Brachial plexus birth injury (BPBI) results in individualized impairments in upper extremity (UE) mobility. A patient-specific understanding of these movement limitations is critical for optimizing decision-making and outcomes; however, current assessments may fail to capture the entirety of a patient's UE mobility. Reachable workspace quantifies an individual's global UE mobility by measuring the regions that can be reached by their hand. Despite most UE activities of daily living requiring adequate close-to-body function, current workspace approaches only assess far-from-body mobility. This study assessed the ability of a motion capture-based workspace approach to evaluate inner, close-to-body UE mobility in children with BPBI. It was hypothesized that the BPBI affected limb would have less inner, close-to-body workspace than the unaffected limb, especially in regions requiring UE movements commonly impaired in BPBI. Fifteen children with unilateral BPBI were assessed with motion capture using real-time visual feedback to measure UE workspace in all regions surrounding the body. All inner, close-to-body points reached by the hand were recorded. A two-way repeated measures ANOVA evaluated percentage workspace reached in each region surrounding the head, thorax, and abdomen. The affected limb had significantly less workspace reached than the unaffected limb for 8 of 9 regions (mean interlimb differences by region, 17.0-49.2%). Affected limb workspace deficits corresponded to common movement impairments in BPBI demonstrating the clinical relevance of this tool. Assessment of inner, close-to-body reachable workspace may provide a valuable new perspective on UE mobility to help guide clinical decision-making and outcomes assessment.

Background The disparity between surgical demand and clinician availability in low- and middle-income countries (LMIC) represents a global health challenge, contributing to preventable morbidity and mortality. Although non-profit organizations can perform short-term outreach trips to address immediate needs, their temporary nature may fail to achieve sustained impact. Formal capacity building initiatives, which aim to empower local health systems to independently address unmet surgical demands are needed. This study aims to 1) identify the barriers/facilitators to capacity building in orthopaedic surgical outreach and 2) match targeted implementation strategies that can enhance the effectiveness of these initiatives. Methods We conducted semi-structured interviews with 20 stakeholders from LMIC and high-income countries (HIC) from six organizations with experience in over 44 countries to identify barriers/facilitators to implementation of capacity building initiatives. Interview transcripts were analyzed using the Consolidated Framework for Implementation Research (CFIR). The Expert Recommendations for Implementing Change (ERIC) mapping tool was used to match barriers with implementation strategies. We subsequently conducted a modified nominal group technique with a consortium of seven surgeons with global surgical outreach expertise to evaluate each strategy's feasibility, cross-context applicability, and prioritization. Following discussions, panelists independently voted on the strategies, requiring a ≥80% consensus for inclusion. Results A total of 34 barriers and 31 facilitators to implementation were identified. Examples of barriers included high cost and lack of an implementation leader while facilitators included longitudinal partnerships and access to technology. 38 strategies were matched to these barriers. Examples of strategies include identify and prepare champions, conduct educational meetings, and conduct local needs assessments. Conclusions This study highlights common barriers to the implementation of capacity building efforts in global surgical outreach and provides a strategy matching tool for capacity building initiatives. Utilization of these strategies improve implementation, ultimately supporting the long-term success and effectiveness of capacity building in LMIC.

INTRODUCTION:The Narakas classification of brachial plexus birth injuries has been widely used but its validity for intraoperative classification of lower root injuries (C8-T1) is debated. This study introduces a new intraoperative classification and assesses its correlation with muscle function before and after operative repair of the brachial plexus. METHODS:The study reviewed 162 primary brachial plexus explorations over 19 years. Based on intraoperative findings, patients were categorized by injury patterns, A (C5-C6), B (C5-C7), C (C5-C8) and D (C5-T1), followed by the number of root avulsions. Preoperative and postoperative active movement scale scores, along with intraoperative findings, were compared in assessing lower root involvement. RESULTS:Ten cases were classified as injury type A, 42 as type B, 14 as type C, and 96 as D. Of 682 injured nerve roots, 189 were avulsed. With a mean follow-up of 5.4 years, the median preoperative total active movement scale score was 39 (IQR 24 to 54) and improved to 55 (IQR 44.25 to 70) at final postoperative follow-up. There was a decline in pre- and postoperative scores with increasing injury severity from A to D. Significant differences were observed between injury subtypes based on number of avulsions, notably in the injury D subgroup (p < 0.001). Horner's syndrome did not significantly impact final postoperative active movement scale scores after adjusting for injury types. CONCLUSIONS:An intraoperative classification that specifies roots involved may better capture variability of brachial plexus birth injuries than the established Narakas system and align more closely with functional recovery. These findings emphasize the importance of intraoperative assessment to guide surgical decision-making. LEVEL OF EVIDENCE:IV.

BACKGROUND:Tendon transfers are often utilized to improve shoulder external rotation and abduction in children with brachial plexus birth injuries and are designed to improve glenohumeral (GH) joint motion. However, changes in scapulothoracic (ST) and GH joint function after tendon transfer are not well defined. The purpose of this study was to quantify changes in GH, ST, and humerothoracic (HT) joint function before and after tendon transfer, and we hypothesized that tendon transfers would reorient the arc of motion into more external rotation and abduction, but not increase GH motion. METHODS:Motion analysis was performed in 15 children (ages 3-16) before and after transfer of teres major and/or latissimus dorsi. ST, GH, and HT joint angles were measured in a neutral, resting position and each of the modified Mallet positions. Joint angular displacements from the neutral position and the total arc of internal-external rotation for each joint were also calculated. Relevant joint angles, joint angular displacements, and internal-external rotation arcs were compared using multivariate analyses of variance with repeated measures and univariate posthoc analyses. RESULTS:Glenohumeral and HT external rotation were significantly increased in all positions postoperatively. The arc of GH internal-external rotation was unchanged, but oriented in more external rotation after surgery. Only 6 patients gained active external rotation. Glenohumeral and HT internal rotation were significantly decreased after surgery, but ST internal rotation was significantly increased. Two patients had loss of midline function. In the abduction position, GH elevation joint angles were unchanged, but ST and HT elevation increased. DISCUSSION:Only 4 patients gained active GH external rotation and maintained their internal rotation. Each of those patients underwent isolated tendon transfer without concomitant joint release. Seven patients maintained their preoperative internal rotation, which was attributed to increased ST internal rotation. The other half of patients lost internal rotation and gained external rotation through reorientation of the arc of rotation. Nine patients gained HT elevation, with 3 attributed to increased ST upward rotation, 5 attributed to a combination of increased ST upward rotation, and increased GH elevation, and 1 attributed to increased GH abduction contracture. These findings challenge the dogma that teres major/latissimus dorsi tendon transfers augment GH motion and highlight the importance of ST function for outcome determination.

Sensory rehabilitation in pediatric patients with traumatic spinal cord injury is challenging due to the ongoing development of their nervous systems. However, these sensory problems often result in nonuse of the impaired limb, which disturbs impaired limb rehabilitation and leads to overuse of the contralateral limb and other physical or psychological issues that may persist. Here, we introduce a soft nanomembrane sensor-enabled wearable glove system that wirelessly delivers a haptic sensation from the hand with tactile feedback responses for sensory impairment assistance. The smart glove system uses gold nanomembranes, copper-elastomer composites, and laser-induced graphene for the sensitive detection of pressure, temperature, and strain changes. The nanomaterial sensors are integrated with low-profile tactile actuators and wireless flexible electronics to offer real-time sensory feedback. The wearable system's thin-film sensors demonstrate 98% and 97% accuracy in detecting pressure and finger flexion, respectively, along with a detection coverage of real-life temperature changes as an effective rehabilitation tool. Collectively, the upper-limb sensory impairment assistance system embodies the latest in soft materials and wearable technology to incorporate soft sensors and miniaturized actuators and maximize its compatibility with human users, offering a promising solution for patient sensory rehabilitation.

Background: Spastic wrist flexion deformity is a common manifestation of cerebral palsy (CP) that not only impairs grasp but also serves as a visible marker of neurologic impairment. The flexor carpi ulnaris to extensor carpi radialis brevis (ECRB) transfer is a well-established technique that both reduces wrist flexion force and augments extension, although it carries a risk of postoperative hyperextension deformity. This study describes the surgical technique and outcomes of an alternative procedure—extensor carpi ulnaris (ECU) to ECRB tendon transfer—for the correction of spastic wrist flexion deformity. Methods: A retrospective study was performed to analyze outcomes of pediatric patients with CP who underwent ECU to ECRB tendon transfer to improve wrist extension and grip strength. The primary assessment included wrist position and range of motion, active grasp, and subjective improvement in grasp after surgery. Secondary outcomes included the need for an additional procedure to further correct wrist position after tendon transfer. Results: Twenty-six wrists in 24 patients underwent ECU to ECRB transfer. Postoperatively, 22 wrists (85%) achieved extension beyond neutral at an average of 28 degrees. Improved grasp was reported by 21 patients (81%). Five underwent revision for recurrent wrist flexion deformity and 1 for fixed extension. Conclusion: ECU to ECRB tendon transfer is a safe and effective technique to reliably improve wrist posture and grasp in patients with spastic CP.

Background: Surgical outreach to low- and middle-income countries (LMICs) by organizations from high- income countries is on the rise to help address the growing burden of conditions warranting surgery. However, concerns remain about the impact and sustainability of such outreach. Leading organizations (e.g., the World Health Organization) advocate for a capacity-building approach to ensure the safety, quality, and sustainability of the local health-care system. Despite this, to our knowledge, no guidelines exist to inform such efforts. We aimed to develop clinical practice guidelines (CPGs) to support capacity-building in orthopaedic surgical outreach utilizing a multistakeholder and international voting panel. Methods: We followed a modified American Academy of Orthopaedic Surgeons (AAOS) CPG development process. We systematically reviewed the existing literature across 7 predefined capacity-building domains (partnership, professional development, governance, community impact, finance, coordination, and culture). A writing panel composed of 6 orthopaedic surgeons with extensive experience in surgical outreach reviewed the existing literature and developed a consensus-based CPG for each domain. We created an international voting panel of orthopaedic surgeons and administrators who have leadership roles in outreach organizations or hospitals with which outreach organizations partner. Members individually reviewed the CPGs and voted to approve or disapprove each guideline. A CPG was considered approved if >80% of panel members voted to approve it. Results: An international voting panel of 14 surgeons and administrators from 6 countries approved all 7 of the CPGs. Each CPG provides recommendations for capacity-building in a specific domain. For example, in the domain of partnership, the CPG recommends the development of a documented plan for ongoing, bidirectional partnership between the outreach organization and the local team. In the domain of professional development, the CPG recommends the development of a needs-based curriculum focused on both surgical and nonsurgical patient care utilizing didactic and hands-on techniques. Conclusions: As orthopaedic surgical outreach grows, best-practice CPGs to inform capacity-building initiatives can help to ensure that resources and efforts are optimized to support the sustainability of care delivery at local sites. These guidelines can be reviewed and updated in the future as evidence that supports capacity-building in LMICs evolves.The global burden of disease warranting surgery is substantial, and morbidity and mortality from otherwise treatable conditions remain disproportionately high in low- and middle-income countries (LMICs) 1,2 . It is estimated that up to 2 million (about 40%) of injury-related deaths in LMICs could be avoided annually if mortality rates were reduced to the level of those in high-income countries (HICs) 3 . Despite this, progress toward improved access to safe, timely surgery in resource-poor areas has been slow. Historically, nongovernmental organizations (NGOs) have tried to address unmet surgical needs through short-term outreach trips; however, growing criticism has highlighted the limitations of short-term trips, including limited follow-up, an increased burden on the local workforce, and further depletion of local resources 4–6 . In light of ongoing concerns, public health priorities have shifted toward models that emphasize long-term capacity-building rather than short-term care delivery. Capacity-building is an approach to health-care development that builds independence through infrastructure development, sustainability, and enhanced problem-solving while taking context into account 7,8 .

Purpose Surgical treatment of Madelung deformity can present challenges due to a need for multiplanar correction. Developing customized cutting guides for osteotomies may improve surgical outcomes by enhancing the surgeon's ' s understanding and surgical correction. Methods All patients who underwent forearm osteotomies for Madelung deformity using computed tomography planning with 3-dimensional- printed customized cutting guides were retrospectively reviewed (n = 8). Seven patients underwent a double osteotomy of the radius, and 1 underwent a single osteotomy. Results Ulnar tilt was improved in all cases. Correction of deformity was significant fi cant on anteroposterior but not on lateral views. The mean preoperative and postoperative radial bow was measured in 2 planes, with an average preoperative bow of 32 degrees degrees (+/- +/- 21 degrees) degrees ) on anteroposterior radiographs and 36 degrees degrees (+/- +/- 17 degrees) degrees ) on lateral radiographs, and an average bow of 10 degrees degrees (+/- +/- 6 degrees) degrees ) on anteroposterior radiographs and 7 degrees degrees (+/- +/- 6 degrees) degrees ) on lateral fi lms after surgery. The predicted radial bow was calculated to be 9.1 degrees degrees (+/- +/- 8 degrees). degrees ). Conclusions Three-dimensional planning allows predictable deformity correction across multiple but not all parameters. Future studies comparing clinical and radiographic outcomes of guided versus nonguided osteotomies are required to justify the additional expense and preoperative planning efforts. (J Hand Surg Am. 2024;49(10):1037.e1-e9. Copyright (c) 2024 by the American Society for Surgery of the Hand. All rights reserved.)

Purpose Lack of shoulder external rotation is common in children with brachial plexus birth injuries. Development of glenohumeral (GH) dysplasia is associated with progressive loss of passive external rotation. Some authors recommend measuring external rotation with the arm adducted, whereas others recommend measurement with the arm in 90° of abduction. The purpose of this study was to compare active and passive external rotation and internal rotation measured in adduction versus abduction. Methods Fifteen children with brachial plexus birth injuries held their affected arms in maximal external and internal rotation with the arm adducted and the arm at approximately 90° of abduction. Active and passive rotations were measured with three-dimensional motion capture. Scapulothoracic (ST) internal/external rotation and GH internal/external rotation joint angles were calculated and compared using multivariable, one-way repeated measures analyses of variance. Results There were no significant differences for active or passive ST rotation in external rotation in adduction versus abduction. Glenohumeral external rotation was significantly increased with the arm in abduction compared with adduction both actively and passively. There were no differences in ST rotation in active versus passive conditions, but all GH rotations were significantly greater passively. Conclusions Shoulder internal/external rotation in abduction and adduction is not interchangeable. Comprehensive assessment of shoulder external and internal rotation should include both adduction and abduction. Clinical relevance For children with brachial plexus birth injuries, both active and passive GH external rotations were greater in abduction. Therefore, early GH joint dysplasia may be missed if GH external rotation is measured in abduction. Additionally, consistency in arm position is important for comparison over time. The entire ST rotation capacity was used to perform maximal internal and external rotation, but the entire passive GH range of motion was not actively used. This highlights an area for potential surgical intervention to improve motion.

BACKGROUND:Brachial plexus birth injuries (BPBI) occur in up 0.4 to 4.6 per 1000 live births. Weakness about the shoulder and development of glenohumeral joint contractures are common sequalae of BPBI. Shoulder function in children with BPBI is frequently assessed using the modified Mallet classification to evaluate upper extremity motion deficits. The purpose of this study was to assess the accuracy of the abduction, external rotation, and hand-to-mouth Mallet classification scores in children with BPBI using motion capture. METHODS:A retrospective study of 107 children with BPBI who underwent motion capture assessment and Mallet scores on the same date were reviewed. Motion capture measurements were used to calculate humerothoracic elevation and external rotation joint angles in the abduction/hand-to-mouth and external rotation positions, respectively. The humerothoracic joint angles were converted to the corresponding Mallet scores. Discrepancies between the Mallet scores determined by clinicians and those determined by motion capture were assessed. RESULTS:For abduction, 24.3% of Mallet scores were misclassified during clinical examination. Of the misclassified scores, 22 were overestimated by 1 point and 4 were underestimated by 1 point compared with motion capture. For external rotation, 72.9% of Mallet scores were misclassified during clinical examination. Only 5 patients had an HT elevation that was less than 40 degrees, with 4 of them (80%) having a Mallet hand-to-mouth score of 4. There were no differences in proportion of patients with HT elevation less than 40 degrees who had a Mallet score of 4 or a Mallet score less than 4. CONCLUSIONS:There was better agreement in global abduction Mallet scores compared with external rotation and hand-to-mouth Mallet scores. This difference was likely due to the complex compensatory strategies that patients employ while performing external rotation and hand-to-mouth positions. The inaccuracy of the clinically determined Mallet scores is alarming given that they are frequently utilized to assist with surgical indications and are commonly used as outcome measures. LEVEL OF EVIDENCE:Level IV Case series.

Background:Radial neck fractures account for 1% of all pediatric fractures and 5% to 10% of pediatric elbow fractures. The mechanism of injury is typically a fall with the elbow in hyperextension and the forearm in supination. A valgus force compresses the radial head against the capitellum, causing a radial neck fracture. Displaced radial neck fractures are difficult to treat and account for a disproportionate number of bad outcomes, including malunion, nonunion, and osteonecrosis. The preferred treatment is closed reduction and fixation, as open reduction is associated with an inordinately high rate of osteonecrosis. Closed intramedullary pinning is an effective technique to achieve and maintain reduction. The procedure relies on an intact periosteum and requires attention to detail. The present video article will demonstrate the technique of closed intramedullary pinning (the Metaizeau technique). Metaizeau et al. previously described their technique of closed reduction and intramedullary pinning of radial neck fractures. A Kirschner wire is inserted retrograde from the distal radius into the posterolateral radial neck with the forearm pronated to avoid injury to the posterior interosseous nerve. Reduction is achieved by rotating the wire 180°. This technique relies on intact periosteum, with care taken to preserve the tenuous blood supply of the radial head and to achieve adequate reduction. Description:General anesthesia is administered, and the patient is positioned supine with use of an arm table or with an image intensifier utilized as an arm table. A tourniquet is applied to the operative limb. Fluoroscopy is utilized to identify the distal radius physis. A radial approach is performed to access the distal radius, proximal to the growth plate, with care taken to protect the sensory nerves. The cortex of the radial metaphysis is opened with use of a drill bit or a bone awl to allow space for the internal fixation device. Opening in a proximal direction and into the medullary canal facilitates intramedullary passage. A Steinmann pin (1.2 to 2.5 mm), Ilizarov wire (2.0 mm), or elastic nail can be utilized for as an intramedullary device. Place the pre-bent Steinmann pin/Ilizarov wire/elastic nail into the metaphysis and advance it in a proximal direction toward the radial neck fracture. The tip of the intramedullary device is directed into the displaced radial neck fracture, engaging the radial epiphysis. The pin/wire/elastic nail is rotated 180° to reduce the fracture, and reduction is confirmed on radiographs. Once reduction and fixation are confirmed, the pin/wire/elastic nail is cut and the skin is closed over it with use of absorbable sutures. A long arm cast is applied for 4 to 6 weeks. Alternatives:Alternatives include cast immobilization for cases of displaced fractures with <20° of angulation, closed reduction by placing the elbow in varus with direct pressure on the radial head, percutaneous reduction with use of a Steinmann pin for leverage, and arthroscopic reduction. Rationale:Retrograde intramedullary reduction and fixation achieves reduction, provides stability, and avoids open reduction. Expected Outcomes:In a study assessing elbow function following treatment of displaced radial neck fractures with use of the Metaizeau technique, Ghonim et al. reported excellent outcomes in 22.2% and good outcomes in 77.8% of patients, as measured with use of the Mayo Elbow Performance Score. The radiographic results were similar. The results were marginally worse than those reported in other similar studies, likely because of the severity of the included radial neck fractures. Klitscher et al. evaluated 28 cases of radial neck fractures treated with the Metaizeau technique. Excellent results were achieved in 23 cases (82%) and good results, in 5 cases (18%), as measured with use of the Mayo Elbow Performance Score. The average score was 97 points, and 3 malunions were reported. Metaizeau et al. reported the use of their technique in 42 radial neck fractures, with 31 fractures having an angulation between 30° and 80° (group 1) and 16 fractures having an angulation of >80° (group 2). Good or excellent results were reported in 30 cases in group 1 and in 11 cases in group 2. Yallapragada and Maripuri assessed the use of the Metaizeau technique in 21 patients with a mean age of 8 years. At 6 weeks after nail removal, 19 patients (90.5%) had excellent or good results and 2 patients (9.5%) had fair results. Zimmerman et al. performed a retrospective analysis of 151 children with surgically treated radial neck fractures. Among the 131 patients with adequate follow-up, 31% had poor outcomes. The suboptimal results were associated with age >10 years, increased fracture severity, and those patients who underwent open reduction. The authors concluded that less invasive reduction methods should be attempted prior to open reduction whenever possible. Important Tips:Avoid the distal radial growth plate.Utilize a T-handle to hold the wire.The use of fluoroscopy is necessary to aid in placement of the wire and to confirm adequate reduction and fracture fixation.Supplemental arthrography should be performed in young children.Very displaced fractures may require supplemental reduction with use of a percutaneous Kirschner wire prior to final flexible nail fixation. Acronyms and Abbreviations:MEPS = Mayo Elbow Performance Score.

IntroductionMedially routed biceps-to-triceps tendon transfer for elbow extension reconstruction in spinal cord injury (SCI) has proven to be a reliable procedure. This technique classically places the tendon transfer superficial to a paralyzed ulnar nerve, with a theoretical risk of compression neuropathy.Case presentationA 21-year-old male with a C5 American Spinal Injury Association Impairment Scale (AIS) grade B SCI who underwent bilateral biceps-to-triceps tendon transfers presented with new-onset paresthesias in the ring and small fingers 10.5 years following initial reconstructive surgery. These symptoms were accompanied by triggered upper extremity spasticity following repeated elbow flexion exercises. Clinical exam findings and ultrasound imaging were consistent with bilateral ulnar nerve compression. Surgical exploration revealed that the ulnar nerve was severely compressed by the tendinous part of the biceps bilaterally. The surgical technique used to decompress the ulnar nerve and perform an anterior transposition without taking down the rerouted biceps tendon is described. The patient demonstrated favorable post-operative outcomes.ConclusionCompression of a paralyzed ulnar nerve in a tetraplegic patient after medially routed biceps-to-triceps tendon transfer can present with both classical and/or atypical findings. Although rare, this complication can be managed surgically by anterior transposition of the ulnar nerve without taking down the rerouted biceps tendon. The senior authors have modified their technique and now recommend passing the rerouted biceps tendon deep to the ulnar nerve to avoid compression neuropathy.

Background: A growing number of nongovernmental organizations from high-income countries aim to provide surgical outreach for patients in low- and middle-income countries in a manner that builds capacity. There remains, however, a paucity of measurable steps to benchmark and evaluate capacity-building efforts. Based on a framework for capacity building, the present study aimed to develop a Capacity Assessment Tool for orthopaedic surgery (CAT-os) that could be utilized to evaluate and promote capacity building. Methods: To develop the CAT-os tool, we utilized methodological triangulation—an approach that incorporates multiple different types of data. We utilized (1) the results of a systematic review of capacity-building best practices in surgical outreach, (2) the HEALTHQUAL National Organizational Assessment Tool, and (3) 20 semistructured interviews to develop a draft of the CAT-os. We subsequently iteratively used a modified nominal group technique with a consortium of 8 globally experienced surgeons to build consensus, which was followed by validation through member-checking. Results: The CAT-os was developed and validated as a formal instrument with actionable steps in each of 7 domains of capacity building. Each domain includes items that are scaled for scoring. For example, in the domain of partnership, items range from no formalized plans for sustainable, bidirectional relationships (no capacity) to local surgeons and other health-care workers independently participating in annual meetings of surgical professional societies and independently creating partnership with third party organizations (optimal capacity). Conclusions: The CAT-os details steps to assess capacity of a local facility, guide capacity-improvement efforts during surgical outreach, and measure the impact of capacity-building efforts. Capacity building is a frequently cited and commendable approach to surgical outreach, and this tool provides objective measurement to aid in improving the capacity in low and middle-income countries through surgical outreach.

Background The surgical burden in low- and middle-income countries (LMICs) as reported by the number of surgical cases per capita is great. To improve global health and help address this burden, there has been a rise in surgical outreach to LMICs. In high-income countries, an electronic health record (EHR) is used to document and communicate data critical to the quality of care and patient safety. Despite this, there is little guidance or precedence on the data elements or processes for utilizing an EHR on outreach trips. We validated data elements and process steps for utilizing an EHR for hand surgery outreach trips. Methods We conducted a literature review to identify data elements collected during surgical outreach trips. A future-state process map for the collection and documentation of data elements within an EHR was developed through literature review and semistructured interviews with experts in global outreach. An expert consortium completed a modified RAND/University of California at Los Angeles Delphi process to evaluate the importance and feasibility of each data element and process step. Results In total, 65 data elements (e.g., date of birth) and 24 process steps (e.g., surgical site marking) were validated for use in an EHR for hand surgery outreach trips to LMICs. Conclusion This validated portfolio of data elements/process steps can serve as the foundation for pilot testing of an EHR to document and communicate critical patient data on hand surgery outreach trips. Utilization of an EHR during outreach trips to LMICs may serve to improve the safety and quality of care provided. The validated data elements/process steps can serve as a guide for EHR development and implementation of other surgical specialties.

The care of children with brachial plexus birth injuries (BPBI) is a complex multidisciplinary endeavor. At the Shriners Hospital for Children in Philadelphia, we have sought to elevate the quality of care delivered to patients through outcomes research and collaboration with colleagues around the world. Our approach to the management of this challenging pathology has evolved time and again. Here, we describe our current approach to patient assessment and operative management in patients with BPBI and its many sequelae.

Introduction: Our study aims to characterize the results of Monteggia fractures treated in our practice and to determine factors associated with good or poor outcomes. Methods: A retrospective review of children aged 17 and under with acute, subacute, or chronic Monteggia fractures who were treated at our institution was performed. The primary outcomes were initial reduction and maintenance of joint reduction, while the secondary outcomes were elbow flexion/extension and forearm supination/pronation. Results: Seventeen patients with Monteggia fractures were identified. Two patients were excluded: 1 was lost to follow-up and 1 had congenital absence of the elbow flexors. Thus, our final cohort was 15 patients (acute n = 3, subacute n = 4, chronic group n = 8). Median final follow-up was 1.9 years (range = 34 days-8 years). Conclusion: Preoperative range of motion (ROM) was the most important factor in determining postoperative ROM in this cohort of patients with chronic Monteggia fractures. All patients who presented with excellent preoperative ROM, regardless of their timing category, had an excellent ROM outcome. Time from initial injury also played an important role. All patients in the acute and subacute categories had good or excellent postoperative ROM. Patients who were further from the initial injury were more likely to present with worse preoperative ROM and, in turn, had worse outcomes with postoperative ROM.

Individuals with C5 or C6 spinal cord injury (SCI) have paralysis of the triceps brachii, and the subsequent loss of elbow extension makes it impossible to reliably use their hands above shoulder level because of the inability to hold the elbow extended against gravity. For persons with cervical SCI, elbow extension can be restored with both tendon and nerve transfers. Elbow extension is necessary for dressing, eating, wheelchair locomotion, pressure relief maneuvers, independent transfers, and reaching objects above shoulder level. Deltoid-to-triceps and biceps-to-triceps tendon transfers have established efficacy and a longer history of use. Transfer of motor branches from the axillary nerve to triceps motor branches is new with no current published prospective studies but shows early promise. This review aims to highlight the amazing potential these procedures can have on the independence and quality of life for people with quadriplegia. Despite the immense benefit possible, fewer than 14% of eligible people with cervical SCI in the United States receive upper limb reconstructive surgery. Surgical timing is critical. A broader understanding and raised awareness of reconstructive options for elbow extension in people with quadriplegia will increase recognition of eligible patients and speed referral time to the appropriate practitioner.

PURPOSE:Brachial plexus birth injury (BPBI) results in upper extremity (UE) movement limitations. Current assessments of UE function used to inform clinical decision-making only evaluate a limited set of static postures and/or movements and have been criticized for being insensitive to certain meaningful differences in function. Reachable workspace provides a numeric and visual assessment of global UE movement ability by quantifying the regions in space that patients can reach with their hands, and it can be collected using real-time feedback to elicit a best-effort acquisition of function. This study evaluated the ability of a real-time feedback reachable workspace tool to assess UE movement in BPBI. METHODS:Twenty-two children with BPBI participated. Reachable workspace data were collected with three-dimensional motion capture using real-time visual feedback to measure UE reaching ability in all regions surrounding the body. All outer, far-from-body points reached by the hand were recorded and analyzed by region. A two-way, within-subjects analysis of variance was used to assess interlimb differences in percentage workspace reached and median reach distance for each of the six regions. RESULTS:The affected limb had significantly less percentage workspace reached than the unaffected limb for all six regions (mean interlimb differences by region, 5.7%-38.6%). The affected limb had significantly less median reach distance than the unaffected limb for all six regions (mean interlimb differences by region, 3.1%-36.8%). CONCLUSIONS:The workspace approach was capable of detecting UE movement impairments of the BPBI-affected limb. The reported deficits in workspace on the affected limb correspond to common movement impairments in BPBI, such as limitations in shoulder elevation, external rotation, extension, and elbow extension. CLINICAL RELEVANCE:The real-time feedback reachable workspace tool is sufficiently robust for assessing UE movement impairments in children with BPBI.