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American Association for Hand Surgery

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Predictors of elbow flexion contracture development in early childhood following brachial plexus birth injury
Allison Mah, MScOT (Candidate)1, Karen Ogilvie, MScOT (Candidate)1, Karen Klar, BScPT2, Alison Anthony, MScPT2, Kristen M Davidge, MD, MSc, FRCS(C)3, Howard M. Clarke, MD, PhD, FRCS(C)4 and Emily S. Ho, BScOT, MEd, PhD5, (1)University of Toronto, Toronto, ON, Canada, (2)Hospital for Sick Children, Toronto, ON, Canada, (3)Division of Plastic Surgery, Hospital for Sick Children, Toronto, ON, Canada, (4)Division of Plastic and Reconstructive Surgery, Hospital for Sick Children, Toronto, ON, Canada, (5)Department of Plastic and Reconstructive Surgery, Hospital for Sick Children, Toronto, Canada, University of Toronto, Toronto, ON, Canada

Introduction: The development of elbow flexion contractures in school-age children with Brachial Plexus Birth Injury (BPBI) is common. While these contractures are not present at birth, several reports indicate onset at or prior to 6 months of age and emerging between 2 to 4 years; however, little is known about their development and trajectory.
Purpose: To determine the prevalence and predictors of EFC during early childhood following BPBI.
Methods: A retrospective cross-sectional study of children with BPBI < 4 years was conducted. Demographic, diagnostic, and outcomes data were extracted from health records and a prospectively collected database. Evaluation of the type of BPBI pattern of injury associated with EFC development was conducted. Root level motor contributions were defined using Active Movement Scale (AMS) outcomes between 6 and 12 months of age.
Results: Of the 183 children who were < 4 years of age that attending the clinic between 2015 and 2019, 171 (77M, 94F) met the inclusion criteria. Of the included children, 87% (n=149) had upper plexus injuries; 15% (n=25) had microsurgical reconstruction of the brachial plexus; and 13% (n=22) had shoulder reconstruction. The mean age at the time of chart review was 21.5 ± 13.0 months. EFC was present in 22% (n=38) of the children. The mean EFC onset was 13.4 ± 11.0 months (range: 3.0 to 47.9 months), while the mean documented degree of contracture at its highest magnitude was -10.8 ± -6.9 degrees. The majority (76%, n=29) of EFCs were < -10 degrees. Treatment for EFC included passive range of motion exercises (73%, n=25), thermoplastic elbow extension orthosis (18%, n=6) and semi-rigid fibreglass casting (9%, n=3). The mean age at the time of AMS evaluation was 2.3 ± 1.4 months to determine predictors of EFC related to pattern of injury. Children with EFC had significantly lower AMS scores in shoulder abduction, flexion, and external rotation; elbow flexion; forearm supination; and wrist extension than children without EFC (Mann Whitney U, p p<0.001). The logistic regression model found that poor elbow flexion with good extension AMS scores was a significant predictor of developing an EFC (p<0.003).
Discussion: This study demonstrates that EFC has greater prevalence in early childhood than previously understood. In this cohort, EFC largely affected those with greater upper trunk involvement. These findings may further the understanding of how C5 and C6 injury leading to denervation of brachialis and bicep brachii contribute to EFC development.


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