We retrospectively reviewed 26 patients who underwent reconstruction of the shoulder for a medial rotation contracture after birth injury of the brachial plexus. Of these, 13 patients with a mean age of 5.8 years (2.8 to 12.9) received an injection of botulinum toxin type A into the pectoralis major as a surgical adjunct. They were matched with 13 patients with a mean age of 4.0 years (1.9 to 7.2) who underwent an identical operation before the introduction of botulinum toxin therapy to our unit. Pre-operatively, there was no significant difference (p = 0.093) in the modified Gilbert shoulder scores for the two groups. Post-operatively, the patients who received the botulinum toxin had significantly better Gilbert shoulder scores (p = 0.012) at a mean follow-up of three years (1.5 to 9.8). It appears that botulinum toxin type A produces benefits which are sustained beyond the period for which the toxin is recognised to be active. We suggest that by temporarily weakening some of the power of medial rotation, afferent signals to the brain are reduced and cortical recruitment for the injured nerves is improved.

Level II.

The purpose of this study was to examine the results of pediatric patients with type I open fractures managed nonoperatively. A retrospective chart review of all type I open fractures managed nonoperatively from 1998 to 2003 was performed. Forty patients were followed until healing of the fracture clinically and radiologically. One deep infection occurred in this series, producing an overall infection rate of 2.5%. This compares favorably with the literature's infection rate of 1.9% in pediatric type I open fractures treated operatively. There was a 0% infection rate in the 32 upper-extremity type I open fractures and a 0% infection rate in the 23 patients under age 12. These results suggest that nonoperative management of pediatric type I open fractures is safe and effective, especially in children under age 12 with upper-extremity fractures.

BackgroundThe management of pediatric type I open fractures remains controversial. There has been no consistent protocol established in the literature for the non-operative management of these injuries.MethodsA protocol was developed at our institution for the non-operative management of pediatric type I open forearm fractures. Each patient was given a dose of intravenous antibiotics at the time of the initial evaluation in the emergency department. The wound was then irrigated and a closed reduction performed in the emergency department. The patient was admitted for three doses of intravenous antibiotics (over approximately a 24-h period) and then discharged home without oral antibiotics.ResultsIn total, 45 consecutive patients were managed with this protocol at our hospital between 2004 and 2008. The average age was 10 (range 4–17) years. The average number of doses of intravenous antibiotics was 4.06 per patient. Thirty patients (67 %) received cefazolin (Ancef®) as the treating medication and 15 patients received clindamycin (33 %). There were no infections in any of the 45 patients.ConclusionIn this study we outline a consistent management protocol for type I open pediatric forearm fractures that has not previously been documented in the literature. Our results corroborate the those reported in the literature that pediatric type I open fractures may be managed safely in a non-operative manner. There were no infections in our prospective series of 45 consecutive type I open pediatric forearm fractures using our protocol. Using a protocol of only four doses of intravenous antibiotics (one in the emergency department and three additional doses during a 24-h hospital admission) is a safe and efficient method for managing routine pediatric type I open fractures non-operatively.

Of 22 infants aged between 11 and 29 months who underwent a combined reconstruction of the upper brachial plexus and shoulder for the sequelae of a birth injury, 19 were followed up for two or more years. The results were evaluated using a modified Gilbert scale. Three patients required a secondary procedure before follow-up. Three patients had a persistent minor internal rotation contracture. All improved by at least two grades on a modified Gilbert scale.