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Improving shoulder and elbow function in children with Erb's palsy
Abstract
Many children who sustain birth injuries to the brachial plexus suffer significant functional limitations due to various sequelae affecting the shoulder and elbow or forearm. The maintenance of full passive mobility during the period of neurological recovery is essential for normal joint development. Early surgical correction of shoulder contractures and subluxations reduces permanent deformity. Reconstruction of forearm rotation contractures significantly improves the appearance and use of the extremity for many basic activities. Each child must be carefully evaluated, therapy maximized, and the surgical approach individualized to obtain the best result.
... Although the majority of infants with NBPP recover with conservative management, 10%-30% require more aggressive treatment, which may include surgical nerve repair or brachial plexus reconstruction [2,3]. Exercise therapy remains an essential component of treatment for all patients with NBPP [2,4] to maintain range of motion (ROM) and muscle strength, and to prevent contractures and joint deformities in the children's affected arm [5,6]. ...
... Biceps power increased significantly, from an average MRC grade 2 to grade 3 at follow-up, which indicates an acquired ability to perform antigravity movements. The lack of significant change in shoulder passive ROM may reflect the observation that these movements are historically difficult to improve [5], particularly external rotation in abduction and adduction, and, consequently, are closely monitored and targeted by therapists [2,6]. However, in the absence of exercise therapy or surgical treatment as indicated, the natural course of NBPP in children results in loss of muscle strength and a decline in ROM, possibly leading to contracture development and joint deformity [1,6]. ...
... The lack of significant change in shoulder passive ROM may reflect the observation that these movements are historically difficult to improve [5], particularly external rotation in abduction and adduction, and, consequently, are closely monitored and targeted by therapists [2,6]. However, in the absence of exercise therapy or surgical treatment as indicated, the natural course of NBPP in children results in loss of muscle strength and a decline in ROM, possibly leading to contracture development and joint deformity [1,6]. Although caregiver confidence increased after receiving the DVD, and some functional measures improved significantly for children who received the DVD, throughout the course of the study, no consistent statistically significant relationship between improved caregiver confidence and functional outcomes was found. ...
To investigate the impact of a video-based educational resource on home exercise compliance among caregivers of children with neonatal brachial plexus palsy (NBPP).
Retrospective analysis of self-reported caregiver home exercise habits and resultant shoulder range of motion (ROM) and biceps power in patients with NBPP.
Home-based exercise program.
Adult caregivers of children with NBPP followed up through the Brachial Plexus Program at the University of Michigan (N = 83 surveyed initially, with N = 37 completing the final survey).
Caregivers completed surveys before and approximately 3, 6, and 12 months (times A, B, and C, respectively) after receiving the "Home Exercise Therapy Program for Brachial Plexus Palsy" digital video disk (DVD). A retrospective analysis of shoulder ROM and biceps power of patients was completed as representative of arm function during the study.
Surveys assessed home exercise compliance, resources used to guide exercises, and caregiver confidence in the correctness of exercises being performed. Functional outcomes analyzed include biceps strength and shoulder active and passive ROM.
Home exercise compliance increased from 74% initially to 96% at time A (P < .001), remained at 94% at time B (P < .001), and fell to 84% at time C (P = .016). Use of the DVD to guide home exercise decreased from 69% at time A to 57% at time B and C (P = .026). After receiving the DVD, exercise frequency and caregiver confidence increased. Although some measures of shoulder active ROM and biceps power improved during the course of the study, there was no consistent statistically significant relationship between increased caregiver confidence and functional outcomes. No causal relationship exists between DVD content and functional status at this time.
As the first formal evaluation of a video-based resource guiding exercise therapy for children with NBPP, we suggest that this population may be receptive to alternative media and may benefit from dynamic modeling of home exercises.
... Typically, a home stretching program is initiated at around age 1 week 11,25 and is supplemented with formal therapy. 4,5,11,25,27,28 The mainstay of treatment has been passive GH external rotation stretching with scapular stabilization, 4e6, 9,12,13,23,25,28,29 but passive GH stretching in other planes, such as abduction, while maintaining scapular stabilization has also been recommended. 4,12,30 This intervention requires a therapist or caretaker to stabilize the scapula firmly against the rib cage while positioning the humerus into the desired orientation. ...
... Typically, a home stretching program is initiated at around age 1 week 11,25 and is supplemented with formal therapy. 4,5,11,25,27,28 The mainstay of treatment has been passive GH external rotation stretching with scapular stabilization, 4e6, 9,12,13,23,25,28,29 but passive GH stretching in other planes, such as abduction, while maintaining scapular stabilization has also been recommended. 4,12,30 This intervention requires a therapist or caretaker to stabilize the scapula firmly against the rib cage while positioning the humerus into the desired orientation. ...
Purpose:
To quantify the effects of scapular stabilization on scapulothoracic and glenohumeral (GH) stretching.
Methods:
Motion capture data during external rotation and abduction with and without scapular stabilization were collected and analyzed for 26 children with brachial plexus birth palsy. These positions were performed by an experienced occupational therapist and by the child's caretaker. Scapulothoracic and GH joint angular displacements were compared between stretches with no stabilization, stabilization performed by the therapist, and stabilization performed by the caretaker. The relationship between the age and ability of the therapist and caretaker to perform the stretches with scapular stabilization was also assessed.
Results:
During external rotation there were no significant differences in either the scapulothoracic or GH joint during stabilization by either the therapist or the caretaker. During abduction, both scapulothoracic and GH joint angular displacements were statistically different. Scapulothoracic upward rotation angular displacement significantly decreased with scapular stabilization by the therapist and caretaker. Glenohumeral elevation angular displacement significantly decreased with scapular stabilization performed by the therapist and caretaker. There were only weak correlations between age and the differences in scapulothoracic and GH joint angular displacement performed by both the therapist and the caretaker.
Conclusions:
The findings of this study indicate that scapular stabilization may be detrimental to passive stretching of the GH joint in children, as demonstrated by a reduced stretch. Based on the findings of this study, we have changed our practice to recommend passive stretches without scapular stabilization for children aged 5 years and older with brachial plexus birth palsy. In infants and children aged less than 5 years, we now recommend stretching with and without scapular stabilization until the effect of scapular stabilization is objectively assessed in these age groups.
Level of evidence/type of study:
Therapeutic IV.
... However, some investigators do report a higher prevalence of shoulder deformity in Narakas group I-II children, suggesting that global muscle weakness in Narakas group III-IV produces a lesser degree of muscle imbalance [20,24,42]. Because all Narakas groupings include injury of the C5 and C6 nerve roots (primary nerve root innervation to the shoulder muscles), we would not expect an association between higher Narakas groupings and the presence of PSS [39,43]. Despite the favorable prognostic outlook of 69%-90% functional recovery in Narakas groups I and II [44], we suggest that all practitioners be aware that PSS occurs with similar prevalence, regardless of the extent of nerve root injury in NBPP. ...
... Resultant shoulder function (PROM and AROM) is closely associated with the degree of deformation of the glenoid as well as with the extent of posterior humeral head dislocation [40], but our study demonstrates that AROM may be the more important factor associated with PSS. Because AROM is limited functionally by PROM, we support the use of early full-arc PROM exercises, consistent with that proposed by other investigators [4,43], with attention to scapular stabilization during external rotation movement [13,50]. Survey responses indicated that all families performed full-arc PROM exercises and that 78% of children (36 of 46) performed the exercises at a frequency of at least once daily. ...
Children with neonatal brachial plexus palsy (NBPP) are often prescribed shoulder range of motion (ROM) exercises; however, extent and timing of exercise implementation remains controversial in the context of shoulder joint integrity. The association of ROM exercises to delayed posterior shoulder subluxation (PSS) is unknown.
To determine prevalence of PSS in children with NBPP who began full passive ROM exercises before 6 months of age, and children characteristics associated with development or absence of PSS.
Cross-sectional study.
Tertiary care NBPP referral center.
Forty-six children with NBPP aged 24-57 months, who initiated full ROM exercises before 6 months of age.
One radiologist conducted bilateral shoulder ultrasound on each child to evaluate for PSS. One occupational therapist evaluated each child clinically for PSS using defined parameters without knowledge of ultrasound results.
By ultrasound, 20% of children had PSS; 46% had PSS by clinical examination. Shoulder active ROM limitations and history of shoulder surgery were associated with presence of PSS. Extent of NBPP was not associated with PSS.
Nine of 46 children (20%) met ultrasound criteria for PSS; alpha angle was 58±21 degrees (mean±SD). Twenty-one children (46%) met clinical criteria. Mean age at examination was 35±10 months. Shoulder active ROM (P≤.004) was associated with PSS, whereas passive ROM was not (P≥.08). History of secondary shoulder surgery and primary nerve graft repair were associated with PSS (P=.04). Extent of NBPP by Narakas classification was not associated with PSS (P=.48).
Early use of full-arc passive ROM home exercise program is not associated with increased prevalence of PSS in children with NBPP compared to prevalence of PSS in published literature. We suggest careful clinical examination, based on defined criteria, provides a reasonable screening examination for evaluating PSS that can be confirmed by non-invasive ultrasound.
Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
... Several groups have advocated for early referral, but to date the impact of early management at a specialty center on functional recovery has not been demonstrated. 3,[12][13][14] In this study, we interrogated a prospectively collected database of conservatively managed children with NBPP evaluated or treated at a single multidisciplinary specialty NBPP center over a 15-year period to demonstrate the trajectory of recovery of active range of motion (AROM) at the shoulder and elbow over time. Specifically, we tested the hypothesis that nonsurgically treated patients with NBPP spontaneously recover full AROM with time, and we ask whether early referral to a specialty center alters the trajectory or maximal extent of recovery (or both). ...
Aim
To demonstrate the trajectory of long‐term recovery of upper‐extremity movement and determine optimal timing of evaluation at multidisciplinary specialty centers in children with neonatal brachial plexus palsy (NBPP).
Method
All children with conservatively managed NBPP seen at one institution from 2005 to 2020 were considered for inclusion. The cohort was divided according to age at formal evaluation (≤30 or > 30 days). Active range of motion (AROM) for shoulder and elbow movements collected at each appointment were compared in local age windows between early and late cohorts. Locally estimated scatterplot smoothing was used to demonstrate the trajectory of recovery for the overall cohort.
Results
More than 13 000 prospectively collected data points for 429 children (220 males, 209 females) were analysed. Elbow flexion improved to nearly full AROM for both groups over the course of the study. Shoulder abduction, forward flexion and external rotation, and forearm supination improved for the entire cohort, although greater absolute improvement, particularly at the shoulder, was seen in the early cohort (age at formal evaluation ≤30 days). AROM for elbow extension remained roughly stable for the early cohort but decreased for the late cohort (age at formal evaluation >30 days). AROM for forearm pronation decreased over time for both cohorts.
Interpretation
Our data demonstrate good long‐term functional recovery for children with conservatively managed NBPP. However, early referral to multispecialty brachial plexus centers may optimize outcomes.
What this paper adds
Many children with conservatively managed neonatal brachial plexus palsy have good long‐term shoulder and elbow outcomes.
Early referral to multidisciplinary clinics may maximize long‐term shoulder and elbow recovery and optimize outcomes.
... 1 This kind of injury leads to motor and sensory lesions in the upper limbs that usually culminates with neuropathic pain, joint stiffness, and muscular weakness. [2][3][4] As the trauma predominantly affects the upper limbs, most studies regarding the consequences of TBPI focus on motor recovery. [4][5][6][7][8] Conversely, the repercussions of TBPI on exercise capacity and diaphragm mobility in those patients who have not undergone nerve transfer surgery is still unknown. ...
Objective:
To investigate the repercussions of traumatic brachial plexus injury (TBPI) on diaphragmatic mobility and exercise capacity, compartmental volume changes, as well as volume contribution of each hemithorax and ventilation asymmetry during different respiratory maneuvers, and compare with healthy individuals. The velocity of shortening of the diaphragm, inspiratory, and expiratory muscles were also assessed.
Participants:
The cross-sectional study was conducted with 40 male individuals (20 with TBPI who have not undergone nerve transfer surgery [mean age 30.1 ± 5.3] and 20 healthy paired by age and body mass index). Only patients with C8-T1 root avulsion were studied.
Main outcome:
Compartmental and hemithoracic volumes, as well as asymmetry between the affected and unaffected sides were assessed using optoelectronic plethysmography. The 6 minute walking test was performed to evaluate exercise capacity, while diaphragm mobility was assessed during quiet breathing (QB) using an ultrasound device.
Results:
TBPI patients with mean lesion time of 174 ± 45.24 days showed a decreased pulmonary function, respiratory muscle strength, exercise capacity, and diaphragm mobility (all p < .001) compared with healthy. The pulmonary ribcage compartment of the affected side was the main contributor to the reduction in volume during inspiratory capacity, vital capacity, and inspiratory load imposition (all p < .05). This compartment also exhibited a higher ventilation asymmetry with reduced shortening velocity of the inspiratory ribcage muscles.
Conclusion:
Compared with healthy, TBPI patients who have not undergone nerve transfer surgery present low exercise capacity and diaphragmatic mobility, as well as reduced volume of the upper ribcage compartment on the affected side that leads to reduced shortening velocity and ventilation asymmetry.
... Our report agrees with the prior Saudi Arabian publication by Al-Essa et al. [15] regarding the appropriate timing for PT/OT referral and initiation that is consistent with current practice, as the published literature demonstrates benefits of early passive range of motion exercise and therapy participation for patients with NBPP in preventing muscular atrophy or joint contraction, and maintaining joint integrity to encourage functional recovery [16][17][18][19]. In contrast, less than half of Saudi Arabian HCPs chose one of two correct answers concerning the timing of brachial plexus surgery, whereas about two-thirds of North American HCPs chose one of two appropriate answers. ...
PurposeEarly referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP.MethodsA 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge.ResultsOf the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner’s syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation.Conclusions
Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.
... 1,7-11 Standard surgical methods of correction are soft tissue release at the elbow joint in conjunction with a lengthening of the biceps, brachialis, and flexor-pronator mass. [12][13][14][15][16][17][18] Here, we report the successful outcome of biceps tendon lengthening (BTL) on 10 OBPI patients, who were resistant to serial casting and had EFC and significantly shorter arm when compared with the unaffected arm after serial casting. ...
Objective: Assessment of surgical outcomes of biceps tendon lengthening (BTL) surgery in obstetric brachial plexus injury (OBPI) patients with elbow flexion contrac-tures, who had unsuccessful serial casting. Background: Serial casting and splinting have been shown to be effective in correcting elbow flexion contractures in OBPI. However , the possibilities of radial head dislocations and other complications have been reported in serial casting and splinting. Literature indicates surgical intervention when such nonoperative techniques and range-of-motion exercises fail. Here, we demonstrated a significant reduction of the contractures of the affected elbow and improvement in arm length to more normal after BTL in these patients, who had unsuccessful serial casting. Methods and Patients: Ten OBPI patients (6 girls and 4 boys) with an average age of 11.2 years (4-17.7 years) had BTL surgery after unsuccessful serial casting. Results: Mean elbow flexion contracture was 40 • before and 37 • (average) after serial casting. Mean elbow flexion contracture was reduced to 8 • (0 •-20 •) post-BTL surgical procedure with an average follow-up of 11 months. This was 75% improvement and statistically significant (P < .001) when compared to 7% insignificant (P = .08) improvement after serial casting. Conclusion: These OBPI patients in our study had 75% significant reduction in elbow flexion contractures and achieved an improved and more normal length of the affected arm after the BTL surgery when compared to only 7% insignificant reduction and no improvement in arm length after serial casting. Patients with permanent obstetric brachial plexus injury (OBPI) develop persistent biceps contracture and loss of extension of the elbow if they do not fully recover. The flexed elbow posture not only limits upper extremity functions but also may cause pain. These OBPI patients with elbow flexion contractures (EFCs) result in shortening of the affected 213
... Zancolli 8 states that a vigorous rehabilitation program, along with the use of a nocturnal orthosis in forearm pronation position, may prevent interosseous membrane contracture. Price et al. 16 emphasized the role of maintaining passive mobility in the development of joint structures and, later, Sutcliffe 17 stated that treatment could be done exclusively with physical therapy and occupational therapy and discard surgery. When relating these observations to the results obtained in the present study, we reinforce our impression that rehabilitation would play a more decisive role than age or level of lesion. ...
Objective
To evaluate the arc of forearm pronosupination of patients with sequelae of birth paralysis and correlate with these variables.
Methods
32 children aged between 4 and 14 years with total or partial lesions of the brachial plexus were evaluated; measurements of pronation and supination, active and passive, were made, both on the injured side and the unaffected side.
Results
A statistically significant difference was observed between the injured side and the normal side, but there was no difference between the groups regarding age or type of injury.
Conclusion
The age and type of injury did not impact on the limitation of the forearm pronosupination in children with sequelae of birth paralysis.
... While many infants with OBPP have transient injuries, at least 20% sustain permanent injuries leading to movement limitations and strength imbalances of the affected limb (Brochard et al., 2014) that may hinder activities of daily living such as grooming, dressing, feeding and other tasks (Dodds and Wolfe, 2000). Persistent neurological deficits may lead to secondary musculoskeletal impairments, such as scapular dysplasia, abnormal glenohumeral morphology, and eventual posterior shoulder dislocation, which further restrict upper limb coordination and function (Dodds and Wolfe, 2000;Pearl and Edgerton, 1998;Price et al., 2000;van Gelein Vitringa et al., 2013;Waters et al., 1998;Waters et al., 2009). Motor habilitation therapies are often prescribed in OBPP. ...
Background:
Obstetrical brachial plexus palsy is a common birth injury to nerves passing through the brachial plexus that may result in structural and functional abnormalities. Individual joint trajectories from kinematic analyses have been used to evaluate the source and extent of abnormalities. Here, two summary measures of limb kinematics were utilized: 1) the Arm Profile Score summarizing upper limb joint kinematic abnormalities from a typical pattern across a task, and 2) the recently developed Multi-joint Coordination Measure using principal component analysis to characterize typical coordination of multiple joints throughout a task and compute deviations in time and space. Our aim was to compare these kinematic measures in persons with and without injury and relate these to clinical and functional scales.
Methods:
3D kinematic data from 10 upper limb joints were collected on 15 children and adolescents with obstetrical brachial plexus palsy and 21 controls during a reach-to-grasp task in both limbs. The two kinematic measures were computed and correlated with each other and the Mallet and ABILIHAND-Kids.
Findings:
Both measures revealed that joint angles primarily contributing to shoulder and wrist motion were most prominently affected in the non-dominant limb in obstetrical brachial plexus palsy, with the Multi-joint Coordination Measure additionally indicating when in the motion coordination worsens. These were moderately interrelated but neither correlated with other scales.
Interpretation:
The Multi-joint Coordination Measure, while related to the Arm Profile Score, may have additional utility for individualized treatment planning and evaluation of any motor task due to the unique spatial-temporal information provided.
... Zancolli 8 afirma que um programa vigoroso de reabilitação, juntamente com o uso de uma órtese noturna em posição de pronação do antebraço, pode prevenir a contratura da membrana interóssea. Price et al. 16 enfatizaram o papel da manutenção da mobilidade passiva no desenvolvimento das estruturas articulares e, posteriormente, Sutcliffe 17 afirmou que o tratamento poderia ser feito exclusivamente com fisioterapia e terapia ocupacional e dispensar a cirurgia. Ao relacionar essas observaç ões com os resultados obtidos no presente estudo, reforçamos nossa impressão de que a reabilitação teria um papel mais determinante do que a idade ou o nível da lesão. ...
Avaliar o arco de pronossupinação do antebraço dos pacientes com sequela de paralisia obstétrica do plexo braquial e correlacionar com essas variáveis.
... 1,7-11 Standard surgical methods of correction are soft tissue release at the elbow joint in conjunction with a lengthening of the biceps, brachialis, and flexor-pronator mass. [12][13][14][15][16][17][18] Here, we report the successful outcome of biceps tendon lengthening (BTL) on 10 OBPI patients, who were resistant to serial casting and had EFC and significantly shorter arm when compared with the unaffected arm after serial casting. ...
Objective:
Assessment of surgical outcomes of biceps tendon lengthening (BTL) surgery in obstetric brachial plexus injury (OBPI) patients with elbow flexion contractures, who had unsuccessful serial casting.
Background:
Serial casting and splinting have been shown to be effective in correcting elbow flexion contractures in OBPI. However, the possibilities of radial head dislocations and other complications have been reported in serial casting and splinting. Literature indicates surgical intervention when such nonoperative techniques and range-of-motion exercises fail. Here, we demonstrated a significant reduction of the contractures of the affected elbow and improvement in arm length to more normal after BTL in these patients, who had unsuccessful serial casting.
Methods and patients:
Ten OBPI patients (6 girls and 4 boys) with an average age of 11.2 years (4-17.7 years) had BTL surgery after unsuccessful serial casting.
Results:
Mean elbow flexion contracture was 40° before and 37° (average) after serial casting. Mean elbow flexion contracture was reduced to 8° (0°-20°) post-BTL surgical procedure with an average follow-up of 11 months. This was 75% improvement and statistically significant (P < .001) when compared to 7% insignificant (P = .08) improvement after serial casting.
Conclusion:
These OBPI patients in our study had 75% significant reduction in elbow flexion contractures and achieved an improved and more normal length of the affected arm after the BTL surgery when compared to only 7% insignificant reduction and no improvement in arm length after serial casting.
... 2Y4 Erbpalsy is only one of the subtypes of OBPI. 5 Many children with OBPI usually have varying degrees of functional impairment of their shoulder, elbow, and forearm due to muscle weakness and muscle imbalance across the involved limb. 6 Bone mineralization is a complex process that requires weight bearing, muscle contraction, and other growth factors. Disturbances in any of these factors may result in lower bone mass. ...
Objective:
The purpose of this study was to evaluate the effects of neuromuscular electrical stimulation during weight-bearing exercises on shoulder function and bone mineral density (BMD) in children with obstetric brachial plexus injury (OBPI).
Design:
This study was a randomized controlled trial. Forty-two children with OBPI were recruited. Their ages ranged from 3 to 5 years. They were randomly assigned either to control group (received a selected program) or study group (received the same program as the control group and neuromuscular electrical stimulation during weight bearing). Mallet grading system and dual-energy x-ray absorptiometry were used to evaluate shoulder function and BMD respectively at entry and after intervention (3 months later).
Results:
No significant differences of the outcome measures were detected at entry. Significant differences were observed within both groups when the pre and post treatment scores within each group were compared. Finally, significant differences favoring the study group were recorded when their post treatment scores were compared.
Conclusion:
Neuromuscular electrical stimulation during weight bearing exercises is an effective and simple method to improve shoulder function and BMD in children with OBPI.
... In some patients, the deficit can be severe (30°-80°), and this is treated surgically [1,[10][11][12][13][14]. Standard surgical treatments reported are soft tissue release at the elbow joint in conjunction with lengthening of the biceps, brachialis, and flexor-pronator mass [12,[15][16][17][18][19]. ...
Progressive loss of extension and concomitant bony deformity of the elbow are results of persistent biceps contracture in obstetric brachial plexus injury (OBPI) patients, if they do not fully recover. This adversely affects the growth and development and functions of the upper extremity.
We have performed biceps tendon lengthening (BTL) using a Z-plasty technique on OBPI patients aged 4 years to adulthood, who had been diagnosed with biceps tendon fixed flexion contractures. Ulnar, radial, and median nerve decompression was also performed at the same sitting. Somatosensory evoked potential (SSEP) monitoring was performed by stimulating the median and ulnar nerves at the wrist and the radial nerve over the dorsum of the hand and recording the peripheral, cervical, and cortical responses. Seven children with obstetric brachial plexus palsy with an average age of 11 years (8.7-14.2 years) were included in this report. Mean follow-up time was 7.4 months (4-11 months). All the patients in this report had the elbow flexion contractures greater than 30°.
Mean flexion contracture was 35° (30°-45°) preoperatively, which was improved to 0°-10° postoperatively with an average follow-up of 7 (4-11) months. This surgical procedure corrected the elbow flexion contractures, about an average of 25° and an improved length almost to normal, and improved the upper extremity functions. Neurophysiological data showed significant improvement in conduction of all three nerves tested after neurolysis. Further, median and radial nerve amplitude increase was statistically significant.
Statistically significant improvement in biceps length as well as nerve conduction was observed after the surgery. None of the children in our study lost biceps function, although weakness of the biceps is both a short- and long-term risk associated with biceps lengthening.
... The results of surgical treatment of the forearm deformity in perinatal brachial plexus palsy Classically pronation deformity of the forearm appear in upper injuries of the brachial plexus with concomitant adduction and internal rotation of shoulder (5,11,12). In own material pronation deformity has been observed also in total lesions (in 5 from 17 operated cases). ...
The aim of the study was the estimation of the results of surgical correction in pronation or supination forearm deformity. Material and methods. Clinical material comprised 19 patients, both sexes, in age from 2 years 3 months to 14 years who were treated in years 2001-2007 because of forearm deformation due to perinatal brachial plexus palsy. Evaluation of the results of surgical treatment has been performed in all cases with using Al-Qattan's scale. Results. As a result of performed tenomioplastic operations in all operated patients functional position of forearm has been achieved (grade 3 in Al-Qattan's scale)., and in 8 cases additionally good range of pronation and supination (grade 4 in Al-Qattan's scale). Conclusions. The necessity of forearm deformity correction in perinatal brachial plexus palsy may concern patients who have been treated microsurgically in very early childhood, and also patients who haven't been qualified to primary surgical treatment because of significant improvement of upper limb function as a result of rehabilitation. Tenomioplastic operations used in forearm position correction should be reserved for patients without fixed contracture who have possibility of forearm passive rotation moves. These procedures are burdened by low risk of complications and with proper qualification they can provide significant improvement of upper limb functional efficiency.
... Una vez diagnosticada la afección, se impone el inicio precoz del tratamiento (24)(25)(26)(27) conservador. Su principal objetivo es mantener al máximo la integridad funcional del miembro, evitando complicaciones osteomioarticulares y contribuir a la recuperación funcional del plexo, de modo que al ir recuperando el plexo su actividad funcional se encuentra con un miembro funcional, y en caso de quedar lesiones permanentes facilita el éxito de los tratamientos quirúrgicos. ...
We carried out a bibliographic review on the different aspects of the obstetric brachial paralysis. We express diagnostic criteria and expose options of surgical and rehabilitating treatments.
... If the patient is seen before this permanent bony deformity occurs, release of the contracture and tendon transfers will improve shoulder function and appearance. The window of opportunity for the approach using the release and transfers depends on the presence of a congruent glenohumeral joint [5]. The latest time for release and transfer has not been established. ...
Various approaches have been developed to treat the progressive shoulder deformity in patients with brachial plexus birth palsy. Reconstructive surgery for this condition consists of complex procedures with a risk for failure.Case PresentationsThis is a retrospective case review of the outcome in eight cases referred to us for reoperation for failed shoulder reconstructions. In each case, we describe the initial attempt(s) at surgical correction, the underlying causes of failure, and the procedures performed to rectify the problem. Results were assessed using pre- and post-operative Mallet shoulder scores. All eight patients realized improvement in shoulder function from reoperation.
This case review identifies several aspects of reconstructive shoulder surgery for brachial plexus birth injury that may cause failure of the index procedure(s) and outlines critical steps in the evaluation and execution of shoulder reconstruction.
... Likewise, the clinical importance of elbow flexion contracture in children with NBPP also may impair their ability to perform activities of daily living, including self-care, and needs to be monitored as well. Therefore every effort should be made to maintain full passive range of motion in all joints and to maximize active movements at an early stage [25]. ...
Objective:
To evaluate the accuracy of home exercise performance by caregivers of children with neonatal brachial plexus palsy (NBPP) who use digital versatile disc (DVD) guidance.
Design:
Prospective cohort study.
Setting:
Brachial Plexus Clinic at the University of Michigan.
Participants:
Seventy-six adult caregivers of a consecutive cohort of pediatric patients with NBPP.
Methods:
Caregivers received the Home Exercise Program for Brachial Plexus Palsy DVD and an initial demonstration of correct hand placement and movement patterns by 1 of 2 occupational therapists. At times A, B, and C (approximately 3, 6, and 12 months), caregiver accuracy in exercise performance at each joint and standard measurements of arm function were recorded.
Main outcome measurements:
Caregiver accuracy in correct hand placement and movement pattern during exercise performance was evaluated with use of a dichotomy scale (yes/no) at each joint. Active and passive range of motion were assessed as indicators of arm function.
Results:
The mean patient age was 38 months, and the median Narakas score was 2. No significant difference in exercise accuracy for all upper extremity joints between the initial evaluation and times A, B, and C or between individual times was observed, except at the shoulder (98.9% initially to 88.3% at time A; P = .0002) and elbow (100% initially to 96.6% at time A; P = .04). Regarding arm function, an increase in active range of motion for shoulder flexion, elbow flexion, forearm supination, wrist extension, and finger flexion was observed during the study period.
Conclusions:
Shoulder and elbow exercises may be more complex, requiring more frequent performance review with the caregiver. However, the home exercise DVD may benefit patients with NBPP and their caregivers and may provide an adjunct to formal therapy sessions.
... The most frequent nerve injury occurs in the upper C5-C6 roots of the brachial plexus (Erb's palsy) [4]. In this group of patients, early surgical intervention has led to improved limb function [5]. In a more devastating form of OBPI termed as total or complete OBPI (COBPI), the entire plexus, involving the upper, middle, and lower roots (C5-T1), is injured. ...
Untreated complete obstetric brachial plexus injury (COBPI) usually results in limited spontaneous recovery of shoulder function. Older methods used to treat COBPI have had questionable success, with very few studies being published. The purpose of the current study was to examine the results of triangle tilt surgery on shoulder function and development in COBPI individuals.
This study was conducted as a retrospective chart review. Inclusion criteria were COBPI patients that had undergone the triangle tilt procedure from 2005 to 2009 and were between the ages of 9 months and 12 years. COBPI was defined as permanent injury to all five nerve roots (C5-T1), with significant degradation in development and function of the hand. Twenty-five patients with a mean age of 5 (0.75-12) years were followed up clinically for more than 2 years.
The triangle tilt procedure resulted in demonstrable clinical enhancements with appreciable improvements in shoulder function, glenoid version, and humeral head congruity. There was a significant increase in the overall Mallet score (2.4 points, p < 0.0001) following surgical correction in patients that were followed up for more than 2 years.
The results of this study demonstrate that COBPI patients who develop SHEAR and medial rotation contracture deformities can benefit from the triangle tilt surgery, which improves shoulder function and anatomy across a range of pediatric ages. Despite these patients presenting late for surgery in general (5 years), significant improvements were observed in their glenohumeral (GH) dysplasia and their ability to perform shoulder and arm movements following surgery.
Erb-Duchenne paralysis is a neurological condition characterized by paralysis of the arm which occurs due to injury of the upper trunk of C5-C6 of the brachial plexus and can lead to disturbances in movement and sensation. Erb-Duchenne paralysis commonly presents with a “Waiter’s Tip” deformity characterized by elbow extension, medial rotation of the arm, forearm pronation, and wrist flexion. Management of Erb-Duchenne paralysis may involve strengthening exercises, range of motion exercises, manual therapy, and neuromuscular electrical stimulation. However, in most cases, the diagnosis of Erb-Duchenne paralysis is not detected early enough for rehabilitation outcomes to be maximized. We herein report a case of a 6-months old child who had Erb-Duchenne paralysis in the left upper limb. The aim of this case report is to highlight the importance of early detection and rehabilitation of Erb-Duchenne paralysis. Furthermore, the report also discusses the physiotherapy techniques that can be used to optimize outcomes.
Erb-Duchenne paralysis is a neurological condition characterized by paralysis of the arm which occurs due to injury of the upper trunk of C5-C6 of the brachial plexus and can lead to disturbances in movement and sensation. Erb-Duchenne paralysis commonly presents with a "Waiter's Tip" deformity characterized by elbow extension, medial rotation of the arm, forearm pronation, and wrist flexion. Management of Erb-Duchenne paralysis may involve strengthening exercises, range of motion exercises, manual therapy, and neuromuscular electrical stimulation. However, in most cases, the diagnosis of Erb-Duchenne paralysis is not detected early enough for rehabilitation outcomes to be maximized. We herein report a case of a 6-months old child who had Erb-Duchenne paralysis in the left upper limb. The aim of this case report is to highlight the importance of early detection and rehabilitation of Erb-Duchenne paralysis. Furthermore, the report also discusses the physiotherapy techniques that can be used to optimize outcomes.
Purpose:
The purpose of this scoping review is to synthesize the current evidence on the risk and protective factors associated with mental health in children with brachial plexus birth injury (BPBI) and associated interventions.
Materials and methods:
MEDLINE, EMBASE, and Cochrane databases were searched for reports on mental health in children with BPBI between 10 and 18 years. Risk and protective factors were charted using the VicHealth review and the Person-Environment-Occupation model.
Results:
Of 732 records found, 133 full text reports were reviewed and 16 reports were included. Multiple mental health risks associated with BPBI were identified, while protective factors were largely unexplored. Person-related risks were most common including negative coping strategies (n = 8, 50%) and pain (n = 6, 38%). Most frequently reported environment and occupation risk factors were social difficulties (n = 9, 56%) and challenges with upper limb function and daily activities (n = 6, 38%). Good self-determination and/or self-concept (n = 5, 30%) was the most common protective factor.
Conclusions:
Research using a strengths-based approach is needed to elucidate protective factors and further understanding of the intersection of person and socio-cultural risk factors of mental health in children with BPBI.
Children who sustain brachial plexus injuries after birth face significant functional limitations due to a variety of sequelae affecting the shoulder, elbow, or forearm. These effects could be permanent or temporary. It is critical for proper joint development to maintain complete passive mobility while neurological function is being restored. Children with Erb’s palsy are more likely to have weak muscles, which can be found by ultrasonography Objective: To determine the effects of physiotherapy on strength, range and function in children with Erb’s palsy. Methods: It was a clinical trial conducted at physiotherapy department outpatient at General hospital Lahore. A sample of 46 children aged between 0-10 years, with the C5 and C6 lesion and with limited range of motion were included while children with any history of previous or recent trauma or surgery to upper limb and to the other roots of brachial plexuses was excluded. Modified Mallet scale and active movement scale was used as outcome measures. The coin toss technique of randomization was adopted, with 'Heads' assigned to strengthening exercises and 'Tails' assigned to general treatment. Independent sample test was employed to assess pre and post differences. Physiotherapy treatments included neurodevelopmental approaches to improve proprioception input, orthosis, and electrical current stimulation. Free weights, resistance bands and manual resistance were used in the strength training. The active range of motion was evaluated using goniometry, and a baseline measurement was generated using a modified mallet scale. The treatment was given every day for six months. Post-intervention measures were implemented two, four, and six months following the intervention. SPSS 25.0 was used for data analysis. Results: The finding showed that pre-interventional oxford scale muscle strength for experimental group showed the mean and standard deviation (1.434± 0.5068), control group (1.65± 0.48) while Oxford scale muscle strength post intervention showed the results with the mean and standard deviation for the experimental group 3.13± 0.54 and control group 2.65± 0.48 and showed significant p value less than 0.005. Conclusions: The study concluded that physiotherapy integrated approach improved upper limb strength, ranges and functional abilities in patients with Erb’s Palsy.
Purpose:
To synthesize the evidence on the prevalence and etiology of elbow flexion contractures secondary to brachial plexus birth injury (BPBI).
Methods:
Using Arksey and O'Malley's scoping review framework, MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched, followed by a comprehensive grey literature search. Articles and abstracts of studies of all level of evidence on the prevalence, natural history, clinical presentation, etiology, and treatment of elbow flexion contractures in BPBI were included.
Results:
Of the 884 records found, 130 full text articles were reviewed, and 57 records were included. The median prevalence of elbow flexion contracture in BPBI was 48%. The magnitude of the contractures was between 5 and 90 degrees. Contractures > 30 degrees were found in 21% to 36% of children. With recent clinical and lab studies, there is stronger evidence that the contractures are largely due to the effects of denervation causing failure in the growth of the affected flexor muscles, while muscle imbalance, splint positioning, and postural preferences play a smaller role.
Conclusion:
The etiology of elbow flexion contractures is multifaceted. The contribution of growth impairment in the affected muscles offers greater understanding as to why maintaining passive range of motion in these contractures can be difficult.
Purpose:
To conduct a systematic review of studies on non-surgical and surgical interventions for elbow flexion contractures secondary to brachial plexus birth injury (BPBI).
Methods:
MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched for randomized controlled trials, observational studies, and case series studies on treatment of elbow flexion contractures secondary to BPBI. Study quality was evaluated using the Effective Public Health Practice Project tool.
Results:
Of the 950 records found, 132 full text articles were reviewed, and 3 cohort studies and 8 case series were included. The overall methodological quality of included studies was weak. The weak quality evidence demonstrated that significant gains in elbow extension passive range of motion (ROM) can be achieved with serial casting (range: 15 to 34.5 degrees) or elbow release surgery (range: 28.4 to 30.0 degrees). At best, a reduction to an elbow contracture between -15.0 and -18.8 degrees (casting) and -8.0 and -43.6 (elbow release surgery) can be achieved. Insufficient outcomes on elbow flexion ROM and strength were found in both non-surgical and surgical studies.
Conclusion:
The quality of evidence on the effectiveness of interventions for an elbow flexion contracture secondary to BPBI is weak. In the context of insufficient evidence on the risks of pursuing such interventions, it is prudent to attempt non-surgical interventions prior to surgery.
Level of evidence:
III - systematic review of level IV studies.
Purpose: The purpose of this study was to identify the functional and aesthetic factors associated with an elbow flexion contracture in children with a brachial plexus birth injury who identified their elbow flexion contracture as a problem.
Materials and methods: A retrospective cross-sectional study of children with brachial plexus birth injury between 7 and 18 years was conducted to compare the characteristics of children who had treatment for an elbow flexion contracture with those who did not.
Results: Fifty of the 200 children included in the study had treatment (one surgical release, 49 serial casting/splinting) for the elbow flexion contracture. Children who had treatment were an average 12.4 years of age, which was significantly older than those who did not have treatment. Elbow extension passive range of motion was an average −40.6° prior to treatment. Stepwise logistical regression model indicated that children who had treatment had greater severity in elbow contracture, higher Brachial Plexus Outcome Measure Activity scores, and lower Brachial Plexus Outcome Measure Self-Evaluation Appearance scores.
Conclusions: In addition to severity of contracture and function, perceived appearance of the limb is important factor to evaluate in the management of elbow flexion contractures.
• Implications for rehabilitation
• Priority is often given to evaluate the functional implications of elbow flexion contractures in brachial plexus birth injury to determine recommendations for rehabilitation interventions such as serial casting and splinting.
• Findings in this study indicate that severity of contracture, upper extremity activity function, and perceived upper extremity appearance are important factors in the management of elbow contractures.
• In addition to upper extremity function, routine evaluation of perceived upper extremity appearance in children and adolescents is important in the management of elbow flexion contractures.
Background:
The physical signs of obstetrical brachial plexus palsy range from temporary upper-limb dysfunction to a lifelong impairment and deformity in one arm. The aim of this study was to analyze the kinematics of the upper limb and to evaluate the contribution of glenohumeral and scapulothoracic joints of obstetrical brachial plexus palsy children.
Methods:
Six children participated in this study: 2 males and 4 females with a mean age of 11.7years. Three patients had a C5, C6 lesion and 3 had a C5, C6, C7 lesion. They were asked to perform five tasks based on the Mallet scale and the kinematic data were collected using the Fastrak electromagnetic tracking device.
Findings:
The scapulothoracic protraction and posterior tilt were significantly increased in the involved limb during the hand to mouth task (p=0.006 and p=0.015 respectively). The scapulothoracic Protraction/glenohumeral Elevation ratio was significantly increased in the involved limb during the hand to neck task (p=0.041) and the elevation task (p=0.015). The ratios of scapulothoracic Tilt on the three glenohumeral excursion angles were significantly increased during the hand to mouth task (p≤0.041). The scapulothoracic Mediolateral/glenohumeral Elevation ratio was significantly increased in the involved limb during the elevation task (p=0.038). The glenohumeral elevation excursion was significantly decreased in the involved limb during the hand to neck task (p<0.001) and the elevation task (p=0.0003).
Interpretation:
This study gives us information about the greater contribution of the scapulothoracic joint to shoulder motion for affected arm of obstetrical brachial plexus palsy patients compared to their unaffected arm. Kinematic analysis could be useful in shoulder motion evaluation during the Mallet score and to evaluate outcomes after surgery.
Background:
The transfer latissimus dorsi and teres major tendons to rotator cuff have been developed to rebalance the muscular dysfunction and improve shoulder range of motion in children with obstetrical brachial plexus palsy (OBPP). No previous study reported the ideal postoperative physical therapy program for these cases.
Aim:
The aim of the present study was to design appropriate postoperative physical therapy (PT) program after latissimus dorsi and teres major tendons transfer to rotator cuff in OBPP to improve upper limb function.
Design:
Time series design.
Population:
Forty seven OBPP infants (4.64±1.21 years with a range of 2.5 to 7 years, 21male and26 female) were allocated to one group. The patients were recruited from outpatient clinic of Kasr EL Aini Hospital, Cairo, Egypt. All patients had functional limitation in the involved arm due to muscle paralysis and contracture. 25patients had C5-C6 nerve root lesions while 22 had C5-C6-C7 nerve root lesions.
Methods:
The children underwent the surgical procedures of the transfer of latissimus dorsi and teres major tendons to rotator cuff. After the surgery the children participate in a designed physical therapy program for 6 months. Active shoulder abduction, flexion and external rotation range of motion (ROM) were assessed by electrogoniometer, and functional assessments were measured using the modified Mallet scale. All measurements were taken preoperative, 6 weeks, 3 months, and 6 months post- operatively after the application of the designed PT program.
Results:
Repeated measure analysis of variance (ANOVA) followed by Bonferroni post hoc test were used to show the improvement in all measured variables. Analysis revealed that shoulder abduction, flexion and external rotation ROM and shoulder function measured by modified Mallet scale were significantly improved (P˂0.0001) after the designed postoperative PT program.
Conclusion:
It can be concluded that the combination treatment of surgical procedure and the postoperative physical therapy program seems to be effective in improving shoulder and arm functions in children with OBPP.
Clinical rehabilitation impact:
This study describes a detailed physical therapy program after latissimus dorsi and teres major tendons transfer to rotator cuff in OBPP.
Purpose:
Brachial plexus birth palsy (BPBP) is the most common peripheral nerve injury in children (prevalence <5.1 per 1000 live births) and conservative management is routinely used to manage them. We have previously systematically reviewed studies investigating primary conservative management, published between 1992 and 2002, and found these to be inconclusive. The aim of this review was to update our previous systematic review to include studies published between 2002 and 2008, synthesise the data thus obtained with that of our previous review and create an up-to-date body of evidence for conservative management of infants with BPBP.
Procedures:
Fifteen databases were searched systematically for quantitative studies (randomised controlled trials, comparative studies, case series), published in English between January 2002 and June 2008 inclusive. Studies were excluded if they investigated infants who, in their first two years of life, underwent microsurgical repair of the brachial plexus, surgical management of secondary deformities or received other treatments traditionally delivered by surgeons, such as Botulinum toxin injections. The eligibility of each study identified from the database searches was evaluated against the inclusion criteria by two independent reviewers. These studies were then critically appraised for level of evidence using the National Health and Medical Research Council of Australia Hierarchy of Evidence and methodological quality using the Critical Review Form - Quantitative Studies. Data pertaining to the demographic characteristics of study participants, treatments received, main results and outcome measures used were also extracted. Where any disagreement between reviewers occurred, consensus was reached by discussion. Data from the recently published studies were narratively synthesised and then combined with the data gained from our previous systematic review to create a body of evidence on primary conservative management for BPBP infants.
Results:
Four publications, representing three studies (one comparative study, two case series), were sourced. Methodological quality scores of these studies ranged from 6 to 12 (maximum =16). The current body of evidence (publications from 1992 to 2008) therefore comprises 11 studies, four using a comparative design and seven using a case series design. Six of the 11 studies were classified as being of "poor" methodological quality (score <8). Conservative management mainly consisted of exercise therapy, although splinting, massage and dynamic traction were also used. All studies lacked a clear definition of conservative management sufficient to allow replication of the treatment in a clinical setting. A variety of outcome measures were used, limiting comparability of the studies. Data from the three case studies suggests that conservative management may be more effective in infants with upper and middle plexus injuries compared with total plexus palsy. However, the different outcome measures used and lack of comparison groups limit the strength of this finding.
Conclusions:
The body of evidence investigating the use of primary conservative management of infants with BPBP remains inconclusive. The studies published to date are limited in number, level of evidence and methodological quality. Further, a variety of outcome instruments, with limited psychometric properties, have been used to investigate management techniques which do not mirror those of contemporary clinical practice.
Birth injuries of the brachial plexus are fairly common, but most affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Modern microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore Voluntary activity to target muscle groups. The degree to which reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed using modern standards of evidence. Brachial plexus reconstruction is only a first step in the multidisciplinary process needed to optimize long-term functional outcomes for severely affected infants.
Background:
Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success.
Methods:
Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation.
Results:
Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures.
Conclusions:
Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention.
Level of evidence:
Level IV-therapeutic.
Introduction. The obstetrical brachial palsy is a relatively frequent entity with origin in the neonatal period. Objective. To determine the incidence and prognosis of obstetric brachial plexus injuries and analyze associated risk factors. Material and metods. Retrospective descriptive study, of all those children born in our center and diagnosed of brachial palsy, in the last 10 years, valuing perinatal variables and evolution of the same ones. Results. Obstetrical brachial palsy was diagnosed in 23 childrens (1/1000 newborn), 13 males (56.5%) and 10 females (43.5%). All the patients were born full term with an incident of distocia of shoulders of 69,5% and an average weight to the birth of 3937 g (3390-5110 g). The palsy was more frequent in the right side (65.2%), mainly of upper roots in all the cases. 74% of the children recovered in the first 6 months of life, needing physical therapy 57.1%, only in two cases other treatments were carried out. In spite of the treatment, 17% of the children presented permanent sequels. Conclusions. The obstetrical brachial palsy continues being a frequent problem in our environment, usually affecting upper roots, unilaterally, with predominance of the right side and can originate permanent sequels.
Background:
Approximately 1 of every 1000 live births results in life-long impairments because of a brachial plexus injury. The long-term sequelae of persistent injuries include glenohumeral joint dysplasia and glenohumeral internal rotation and adduction contractures. Scapular winging is also common, and patients and their families often express concern regarding this observed scapular winging. It is difficult for clinicians to adequately address these concerns without a satisfying explanation for why scapular winging occurs in children with brachial plexus birth palsy. This study examined our proposed theory that a glenohumeral cross-body abduction contracture leads to the appearance of scapular winging in children with residual brachial plexus birth palsy.
Methods:
Sixteen children with brachial plexus injuries were enrolled in this study. Three-dimensional locations of markers placed on the thorax, scapula, and humerus were recorded in the hand to mouth Mallet position. The unaffected limbs served as a control. Scapulothoracic and glenohumeral cross-body adduction angles were compared between the affected and unaffected limbs.
Results:
The affected limbs demonstrated significantly greater scapulothoracic and significantly smaller glenohumeral cross-body adduction angles than the unaffected limbs. The affected limbs also exhibited a significantly lower glenohumeral cross-body adduction to scapulothoracic cross-body adduction ratio.
Conclusions:
The results of this study support the theory that brachial plexus injuries can lead to a glenohumeral cross-body abduction contracture. Affected children demonstrated increased scapulothoracic cross-body adduction that is likely a compensatory mechanism because of decreased glenohumeral cross-body adduction. These findings are unique and better define the etiology of scapular winging in children with brachial plexus injuries. This information can be relayed to patients and their families when explaining the appearance of scapular winging.
Level of evidence:
Level II.
Brachial plexus birth palsy occurs in 0.4 to 4.6 of every 1000 live births, with residual shoulder dysfunction in approximately one third of cases. Clinical measures, such as the Mallet classification, provide no insight into the scapulothoracic and glenohumeral contributions to tested global shoulder movements. This study describes the scapulothoracic and glenohumeral components of shoulder motion during the modified Mallet test.
Twelve children with Erb's palsy (C5-6) and 8 children with extended Erb's palsy (C5-7) were recruited. The unaffected limbs of 6 subjects were also tested. Locations of markers placed on the thorax, humerus, and scapula were recorded in a neutral position and each of the modified Mallet positions. Scapulothoracic, glenohumeral, and humerothoracic helical displacements and acromion process linear displacements were compared between groups.
The brachial plexus birth palsy groups exhibited significantly smaller glenohumeral displacements in all modified Mallet positions and significantly larger scapulothoracic displacements in the global external rotation and hand to mouth positions. Discriminant function analysis using only humerothoracic variables correctly classified 76.9% of subjects. Discriminant function analysis incorporating scapulothoracic, glenohumeral, and acromion process displacement variables produced accuracy of 92.6%.
Children with brachial plexus birth palsy demonstrated decreased glenohumeral contributions to achieve every modified Mallet position and increased scapulothoracic contribution in two positions compared with the unaffected group. Different scapulothoracic and glenohumeral strategies were identified between groups. Finally, scapulothoracic and glenohumeral components of shoulder motion are more specific than humerothoracic measures to diagnostic classification.
As primary health care clinicians, chiropractors are increasingly providing the initial assessment of many diverse musculoskeletal conditions. As a consequence, occasionally chiropractors are consulted to assess rare neuromusculoskeletal disorders. A 12-year-old girl was brought in by her mother for a second opinion on the present status of her daughter’s Erb-Duchenne palsy (Erb’s palsy), a diagnosis given at birth. Erb’s palsy is a birth-induced upper brachial plexus injury that, if unresolved, is known to lead to permanent developmental shoulder and elbow articular deformities. These deformities can result in severe restrictions in the proper function of the involved upper limb. The exact pathogenesis is unclear and therefore certain theories are presented. It would appear that early detection of these functional restrictions and the restoration of normal joint function, through active and passive mobilisation during childhood, are an important factor in limiting the extent of these disabilities.
We present a personal experience with 750 children suffering from obstetrical brachial plexus palsy. The related surgery is described, including early microsurgical nerve reconstruction and secondary procedures including tendon and muscle transfers. The clinical examination, indications and timing for surgery, technical details of primary and secondary operations and the possible outcome are discussed. Both clinical and research work need an interdisciplinary team approach, and diagnostic, therapeutic and prognostic improvement is based on the refinements of microsurgical skills and the continuous exchange of information between specialized centers.
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The purpose of this article was to report the development of a new assessment tool, the Brachial Plexus Outcome Measure (BPOM) and the evaluation of its internal consistency and construct validity.
A retrospective case series of children aged 4-19 years with obstetrical brachial plexus palsy (OBPP) was conducted. Intraclass coefficients were calculated for the BPOM Activity Scale items. Correlation between the Active Movement Scale (AMS) and BPOM Activity Scale scores were conducted to determine the convergent validity.
The BPOM Activity Scale items (N=306) had good internal consistency (Cronbach's α=0.87). A strong correlation between the BPOM Activity Scale and AMS (n=284) was found (r=0.71, p=0.001, α=0.05).
The BPOM Activity Scale demonstrates good internal consistency and construct validity as a discriminative functional outcome measure in children with OBPP.
IV.
A contracture of the shoulder joint in the course of perinatal brachial plexus palsy significantly affects the function of the upper limb as a whole. The aim of this paper is to present the authors' experience in surgical procedures carried out to improve shoulder joint function impaired as a result of perinatal brachial plexus palsy and evaluate the treatment outcomes.
The study involved 36 patients who underwent 37 tenomyoplastic procedures (subscapular release, teres major transfer, transfer of a portion of the trapezius). Pre- and postoperative shoulder joint function was assessed with the Gilbert scale.
Surgical release of the subscapular muscle improved shoulder function in all patients, usually by 1 degree in the Gilbert scale. Teres major transfer improved shoulder function in all 4 patients (grade IV - 3 children, grade V - 1 child). One patient benefited from tenomyoplasty involving the trapezius.
1. Indications for tenomyoplasty procedures in the region of the shoulder joint may be present both in children who had previously undergone microsurgery and in those in whom rehabilitation had led to a good outcome of perinatal brachial plexus palsy. 2. The fact that most patients improved following tenomyoplastic procedures justifies their advisability. A visible functional improvement of the upper limb can be achieved with a relatively low risk of complications.
We present our personal experience with 650 children suffering from obstetric brachial plexus palsy. We describe the related surgery including early microsurgical nerve reconstruction and later tendon and muscle transfers. We discuss our clinical approach, the indications and timing for surgery, the technical details of primary and secondary surgery in our hands, and the possible outcome. We emphasize that both clinical work and research work need an interdisciplinary team approach and that diagnostic, therapeutic, and prognostic improvement is based on the refinements of our (micro)surgical skill and the continuous exchange of information between specialized centers.
This article reviews the authors' experience over the last decade in the multidisciplinary management of children with brachial plexus birth injuries. When compared with the results of a study of 91 children who received nonoperative treatment, the results of surgical intervention can improve the functional outcome in properly selected infants.
Elbow flexion contractures are a common sequela in obstetric brachial plexus palsy. The etiology and best management of these contractures is unclear. Nonsurgical treatment involving serial casting and splinting is supported in the literature. The purpose of this study is to evaluate the effectiveness of serial casting and splinting of elbow flexion contractures in children with obstetric brachial plexus palsy.
A retrospective review of children with obstetric brachial plexus palsy who participated in serial casting and splinting for an elbow flexion contracture was conducted. Elbow extension passive range of motion measurements at initial, best-achieved, and final outcome were compared.
Nineteen patients, aged 2 to 16 years, were studied. Elbow passive range of motion improved from initial to best-achieved and final outcome measurements. Fifty-three percent of patients were noncompliant between the time of best-achieved and final outcome. Loss of passive range of motion during the noncompliant period was statistically significant. Compliant patients had better treatment results. A clinical decision tree for elbow contractures in obstetric brachial plexus palsy was formulated.
Serial casting and splinting of elbow contractures in children with obstetric brachial plexus palsy is effective. Successful maintenance of treatment effects is dependent on patient age and compliance.
Therapeutic IV.
Erb's palsy is initially frightening. The infant's arm hangs limply from the shoulder with flexion of the wrist and fingers due to weakness of muscles innervated by cervical roots C5 and C6. Risk factors are macrosomia (large baby) and shoulder dystocia. However, Erb's palsy may occur following cesarian section. The experience of the delivering physician may not influence the risk of Erb's palsy (0.9 to 2.6 per 1000 live births). Differential diagnosis includes clavicular fracture, osteomyelitis and septic arthritis. Fortunately, the rate of complete recovery is 80% to 96%, especially if improvement begins in the first two weeks. Recommended treatment includes early immobilization followed by passive and active range of motion exercises (although there is no proof that any intervention is effective). For the few infants with no recovery by three to five months, surgical exploration of the brachial plexus may improve the outcome. Three infants with Erb's palsy who illustrate variations in the evolution of this disorder are presented.
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.
Sekundäreingriffe nach kindlicher Plexuslähmung werden normalerweise zwischen dem 2. und 6. Lebensjahr durchgeführt, bei Spätvorstellungen auch danach. Sie beinhalten Kontrakturlösungen und Muskel- sowie Sehnenverlagerungen. Die Indikationsstellung muss individuell ausführlich besprochen und geprüft werden; als Erfolg kann nur eine wirkliche Funktionsbesserung im Alltag gelten.
Wir beschreiben übliche Verfahren nach topografischer Region geordnet und stellen eine Übersicht unserer Resultate vor. Diese Kenntnisse sollten die Entscheidung zu jedem Korrektureingriff bei Plexuskindern beeinflussen.
Children with brachial plexus birth palsy (BPBP) may have shoulder external rotation and abduction weakness that can restrict activities of daily living (ADLs). Static range of motion measurements may not measure ADL restrictions. Motion analysis has been used to quantify gait limitations and measure changes associated with treatment. The purpose of this study was to determine whether upper extremity motion analysis (UEMA) can measure the differences in shoulder motion during ADLs between children with BPBP and normal children. Following a previously described UEMA protocol, 55 children with BPBP and 51 normal children (control group) were studied. Kinematic data of selected ADLs were collected before surgery. UEMA was used to measure statistically significant differences between children with BPBP and control subjects for all planes of shoulder motion in all activities tested. The authors conclude that UEMA can discriminate between children with BPBP and control subjects during selected ADLs, and suggest that UEMA can also be used to measure the effects of surgical interventions in children with BPBP.
The association between internal rotation contracture secondary to brachial plexus birth palsy and deformity and posterior dislocation of the glenohumeral joint has been known for a long time. The precise nature of these deformities and their pathogenesis, however, remain unclear. Twenty-five children, ranging in age from 1.5 to 13.5 years, had an operation to release an internal rotation contracture secondary to brachial plexus birth palsy; eleven had a latissimus dorsi transfer to augment external rotation power as well. Arthrograms were made intraoperatively in order to clarify the pathological changes that occur in the glenohumeral joint during growth in patients who have this condition. Seven children had a concentric glenohumeral joint (the humeral head was well centered in the glenoid fossa). The remaining eighteen children (72 per cent) had a deformity of the posterior aspect of the glenoid. Five of these children had flattening of the posterior aspect of the glenoid, seven had a biconcave glenoid with the humeral head articulating with the posterior of the two concavities, and six had a so-called pseudoglenoid (the most severe deformity, in which the humeral head articulated with a distinct, retroverted, posterior articular surface). Internal rotation contracture secondary to brachial plexus birth palsy may lead to glenoid deformity that is severely advanced by the time that the child is two years old. In patients who have such a contracture, we recommend early imaging of the shoulder with arthrography or some other modality to allow visualization of the skeletally immature glenohumeral joint.
The careful observation and stewardship of any large number of cases implies a certain responsibility to one's fellow workers. A report should be made of this stewardship so that they may profit by such an experience. I am therefore presenting a brief report of 1,100 cases of obstetric paralysis, in a large number of which I have been able to obtain fairly accurate data. These data will be presented because, by its numbers alone, it is the largest series of such cases ever recorded, and so far as that fact goes, must have a certain fundamental statistical value in establishing facts about this condition of obstetric paralysis.The accompanying table shows in detail certain data in regard to these cases.These figures alone, however, will not give one a complete picture of obstetric paralysis, as they record only the conditions occurring at birth, and serve only to suggest etiologic factors.
34 subjects with 36 obstetrical paralysis of the brachial plexus were studied. The diagnosis was made immediately after birth in the great majority. 5 pareses of the lower plexus, however, were only recognized later. All subjects were first seen by us under the age of 13 years, 25 during the first year of life. At follow-up the age of the 34 subjects varied between 3 and 24 years. 32 patients had undergone daily physiotherapy, in 5 electrotherapy had also been applied. There was no correlation between these treatments and the outcome. Of the 20 cases of paresis of the lower plexus 3 were severely handicapped after the age of 3. This was the case for 9 of the 12 patients with total paresis. Everyday activities of these patients are influenced by the motor deficit. Even subjects with relatively serious sequelae apparently enjoy an almost normal life and have a good self-image. A significant improvement generally occurred as early as the first 3 years of life.
This article provides an overview of the historical perspectives of shoulder deformity. Biomechanical considerations are discussed, as well as the authors' personal approach to these types of injuries.
One hundred and five children with the whole spectrum of obstetric brachial plexus (OBP) injuries, from severe to full recovery, were examined at the age of 5 years with regard to motor and sensory functions as well as to use of the affected limb. Since root involvement level does not fully reflect the degree of disability, a classification based on range of motion and grip-strength was formulated and found to correspond well with functional abilities. The results from this study indicate that the eventual outcome in upper-plexus lesions is more complex than is commonly believed. Hand function is affected due to the effect of limited shoulder movements on hand positioning. Grip strength was also reduced in many of these children. All the children with total-plexus lesions had diminished grip strength and half of them had impaired tactile sensibility. In most children with total-plexus lesions, performance of activities in daily life was affected as were bimanual activities requiring use of the involved limb. Hand preference was affected in children with a right-sided injury. From a clinical perspective, as well as for research, it is important to describe OBP injuries not only in terms of impairment but also of disability.
Ninety-four patients who had brachial plexus birth palsy were entered into a prospective study to evaluate the association between persistent palsy, age-related musculoskeletal deformity, and functional limitations. Of these patients, forty-two had either computerized tomography or magnetic resonance imaging to assess the presence and degree of incongruity of the glenohumeral joint, deformity of the humeral head, and hypoplasia of the glenoid as part of the preoperative planning for a reconstructive operation. Functional ability was rated with use of the classification of Mallet, on a scale of 1 to 5. The mean glenoscapular angle (the degree of retroversion of the glenoid) on the affected side was -25.7 degrees compared with -5.5 degrees on the unaffected side. Twenty-six (62 per cent) of the forty-two shoulders had evidence of posterior subluxation of the humeral head, with a mean of only 25 per cent (range, 0 to 50 per cent) of the head being intersected by the scapular line. Progressive deformity was found with increasing age (p < 0.001). The natural history of untreated brachial plexus birth palsy with residual weakness is progressive glenohumeral deformity due to persistent muscle imbalance. The status of the glenohumeral joint must be addressed when the choice between tendon transfer and humeral derotation osteotomy for reconstruction of the shoulder is considered for these patients.
Seven children were operated on for pronation contractures of the forearm due to obstetric brachial plexus injuries. All underwent extensive preoperative evaluations to determine the extent of injury, secondary deformities, and capacity to perform a few basic tasks. Sequential video studies were used to document these findings. Operative procedures performed included various combinations of tendon/muscle lengthenings and/or transfers. Postoperative evaluations focused on function rather than gains in active range of motion and the patient/parental assessment of the benefit of the procedure by response to a questionnaire. All patients were followed for a minimum of I year following surgery. The average gain in active supination was 45 degrees. Each patient showed significant functional gains with a high degree of satisfaction.
1. In a survey of 107 cases of Erb's paralysis, twenty-seven instances of incipient or actual posterior dislocation of the upper end of the radius were discovered.
2. The type of case in which the dislocation occurs is defined and the early clinical and radiographic signs of the displacement are described and illustrated.
3. The probable causesâmuscle imbalance and rigid splinting over a long periodâare adumbrated and the prevention and remedies are suggested.
4. The occurrence of anterior dislocationâsix casesâand its significance are discussed.
The development of the proximal humerus in the neontate
- Goddard
Goddard N: The development of the proximal humerus in the neontate, in Tubiana R (ed): The Hand (vol 3). Philadelphia, PA, WB Saunders, 1993, pp 624-631
Obstetrical lesions of the brachial plexus: Natural history in 34 personal cases
- Rossi