childbirth. The etiology of BPBI is multifactorial, involving maternal, obstetric, and neonatal associative factors. Despite opportunities for spontaneous recovery, recent literature demonstrates that a significant proportion of infants experience residual deficits and functional limitations as they age. Understanding the complex anatomy of the brachial plexus, clinical presentations of the pathology, diagnostic workup, current treatment options, and common secondary sequelae is instrumental for appropriate management of BPBI. Methods:Following a comprehensive search strategy used by the authors to identify relevant literature relating to the progression, patho-anatomy, clinical presentation, management, and treatment of BPBI, this comprehensive narrative review outlines current approaches to assess, manage, and advance BPBI care. Results:We advocate for prompt referral to specialized multicenter brachial plexus clinics for accurate diagnosis, timely intervention, and individualized patient-centered assessment. Further research is needed to elucidate mechanisms of injury, refine diagnostic protocols, and optimize long-term outcomes. Conclusions:Collaboration between healthcare providers and families is paramount in providing comprehensive care for infants with BPBI. This review offers insights into the current understanding and management of BPBI, highlighting the importance of tailored approaches and intraoperative decision-making algorithms to optimize functional outcomes.

Background: There are no reports in the literature on flexible intramedullary nails (FIN) for the treatment of pediatric femoral shaft fractures in children with neuromuscular disorders. The purpose of this study is to investigate the outcomes of FIN for femoral shaft fractures in children with neuromuscular disorders. We hypothesized that FIN would yield favorable outcomes despite technical challenges in this population. Methods: Retrospective review was conducted on all patients with femoral shaft fractures at a tertiary care pediatric hospital from 2004-2018. Inclusion criteria were femoral shaft fracture treated with …

Background: Controversy exists regarding the treatment of length unstable pediatric femoral shaft fractures. The purpose of this study was to investigate the outcomes of skeletally immature children with length unstable femur fractures treated with titanium elastic nails (TENs). Methods: A retrospective review was conducted on all patients with femoral shaft fractures at a tertiary care pediatric hospital from April 2006 to January 2018. Patients with femoral shaft fractures treated with TEN and minimum 6 months follow-up were included. Exclusion criteria were age 11 years or above, weight >50 kg, pathologic fracture, and neuromuscular disorders. Femur fractures were categorized into 2 groups: length unstable (spiral, comminuted, or long oblique fractures) versus length stable (transverse and short oblique). Complications and reoperations were compared between the groups. Results: A total of 57 patients with 58 femoral shaft fractures were included. The mean age was 5±2 (1 to 11) years and mean follow-up was 20.4±18.1 (6.0 to 81.2) months. The mean weight was 22.9±7.7 (11.0 to 40.5) kg. There was no difference in age (P=0.32), weight (P=0.28) or follow-up length (P=0.57) between patients with length unstable fractures and those with length stable fractures. A total of 32/58 (55%) fractures were length unstable and 26/58 (45%) were length stable. Mean time to union was 4.6 months, and there was no significant difference in mean time to union between the 2 groups (P=0.71). Thirty-one complications occurred in 27 patients. There was no difference between groups in the incidence of major complications requiring revision surgery (P=0.68) and minor complications that did not require revision surgery (P>0.99). Conclusions: In children with femoral shaft fractures treated with TEN, there was no difference in the incidence of complications or reoperations between those with length unstable fractures and those with length stable fractures. TEN are a safe and effective choice for operative fixation of length unstable femoral shaft fractures in children. Level of Evidence: Level III—retrospective comparative study.

Volkmann's ischemic contracture is the outcome of prolonged muscle and nerve ischemia resulting most commonly from acute compartment syndrome. Surgical management involves flexor origin slide for mild-to-moderate contracture and free functional muscle transfer for severe contracture. Therapeutic management is directed toward maintenance of passive joint motion, preservation, and strengthening of remaining muscle function, and correction of contracture through static progressive splinting. Deficits in the upper extremity that are not amenable to tendon, nerve, or rotational muscle transfers may benefit from free functional muscle transfer. Common indications are Volkmann ischemic contracture, late reconstruction of brachial plexus injuries, traumatic muscle loss, oncologic resection, and congenital absence of motor function. Therapeutic management is directed toward specific phases of rehabilitation: nerve reinnervation phase, muscle and nerve activation phase, and muscle strength and function phase.

AIMS:To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).METHODS:All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up.RESULTS:All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016).CONCLUSION:Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246-253.

Abstract Purpose There is little information in the literature regarding flexible intramedullary nails (FIN) for treating femur fractures in children with neuromuscular disorders. The purpose of this study is to investigate the outcomes of FIN for femoral shaft fractures in non-ambulatory children with neuromuscular disorders. Methods A retrospective review was conducted on patients with femur fractures at a paediatric hospital between 2004 and 2018. Inclusion criteria were femoral shaft fracture treated with FIN. Outcomes were compared between patients with neuromuscular disorders (NM group) and a control group of those without neuromuscular disorders. Results A total of 37 patients with 37 femoral shaft fractures were studied (12 patients in the NM group and 25 in the control group). All NM group patients were non-ambulatory at baseline. Fractures were length stable in all 25 patients in the control group and in 2/12 (17%) patients in the NM group. All fractures healed in both groups. Three complications (all nail migrations) requiring reoperation before fracture union occurred in the NM group, yielding a major complication rate of 25% (3/12) in the NM group versus 0% (0/25) in controls (p = 0.03). Angular deformity occurred in 5/12 (42%) NM group patients and 1/25 (4%) control group patient (p = 0.009); none required reoperation. Conclusion Femur fractures in non-ambulatory children with neuromuscular disorders can be successfully treated with FIN. Angular deformities are common in this population, but had no functional impact in the non-ambulatory NM group patients. Surgeons must also be vigilant for implant prominence and skin breakdown in these patients. Level of evidence III

Macrodactyly is a rare and debilitating pediatric hand anomaly that has historically been treated with amputation. Recent advances in our understanding of macrodactyly have increasingly implicated the digital nerve as the underlying cause of the condition. In addition, much progress has been made toward digital salvage in treating macrodactyly. Modern techniques often advocate for digital nerve resection to prevent recurrence and treat the underlying etiology. However, little if any emphasis has been given to sensory reconstruction for purposes of protective sensation and acceptable 2-point discrimination at the volar digital pulp. We report 2 cases of macrodactyly treated with digital nerve resection and nerve allograft reconstruction of large sensory nerve gaps which show early promising sensory outcomes. There remain little if any data on the use of nerve allograft in pediatric populations, and its application in the treatment of macrodactyly. This technique permits digit salvage with the potential for improved sensory outcomes without the donor morbidity of autologous nerve harvest.

The pediatric floating elbow involves fractures of the humerus and forearm. Majority of these injuries include supracondylar humerus fractures with ipsilateral forearm fractures. These fractures should be managed with great caution as they often result from higher energy injuries and have increased risks of nerve palsies, open fractures, loss of forearm fracture reduction, and compartment syndrome. Previous literature has advocated for operative fixation of ipsilateral forearm fractures in addition to stabilization of the supracondylar humerus fracture, to allow for noncircumferential immobilization to decrease the risk of compartment syndrome. However, recent studies have questioned the universal need for forearm fixation in patients with these injuries. This paper will discuss the pediatric floating elbow, review the available literature, and describe our technique for managing these injuries. (C) 2018 Published by Elsevier Inc.

Background: The distal radius is commonly used as a bone graft donor site for surgery in the hand and wrist. The aim of this study was to evaluate the volume and relative density of cancellous bone in the distal radius. Methods: Thirty-four consecutive computed tomographic scans of the wrist in 33 patients without distal radius pathology were included. For each subject, 6 spherical regions of interest (ROIs) were identified within the distal radius. In each ROI, volumetric measurements and mean Hounsfield unit (HFU) values were recorded by 2 observers using a 3-dimensional imaging reconstruction software. Results: Compared with proximal bone, distal bone had larger volume (0.82 vs 0.27 cm3) and greater relative density (178 vs 152 HFU) on average. Among the 6 ROIs, the distal-central region had the largest average volume (1.20 cm3) and the distal-ulnar ROI had the greatest average relative density (193 HFU). Conclusion: Based on these results, we recommend performing cancellous autograft harvest relatively distal and ulnar within the distal radius.

Scaphoid nonunion can occur in both non-operative and operatively treated scaphoid fractures. Without treatment, this can lead to a predictable pattern of carpal collapse and degenerative arthritic change and patients can experience both pain and functional loss in the early and late phases of progression. An operative technique with a high success rate for union is important. This paper describes a technique for treatment of scaphoid nonunion with K-wire fixation and iliac crest cancellous bone graft.

We present a case of primary tendon grafting in a 14-month-old infant for an index finger flexor digitorum profundus tendon laceration sustained during cesarean section with excellent functional results at 2-year follow-up. (Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved.)