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This diagram shows the Hoffer procedure, a transfer of the latissimus dorsi and teres major muscles to the rotator cuff posteriorly through a transaxillary approach. This procedure is designed primarily to improve external rotation of the shoulder
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Obstetric brachial plexus injuries (OBPP) are a relatively common stretch injury of the brachial plexus that occurs during delivery. Roughly 30 % of patients will not recover completely and will need a surgical repair. Two main treatment strategies have been used: primary surgery, consisting in exploring and reconstructing the affected portions of...
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Purpose: To compare results from our surgical treatment experiences in children with obstetric brachial plexus injuries (OBPI), to those who have had other surgical treatments. Methods: We conducted a retrospective study in our medical records consisting of two groups of OBPI patients. Group 1: 26 OBPI children (16 girls and 10 boys), age range bet...
Citations
... However, current conservative management for patients with OBP is not standardized, highlighting the limitations and the need for the development of international consensus clinical guidelines [7]. In contrast, if there is no muscle activity in the first 3 months or if Horner syndrome is present, magnetic resonance imaging should be requested to assess the extent of the lesion or identify neuromas to determine the need for surgical treatment either for grafting or nerve transfer depending on the case, which should be performed before the age of 9 months to prevent permanent damage to the motor plate of the affected muscle [14,[17][18][19]. ...
Background
Obstetric brachial palsy (OBP) is a pathology caused by complications during childbirth because of cervical spine elongation, affecting the motor and sensory innervation of the upper limbs. The most common lesion occurs on the C5 and C6 nerve branches, known as Erb-Duchenne palsy. The least common lesion is when all nerve roots are affected (C5-T1), which has the worst prognosis. Virtual reality (VR) is commonly used in neurological rehabilitation for the evaluation and treatment of physical deficits.
Objective
This systematic review aims to assess the efficacy of VR in the rehabilitation of upper limb function in patients with OBP.
MethodsA search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines in several scientific databases—PubMed, Web of Science, PEDro, Cochrane, MEDLINE, Scopus, and CINAHL—without language or date restrictions and including articles published up to April 2023. The inclusion criteria were established according to the population, intervention, comparison, outcome, and study (PICOS) design framework: children aged
... Interventions for existing pathoanatomy can be termed secondary procedures [23]. These can be categorized under several headings: relaxation of contractures, tendon transfers and removal of muscle imbalances, joint reduction, nerve decompression and osteotomies [14]. ...
Since the natural course of obstetric brachial plexus palsy is variable, several problems are encountered. One important question, in considering patients with OBPP under observation in outpatient clinical settings, is whether children will have length discrepancies in their arms. The aim of this study was to determine differences in the length of the affected extremity, in comparison to the opposite upper extremity. As such, 45 patients, aged 6 months to 18 years, with unilateral brachial plexus palsy developed due to obstetric reasons, were included in the study. Affected and healthy side humerus, ulna, radius, 2nd metacarpal and 5th metacarpal lengths were evaluated according to gender, age, side, Narakas classification, primary and secondary surgery. Statistically significant differences were found in the change rates of affected/healthy humerus, radius, 2nd metacarpal and 5th metacarpal lengths according to age (93%, 95%, 92%, 90% and 90%, respectively). Affected/healthy change rates of ulna, radius, 2nd metacarpal and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to the Narakas classification variable (94%, 92%, 95%, 94% and 94%, respectively). There were no statistically significant differences in the ratios of affected/healthy change in the lengths of the humerus, ulna, radius and 5th metacarpal compared to the primary surgery (p > 0.05). The ratios of affected/healthy change in ulna, radius and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to secondary surgeries (93%, 91%, 91% and 92%, respectively). Joint and bone deformities and bone shortening were observed after changes that occurred in the postnatal and growing periods due to obstetric brachial plexus palsy. Every increase in function to be gained in the upper extremity musculature was also potentially able to reduce problems, such as shortness.
... [1][2][3] With a prevalence of 2.9/1000 in live births, the clinical manifestations of BPBP varies according to the number of the affected nerves and the severity of the traumatic injury. [3][4][5] Although prompt physical therapy and surveillance enables total recovery in most of the patients, permanent joint stiff-the physical therapy and to maintain the anatomic growth of the shoulder and the elbow joints. [8,9] However, recurring botulinum toxin injections may cause muscular atrophy and the clinical effects of these injections on the future tendon transfers of the injected muscles are uncertain. ...
Background:
In brachial plexus birth palsy (BPBP), botulinum toxin may be utilized to prevent glenohumeral dysplasia and to maintain the stable growth of the glenohumeral joint. Repeated injections may cause muscular atrophy and their functional effects are uncertain. The aim of this study was to compare the microstructure and the function of the muscles that received two injections before transfer with the muscles that were not injected.
Methods:
BPBP patients that were operated between January 2013 and December 2015 were included in the study. Latissimus dorsi and teres major muscles were transferred to humerus in standard fashion. Patients were divided in two groups according to bo-tulinum toxin status. Group 1 was toxin negative whereas Group 2 was toxin positive. For each patient, mean latissimus dorsi myocyte thickness (LDMT) was measured with electron microscopy and pre-operative and post-operative active shoulder abduction, flexion, external and internal rotation, and Mallet scores were evaluated with goniometry.
Results:
Fourteen patients (seven patients per group) were evaluated. Five patients were female whereas nine were male. Mean LDMT was not affected significantly (p>0.05). The operation improved shoulder abduction, flexion, and external rotation significantly (p<0.05), independent of the toxin status. The internal rotation decreased significantly only in Group 2 (p<0.05). The Mallet score increased in both groups, but it was not significant (p>0.05), independent of the toxin status.
Conclusion:
Botulinum toxin that was applied twice prevented glenohumeral dysplasia and it did not cause permanent latissimus dorsi muscle atropy and function loss in late period. It augmented upper extremity functions by alleviating internal rotation contracture.
... Tradicionalmente se ha seguido una actitud conservadora para la intervención de la PBO, basada principalmente en esperar a ver el grado de recuperación espontánea y después plantear tratamientos quirúrgicos paliativos, como transferencia de tendones, osteotomías o artrodesis. Sin embargo, en la actualidad se tiende al tratamiento quirúrgico precoz en los primeros meses 9 . Al respecto, la recuperación del bíceps a los 2 meses de vida predice, en la mayoría de los casos, una recuperación espontánea y completa, mientras que la ausencia de contracción a los 3 meses pronostica la necesidad de realizar tratamiento quirúrgico 10 , cuyos resultados han demostrado ser beneficiosos siempre que sean seguidos por rehabilitación 11 . ...
Introducción: La parálisis braquial obstétrica (PBO) es una parálisis flá- cida del brazo asociada a eventos adversos durante el parto y que lesiona los nervios de las raíces cervicales C5 a T1. Convencionalmente, su rehabilitación es mediante intervenciones kinésicas y de terapia ocupacional (TC), o bien con una herramienta innovadora: asistencia robótica y realidad virtual llamada Armeo®Spring Pediatric (Armeo). Entonces, el objetivo de investigación fue comparar la efectividad del Armeo con la TC en la función de la extremidad superior. Materiales (o pacientes) y Métodos: Ensayo clínico controlado, paralelo, aleatorizado con enmascaramiento simple. Participaron 10 usuarios/ as activos entre 5 y 8 años de edad con PBO, Narakas I, del Instituto Teletón Concepción. Se realizaron 15 entrenamientos de 45 minutos cada uno, 3 veces por semana, evaluando según escala de Mallet y rangos articulares de movimiento pasivo (ROM) post intervención, a 3 y 6 meses. Resultados: Hubo diferencias estadísticas significativas en la escala Mallet: Rotación externa a 3 y 6 meses, Mano-cabeza post intervención y en el puntaje Total post intervención, a 3 y 6 meses. Según la evaluación ROM, dichas diferencias se registraron en Abducción a 3 y 6 meses. En todos estos indicadores la TC tuvo mejores efectos y más perdurables. Conclusiones: Los resultados obtenidos con el Armeo requieren de un ambiente especializado para perdurar en el tiempo, mientras que los obtenidos con la TC perduran más, dada la mayor variedad de experiencias sensoriomotoras que ésta ofrece y por la posibilidad de practicar cotidianamente lo aprendido en los entrenamientos.
... Pediatric patients also underwent shoulder arthroscopy for obstetric brachial plexus birth palsy, usually corrected during the first few years of life and rarely extending to adulthood. 34 In this study, variability in reported outcome scores and follow-up duration of the current literature made it difficult to draw specific conclusions about the clinical impact of shoulder arthroscopy in pediatric patients. An additional barrier to determining the outcomes and cause of the complication rate of up to 25% is the variability of surgical approach, particularly for instability patients. ...
Purpose
The purpose of this review was to systematically evaluate the literature on pediatric shoulder arthroscopy and outline its indications, outcomes, and complications.
Methods
This systematic review was carried out in accordance with PRISMA guidelines. PubMed, Cochrane Library, ScienceDirect, and OVID Medline were searched for studies reporting the indications, outcomes, or complications in patients undergoing shoulder arthroscopy under the age of 18 years. Reviews, case reports, and letters to the editor were excluded. Data extracted included surgical techniques, indications, preoperative and postoperative functional and radiographic outcomes, and complications. The methodological quality of included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool.
Results
Eighteen studies, with a mean MINORS score of 11.4/16, were identified, including a total of 761 shoulders (754 patients). Weighted average age was 13.6 years (range, 0.83-18.8 years) with a mean follow-up time of 34.6 months (range, 6-115). As part of their inclusion criteria, 6 studies (230 patients) recruited patients with anterior shoulder instability and 3 studies recruited patients with posterior shoulder instability (80 patients). Other indications for shoulder arthroscopy included obstetric brachial plexus palsy (157 patients) and rotator cuff tears (30 patients). Studies reported a significant improvement in functional outcomes for arthroscopy indicated for shoulder instability and obstetric brachial plexus palsy. A significant improvement was also noted in radiographic outcomes and range of motion for obstetric brachial plexus palsy patients. The overall rate of complication ranged from 0% to 25%, with 2 studies reporting no complications. The most common complication was recurrent instability (38 patients of 228 [16.7%]). Fourteen of the 38 patients (36.8%) underwent reoperation.
Conclusion
Among pediatric patients, shoulder arthroscopy was indicated most commonly for instability, followed by brachial plexus birth palsy, and partial rotator cuff tears. Its use resulted in good clinical and radiographic outcomes with limited complications.
Level of Evidence
Systematic review of Level II to IV studies.
... Although there are no Level 1 evidence-based studies investigating surgical treatment of NBPP against spontaneous recovery in a randomized manner, poor functional outcomes of spontaneous recovery have been found in NBPP patients . Thirty percent of patients are unable to fully recover through a conservative approach and require surgical repair, including primary and secondary surgeries (Socolovsky et al., 2016). For this reason, many surgeons have recommended early microsurgical nerve repair for severe brachial plexus palsy (Chuang & Ma, 2004). ...
Background:
Neonatal brachial plexus palsy (NBPP) is a serious complication of high-risk deliveries with controversy surrounding timing of corrective nerve surgery. This review systematically examines the existing literature and investigates correlations between age at time of upper trunk brachial plexus microsurgery and surgical outcomes.
Methods:
A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA-IPD guidelines was conducted in January 2020 to include full-text English papers with microsurgery in upper trunk palsy, pediatric patients. Spearman rank correlation analysis and two-tailed t-tests were performed using individual patient data to determine the relationship between mean age at time of surgery and outcome as determined by the Mallet, Medical Research Council (MRC), or Active Movement Scale (AMS) subscores.
Results:
Two thousand nine hundred thirty six papers were screened to finalize 25 papers containing individual patient data (n = 256) with low to moderate risk of bias, as assessed by the ROBINS-I assessment tool. Mallet subscore for hand-to-mouth and shoulder abduction, AMS subscore for elbow flexion and external rotation, and MRC subscore for elbow flexion were analyzed alongside the respective age of patients at surgery. Spearman rank correlation analysis revealed a significant negative correlation (ρ = -0.30, p < .01, n = 89) between increasing age (5.50 ± 2.09 months) and Mallet subscore for hand-to-mouth (3.43 ± 0.83). T-tests revealed a significant decrease in Mallet hand-to-mouth subscores after 6 months (p < .05) and 9 months (p < .05) of age. No significant effects were observed for Mallet shoulder abduction, MRC elbow flexion, or AMS elbow flexion and external rotation.
Conclusion:
The cumulative evidence suggests a significant negative correlation between age at microsurgery and Mallet subscores for hand-to-mouth. However, a similar correlation with age at surgery was not observed for Mallet shoulder abduction, MRC elbow flexion, AMS external rotation, and AMS elbow flexion subscores.
... Guidelines for patients with OBPI recommend early referral to multidisciplinary centers (at 1 month of age) (3). If no recovery occurs, early surgery is indicated at 3-9 months after birth, depending on the extent and severity of the injury (4). ...
... The efforts that had already been pursued to improve the situation did not lead to satisfactory results for the patient. Furthermore, surgical procedures to improve function in severe Narakas IV lesions of the plexus are limited and restoring meaningful hand function is challenging (4). A case report of three female adults undergoing a modified Quad surgery, which is a combination of muscle transpositions, resulted in an improvement of the total modified Mallet Score in two of them after the surgery (5). ...
Introduction: Many adults who had a severe Narakas IV obstetric brachial plexus injury (OBPI) suffer from extensive impairments in daily living due to limited hand-arm function. The dramatic loss of axonal support at this very early age of development often render the entire extremity a biologic wasteland and reconstructive methods and therapies often fail to recover any functional hand use. In this scenario bionic reconstruction, including an elective amputation and a subsequent prosthetic fitting, may enable functional improvement in adults suffering from the consequences of such severe brachial plexus injuries. We here describe our experience in treating such patients and lay out the surgical rational and rehabilitation protocol exemplified in one patient.
Case Presentation/Methods: A 27-year-old adult with a unilateral OBPI contacted our center. He presented with globally diminished function of the affected upper extremity with minimal hand activity, resulting in an inability to perform various tasks of daily living. No biological reconstructive efforts were available to restore meaningful hand function. An interdisciplinary evaluation, including a psychosocial assessment, was used to assess eligibility for bionic reconstruction. Before the amputation and after the prosthetic fitting functional assessments and self-reported questionnaires were performed.
Results: One month after the amputation and de-rotation osteotomy of the humerus the patient was fitted with a myoelectric prosthesis. At the 1.5 year-follow-up assessment, the patient presented with a distinct improvement of function: the ARAT improved from 12 to 20 points, SHAP score improved from 8 to 29, and the DASH value improved from 50 to 11.7. The average wearing times of the prosthesis were 5 to 6 h per day (on 4–5 days a week).
Discussion: The options for adults suffering from the consequences of severe OBPIs to improve function are limited. In selected patients in whom the neurological deficit is so severe that biologic hand function is unsatisfactory, an elective amputation and subsequent restoration of the hand with mechatronic means may be an option. The follow-up results indicate that this concept can indeed lead to solid hand function and independence in daily activities after amputation, subsequent prosthetic fitting, and rehabilitation.
... The timing of the surgical reconstruction has always been strongly dependent on the process of spontaneous regeneration [3]. As the time allotted for spontaneous regeneration passes and no clear clinical and electrophysiological signs of regeneration are seen, the majority of surgeons advocate for active surgical reconstruction [4]. ...
... The dynamics of spontaneous regeneration are well described in newborns with obstetric BPI [4,5]. It is often accompanied by co-contractions (Co-C) of de novo reinnervated muscles [6], which respond well to injections of botulinum toxin A [7]. Less information can be found concerning the management of the Co-C in cases of a-BPI [8]. ...
A certain number of spontaneously recovering birth injuries to the brachial (BPI) plexus are known to be accompanied by muscle co-contractions (Co-Cs). The process of aberrant spontaneous regeneration contributes to the appearance of this phenomenon. Treatment strategies are mostly narrowed down to temporarily “switching off” the antagonist, allowing the agonist to perform. Less is known about the incidence of BPI-associated Co-Cs in adults (a-BPI), the control of which mainly presumes the extrapolation of a treatment strategy that has been shown to be effective in infants. Nowadays, surgical reconstruction of independent elbow flexion at BPIs relies heavily on redirection (transfer) of nerves that produce their own Co-Cs. These induced Co-Cs could potentially be reduced. Selecting the appropriate nerve transfer strategy (when the donor pool is narrowing), with its potential impact on the already complex and intricate global and segmental biomechanics of the upper extremity, becomes challenging. The chapter presents the anatomical background for the occurrence of muscular Co-Cs, a work on clinical classification of both regeneration associated and induced Co-Cs, possible surgical strategies, their benefits and limitations, in the presence of regeneration-associated muscle Co-Cs at a-BPI and clinical examples.
... The clinical assessment should include a thorough history (including gestational and birth history) and a careful and complete physical examination. [11][12][13][14] History and physical examination should be directed toward the following goals: ...
... In addition to motor testing and localization, other findings like presence of Horner syndrome (usually associated with a proximal injury to C8 and/or T1 and correspondingly predictive of a persistent deficit), asymmetrical chest expansion (may suggest injury to the phrenic nerve and hemidiaphragm paralysis), joint subluxation, or contractures should also be assessed clinically. 12,13,15 Magnetic resonance Imaging (MRI) of cervical spine and brachial plexus may show evidence of nerve root avulsion such as pseudomeningocele or a pseudomeningocele with absent rootlets. 15,16 The utility of electrodiagnostic tests is debated, especially in children as they are difficult to perform on infants. ...
... Absent fibrillations most likely points toward neuropraxia, while absent sensory conductions may be diagnostic of avulsion of nerve root from the spinal cord. [12][13][14][15][16] ...
Neonatal brachial plexus injuries are a common type of birth injury. Although sponta- neous recovery occurs in most of the cases, there is a large subset of cases in which recovery does not happen and primary or secondary surgical interventions are required. With the advancement of microsurgical techniques, the results of nerve surgery are encouraging. Good results are possible with timely surgical intervention even in severe cases. In this review article, in addition to the anatomy, etiology, and pathophysiology of neonatal brachial plexus injuries, the importance of timely surgical intervention and various primary and secondary surgical procedures are discussed in detail.
... Early plexus reconstruction ≤3 months) offers the best functional results and reduces the need for secondary reconstructions [10], [15]. Two main treatment strategies have been used: primary surgery consists of the exploration and reconstruction of the affected part of the brachial plexus, and secondary procedures that include tendon or muscle transfer, ost€eotomy, and other orthopedic techniques. ...
BACKGROUND: Brachial plexus injury (BPI) is one of the most devastating nerve injuries to the extremities. BPI in adults is an increasingly common clinical problem due to road traffic accident. Injury patterns, the timing of surgery, priority on the recovery of function, and patient’s understanding about the expectations of the prognosis are things that are important to consider before deciding on surgical management. The coronavirus pandemic coronavirus disease 2019 (COVID-19) has significantly affected all sectors, one of which is a surgical practice both in terms of medical personnel and equipment, also patient perceptions of hospital services. AIM: This study will analyze epidemiological data on BPI patients who underwent surgery during the COVID-19 pandemic. METHODS: A retrospective descriptive study of BPI profile in Prof. Soeharso Orthopedic Hospital before (2019) and during (2020) the COVID-19 pandemic. Demographic data, the total number of surgery, type of surgical procedure, and patient origin were collected. We compared to the same period in 2019 before pandemic started. RESULTS: In the data obtained from patients treated or undergoing BPI surgery before pandemic (March 1, 2019 to December 31, 2019) and during the pandemic (March 1, 2020 to December 31, 2020), Indonesia first confirms case was on March 2, 2020, until today. There were 51 and 43 cases, respectively. Panplexal type before the pandemic there were 27 patients (52%), and during the pandemic were 20 patients (46%), the upper type before: during the pandemic was 24 (48%): 23 (54%), and lower type 0 cases. Primary reconstruction before: during the pandemic was 26 (55%): 27 (62%) case, and secondary reconstruction before: during the pandemic was 25 (49%): 16 (38%) case, respectively. CONCLUSION: COVID-19 pandemic has no significant effect in the term of the number of BPI surgery performed. Better outcome in BPI surgery is influenced by the timing of the operation, therefore primary reconstruction remains the main choice for BPI patients with safety concern or health protocols. Pre-operative screening applied in our hospital includes laboratory examination, chest radiograph, and polymerase chain reaction swab test. Surgical personnel using personal protective equipment such as protective suit, face shield, google, shoes and medical mask during the COVID-19 pandemic. Patients with significant axon loss and limited clinical recovery are considered “urgent”, as surgery should be performed within 6 months or sooner (depending upon the distance to recipient’s muscle) to avoid irreversible muscle atrophy and degradation of motor endplates.
