Surgical Treatment of Pathological Developmental Dysplasia of the Hip: A 12-Year Study

Volume 7 | Issue 2 | May-August 2021 | Page: 02-06 | Qaisar Choudry, Robin W. Paton

Authors: Qaisar Choudry [1], Robin W. Paton [1]

[1] Department of Orthopaedics, East Lancashire Hospitals NHS Trust, England.

Address of Correspondence
Dr. Qaisar Choudry
Department of Orthopaedics, East Lancashire Hospitals NHS Trust, England.
E-mail: qaisar.choudry@elht.nhs.uk

Abstract

Aim: We aimed to assess outcomes of a 12-year longitudinal observational study of developmental dysplasia of the hip (DDH) requiring surgical intervention.

Method: We conducted a prospective study from 2004 to 2015 of all cases of DDH undergoing surgical intervention. In addition to clinical examination, Tönnis acetabular index (AI) method and International Hip Dysplasia Institute (IHDI) grading used.  Avascular necrosis of the femoral head (AVN) was assessed by the Kalamchi method.

Results & Discussion: There were 81 hips in 72 patients (12 male, 60 female).  Mean age of the first operative procedure was 16.4 months (95% CI, 13.66 to 19.14). Mean follow up was 47.6 months (95% CI, 41.8 to 53.4). 31 children underwent closed reductions, 48 required open reduction; 17 femoral and 39 pelvic osteotomies were performed during the course of the study. Overall, post-surgery 96.3 % were noted to have an acceptable AI (< 2 SD of the mean).  Five hips were considered to have poor results due to residual subluxation/ dislocation (6.2%).  Evidence of avascular necrosis was present in 16 of the 81 hips (19.8%).

Higher grades of hip pathology were generally associated with a later age of diagnosis and likely to require more extensive surgical interventions.

Conclusion: Operative intervention for DDH results in acceptable clinical and radiographic outcomes in the vast majority of children.

Keywords: DDH, Developmental Dysplasia of the hip, Surgery.

References 

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How to Cite this Article:  Choudry Q, Paton RW | Surgical Treatment  of Pathological Developmental Dysplasia of the Hip: A 12-Year Study | International Journal of Paediatric Orthopaedics | May-August 2021; 7(2): 02-06.

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Management of Acute Lateral Condyle Fractures of Humerus

Volume 7 | Issue 2 | May-August 2021 | Page: 30-34 | Sandeep Patwardhan, Arkesh Madegowda

Authors: Sandeep Patwardhan [1], Arkesh Madegowda [1]

[1] Department of Paediatric Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune Maharashtra, India.

Address of Correspondence
Dr Sandeep Patwardhan,
Professor, Paediatric Orthopaedic surgeon, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: sandappa@gmail.com

Abstract

Lateral condyle fractures of humerus are one of the common elbow injuries seen in children. These fractures are often difficult to visualise as fracture line passes through unossified cartilage and may need additional investigations to properly assess the fracture pattern. Non operative management is generally indicated for fractures having <2mm displacement. Closed reduction and percutaneous pinning is recommended for those fractures with >2mm displacement and loss of articular cartilage hinge. Intraoperative arthrogram helps to confirm the fracture reduction and restoration of congruent articular surface. Open reduction and fixation may become necessary for fractures with gross displacement and malrotation of the fragment. Complications of lateral condyle fractures include delayed presentation, malunion, lateral spurring and fishtail deformity.
Keywords: Lateral condyle fractures, Internal oblique view, Arthrogram, Aartilage hinge, Displacement.

References

1. Bhandari M, Tornetta P and Swiontkowksi MF The Evidence-Based Orthopaedic Trauma Working Group. Displaced lateral condyle fractures of the distal humerus. J Orthop Trauma 2003; 17: 306–308.
2.Hardacre JA, Nahigian SH, Froimson AI and Brown JE.Fractures of the lateral condyle of the humerus in children. J Bone Joint Surg Am 1971; 53: 1083–1095.
3.Song KS, Kang CH, Min BW, Bae KC, Cho CH. Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children. J Bone Joint Surg Am. 2007 Jan;89(1):58-63.
4. Horn BD, Herman MJ, Crisci K, Pizzutillo PD, MacEwen GD. Fractures of the lateral humeral condyle: role of the cartilage hinge in fracture stability. J Pediatr Orthop. 2002 Jan-Feb;22(1):8-11
5. Kamegaya M, Shinohara Y, Kurokawa M, Ogata S. Assessment of stability in children’s minimally displaced lateral humeral condyle fracture by magnetic resonance imaging. J Pediatr Orthop. 1999 Sep-Oct;19(5):570-2.
6. Song KS, Kang CH, Min BW, Bae KC, Cho CH, Lee JH: Closed reduction and internal fixation of displaced unstable lateral condylar fractures of the humerus in children. J Bone Joint Surg Am 2008;90:2673-2681.
7.Weiss JM, Graves S, Yang S, Mendelsohn E, Kay RM, Skaggs DL: A new classification system predictive of complications in surgically treated pediatric humeral lateral condyle fractures. J Pediatr Orthop 2009;29:602-605.
8. Qin YF, Li ZJ, Li CK, Bai SC, Li H. Unburied versus buried wires for fixation of pediatric lateral condyle distal humeral fractures: A meta-analysis. Medicine (Baltimore). 2017 Aug;96(34):e7736.
9. McGonagle L, Elamin S, Wright DM. Buried or unburied K-wires for lateral condyle elbow fractures. Ann R Coll Surg Engl. 2012 Oct;94(7):513-6.
10. Xie LW, Wang J, Deng ZQ, Zhao RH, Chen W, Kang C, Ye JJ, Liu X, Zhou Y, Shen H. Treatment of pediatric lateral condylar humerus fractures with closed reduction and percutaneous pinning. BMC Musculoskelet Disord. 2020 Oct 27;21(1):707.
11. Abzug JM, Dua K, Kozin SH, Herman MJ. Current Concepts in the Treatment of Lateral Condyle Fractures in Children. J Am Acad Orthop Surg. 2020 Jan 1;28(1):e9-e19.
12. Tomori Y, Nanno M, Takai S. Anterolateral approach for lateral humeral condylar fractures in children: Clinical results. Medicine (Baltimore). 2018 Sep;97(39):e12563.
13. Skak SV, Olsen SD, Smaabrekke A:Deformity after fracture of the lateral humeral condyle in children. J Pediatr Orthop B 2001;10:142-152.
14. Park H, Hwang JH, Kwon YU, Kim HW: Osteosynthesis in situ for lateral condyle nonunion in children. J Pediatr Orthop 2015;35:334-340.
15. Liu TJ,Wang EB, DaiQ, Zhang LJ, Li QW, Zhao Q: Open reduction and internal fixation for the treatment of fractures of the lateral humeral condyle with an early delayed presentation in children: A radiological and clinical prospective study. Bone Joint J 2016;98-B:244-248.
16. Agarwal A, Qureshi NA, Gupta N, Verma I, Pandey DK: Management of neglected lateral condyle fractures of humerus in children: A retrospective study. Indian J Orthop 2012;46:698-704.
17. Narayanan S, Shailam R, Grottkau BE, Nimkin K: Fishtail deformity: A delayed complication of distal humeral fractures in children. Pediatr Radiol 2015;45:814-819.
18. Cates RA, Mehlman CT: Growth arrest of the capitellar physis after displaced lateral condyle fractures in children. J Pediatr Orthop 2012;32:e57-e62.

How to Cite this Article:  Patwardhan S, Madegowda A | Management of Acute Lateral Condyle Fractures of Humerus | International Journal of Paediatric Orthopaedics | May-August 2021; 7(2): 30-34.

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Bilateral Septic Hip Epiphyseal Detachment in Children: A Case Report and Review of the Literature

Volume 7 | Issue 2 | May-August 2021 | Page: 20-23 | Ferdinand Nyankoue Mebouinz, Serge Etoundi Bekoé, Rose Bengono, Bertine Manuela Ndjeunga, Cathy Bebey Engome, Fabrice Arroye Betou

Authors: Ferdinand Nyankoue Mebouinz [1], Serge Etoundi Bekoé [1], Rose Bengono [1], Bertine Manuela Ndjeunga [2], Cathy Bebey Engome [3], Fabrice Arroye Betou [4]

[1] Department of Orthopaedic Trauma Surgery, Aristide Le Dantec Hospital, Cheikh Anta Diop University, Dakar, Senegal.
[2] Obstetrics Gynecology Clinic, Aristide Le Dantec Hospital, Cheikh Anta Diop University, Dakar, Senegal.
[3] Albert Royer Children’s Hospital University teaching Hospital of Fann, Cheikh Anta Diop University, Dakar,Senegal.
[4] Department of Cardiovascular and Thoracic Surgery, University teaching Hospital of Fann, Cheikh Anta Diop University, Dakar, Senegal.

Address of Correspondence
Dr Ferdinand Nyankoue Mebouinz,
Estrada do Forte do Alto Duque, 1449-005, Lisbon.
E-mail: ferdinandmebouinz@gmail.com

Abstract

Background: Diagnosed and treated fairly early, children’s septic arthritis of the hip has few or no complications. Septic epiphyseal detachment of the hip in children is a rare complication due to delayed treatment. Unilateral forms have been reported, but bilateral involvement has never been described in the literature.
Case presentation: We report the case of an 8-year-old girl who presented with hip pain associated fever and diminished lower limb movements, approximately 4 months after the onset of symptoms. The diagnosis of bilateral septic epiphyseal detachment of the hips was made and computerized tomography (CT) scan revealed osteonecrosis of both femoral heads. The necrotic epiphyses required removal in order to control the infection.
Conclusion: This report highlights the importance of early diagnosis of septic arthritis of the hip in the neonatal period. Any delay in presentation, diagnosis or management can result in irrecoverable sequelae for the developing hip and seriously impact long-term function.
Keywords: Septic arthritis, Bilateral, Epiphysis detachment, Hip, Ablation.

References

1. Barthes X, Safar A, Seringe R. Treatment of septic arthritis in children. Arch Pediatr. 1 mai 1997;4(5):460‑3.
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3. Siffert RS. The Effect of Juxta-epiphyseal Pyogenic Infection on Epiphyseal Growth. Clin Orthop Relat Res. Oct 1957; 10:131.
4. Teklali Y, Ettayebi F, Benhammou M, El Alami ZF, El Madhi T, Gourinda H, et al.
Septic arthritis in infants and children about 554 cases. J Pediatrics and Childcare. 2002;15(3):137‑41. https://doi.org/10.1016/S0987-7983(02)83036-5
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9. Mue DD, Salihu MN, Yongu WT, Ochoga M, Kortor JN, Elachi IC. Paediatric Septic Arthritis in a Nigerian Tertiary Hospital: A 5-Year Clinical Review. West Afr J Med. Aug 2018; 35(2):70‑4.
10. Atarraf K, Arroud M, Chater L, Afifi MA. Post-infectious femoral epiphysis detachment, about two cases. Pan Afr Med J. Aug 2014; 18:319. https://doi: 10.11604/pamj.2014.18.319.2242.
11. Schiavon R, Borgo A, Micaglio A. Septic physeal separation of proximal femur in a newborn. J Orthop Traumatol. Jun 2009; 10(2):105‑10.
12. Singh D, Krishna LG, Siddalingaswamy MK, Gupta V. Extra capsular extrusion of femoral capital epiphysis – an unusual presentation of sequelae of septic arthritis of hip. J Pediatr Orthop Part B. Nov 2011; 20(6):428‑31.
13. Goergens ED, McEvoy A, Watson M, Barrett IR. Acute osteomyelitis and septic arthritis in children. J Paediatr Child Health. 2005;41(1‑2):59‑62.https://doi.org/10.1111/j.1440-1754.2005.00538.x
14. RAMSEYER P, CAHUZAC JP. Acute osteo-articular infection of limbs in children. Rev Prat. 2001; 9:337‑45.
15. Rasigade J-P, Trouillet-Assant S, Laurent F. Staphylococcal bone and joint infections.Rev Francoph Lab. 2016;2016(480):33‑40. http://doi.org/10.1016/S1773-035X(16)30085-5
16. Sferopoulos NK, Papavasiliou VA. [Proximal epiphyseal separation of the femur in the newborn: early ultrasonic diagnosis]. Revue de Chirurgie Orthopedique et Reparatrice de L’appareil Moteur. 1994 ;80(4):338-341.
17. Laine JC, Denning JR, Riccio AI, Jo C, Joglar JM, Wimberly RL. The use of ultrasound in the management of septic arthritis of the hip. J Pediatr Orthop Part B. 2015;24(2):95‑8.
18. Le Saux N. Diagnosis and management of acute osteoarticular infections in children. Paediatr Child Health. 18 jul 2018;23(5):344‑52.
19. Akakpo-Numado GK, Gnassingbe K, Songne B, Amadou A, Tekou H. [Hip septic arthritis in young children with sickle-cell disease]. Revue de Chirurgie Orthopedique et Reparatrice de L’appareil Moteur. Feb 2008; 94(1):58‑63. http://doi.org/10.1016/j.rco.2007.09.004
20. Fernandez FF, Langendörfer M, Wirth T, Eberhardt O. Treatment of septic arthritis of the hip in children and adolescents. Orthopeadic Trauma Surgery. Dec 2013; 151 (6):596‑602.
21. Seivert V, Milin L, Coudane H, Delagoutte J-P, Martrille L. Medical conditions and arthroscopy Osteoarthritis, osteochondromatosis, synovitis septic and rheumatologic arthritis. In: Hulet C, Flurin P-H, editors. Arthroscopic Technics of Upper Limb. Paris: Elsevier Masson; 2013 p. 153‑63.
22. Daffe M, Sarr L, Gueye AB, Dembele B, Diouf AB, Sane A, et al. Hip Septic Arthritis: A Rare Complication. Int J Paediatr Orthop. 2019; 5(1):25‑6.
23. Choi IH, Pizzutillo PD, Bowen JR, Dragann R, Malhis T. Sequelae and reconstruction after septic arthritis of the hip in infants. JBJS. 1990; 72(8):1150‑65.
24. Hunka L, Said SE, MacKenzie DA, Rogala EJ, Cruess RL. Classification and surgical management of the severe sequelae of septic hips in children. Clin Orthop Relat Res. 1982;171:30‑6.
25. Choi IH, Shin YW, Chung CY, Cho T-J, Yoo WJ, Lee DY. Surgical treatment of the severe sequelae of infantile septic arthritis of the hip. Clin Orthop. 2005; (434):102‑9.

How to Cite this Article:  Mebouinz FN, Bekoé SE, Bengono R, Ndjeunga BM, Engome CB, Betou FA | Bilateral Septic Hip Epiphyseal Detachment in Children: A Case Report and Review of the Literature |
International Journal of Paediatric Orthopaedics | May-August 2021; 7(2): 20-23.

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Mitten deformity

Volume 7 | Issue 1 | January-April 2021 | Page: 27 | Yashdeep Singh Pathania

Authors: Yashdeep Singh Pathania MD [1]

[1] Department of Dermatology, Venereology and Leprology, All India Institute of Medical Sciences, Jodhpur 342005, India.

Address of Correspondence
Dr. Yashdeep Singh Pathania
Senior Resident, Department of Dermatology, Venereology and Leprology, All India Institute of Medical Sciences, Jodhpur 342005, India.
Email: yashdeepsinghpathania@gmail.com

A 10-year-old boy, a known case of severe recessive dystrophic epidermolysis bullosa since childhood, presented with widespread scarring over scalp, face, upper and lower limbs. Hands and feet showed flexion contracture, anonychia. There was fusion of digits of the feet by a thin membrane of scar tissue producing pseudosyndactyly, known as mitten deformity (Figure 1). In pseudosyndactyly, digits are fused together by thin membrane and involve only the distal portion of digits, which can be released through surgery where as in syndactyly actual and complete fusion of digits occur and involve base of the digits.

Figure: Scarring over legs with flexion contracture and pseudosyndactyly of foot.

 

How to Cite this Article:  Singh Pathania Y  | Mitten deformity | International Journal of Paediatric Orthopaedics | January-April 2021; 7(1): 27.

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Horizontal Intra-articular dislocation of patella with intact periosteal sleeve in an adolescent: Case report and review of literature

Volume 7 | Issue 1 | January-April 2021 | Page: 22-26 | Mudit Shah, Amin Shah, Mandar Agashe

Authors: Mudit Shah MBBS, MS Ortho. [1], Amin Shah MBBS, MS Ortho.[2], Mandar Agashe MBBS, MS Ortho.[3]

[1] Director and CEO, Sapna Healthcare centre, Ghatkopar west, Mumbai, Maharashtra, India.
[2] Fellow of Paediatric Orthopaedic, Dr. Agashe`s Maternity & Surgical Nursing Home, Kurla west, Mumbai, Maharashtra, India Mumbai, Maharashtra, India.
[3] Consultant paediatric Orthopaedic surgeon, Dr. Agashe`s Maternity & Surgical Nursing Home, Kurla west, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Mandar Agashe,
Consultant paediatric Orthopaedic surgeon, Dr. Agashe`s Maternity & Surgical Nursing Home, Kurla west, Mumbai, Maharashtra, India.
E-mail: mandarortho@gmail.com

Abstract

Intra-articular patella dislocations are uncommon, but the majority of cases can be reduced by closed methods. We present a rare case that required open reduction and highlight the reasons and present a review of the same.
We describe a rare case of horizontal intra-articular patella dislocation associated with an intact periosteal sleeve and extensor retinaculum in a 13-year-old boy requiring open reduction.
Horizontal intra-articular patellar dislocation is an uncommon injury, especially in the adolescent age group. Open reduction should only be performed if closed reduction is unsuccessful.
Keywords: Horizontal intra-articular dislocation of patella, Intact periosteal sleeve, Open reduction.

References 

1. Pagdal S, Lande O, Jadhav U. Intra-articular dislocation of patella reduced by closed method – A rare case report. J Clin Orthop trauma [Internet]. 2016;7(Suppl 1):118–20. Available from: http://dx.doi.org/10.1016/j.jcot.2016.03.002.
2. Uluyardımcı E, Bozkurt İ, Öçgüder DA, Yalçın N. Unusual Horizontal Patellar Dislocation Reduced without General Anesthesia. JBJS Case Connect [Internet]. 2019 Jan;9(1):e2. Available from: http://insights.ovid.com/crossref an=01709767-201903000-00003.
3. Rangdal S, Bachhal V, Vashisht S, Dhillon MS. Intra-articular dislocation of the patella: a rare variant to an uncommon injury. BMJ Case Rep [Internet]. 2019 Apr 24;12(4). Available from: http://www.ncbi.nlm.nih.gov/pubmed/31023730.
4. Shaw DL, Giannoudis P V., Archer IA. Intra-articular dislocation of patella. Injury [Internet]. 1995 May;26(4):273–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7649634.
5. Bashir S, Manan A, Wani D, Tantray O, Beigh M, Sharma R. Bilateral intra-articular dislocation of patella in an elderly: a rare presentation. Internet J Orthop Surg. 2010;19(1).
6. Fithian DC, Paxton EW, Stone M Lou, Silva P, Davis DK, Elias DA, et al. Epidemiology and natural history of acute patellar dislocation. Am J Sports Med [Internet]. 32(5):1114–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15262631.
7. Kramer DE, Simoni MK. Horizontal intra-articular patellar dislocation resulting in quadriceps avulsion and medial patellofemoral ligament tear: a case report. J Pediatr Orthop B [Internet]. 2013 Jul;22(4):329–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22828187.
8. Tsai C-H, Hsu C-J, Hung C-H, Hsu H-C. Primary traumatic patellar dislocation. J Orthop Surg Res [Internet]. 2012;7(1):21. Available from: http://josr-online.biomedcentral.com/articles/10.1186/1749-799X-7-21.
9. Venkatesh Gupta SK, H P P, Prathik R, Jeetesh L. Traumatic Intra-articular Intercondylar Dislocation of the Patella Reduced by the Closed Method with Open Quadriceps Repair in an Adolescent: A Rare Case Report. Cureus [Internet]. 2018 Dec 8; Available from: https://www.cureus.com/articles/14706-traumatic-intra-articular-intercondylar-dislocation-of-the-patella-reduced-by-the-closed-method-with-open-quadriceps-repair-in-an-adolescent-a-rare-case-report.
10. McHugh G, Ryan E, Cleary M, Kenny P, O’Flanagan S, Keogh P. Intra-Articular Dislocation of the Patella. Case Rep Orthop [Internet]. 2013;2013:1–3. Available from: http://www.hindawi.com/journals/crior/2013/535803/
11. Al Khalifa A, Syed K. Intra-articular dislocation of patella with femoral impaction—A case report and review of literature. Int J Surg Case Rep [Internet]. 2019;59:176–9. Available from: https://doi.org/10.1016/j.ijscr.2019.05.041.
12. van den Broek TAA, Moil PJ. Horizontal rotation of the patella: A case report with review of the literature. Acta Orthop Scand [Internet]. 1985 Jan 8;56(5):436–8. Available from: http://www.tandfonline.com/doi/full/10.3109/17453678508994367.
13. Berenger V, Pesenti S, Ollivier M, Buord J-M, Pinelli P-O. Traumatic inter-condylar dislocation of the patella: Report of two cases. Orthop Traumatol Surg Res [Internet]. 2013 Dec;99(8):979–81. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1877056813002077.
14. Potini VC, Gehrmann RM. Intra-Articular Dislocation of the Patella With Associated Hoffa Fracture in a Skeletally Immature Patient. Am J Orthop (Belle Mead NJ) [Internet]. 2015 Jun;44(6):E195-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26047005.

How to Cite this Article:  Shah M, Shah A, Agashe M  | Horizontal Intra-articular dislocation of patella with intact periosteal sleeve in an adolescent: Case report and review of literature | International Journal of Paediatric Orthopaedics | January-April 2021; 7(1): 22-26.

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Elbow, Forearm and Wrist Issues in Brachial Plexus Birth Palsy: Current Concepts

Volume 7 | Issue 1 | January-April 2021 | Page: 55-64 | Praveen Bhardwaj, Darshan Kumar A Jain, Maulin M Shah, Rujuta Mehta, Badarinath Athani

Authors: Praveen Bhardwaj MS Ortho., DNB Ortho. FNB [1], Darshan Kumar A Jain MS Ortho., FNB [2],
Maulin M Shah MS Ortho. [3], Rujuta Mehta MS Ortho. DNB Ortho. [4], Badarinath Athani MS Ortho., DNB (PMR) [5]

[1] Consultant Hand and Reconstructive Microsurgeon, Ganga Hospital, Coimbatore, Tamil Nadu, India.
[2] Consultant Hand and Reconstructive Microsurgeon. Ramaiah Hospitals, Bangalore, Karnataka, India.
[3] Consultant Paediatric Orthopaedic Surgeon, Orthokids Clinic, Ahmedabad, Gujarat, India.
[4] HOD Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India.
[5] Principle consultant Safdarjung Hospital, Vardhaman Mahavir Medical College, New Delhi, India.

Address of Correspondence
Dr. Praveen Bhardwaj ,
Consultant Hand and Reconstructive Microsurgeon, Ganga Hospital, Coimbatore, Tamil Nadu, India.
E-mail: drpb23@gmail.com

Abstract

The variable presentation of the sequelae of brachial plexus birth palsy (BPBP) at the elbow, forearm and wrist and their association with much extensive brachial plexus involvement makes reconstruction at these levels demanding . Functional limitation and cosmetic concern are common indications for surgical intervention. This article presents a synopsis of the incidence, pathogenesis, clinical presentation and parental concerns related to these deformities, decision-making considerations, management strategies and expected outcome for correction of these deformities. Deformities at the forearm and wrist can be often corrected simultaneously as they could be interrelated. The pattern of deformities, their severity and their impact on the overall function of the limb and parental concern differ. Each child needs a tailor-made management plan, weighing the expected outcome against parental expectation.
Keywords: Brachial plexus birth palsy, Forearm deformity, Supination deformity, Elbow flexion deformity, Pronation deformity, Ulnar deviation deformity.

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How to Cite this Article:  Bhardwaj P, Jain DA, Shah MM, Mehta R, Athani B | Elbow, Forearm and Wrist Issues in Brachial Plexus Birth Palsy: Current Concepts | International Journal of Paediatric
Orthopaedics | January-April 2021; 7(1): 55-64.

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