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

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

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.