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Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury
David S Liu1, Patricia Miller1, Anna Rothenberg1
1Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.
Insights
Children with elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are at higher risk for shoulder contracture and surgery. Early screening for EFC can help identify at-risk infants for prompt evaluation and intervention.
Area of Science:
- Pediatric Orthopedics
- Neonatal Care
- Rehabilitation Medicine
Background:
- Brachial plexus birth injury (BPBI) can lead to significant upper extremity dysfunction in infants.
- Elbow flexion contracture (EFC) is a common complication, but its association with shoulder issues is not fully understood.
- Early identification of secondary complications is crucial for optimal outcomes in infants with BPBI.
Purpose of the Study:
- To investigate the relationship between elbow flexion contracture (EFC) and the development of shoulder contracture in infants with brachial plexus birth injury (BPBI).
- To determine if EFC is a predictor for increased likelihood of surgical intervention for shoulder complications.
- To evaluate EFC as a potential screening tool for identifying infants requiring specialized BPBI care.
Main Methods:
- Retrospective review of pediatric patients diagnosed with BPBI between 1993 and 2020.
- Inclusion criteria: children under 2 years of age with BPBI and an elbow flexion contracture of ≥10°.
- Matched cohort analysis comparing patients with and without EFC, assessing range of motion, contracture development, and surgical outcomes.
Main Results:
- Patients with EFC exhibited significantly reduced shoulder range of motion (12° less) compared to controls.
- The presence of EFC was associated with a 2.5-fold increased odds of developing shoulder contracture.
- Each 5° increase in EFC correlated with a 50% increase in the odds of shoulder contracture and a 62% increase in the odds of requiring shoulder surgery.
Conclusions:
- Elbow flexion contracture (EFC) serves as a valuable screening tool for identifying shoulder contractures in infants with brachial plexus birth injury (BPBI) that may be difficult to assess directly.
- Prompt referral to a BPBI specialty clinic is recommended for infants with EFC to prevent the progression of shoulder contractures and potentially avoid more complex surgical procedures.
- Early detection and management of EFC can mitigate the risk of secondary shoulder complications in the pediatric BPBI population.
Objective:
To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment.
Study Design:
Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data.
Results:
There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%.
Conclusions:
In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.
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