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Cross-sectional clinical measurement study. Scapular winging is a frequent complaint among children with brachial plexus birth palsy (BPBP). Therapeutic taping for scapular stabilization has been reported to decrease scapular winging. This study aimed to determine which therapeutic taping construct was most effective for children with BPBP. Twenty-eight children with BPBP participated in motion capture assessment with 4 taping conditions: (1) no tape, (2) facilitation of rhomboid major and rhomboid minor, (3) facilitation of middle and lower trapezius, and (4) facilitation of rhomboid major, rhomboid minor, and middle and lower trapezius (combination of both 2 and 3, referred to as combined taping). The participants held their arms in 4 positions: (1) neutral with arms by their sides, (2) hand to mouth, (3) hand to belly, and (4) maximum crossbody adduction (CBA). The scapulothoracic, glenohumeral and humerothoracic (HT) joint angles and joint angular displacements were compared using multivariate analyses of variance with Bonferroni corrections. Scapular winging was significantly decreased in both the trapezius and combined taping conditions in all positions compared with no tape. Rhomboids taping had no effect. Combined taping reduced HT CBA in the CBA position. Rhomboid taping cannot be recommended for treatment of children with BPBP. Both trapezius and combined taping approaches reduced scapular winging, but HT CBA was limited with combined taping. Therefore, therapeutic taping of middle and lower trapezius was the most effective configuration for scapular stabilization in children with BPBP. Resting posture improved, but performance of the positions was not significantly improved. Level II.

Shoulder joint deformities continue to be a challenging aspect of treating upper plexus lesions in children with perinatal brachial plexus palsy (PBPP). It is increasingly recognized that PBPP affects the glenohumeral joint specifically, and that abnormal scapulothoracic movements are a compensatory development. The pathophysiology and assessment of glenohumeral joint contractures, the progression of scapular dyskinesia and skeletal dysplasia, and current shoulder imaging techniques are reviewed.

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.

Clinical upper extremity (UE) functional assessments and motion capture measures are limited to a set of postures and/or motions that may provide an incomplete evaluation of UE functionality. Reachable workspace analysis offers a more global assessment of UE function, but is reliant on patient compliance with instructions and may result in underestimates of a patient’s true UE function. This study evaluated a clinical tool that incorporates real-time visual feedback with motion capture to provide an innovative means of engaging patients to ensure a ‘best effort’ quantification of their available UE workspace. Reachable workspace for 10 children with brachial plexus birth injury was collected with and without real-time feedback on the affected and unaffected limbs. Real-time feedback consisted of subjects reaching for virtual targets surrounding their physical space using a virtual cursor controlled by the real-time location of their hand. Real-time feedback resulted in significantly greater workspace in multiple regions on both the affected (3/6 octants; mean differences 10.8%-20.0%) and unaffected (6/6 octants; mean differences 24.3%-40.0%) limbs. Use of real-time feedback also yielded significant interlimb differences in workspace across more regions (4/6 octants; mean differences 29.0%-39.9% vs. 1/6 octants; mean difference 17%). Finally, real-time feedback resulted in significant interlimb differences in median reach distance across more regions (4/6 octants; mean differences 7.5%-44.8% vs. 1/6 octants; mean difference 11.2%). A reachable workspace tool with real-time feedback results in more workspace and UE function recorded and offers a highly visual and intuitive depiction of a patient’s UE abilities.

Abstract Background Shoulder abnormalities are the major cause of morbidity in upper brachial plexus birth palsy (BPBP). We developed a rat model of upper trunk BPBP and compared our findings to previously reported animal models and to clinical findings in humans. Methods Forty-three 5-day-old newborn rats underwent selective upper trunk neurectomy of the right brachial plexus and were studied 3 to 20 weeks after surgery. The passive shoulder external rotation was measured and the shoulder joint was assessed bilaterally by a 7.2T MRI bilaterally. Results We found a marked decrease in passive shoulder external rotation, associated with a severe subscapularis muscle atrophy and contracture. None however developed the typical pattern of glenohumeral dysplasia. Conclusions In contradiction with previous reports, our study shows that the rat model is not adequate for preclinical studies of shoulder dysplasia. However, it might serve as a useful model for studies analyzing shoulder contracture occurring after upper BPBP.

This study aims to assess the relationship between the modified Mallet classification and the Brachial Plexus Profile activity short form (BP-PRO activity SF). The therapist or surgeon classifies upper extremity movement for the modified Mallet classification, while the BP-PRO assesses parents' perceptions of difficulty performing activities. To provide a deeper understanding of the relationship of functional and perceived outcome measurements. Prospective, correlational design. Eighty children with brachial plexus birth injuries were evaluated using the modified Mallet classification, while parents simultaneously answered the BP-PRO activity SF questions. All patients had undergone one of three surgical interventions to improve shoulder function. The relationship between the two measures, patient injury levels, and surgical histories were assessed. The average modified Mallet scores and BP-PRO activity SF scores weakly correlated (r = 0.312, P = .005) and both measures differentiated between C5-6 and C5-7 injury levels (P = .03 and P = .02, respectively). Conversely, the modified Mallet scores could differentiate between the three surgical groups (F = 8.2, P < .001), while the BP-PRO activity SF could not (P = .54). The results suggest that these tools measure different aspects of patient outcomes. The Mallet classification may be more focused on shoulder motion than the BP-PRO activity SF. Additional questions that specifically require shoulder function could be incorporated into the BP-PRO activity SF to improve understanding of patient/parent perceptions of shoulder function for children with brachial plexus injuries. Clinicians should be aware of the strengths, weaknesses, and limitations of each outcome assessment tool for appropriate use and interpretation of results. •The modified Mallet classification discriminated between C5-C6 and C5-C7 injuries.•The activity BP-PRO activity SF discriminated between C5-C6 and C5-C7 injuries.•The BP-PRO activity SF did not discriminate between the surgical groups.•The BP-PRO activity SF may not be sensitive to differences in shoulder function.•A PRO to assess shoulder function in children with BPBI may improve understanding.•Understanding applications of outcome measures will improve use and interpretation.

An integrated pharmaceutical, surgical, and therapeutic approach is described for the management of patients with spasticity and paralysis of the elbow due to central nervous system injury. The patient populations considered in this article include those with cerebral palsy, traumatic brain injury, and spinal cord injuries. Therapy evaluations and techniques and pharmacologic interventions to prevent loss of elbow motion are presented. Surgical techniques such as tendon lengthening, joint releases, and/or tendon transfer and postoperative therapy guidelines to restore loss of elbow motion are reviewed. Outcomes of this team approach in one clinical setting are presented.

Instructions 1. Review the stated learning objectives at the beginning of the CME article and determine if these objectives match your individual learning needs. 2. Read the article carefully. Do not neglect the tables and other illustrative materials, as they have been selected to enhance your knowledge and understanding. 3. The following quiz questions have been designed to provide a useful link between the CME article in the issue and your everyday practice. Read each question, choose the correct answer, and record your answer on the CME REGISTRATION FORM at the end of the quiz. 4. Type or print your full name and address and your date of birth in the space provided on the CME Registration Form. 5. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity. 6. Complete the Evaluation portion of the CME Regi stration Form. Forms and quizzes cannot be processed if the Evaluation portion is incomplete. The Evaluation portion of the CME Registration Form will be separated from the quiz upon receipt at ORTHOPEDICS. Your evaluation of this activity will in no way affect the scoring of your quiz. 7. Send the completed form, with your $15 payment (check or money order in US dollars drawn on a US bank, or credit card information) to: ORTHOPEDICS CME Quiz, PO Box 36, Thorofare, NJ 08086, OR take the quiz on-line. Visit www.ORTHOSuperSite.com for details. 8. Your answers will be graded, and you will be advised whether you have passed or failed. Unanswered questions will be considered incorrect. A score of at least 80% is required to pass. If a passing score is achieved, Vindico Medical Education will issue an AMA PRA Category 1™ certificate within 4–6 weeks. 9. Be sure to mail the CME Registration Form on or before the deadline listed. After that date, the quiz will close. CME Registration Forms received after the date listed will not be processed. CME Accreditation This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Vindico Medical Education and ORTHOPEDICS. Vindico Medical Education is accredited by the ACCME to provide continuing medical education for physicians. Vindico Medical Education designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This CME activity is primarily targeted to orthopedic surgeons, hand surgeons, head and neck surgeons, trauma surgeons, physical medicine specialists, and rheumatologists. There is no specific background requirement for participants taking this activity. Full Disclosure Policy In accordance with the Accreditation Council for Continuing Medical Education's Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Drs Abzug and Kozin have no relevant financial relationships to disclose. Dr Morgan, CME Editor, has disclosed the following relevant financial relationships: Stryker, speakers bureau; Smith & Nephew, speakers bureau, research grant recipient; AO International, speakers bureau, research grant recipient; Synthes, institutional support. Dr D'Ambrosia, Editor-in-Chief, has no relevant financial relationships to disclose. The staff of ORTHOPEDICS have no relevant financial relationships to disclose. Unlabeled and Investigational Usage The audience is advised that this continuing medical education activity may contain references to unlabeled uses of FDA-approved products or to products not approved by the FDA for use in the United States. The faculty members have been made aware of their obligation to disclose such usage. Educational Objectives As a result of reading this article, physicians should be able to: 1. Explain how to diagnose infants with birth-related brachial plexus injuries. 2. Describe the classification system used to characterize brachial plexus injuries. 3. List the indications for microsurgical intervention for brachial plexus birth palsies.

OBJECTIVE. In this study, we aimed to assess whether therapeutic taping for scapular stabilization affected scapulothoracic, glenohumeral, and humerothoracic joint function in children with brachial plexus birth palsy and scapular winging. METHOD. Motion capture data were collected with and without therapeutic taping to assist the middle and lower trapezius in seven positions for 26 children. Data were compared with one-way multivariate analyses of variance. RESULTS. With therapeutic taping, scapular winging decreased considerably in all positions except abduction. Additionally, there were increased glenohumeral cross-body adduction and internal rotation angles in four positions. The only change in humerothoracic function was an increase of 3° of external rotation in the external rotation position. CONCLUSION. Therapeutic taping for scapular stabilization resulted in a small but statistically significant decrease in scapular winging. Overall performance of positions was largely unchanged. The increased glenohumeral joint angles with therapeutic taping may be beneficial for joint development; however, the long-term impact remains unknown.