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Pediatric Traumatic Brain Injury, Heterotopic Ossification and Peripheral Neuropathy
Shai Luria, MD; Ayelet Gal, MSc; Emmanuele Kornitzer, MD; Sharon Eylon, MD
University Medical Center, Jerusalem, Israel

Introduction: Patients with severe traumatic brain injury (TBI) may suffer from heterotopic ossification (HO), mainly of the elbow or hip joints. This is well described in adults, but less so in pediatric patients. Timing of surgical excision of the HO as well as postoperative treatment with NSAID or single dose irradiation are questions debated in adults. There is very little data in children and no clear recommendations. The aim of this study was to examine the frequency of this problem in the pediatric population and examine possible risk factors for its occurrence.
Methods: The medical records of all patients with severe TBI between the ages of 0 to 16, hospitalized at the pediatric & adolescent rehabilitation center during the years 2000-2013 were reviewed. Data regarding brain and additional injuries, diagnosis and care of HO were collected.
Results: There were 83 patients including 60 boys and 23 girls. Eight were excluded due to insufficient data. Of the remaining 75 patients, HO was diagnosed in 6 patients at an average of 4 months from the injury, 4 at the elbow and 2 in the lower limb. The age at injury ranged between 7 and 14 years and Glasgow Coma Scale at admission was between 5 and 8. Of the 6 patients, 2 had fractures in the same limb, 2 had botulinum toxin injections followed by serial casting in the same limb, and in all, the involved side was the plegic limb, with increased muscle tone. Symptoms resolved in 5 patients with NSAIDS treatment and rest. One patient required surgical excision of the elbow HO, due to a progressive ulnar neuropathy, 6 months post injury. Post-op management included NSAIDs for 6 weeks. After 3 months, the clinical signs of the ulnar neuropathy had resolved yet some of the elbow contracture recurred.
Conclusions: Severe TBI in children may be complicated by HO of the plegic, increased muscle tone limb. When diagnosed, monitoring of the limbís neurologic status is needed to detect early signs of nerve entrapment in addition to the neurologic deficits of the brain injury. A peripheral neuropathy may be an indication for more aggressive treatment of the HO.

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