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Brachial Plexus Birth Palsy: A 10-Year Report on the Incidence and Prognosis
Abstract
Sixty-one cases of brachial plexus birth palsies were documented in 30,451 live births at Kaiser Foundation Hospital, San Francisco, between January 1972 and December 1982, for an incidence of 2.0/1,000 births. Thirty-eight patients were evaluated in follow-up ranging from 1 year to 11 years 6 months. Associated birth traumas include facial palsy, clavicle fracture, arm ecchymosis, and cephalohematoma. The prognosis was excellent, with full recovery in 95.7% of cases. The presence of a palsy did not preclude the development of dominant use of the extremity. Right-handedness was noted in 73% of right-sided palsies. This study showed that the incidence of palsies has not declined in the past 10 years. Risk factors and associated birth injuries were similar to those in other reports. The severity of palsies has lessened, and early recovery is usual.
... The incidence of BPBP is approximately 0.9 to 2.0 out of 1,000 live births. [1][2][3] Risk factors include shoulder dystocia, macrosomia, difficult or instrumented delivery, and breech presentation. 1 BPBP varies in severity and the extent of plexus involvement, ranging from transient neuropraxia to complete cervical nerve root avulsion of part or all of the brachial plexus. ...
... Historically, 80 to 90% of patients were thought to demonstrate spontaneous recovery within the first 2 months of life, with subsequent normal upper extremity function. 2,3,5,[7][8][9][10] More recent investigation has suggested a much lower recovery rate, with only 66% of affected children recovering completely and 10% to 30% with considerable permanent weakness. 11,12 The variation in reported recovery rates may correlate with regional differences in injury severity, referral patterns, and treatment strategies. ...
Background:
Microsurgical reconstruction is indicated for infants with brachial plexus birth palsy (BPBP) that demonstrate limited spontaneous neurological recovery. This investigation defines the demographic, perinatal, and physical examination characteristics leading to microsurgical reconstruction.
Methods:
Infants enrolled in a prospective multicenter investigation of BPBP were evaluated. Microsurgery was performed at the discretion of the treating provider/center. Inclusion required enrollment prior to six months of age and follow-up evaluation beyond twelve months of age. Demographic, perinatal, and examination characteristics were investigated as possible predictors of microsurgical reconstruction. Toronto Test scores and Hospital for Sick Children Active Movement Scale (AMS) scores were used if obtained prior to three months of age. Univariate and multivariate logistic regression analyses were performed.
Results:
365 patients from six regional medical centers met the inclusion criteria. 127 of 365 (35%) underwent microsurgery at a median age of 5.4 months, with microsurgery rates and timing varying significantly by site. Univariate analysis demonstrated that several factors were associated with microsurgery including race, gestational diabetes, neonatal asphyxia, neonatal intensive care unit admission, Horner's syndrome, Toronto Test score, and AMS scores for finger/thumb/wrist flexion, finger/thumb extension, wrist extension, elbow flexion, and elbow extension. In multivariate analysis, four factors independently predicted microsurgical intervention including Horner's syndrome, mean AMS score for finger/thumb/ wrist flexion <4.5, AMS score for wrist extension <4.5, and AMS score for elbow flexion <4.5. In this cohort, microsurgical rates increased as the number of these four factors present increased from zero to four: 0/4 factors = 0%, 1/4 factors = 22%, 2/4 factors = 43%, 3/4 factors = 76%, and 4/4 factors = 93%.
Conclusions:
In patients with BPBP, early physical examination findings independently predict microsurgical intervention. These factors can be used to provide counseling in early infancy for families regarding injury severity and plan for potential microsurgical intervention.Level of Evidence: Prognostic Level I.
... Significant secondary shoulder deformities in children with Erb's palsy were detected [3]. More than one third of these patients have required surgery to resolve shoulder deformities [4]. Children with Erb's palsy might underwent clavicle osteotomy as an appropriate surgical treatment option [5]. ...
Introduction and importance
Erb's palsy defined as muscle weakness and loss of motion caused by a nerve condition in the shoulder and arm. Children with Erb's palsy might underwent clavicle osteotomy as an appropriate surgical treatment method. However, few number of these patients who underwent clavicle osteotomy experienced nonunion and complained of shoulder deformity and pain. The aim of the present case report was to present new surgical treatment of a nonunion following clavicle osteotomy in a child affected by Erb's palsy.
Case presentation
A six years old boy with a history of Erb's palsy who underwent clavicle osteotomy at age of 6 months was referred to hospital. There was a nonunion following clavicle osteotomy. The patient had right shoulder deformity and complained of its-related pain. To correct a nonunion following clavicle osteotomy in this case, middle third fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was used. After five months of follow-up, a clavicle nonunion and shoulder deformity was thoroughly corrected.
Clinical discussion
As clavicle osteotomy, the most commonly surgical method for Erb's palsy, has been demonstrated to not work effectively and cause nonunion in some cases, a new surgical method for correcting clavicle nonunion other than repeated clavicle osteotomy is needed. In the present case report, fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was applied and demonstrated remarkable improvement.
Conclusion
Totally, use of fibula auto grafting and fixing it to the cite of clavicle nonunion by pins might be an effective surgical treatment for such cases.
... Brachial plexus birth injury (BPBI) is a rare dystocia complication, affecting 0.04% to 0.3% of live births worldwide [1,2]. Although it has a good prognosis with a spontaneous recovery rate of 66% to 82%, a significant number retain functional impairment to varying degrees [3][4][5]. Internal rotation contracture of the glenohumeral joint is the most common disabling sequela of BPBI, attributable to weak abductors and external rotators and relatively hyperactive adductors and internal rotators. Historically, fixed internal rotation deformity has been correlated with glenohumeral dysplasia (GHD), which appears as early as six months old and progresses with age [6,7]. ...
Objectives: Brachial plexus birth injury (BPBI) is a rare dystocia complication. Although it has a good prognosis, a significant number retain functional impairment to varying degrees. The data concerning shoulder function improvement and complication rates are conflicting due to variations in outcome measures between the studies. Therefore, we report our experience with this approach.
Methods: It was a retrospective study conducted at King Faisal Specialist Hospital and Research Center in Riyadh (FSH&RC), Saudi Arabia. Data such as patient demographics, Mallet scores, and passive external rotation (PER) in adduction and abduction were retrieved from the medical records.
Results: In active shoulder function, Mallet score significantly improved (P=0.00). The improvement was most remarkable in active external rotation movement (P=0.00) followed by hand to the neck. However, no significant gain was observed in active abduction and hand-to-back. At the final follow-up, with a mean of 2.9 years, the improvement in PER in adduction and abduction was maintained. Compared to six months postoperative, no significant difference was found in hand-to-neck, hand-to-back, and total Mallet score.
Conclusion: Subscapularis z-lengthening with coracoidectomy was consistently effective in correcting internal rotation contraction in a patient with BPBI. Significant improvements were observed in the Mallet score and PER in adduction and abduction.
... Erb's palsy (C5, 6) is a very common type of OBPP. Most of the infants with Erb's palsy will show spontaneous recovery (1,2) . However, some of them show internal rotation contracture of the shoulder joint due to lack of opposition to muscle forces generated by latissmus dorsi, pectoralis major, subscapularis and teres major muscles.If this internal rotation deformity is not repaired, it may progress to posterior dislocation of the shoulder joint with bony deformity of the glenoid (3) . ...
... A strong prognostic marker for full recovery is the activation of full ROM elbow flexion against gravity by 2 months of age. 8,10,41 On the other hand, it has been shown that complete recovery is highly unlikely if there is no biceps activation by 3 months of age 42,43 or a failed cookie test at 9 months of age. 44 Other factors associated with worse recovery are concomitant phrenic nerve injury and Horner's syndrome, both of which strongly associate with nerve root avulsions. ...
The aims of this study are: to calculate the annual incidence of permanent BPBI
in the hospital district of Helsinki and Uusimaa in 1995-2019, to analyze whether
cervical MRI is reliable in detecting root avulsions, to assess if shoulder dysplasia
can be prevented by a protocol including early ROM exercises, ultrasound (US)
screening, and BTX injections in combination with spica bracing, and to develop
a new neurotization technique to restore active shoulder external rotation (ER)
in adduction.
HUS, New Children’s Hospital is the only treatment center for permanent BPBI for
the 1.7 million residents of the region of Uusimaa, Finland. The hospital serves as
a tertiary treatment center for a population of 2.2 million. 431 children with BPBI
were referred to our brachial plexus clinic between 1995 and 2019. The injury was
temporary in 173 and permanent in 258 children. Of children with permanent
injury, 179 were born in our primary catchment area, with 437454 births during the
25-year-long study period. Cervical MRI was done to all 34 children born between
2007 and 2013 who were clinically potential candidates for plexus surgery. Root
avulsion in MRI served as one indication to recommend plexus repair.
Our shoulder protocol to prevent shoulder dysplasia, including ROM exercises,
US screening, BTX injections, and shoulder ER spica bracing, was developed
between 2000 and 2009. The time of shoulder dysplasia detection and the type
and rate of shoulder surgery were registered and shoulder outcome was assessed in
237 of the 285 children with permanent BPBI. A new surgical technique to restore
active shoulder ER in patients with congruent shoulders and active abduction above
horizontal was developed in 2014. The midterm outcome of our new technique
to neurotize the infraspinatus muscle with the spinal accessory nerve (SAN) was
clinically assessed in 14 children.
7
The risk for permanent BPBI in the hospital district of Helsinki and Uusimaa from
vaginal births varied annually between 0.1 and 0.9 per 1000, with a decreasing
tendency from 1995 to 2019. MRI was a reliable imaging modality with both high
sensitivity (0.88) and specificity (1.00) for avulsion injuries. Posterior shoulder
subluxation, as a result of advancing shoulder dysplasia, was verified by imaging in
48% (114/237) of children with permanent injury. Mean age at detection dropped
from 5 years (range 0.3-8.6) in children born before 2000 to 4.9 months (range
1.1-12) in children born 2010 or later. The rate of shoulder relocation declined
from 28% (15/55) to 7% (5/76) respectively. Active shoulder ER in adduction had
improved by mean 57° (range 40-95°) in 12/14 children, active ER in abduction
by mean 56° (range 30-85) and active abduction mean 27° (range 10-60°) in all
14 patients 4 years (range 2-5) after specific neurotization of the infraspinatus
muscle with SAN.
The annual incidence of permanent BPBI shows marked variation with a
decreasing trend in the region of Uusimaa, Finland. MRI has both high sensitivity
and specificity for detecting root avulsion injuries. Half of all children with
permanent BPBI develop shoulder dysplasia during the first year, which can be
reliably detected with US. ROM exercises, BTX injections and spica bracing seem
beneficial in preventing and treating shoulder dysplasia in children 6-12 months
old. Active ER in adduction can be reliably restored and maintained by neurotizing
the infraspinatus muscle with SAN.
... Entre el 66% y el 92% de niños con PBO se recupera espontáneamente sin ningún gesto quirúrgico añadido (41,42,43). Esta recuperación puede producirse hasta los dos primeros años tras la lesión y depende de la severidad y el nivel de la lesión nerviosa. ...
... [1], [2] Obstetric brachial plexus injury is a very rare type of injury seen in 0.5 − 2.0 births per 1000 live births. [3] Most of the birth brachial plexus injury cases are due to the obstructed delivery [4] (shoulder dystocia, forceps delivery, etc.). Despite major advances in microsurgical techniques, tissue glues, autogenic, allogeneic, and synthetic grafts, surgical outcomes after nerve repair are nothing to boast off. ...
Objective:
The purpose of the study is to conduct the systematic review of literature available on resting-state functional MRI (fMRI) and brachial plexus injury.
Methods:
We reviewed all the literature that are available on PubMed; keywords used were resting state, brachial plexus injury, and functional imaging. The reference papers listed were also reviewed. The research items were restricted to publications in English. Some papers have also incorporated studies such as task-based fMRI and transcranial magnetic stimulation (TMS), but only resting-state studies were included for this review.
Results:
A total of 13 papers were identified, and only 10 were reviewed based on the criteria. The reviewed papers were further categorized on the basis of whether or not any surgical intervention was done. Seven papers have surgical management such as contralateral cervical 7 (CC7) neurotisation or intercostal nerve (ICN) musculocutaneous nerve (MCN) neurotisation.
Conclusion:
There is conclusive evidence showing that there is cortical reorganisation following brachial plexus injury in both birth and traumatic cases. The changes are restricted to some of the resting-state networks only (default mode network, sensorimotor network, in particular). However, no study till date has focused on a far more longitudinal approach at studying these changes. It will be interesting to see the exact time and effect of these changes.
... [2][3][4]7,8 Different rates could be attributed to varying definitions of recovery, however, recent review suggests that the rates may be overestimated. [4][5][6][7] Pondaag et al concluded that studies on recovery rates conducted before 2001 were methodologically insufficient. 7 Despite neurologic recovery, longstanding and disabling sequelae caused by glenohumeral joint dysplasia (GHD) and contractures of the shoulder are common. ...
Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.
... Brachial plexus birth palsy (BPBP) refers to a birth related paralysis of the upper extremity. 1 The reported incidence of birth palsy varies from 0.42 to 2.5/1.000 births. 2 This palsy most commonly involves the upper roots (Erb's palsy), affecting the shoulder musculatures usually. ...
Background: Brachial plexus birth palsy (BPBP) refers to a birth related paralysis of the upper extremity.
The current study was designed to evaluate the efficacy of computed tomography (CT) in the assessment
of humeral head posterior subluxation and glenoid retroversion preoperatively and to evaluate whether
or not bony deformity correlates with functional improvement (based on Modified Mallet Score)
following tendon transfer in brachial plexus birth palsy patients.
Patients and methods: This prospective study included 30 patients, 15 below 4 years and 15 above 4 years
old, with a mean age 3.65 ± 1.39 (range 2e8) years old. Thirteen patients were males (43.3%) and 17 were
females (56.6%). The left side was affected in 13 patients (43.3%), while the right in 17 (56.7%). The
Modified Mallet Score was used for clinical assessment of the shoulder function. A multislice CT scan
with 3D reconstruction was used as a preoperative radiological assessment of the shoulder. An electromyography
(EMG) of the muscles around the shoulder was performed. All patients were operated
upon by anterior release of the internal rotators to improve the external rotation range of motion and by
transfer of teres major and latissimus dorsi to improve the abduction motion through one anterior
deltopectoral incision and a small posterosuperior incision. Postoperatively, the range of shoulder
abduction and external rotation had been assessed after shoulder spica removal and till the end of follow
up.
Results: Fourteen patients (46.7%) had a normal glenoid version angle (normal range from �12� to 2�)
and normal range of articulation with the glenoid (42.3%e71.4%) and 16 patients (53.3%) had an
abnormal glenoid version angle and abnormal range of articulation with the glenoid. According to the
Modified Mallet Score, there was a statistically significant difference in the mean value of global
abduction (P ¼ 0.04), external rotation (P ¼ 0.03), hand to mouth (P ¼ 0.02), hand to neck (P ¼ 0.03) and
hand to spine (P ¼ 0.02) between the pre- and post-operative assessment of all patients. There was a
statistically significant difference in the mean value of postoperative Modified Mallet Score between the
patients under the age of 4 years and those above the age of 4 years. There was no statistically significant
difference between the patients with normal CT angles and those with abnormal CT angles. There was no
statistically significant difference in the mean value of glenoid version angle and percentage of humeral
head articulation between the patients below the age of 4 years and those above 4 years (P ¼ 0.845).
Conclusion: The study concluded that the glenoid version angle and humeral head articulation percentage
do not negatively affect results of the tendon transfer around the shoulder in patients of upper
brachial plexus birth palsy.
Level of evidence: IV.
... Compared with the range of 30%-90% recovery rate in the literature, our finding of 55% is still below the high expectations quoted in previous studies. 25,26 The varying degrees of the recovery rates show that patients need to be strictly monitored. For the diagnosis of BP injuries and treatment planning, a clinical assessment needs to be made in conjunction with an imaging examination. ...
Background and purpose:
Brachial plexus birth injury is caused by traction on the neck during delivery and results in flaccid palsy of an upper extremity commonly involving C5-C6 nerve roots. MR imaging and MR myelography help to assess the anatomic location, extent, and severity of brachial plexus injuries which influence the long-term prognosis along with the surgical decision making. Recently, sonography has been increasingly used as the imaging modality of choice for brachial plexus injuries. The aim of this study was to assess the degree of correlation among brachial plexus sonography, MR imaging, and surgical findings in children with brachial plexus birth injury.
Materials and methods:
This prospective study included 55 consecutive patients (girls/boys = 32:23; mean age, 2.1 ± 0.8 months) with brachial plexus birth injury between May 2014 and April 2017. The patients were classified according to the Narakas classification and were followed up at 4- to 6-week intervals for recovery by the Modified Mallet system and sonography without specific preparation for evaluation. All patients had MR imaging under general anesthesia. Nerve root avulsion-retraction, pseudomeningocele, and periscalene soft tissue were accepted brachial plexus injury findings on imaging. Interobserver agreement for MR imaging and the agreement between imaging and surgical findings were estimated using the κ statistic. The diagnostic accuracy of sonography and MR imaging was calculated on the basis of the standard reference, which was the surgical findings.
Results:
Forty-three patients had pre- and postganglionic injury, 12 had only postganglionic injury findings, and 47% of patients underwent an operation. On sonography, no patients had preganglionic injury, but all patients had postganglionic injury findings. For postganglionic injury, the concordance rates between imaging and the surgical findings ranged from 84% to 100%, and the diagnostic accuracy of sonography and MR imaging was 89% and 100%, respectively. For preganglionic injury, the diagnostic accuracy of MR imaging was 92%. Interobserver agreement and the agreement between imaging and the surgical findings were almost perfect for postganglionic injury (κ = 0.81-1, P < .001).
Conclusions:
High-resolution sonography can identify and locate the postganglionic injury associated with the upper and middle trunks. The ability of sonography to evaluate pre- and the postganglionic injury associated with the lower trunk was quite limited. Sonography can be used as a complement to MR imaging; thus, the duration of the MR imaging examination and the need for sedation can be reduced by sonography.
... While spontaneous recovery does occur in a significant proportion of babies it is not the norm -far from it -and those with more severe injuries often get delayed or no treatment leading to an inferior outcome. Reported incidence of spontaneous recovery varies from 30% to 90% in various series 1,[5][6][7][8][9][10][11][12][13] . ...
... Evaluar otras lesiones asociadas a la columna vertebral, el plexo braquial o el húmero. (Greenwald, Schute, & Shiveley, 1984) ...
RESUMEN.
Introducción: El trauma obstétrico incluye las lesiones producidas en el feto a consecuencia de fuerzas mecánicas (compresión, tracción) durante el trabajo de parto. Los traumas obstétricos son causados por la mecánica del feto al pasar por el canal del parto o por la tracción y presión producidas por la manipulación durante el parto. La variedad de estos traumas incluye a los casi fisiológicos y a los graves que pueden conducir a la muerte del recién nacido o dejar secuelas para el resto de la vida del niño. En México se desconoce la incidencia de trauma obstétrico a pesar de ser un tema de interés en pediatría. En el año 2010, 58 por cada 1000 nacidos presentaron trauma obstétrico. Actualmente en México se desconoce la incidencia por lo que es importante la prevención y disminución del trauma obstétrico. Este estudio permitirá identificar ambos aspectos al describir las situaciones particulares en las que se da un trauma obstétrico y dar a conocer las oportunidades para la prevención. Material y Métodos: Se procedió a analizar los datos de los nacimientos en Yucatán de todos los nacidos vivos en el estado de Yucatán en el 2015, mediante un estudio analítico, descriptivo, de temporalidad retrospectiva, realizado con los datos estatales del subsistema de nacimientos correspondiente al año 2015. Resultados. Los traumas obstétricos más frecuentes fueron caput succedaneum con una frecuencia de 88.8%, el cefalohematoma con un porcentaje 3.75% y las lesión asociada al plexo braquial un 0.99%. Las madres primigestas tuvieron el índice más alto con nacimientos con trauma obstétrico, Discusión. El trauma obstétrico estuvo asociado a las madres primigestas, mientras más número de partos la probabilidad de sufrir un trauma obstétrico decrece. Las lesiones, los recién nacidos con traumatsobstétricos en Yucatán, durante el 2015 fueron productos con peso adecuado y peso elevado.
... Studies have reported recovery rates as high as 80-95%. [5][6][7] However, prompt physical and occupational therapy is crucial in managing nonsurgical candidates and optimizing functional recovery. 8 Delays in treatment could have an important impact on these patients. ...
Background:. Prompt physical and occupational therapy is crucial in managing nonsurgical candidates with obstetrical brachial plexus injuries (OBPI). The objective of our study was to identify newborns suffering from nonoperative OBPI in need of a “fast-track” evaluation by a multidisciplinary team.
Methods:. This is a retrospective review of patients with OBPI from June 1995 to June 2015. All nonsurgical candidates (Narakas class 1) were included in the study. The Gilbert score and the Medical Research Council grading system were used to measure shoulder and elbow function, respectively. The relationship between shoulder and elbow functional outcomes and time delay to consultation was studied using analysis of variance and Welch’s tests. Various subgroups were studied based on OBPI risk factors: maternal diabetes, birth weight >4 kg, use of forceps, asphyxia, multiple comorbidities, and Apgar score at 1 and 5 minutes.
Results:. A total of 168 patients were included in this study. Mean follow-up time was 313.8 weeks (minimum: 52; maximum: 1072; SD: 228.1). A total of 19 patients had an Apgar scores
... A persistência destes desequilíbrios musculares leva a contractura do membro superior em adução e rotação interna e, consequentemente, a alterações articulares da glenoumeral com instabilidade posterior do ombro, que pode ser irreversível se não tratada precocemente [4][5][6] . ...
A paralisia obstétrica do plexo braquial é rara originando disfunção grave e défice marcado da rotação externa e da abdução do ombro. Reviram-se retrospectivamente 11 casos de paralisia obstétrica do plexo braquial (sete com paralisia alta e quatro com paralisia completa) tratados cirurgicamente pela técnica de L’Épiscopo modificada por Hoffer. Estes resultados foram padronizados segundo o tipo de lesão (grupo A – lesão alta; grupo B – lesão completa) e a idade (grupo I ≤ 4 anos; grupo II > 4 anos). O seguimento médio foi de 35 meses. A idade média aquando da cirurgia era de 6,5 anos (r= 2–11). Todos, excepto um, apresentaram melhoria funcional, com aumento da pontuação média de Mallet de 4,6 pontos. Os dois subtipos de paralisia tiveram pontuação média de Mallet sobreponível (grupo A – 4.6; grupo B – 4.7); a idade aquando da cirurgia não influenciou o resultado clínico (pontuação média (grupo I) – 4.8; (grupo II) – 4.4). Não foram registadas complicações. A técnica de L’Épiscopo modificada por Hoffer é eficaz no tratamento paliativo do ombro em paralisia obstétrica do plexo braquial, permitindo recuperação da abdução e rotação externa do ombro. Está indicada em paralisias altas e completas, quando associada a outras cirurgias de recuperação da função do cotovelo, punho e/ou mão. Idade superior a 4 anos não contra-indica a cirurgia desde que sejam excluídas alterações da articulação glenoumeral.
... Neonatal brachial plexus palsy (NBPP) occurs during the perinatal period and manifests as a loss of movement and sensation of the arm as a result of damage to nerves of the brachial plexus. NBPP affects approximately 0.1-5.1 per 1000 live births [1][2][3][4]. The majority of infants will recover without any intervention, but 5%-25% will have persistent NBPP with continuing functional deficits of the arm [5]. ...
Background:
The term self-determination refers to decision-making, goal setting, and perseverance to achieve those goals. Numerous studies have established the importance of self-determination to enhance learning and improve post-school outcomes. However, most studies evaluate students with learning disabilities, cognitive impairment, or behavioral disabilities. There is an absence of research on self-determination for adolescents with physical disabilities.
Objective:
To assess self-determination of adolescents with neonatal brachial plexus palsy (NBPP) compared to their typically developing peers via self-reported measures of function.
Design:
Case-control study.
Setting:
Brachial plexus clinic.
Participants:
Twenty NBPP adolescents (aged 10-17 years) and their parents, and 20 age/gender-matched typically developing adolescents and their parents were recruited. Non-English-speaking participants and those with other physical impairments were excluded from study.
Methods:
Participants completed demographic and American Institutes for Research (AIR) self-determination surveys. One of two designated occupational therapists evaluated participant physical function.
Main outcome measurements:
Demographic survey, AIR self-determination assessment, active range of motion measurements in shoulder forward flexion, elbow flexion, elbow extension, forearm pronation and supination. Grip/pinch strength, MRC muscle strength, 9-Hole Peg Test, and Mallet scale scores were also evaluated.
Results:
Despite physical differences, NBPP adolescents presented similar self-determination levels as their typically developing peers. NBPP adolescents rated their opportunities to engage in self-determined behaviors at school significantly lower than at home. Both adolescents with NBPP and those in the control group rated their opportunities to engage in self-determined behaviors at school significantly lower than at home.
Conclusions:
NBPP adolescents presented similar self-determination scores as their age/gender-matched typically developing peers. These results could be a reflection of our program's patient- and family-centered care approach. Therefore, caregivers and providers should encourage personal development and fulfillment in adolescents with NBPP. Teachers and schools should be aware that opportunities for acquiring self-determination skills might be more limited at school than at home in this age group.
BACKGROUND AND OBJECTIVES
Neonatal brachial plexus palsy (NBPP) almost universally affects movement at the shoulder, elbow, and forearm. Timing of nerve reconstruction surgery to optimize long-term outcomes remains unknown. This study aimed to determine if timing of nerve reconstruction affects long-term recovery of an active range of motion (AROM) at the shoulder, elbow, and forearm in NBPP.
METHODS
We interrogated a prospectively collected database of all patients with NBPP who underwent primary nerve surgery at a single tertiary referral center between 2005 and 2020. The cohort was divided into those who underwent surgery at ≤6 or >6 months old and ≤9 or >9 months old. AROM for shoulder abduction, forward flexion, and external rotation, elbow flexion and extension, and forearm supination were collected at each visit.
RESULTS
Ninety-nine children were included in the analysis; 28 underwent surgery at ≤6 months old, 71 at >6 months, 74 at ≤9 months, and 25 at >9 months. There was no difference in AROM at 5 years for any of the movements between the ≤6- and >6-month groups. The ≤9-month group had significantly better shoulder forward flexion and elbow extension AROM than the >9-month group at a 5-year follow-up and better forearm supination at up to a 15-year follow-up. Patients who presented earlier were more likely to have earlier operations.
CONCLUSION
Surgery before 9 months may improve long-term upper extremity recovery in NBPP. Early referral should be encouraged to optimize timing of operative intervention.
BACKGROUND AND OBJECTIVES
There is a relative dearth of published data with respect to recovery of upper extremity movement after nerve reconstruction for neonatal brachial plexus palsy (NBPP). This study aimed to demonstrate long-term recovery of active range of motion (AROM) at the shoulder, elbow, and forearm after nerve reconstruction for NBPP and to compare that with patients managed nonoperatively.
METHODS
We interrogated a prospectively collected database of all patients evaluated for NBPP at a single institution from 2005 to 2020. AROM measurements for shoulder, elbow, and forearm movements were collected at every visit up to 5 years of follow-up and normalized between 0 and 1. We used generalized estimated equations to predict AROM for each movement within local age windows over 5 years and compared the operative and nonoperative cohorts at each age interval.
RESULTS
In total, >13 000 collected datapoints representing 425 conservatively and 99 operatively managed children were included for analysis. At 5 years, absolute recovery of AROM after nerve reconstruction was ∼50% for shoulder abduction and forward flexion, ∼65% for shoulder external rotation, and ∼75% for elbow flexion and forearm supination, with ∼20% loss of elbow extension AROM. Despite more limited AROM on presentation for the operative cohort, at 5 years, there was no significant difference between the groups in AROM for shoulder external rotation, elbow extension, or forearm supination, and, in Narakas grade 1–2 injury, shoulder abduction and forward flexion.
CONCLUSION
We demonstrate recovery of upper extremity AROM after nerve surgery for NBPP. Despite more severe presenting injury, operative patients had similar recovery of AROM when compared with nonoperative patients for shoulder external rotation, elbow extension, forearm supination, and, for Narakas grade 1–2 injury, shoulder abduction and forward flexion.
Aim:
The primary aim of this study was to determine the risk factors for the occurrence of brachial plexus injury in cases of shoulder dystocia. Secondly, it was aimed to determine the factors affecting the occurrence of permanent sequelae in cases with brachial plexus injury.
Subjects and methods:
ICD-10 codes were scanned from the records of patients who gave birth between 2012 and 2018, and the records of patients with brachial plexus injury and shoulder dystocia were reached. Shoulder dystocia cases with brachial plexus damage were accepted as the study group, and shoulder dystocia cases without brachial plexus damage were considered the control group. Shoulder dystocia patients with brachial plexus injury and without injury were compared for 2-year orthopedics clinic follow-up reports, surgical intervention, permanent sequelae status as well as birth data, maternal characteristics, and maneuvers applied to the management of shoulder dystocia.
Results:
Five hundred sixty births with shoulder dystocia were detected. Brachial plexus injury was observed in 88 of them, and permanent sequelae were detected in 12 of these patients. Maneuvers other than McRobert's (advanced maneuvers) were used more and clavicle fracture was seen more in the group with plexus injury (P < 0.05, P < 0.05, respectively). Logistic regression analysis was performed to determine the risk factors of brachial plexus injury. Brachial plexus injury was observed 4.746 times more in infants who were delivered with advanced maneuvers and 3.58 times more in infants with clavicle fractures at birth.
Conclusion:
In patients with shoulder dystocia, the risk of brachial plexus injury increased in deliveries in which advanced maneuvers were used and clavicle fracture occurred.
Oral cavity (HN reconstruction) can be safely done with an armamentarium of few flaps free
and pedicle flaps when utilised in their possible shapes and sizes. To achieve the twin dream
objectives of best of reconstruction in terms of form, function and aesthetics and a minimal
donor site morbidity; a larger armamentarium of flaps, mastery over perforator-based
harvest, use of chimerism and appropriate use of technology is desirable.
Introduction:
Neonatal brachial plexus palsy (NBPP) results in muscle weakness and impaired somatosensory function of the arm. Current functional assessment is primarily based on clinician-elicited measurements including muscle strength and range of motion. To what extent these measures are representative of real-world arm movement is unclear. However, advances in wearable technology have made it possible to monitor real-world upper limb movement.
Objective:
To determine the feasibility of using body-worn accelerometers to remotely assess arm movements in children with NBPP.
Design:
Criterion standard.
Setting:
Academic medical center.
Participants:
Nine adolescents with NBPP and nine age- and gender-matched control adolescents participated in the study. All were enrolled in school and participated in community activities.
Interventions:
Not applicable.
Methods:
Standard clinician-elicited measurements were collected. For assessing spontaneous arm movements, participants wore activity monitors during all waking hours for 7 days. Results were expressed as ratios of affected to unaffected arm motion for duration and magnitude and correlated with traditional clinic-based assessments. Spearman correlations were used to determine relationships between accelerometry results and traditional assessments. P-value <.05 was considered statistically significant.
Main outcome measurements:
Accelerometry measurements of arm motion and traditional clinical assessments.
Results:
Compared to control ratios, duration of arm movement and magnitude ratios were reduced in the NBPP group, particularly for arm magnitude due to reduced affected arm movement and an increase in unaffected arm movement. Ratios were highly correlated with shoulder function and, to a lesser extent, with elbow function.
Conclusions:
Real-world arm use is an appropriate outcome measure that reflects functional recovery. We demonstrate the feasibility of wearable technology to quantify duration and intensity of spontaneous arm movement in children with NBPP. Accelerometry also allows for the association between traditional clinician-elicited assessment measures and spontaneous arm movements, demonstrating the importance of the shoulder as a focus of treatment in NBPP. This article is protected by copyright. All rights reserved.
Resumen
La parálisis neonatal del plexo braquial define el conjunto de lesiones de una o de varias raíces de dicho plexo que se producen en un parto difícil. Es una afección relativamente rara cuya incidencia ha permanecido constante durante estas últimas décadas, por la imprevisibilidad de los factores de riesgo, y en particular, de la distocia de hombros. El diagnóstico y la evaluación para la recuperación se basan esencialmente en la exploración física. La electromiografía, de interpretación difícil en el lactante, tiene poco interés. La resonancia magnética de la columna cervical, que a esta edad requiere una premedicación o incluso una anestesia general, es una técnica de exploración particularmente indicada en el marco del estudio preoperatorio en busca de una lesión preganglionar. El pronóstico depende fundamentalmente del nivel lesional (pre o posganglionar), de la extensión y de la gravedad de las lesiones pléxicas posganglionares, de la velocidad de recuperación y de la calidad del tratamiento inicial. Aunque su evolución a menudo es hacia la recuperación espontánea, algunos niños quedan con secuelas más o menos importantes, que en algunos casos pueden suponer la pérdida total de la función del miembro afectado. Aunque recientes publicaciones han facilitado una mejor comprensión de las indicaciones quirúrgicas, numerosas cuestiones siguen siendo controvertidas, en particular la indicación y el momento exacto para la reparación nerviosa.
Background and Objectives
The towel test is a reliable and straightforward tech- nique to find elbow flexion in brachial plexus birth palsy. This study evaluates the role and reliability of towel test in children at 6 and 9 months of age.
Materials and Methods
We conducted the towel test in 30 consecutive children at 6 and 9 months of their ages between 2015 and 2020. We recorded the results along with the side involved in these children and the mother’s handedness. Based on the results of towel tests, we did a statistical correlation.
Results
Sixteen of the 30 children were boys. Twelve of the 30 children had left-side involvement. Four mothers were left handed. Four (13%) infants (male = 3; female = 1) had false-negative towel test at 6 and 9 months. There is a significant correlation between the left-hand mother’s and infant who had false-negative towel test (p < 0.01)
Conclusion
The towel test is reliable and straightforward to assess the elbow flexion at 6 and 9 months. It can be falsely negative in 13% of children because of handedness. Mother’s handedness is crucial and should be recorded during the children assess- ment. Alternate tests will further evaluate the elbow flexion in such false-negative towel-tested brachial plexus birth palsy children.
This paper presents the studies’ results on the probability-determined models development based on Bayesian networks to estimate the economic development measure of Ukraine. Considering that one of the difficulties in the Bayesian networks development is the exponential increase in the parameters amount in conditional probability tables (CPT), this study proposes a technique for applying Noisy-MAX nodes to model economic processes taking into account the time component. It is shown that if the proportion of enterprises that implement innovations is increased now by 31%, while the share of profits of these enterprises increases by only 2%, at the next time step the measure of manufacturability and innovation of Ukraine will rise by 81% and will tend to the maximum.
Objectives: The towel test is considered as a reliable clinical examination finding to test the elbow flexion in Brachial plexus birth palsy. A mature central nervous system makes this test positive at 6 months’ time and those who failed the test require microsurgical exploration and nerve repair/transfers for upper limb functions. Not all infants pass in this test. Majority of the children develop a clear hand preference at 6 months of age. We hypothesize the validity of the towel test in brachial plexus birth palsy children between 6 and 9 months of age and the possibility of mother and infant handedness in the false-negative tests. Materials and Methods: A retrospective analysis conducted between 2015 and 2019 about the utility of “towel test” involving 12 boys and 11 girls was analyzed and interpreted. The side involved in these infants and the mother’s handedness was also noted. Based on the age, side, gender, and mother-handedness, the results of towel tests were statistically interpreted. Results: The mean age of the infants involved was 6.6 months (range 6–9 months). Twenty children (87%) had positive tests. Three (13%) infants (male = 2; female = 1) had false-negative test. There was no action on the normal side to remove the towel but weak movements in the affected upper limb persisted to try and remove the towel. The left-hand mother’s infant had false-negative towel test, which was found statistically significant (P < 0.01). Conclusion: Clinicians should know that false negativity may coexist while using the towel test and handedness could be a possibility in them. In such conditions, additional tests can be used to assess the ongoing motor recovery in brachial plexus birth palsy children between 6 and 9 months of age.
Keywords: Brachial plexus birth palsy, false negativity, handedness, towel test
Background
Shoulder deformity and inadequate shoulder function in brachial plexus birth palsy (BPBP) occur due to imbalance between the shoulder abductors, external rotators, adductors and internal rotators. This is due to cross innervation of the regenerating axons and subsequent target muscle innervation. These lead to internal rotation deformity along with glenohumeral dysplasia. Conjoint muscle transfer in the form of latissimus dorsi and teres major muscle combined with release and slide of subscapularis muscle improves shoulder functions. This study aims to evaluate the outcomes of shoulder function after a simultaneous conjoint muscle transfer and subscapularis slide in the management of BPBP.
Methods
18 children with BPBP, who presented with shoulder deformity and inadequate shoulder functions, underwent conjoint muscle transfer along with subscapularis muscle slide. At 18 months, shoulder functions were assessed preoperatively and postoperatively using Mallet score system and range of motions. Statistical analysis was performed to ascertain if the outcomes were statistically significant.
Results
Mean age was 4.64 years with a mean preoperative Mallet score of 10.89 ± 1.60 and mean postoperative Mallet score of 16.22 ± 1.86. At 18 months, mean gain in shoulder abduction at 18 months was 57.22 ± 16.11° with external rotation of 26.66 ± 7.67°. All children showed improvement in shoulder functions. There was no correlation between the clinical outcomes and age of the child.
Conclusion
This procedure was effective in improving shoulder functions in a cohort of patients. The long-term effect of this procedure, however, remains to be evaluated by further follow-up and with similar such studies.
Background:
Soft-tissue contractures about the shoulder in patients with brachial plexus birth injury are common and can lead to progressive shoulder displacement and glenohumeral dysplasia. Open or arthroscopic reduction with musculotendinous lengthening and tendon transfers have become the standard of care. The clinical function and radiographic joint remodeling beyond the first 2 years after surgery are not well understood.
Methods:
We performed a follow-up study of 20 patients with preexisting mild to moderate glenohumeral joint deformity who had undergone open glenohumeral joint reduction with latissimus dorsi and teres major tendon transfers and concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis. Prospective collection of Modified Mallet and Active Movement Scale (AMS) scores and radiographic analysis of cross-sectional imaging for glenoid version, humeral head subluxation, and glenohumeral joint deformity classification were analyzed for changes over time.
Results:
The average duration of radiographic follow-up was 4.2 years (range, 2 to 6 years). The mean glenoid version improved from -31.8° to -15.4° (p < 0.0001). The mean percentage of the humeral head anterior to the middle of the glenoid (PHHA) improved from 9.6% to 30.4% (p < 0.0001). The mean glenohumeral joint deformity score improved from 3.7 to 2.1 (p < 0.0001).
Conclusions:
All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. There were no significant changes beyond the 1-year time point in the Mallet scores, AMS scores, or radiographic outcome measures, possibly because of insufficient power, although trends of improvement were noted for some outcomes. No decline in outcome measures was found during the study period.
Level of evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Neonatal brachial plexus palsy (NBPP) is a birth injury that can cause severe functional loss in the affected limb. The purpose of this study was to determine the temporal changes in the national incidence of this condition and whether associated risk factors have changed over time. Children born via vaginal delivery were identified in the Kids' Inpatient Database (KID) from 1997 to 2012, and those with NBPP were identified. The trend in incidence and risk factors were assessed through the study period. The nationwide incidence of NBPP decreased during the study period. Infants with shoulder dystocia, fetal macrosomia, and gestational diabetes had the highest risk of developing NBPP, while multiple birth mates during delivery had a protective effect. Multiple risk factors, including shoulder dystocia, macrosomia, and heavy for dates became less predictive of the development of NBPP over time. Several risk factors predispose children to the development of NBPP, and the effect of these risk factors has been changing. This information can guide obstetric treatment to help prevent NBPP. Level of evidence is diagnostic, level 3.
Aim: To evaluate whether obstetric brachial plexus injury (OBPI) children who had mod Quad and triangle tilt surgeries maintained their recovered upper extremity functional movements over 10 years.
Background: The short-term outcomes of surgery in OBPI patients are well documented. However, only a few publications with results over 10-year postoperative follow-up exist. We have previously reported the outcomes of these 2 surgeries in OBPI after 1, 2, and 5 years. Here, we report the successful outcomes in 17 of these patients over 10 years.
Methods: Seventeen OBPI patients, who had mod Quad, a modified muscle release operation and triangle tilt, a bony surgical procedure with us between 2005 and 2008, had postoperative follow-up of 10 years and met the inclusion criteria. Patients who had multiple surgeries and did not have 10-year follow-up are excluded in this study.
Results: Fifteen of 17 children maintain their recovered upper extremity functions for extended long period (mean, 10 years; range, 9–13 years). There was statistically significant improvement in total functional Mallet score after 3 years (mean, 18.8 ± 2.1; P ≤ 0.01) from the preoperative mean total Mallet score of 14.5 ± 1.2. This improvement was not only maintained for extended period but also improved (mean total Mallet score, 20.35 ± 2.3; P ≤ 0.01) in some patients.
Conclusions: Overall, all upper extremity functions improved greatly after mod Quad and triangle tilt surgeries in OBPI children, and they were able to maintain their recovered functional movements over extended period of 10 years.
Purpose:
Brachial plexus birth palsy (BPBP) is common; however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known risk factors, and evaluate hypotonia as a new risk factor, as well as estimate the length of stay (LOS) and direct costs of children with an associated BPBP injury.
Methods:
Data from the 1997 to 2012 Kids' Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and direct costs was also performed. Multivariable logistic regression analysis was utilized to assess the association of BPBP with its known and previously undescribed risk factors.
Results:
The incidence of BPBP has steadily decreased from 1997 to 2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number 1 risk factor for the development of a BPBP injury. Hypotonia is a newly recognized risk factor for the development of BPBP. Fifty-five percent of infants with BPBP have no known perinatal risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay direct costs are approximately 40% higher.
Conclusions:
The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the most common risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer LOSs and hospital direct costs compared with children without a BPBP injury.
Type of study/level of evidence:
Prognostic II.
•Development dysplasia of the hip represents a spectrum of disease. Selective screening by physical examination and imaging is recommended.
•Most cases of congenital muscular torticollis resolve spontaneously. Physical therapy and surgery are reserved for recalcitrant cases.
•A variety of foot deformities are common and can be encountered in the neonate. Stretching, casting, or surgery may be required for resolution.
•Torsional and angular deformities of the lower extremities must be differentiated from physiologic variants. Asymmetry and rapid progression are the hallmarks of pathologic variants.
•Congenital vertebral anomalies result from failures of formation or segmentation of spinal elements. Spinal deformities such as scoliosis or kyphosis may ensue.
Birth trauma refers to the variety of injuries that can be sustained by the infant during the process of labour and delivery. It is a significant cause of neonatal morbidity and mortality. The process of birth involves a combination of mechanical forces acting upon the fetus that can produce tissue haemorrhage and disruption of physiological integrity. These factors may result from the method of delivery, route of delivery or fetal position and size. In addition, obstetric intervention may amplify the effects of these forces and cause or exacerbate birth trauma. Whilst one aim of the obstetrician is to prevent birth trauma by identifying fetuses at risk and making appropriate plans for delivery, most birth injuries are unavoidable and occur despite skilled obstetric and neonatal care. In any discussion of birth trauma it is important to realise that whilst caesarean delivery may be protective of some types of birth trauma, fetal injuries can be seen with caesarean section, even when this is performed as an elective procedure.
Forearm supination contractures can occur as a result of neurological derangement of the upper extremity. Primarily, this is observed in patients with neonatal brachial plexus birth palsy. The contractures develop slowly over time and become problematic in childhood as the patients begin requiring forearm pronation for activities of daily living including typing on a keyboard and writing. Although supination contracture is a well-described sequelae of neonatal brachial plexus birth palsy, there is a paucity of literature describing techniques and outcomes for reconstruction and restoration of forearm pronation. The initially described technique included release of the interosseous membrane for flexibility combined with rerouting of part of the biceps tendon to change its biomechanical pull from supination to pronation. More recently, bone and soft tissue procedures have been combined with various forearm osteotomies. We present a combined derotational radial osteotomy and biceps rerouting to realign the forearm in resting pronation and convert the biceps from a supinator to a pronator. This novel surgical technique has not been described as a solution for supination contracture to restore pronation and provide biomechanical advantage of the biceps insertion.
Nerve root compression or compromise is one of the most common reasons for electrodiagnostic testing in adults. By comparison, radiculopathy is less common in childhood and adolescence but remains an important diagnostic consideration due to its debilitating symptoms and numerous etiological considerations in this age group. This chapter will discuss pediatric radiculopathies, brachial and lumbar plexopathies with particular attention paid to neonatal brachial plexus palsies (previously known as obstetrical brachial plexus palsies).
Aims: The aim of this study was to examine 24 cases of obstetric brachial plexus palsy (OBPP) in 41,002 deliveries occurred at San Camillo–Forlanini Hospital in Rome, during the period 2000–2012.
Materials and methods: A population-based retrospective case-control study was designed and the database of the hospital was searched; for each case, maternal and fetal records were examined and some risk factors were evaluated.
Results: A statistically significant association between the 24 cases OBPP and the following risk factors: primiparity (p < .014), birth weight (p < .002), maternal age (p < .02), diabetes (p < .03) and shoulder dystocia (p < .003) was found, moreover all the OBPP cases were recorded only in vaginal deliveries.
Conclusions: The absence of OBPP cases in cesarean deliveries highlighted in this study supports the option of proposing an elective cesarean in the presence of known risk factors after a full disclosure with the mother of risks and benefits in order to obtain a valid consent. Furthermore, when cases of OBPP occur, communication between the physician and the parents of newborns is crucial and it may represent a valid risk-management tool to reduce malpractice lawsuits.
Brachial plexus birth palsy resolves spontaneously in a majority of patients, however, others may have serious permanent dysfunction. Although nerve transfers or grafts are early options for treatment, many children have residual deficits or present too late for such procedures. In these patients, rotational osteotomy of the humerus may restore improved function and motion. Unfortunately, traditional humeral osteotomies only provide correction in a single plane, therefore appropriate correction of the typical residual deformity is incomplete. Here, we describe a novel technique for obtaining a calculated correction in 3 planes using a single osteotomy of the humerus on the basis of a mathematical equation. Nine patients are described here with an average of 35.4 months follow-up. Corrections were obtained in adduction, extension, and either internal or external rotation depending on the initial deformity and Modified Mallet scores were collected for each patient. There was 1 case of transient radial nerve palsy with no long-term complications overall.
While the majority of obstetrical brachial plexus palsies may be managed nonoperatively, a noteworthy proportion of patients will necessitate microsurgical reconstruction in order to optimize long-term functional outcome. The indications for operative management, as well as the timing of surgical intervention and the microsurgical techniques employed, vary extensively between specialist units. This is in part due to the anatomical complexity of the brachial plexus, an imperfect understanding of the natural history of obstetrical brachial plexus palsy, and the broad clinical phenotype with which this challenging condition presents.
Whereas surgical exploration of the child with a flail limb and an ipsilateral Horner’s syndrome is without contention, those with more subtle clinical signs represent a greater management challenge. The importance of treating these children within the context of a specialist multidisciplinary team cannot be overemphasized; indeed the physical and occupational therapists play a fundamental role in the assessment of these complex children. The indications for primary reconstructive surgery will be examined together with the value of specific radiologic and electrodiagnostic investigations in guiding clinical decision making. The reconstructive priorities center on the restoration of hand function, elbow flexion, and shoulder movement. The mainstay of achieving these goals is open surgical exploration of the brachial plexus with neuroma excision and, wherever possible, sural nerve cable grafting of the resultant defect. In limited circumstances neurolysis may be indicated. Intra-plexal and extra-plexal motor nerve transfers are also frequently performed when indicated by the clinical motor examination and the anatomy of the plexus injury.
The surgical principles employed in microsurgical reconstruction of obstetrical brachial plexus palsy will be detailed together with key technical tips in the perioperative management of these children. Parents must be adequately counseled regarding the risks and realities of surgical intervention, with appropriate management of parental expectations regarding likely functional goals and the potential need for secondary surgery.
According to the literature, in Europe 0.4–1.2 cases of obstetrical plexus brachial paresis occur per 1000 births. A 4–6 times higher energy in axial delivery of the newborn leads to a neurotmesis of the plexus. If the energy used is more than 10 times higher, root avulsion occur. Early operative therapy for obstetrical plexus paresis is mandatory. The best period for an operation is between the 3rd and 6th months of age. CT and MRI imaging as well as electrophysiological investigations are of the utmost importance. Birch, Gilbert and Gu think there is an indication for operation if no active elbow flexion can be performed at the age of 6 months. Primary coaptation is easier in babies than in adults. However, large defects have to be a bridged by autologous nerve grafts. For root avulsions, neurotization with the accessory and phrenic nerves (Gu) is being used more and more. In 362 children with 52 operated cases, after a follow-up from 2 to 10 years, we found 37 functional, useful recoveries. Nine operations were unsatisfactory and two had poor results. In four cases the operation was unnecessary.
This manuscript will review the literature and focus on the present controversies regarding the natural history, microsurgical treatment, and secondary shoulder reconstructive surgery in infants with brachial plexus birth palsies. Surgical indications, expected outcomes, and complications will be addressed. The controversy regarding the timing of microsurgery in extraforaminal ruptures will be addressed in detail. The developments in assessment and care of glenohumeral deformity with magnetic resonance imaging scans, arthroscopic and open reductions, and tendon transfers about the shoulder will be discussed. Recommendations for microsurgery and shoulder reconstruction will be based on the present evidence from the literature.
Glenohumeral dysplasia is a disorder that occurs in the growing skeleton following a partial denervation of the muscles around the shoulder due to an obstetric brachial plexus palsy. Typically, there is an unopposed internal rotation force resulting in soft tissue and skeletal abnormalities. Management depends on a number of factors, but in the neonate consists of microsurgical reconstruction of the brachial plexus, and in the older child rebalancing of the muscles around the shoulder in the form of tendon transfers. Once skeletal deformities develop these need addressing in the form of reconstruction of the glenoid and humerus.
One hundred and sixty-nine cases of brachial palsy in newborn infants among 66,149 deliveries during a 10 year period have been analyzed. The incidence of this injury was 1:391 deliveries or 0.25 per cent. Sixty-four cases of brachial palsy were reported in a total of 54,629 spontaneous deliveries or 0.11 per cent; 34 occurred among the 2,857 breech presentations or 1.19 per cent; 67 were observed in a total of 5,184 forceps deliveries or 1.29 per cent; and finally 4 cases were included among the 1,710 vacuum extractions or 0.23 per cent.
The main types of orthoses that have been used in 18 adults and 10 children with partial and complete brachial plexus injuries are as follows: functional arm brace for the total and upper brachial plexus lesions; handsplints, modified with dynamic thumb and finger components for lower lesions; and in children, modifications of these basic types adapted to the needs of the growing child. Of the 18 adults the Schottstaedt Robinson type of functional arm brace was used in 7 with total plexus injury and helped relieve pain. It was also used in 5 patients with upper trunk lesion. Because these patients have some degree of elbow extension and a hand with sensation, the functional arm brace can give not only relief of pain but also selective positioning of the hand which allows the patient to use the involved hand in bimanual activities while awaiting recovery or reconstructive surgery. Handsplints were used in 5 patients. Their function was to support joints, to prevent the deformity that follows muscle imbalance and to assist weak muscles so that they became functional. In 10 children, 8 having upper and 2 total plexus lesions, dynamic bracing was successful in preventing contractures and encouraging use of the remaining musculature to help gain bimanual function.
The authors consider the prognosis with and without treatment in the disability of partial paralysis of the shoulder girdle muscles. They review modes of treatment and the optimal time in life for attainment of a successful result.
Introduction
NUMEROUS AUTHORS have recently emphasized the importance of early learning and experience, which seem to be of a different kind than that which occurs later in life. They also have insisted on the possibility of an age limit in acquiring certain skills, perceptual knowledge, and even more complex types of behavior. Indeed, many facts tend to show that the results and functional success of certain experiments in neurophysiology and in behavioral sciences have a different outlook whether performed in a newborn or in an adult.Certain personal clinical observations suggested the same conclusion. Long-term followup of patients born with lesions of the lower motor neuron type, mainly in Erb's palsy, but also in spina bifida1,2 showed comparatively normal electrophysiological findings despite the prolonged atrophy and the loss of function. The electromyographic (EMG) findings were characterized by normal motor units, sometimes of low amplitude, recruited by stimulation or by
The labours of 8 patients which resulted in the birth of babies with brachial plexus injury were studied. Four of the mothers were Black, 1 was Asian and 3 were White. Seven had instrumental deliveries. All babies were above average birth weight. Shoulder dystocia occurred in 7, with 5 of these showing abnormal partographic patterns. The abnormal active phase on the partogram should serve as a first stage warning of the possibility of shoulder dystocia. Methods of management of this second stage complication are reviewed.
Eight patients are presented suffering from obstetrical brachial paralysis having in common the fact that they had not received treatment of any kind before they came to us. The detailed study carried out, together with the therapeutical indications, surgical technique used, and final evaluation of each case constitutes this study paper.
20 cases of birth injury to the brachial plexus were explored by metrizamide myelography, 6 under general anesthesia, and 14 under diazepam sedation, without any complication. Age ranged from 2 to 19 months, the average being 5 months. All patients underwent surgery within the week following this examination. The confrontation of radiological and surgical data showed the accuracy of the radiological diagnosis; the positive sign of radicular avulsion is the presence of a pseudomeningocele. Unfortunately when the radiological examination is performed long after birth, this sign may be absent even in the presence of a nerve root avulsion. Nevertheless due to the difficulties of interpreting the electromyogram in such cases, our surgeons consider myelography indispensable prior to surgery.