Paediatric Upper Limb Conditions

Brachial Plexus Birth Palsy

Risk Factors

  • Large babies
  • Breech position
  • Shoulder Dystocia
  • Instrumented delivery
  • History of BPBP in past

Clinical Presentation

  • Baby has a floppy arm

Classification – Anatomic

Type Nerves Affected Prognosis Affected Muscles
Erb’s Palsy C5/6 (+/- C7) Best Prognosis Deltoid, external rotators, biceps, wrist extension (Waiter’s tip)
Klumpke’s C8/T1 Poor Prognosis Wrist flexors, finger intrinsics
Total Plexus All nerves Worst Prognosis Multiple muscles affected

Prognostic Factors

  • Poor Prognostic Factors:
    • Pre-ganglionic Injury
    • Root avulsion
    • Horner’s syndrome
    • Klumpke’s or Total Plexus palsy
    • No biceps recovery by 5-6 months
  • Positive Prognostic Factors:
    • Some biceps recovery < 3 months – indicates complete recovery
    • Erb’s Palsy

Management

  1. Initial Observation:
    • 90% have full recovery.
    • ROM and PT to prevent contracture.
  2. Surgical Options:
    • Microsurgical nerve grafting.
    • Transfers:
      • Latissimus & Pec Major to cuff (L’Esciposos transfer).
      • Pectoralis to elbow.
    • External rotation osteotomy of proximal humerus.
  3. Outcomes:
    • 90% full recovery; partial recovery in others.
    • Risk of paralytic posterior shoulder dislocation leading to Glenohumeral Dysplasia.

Congenital Pseudoarthrosis of the Clavicle

  • Aetiology:
    • Failure of clavicle medial and lateral ossification centres to unite.
    • Possibly due to subclavian artery pulsations.
  • Clinical Features:
    • Slow-growing, firm mass.
    • Rarely painful.
  • Management:
    • Non-operative unless functional deficits or appearance issues.
    • Surgical: Excision, ORIF, and bone grafting.

Sprengel’s Deformity Shoulder

Aetiology

  • Incomplete descent of scapula with hypoplastic musculature.

Associations

  • Scoliosis.
  • Klippel-Feil.
  • Omovertebral bone (30%).

Clinical Features

  • Deformity and shoulder dysfunction (especially abduction).

Classification

  • Cavendish: Based on appearance.

Management

  • Non-operative: Mild cases with follow-up until maturity.
  • Surgical:
    • Woodward Procedure:
      • Release of scapulothoracic muscles.
      • Excision of Omovertebral bar.
      • Downward translation of scapula.
    • Clavicle osteotomy for large corrections.
    • Complications:
      • Brachial plexus palsy.
      • Scapula winging.

Congenital Synostosis of Forearm

Aetiology

  • Failure of forearm differentiation from the common cartilage mesenchymal anlage (~5 weeks gestation).

Clinical Features

  • Fixed in pronation (60% bilateral).
  • Associations:
    • Polands, Alperts, Kleinfelters.

Classification

Type Description
Type 1 Synostosis alone
Type 2 Synostosis with radial head dislocation

Management

  • Non-operative unless significant functional deficits.
  • Surgical:
    • Excision of synostosis or rotational osteotomy (preferred).

Trigger Finger/Thumb

Clinical Presentation

  • Child holds thumb flexed at IPJ due to pain.
  • Palpable nodule and painful ROM.

Management

  1. Observation:
    • Spontaneous resolution possible by 1 year.
  2. Surgical Release:
    • Transverse incision.
    • Divide A1 pulley radially (avoid oblique pulley).

Congenital Dislocations

Congenital Dislocation of the Knee

  • Epidemiology: Rare.
  • Aetiology: Intrauterine breech position, congenital ACL deficiency.
  • Associations: Arthrogryposis, myelodysplasia.
  • Clinical Features:
    • No passive knee flexion.
    • Hyperextending knee with anterior skin dimple.
  • Management:
    • Closed Reduction:
      • Serial casting (most cases).
    • Open Reduction:
      • Quads release.

Congenital Dislocation of the Patella

  • Aetiology: Generalized problem.
  • Clinical Features:
    • FFD of knee.
    • No knee extension.
  • Management:
    • Surgery only:
      • Releases, relocations, and repairs.
      • Trochleoplasty.

Congenital Radial Head Dislocation

Epidemiology

  • Fairly common, often bilateral.

Associations

  • Achondroplasia, Nail Patella Syndrome.

Pathoanatomy

  • Short ulna.
  • May be anteriorly, posteriorly, or laterally dislocated.

Management

  • Non-operative:
    • Most cases (minimal symptoms).
  • Surgical (Indications: Pain, reduced ROM):
    • Radial head excision (post-skeletal maturity).
    • Annular ligament reconstruction.
    • Ulna lengthening or radius shortening.
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