Shoulder deformities in obstetric brachial plexus paralysis: a computed tomography study

Obstetric brachial plexus palsy invariably involves the upper roots. If left untreated, characteristic deformities of the shoulder are common sequelae. The most objective way to investigate these shoulder deformities is computed tomographic (CT) scanning of bilateral upper limbs. In this study, specific measurements on CT scans of bilateral upper extremities were performed in a population of patients with obstetric brachial plexus palsy before and after reconstruction (nerve repairs and secondary procedures). The measurements showed that the restoration of external rotation and the scapula stabilization procedure correct the inclination of the humeral head, improve the joint congruency significantly, and decrease the winging of the scapula, thus improving the kinetics of the shoulder. Periodic CT measurement is an objective method of measuring the changes at the shoulder joint that occur over time during the natural evolution of the obstetric brachial plexus palsy lesion and of documenting the benefits of microsurgical intervention.

Obstetric brachial plexus lesions: a study of 74 children registered with the British Paediatric Surveillance Unit (March 1998-March 1999)

Seventy-four children with obstetric brachial plexus palsy registered with the British Paediatric Surveillance Unit were prospectively followed for a minimum of 2 years. Thirty-nine (52.7%) spontaneously recovered to normal or nearly normal levels and a further 29 (39.3%) regained good function in the upper limb. The most important secondary deformity involved the gleno-humeral joint and 20 patients (27%) needed surgical correction. Two more children await operation for shoulder deformity. The brachial plexus was explored in nine patients (12.2%) and repaired in seven.

Assessment of the motor power in older children with obstetric brachial plexus palsy

The King Saud University (KSU) muscle grading system used for assessing the upper limb in older children with obstetric brachial plexus palsy is presented and compared to other muscle grading systems.

Obstetric brachial plexus palsy: a clinical and electrophysiologic evaluation

BACKGROUND

Obstetrical brachial plexus palsy (OBPP) occurs as sequelae of birth-related trauma, antenatal and parturition related complications. It is associated with varying degrees of functional disability. Electrodiagnostic studies (EDS) are an adjunctive tool and help to localise and prognosticate the outcome of OBPP.

METHODS

Fourteen children, presenting with OBPP to the Clinical Neurophysiology Lab, were analyzed. Details of birth history were obtained, and EDS were performed to characterize the lesion.

RESULTS

The age ranged from one month to one year. Ten had unilateral and four bilateral brachial palsy. On EDS, five had pan-plexus, six predominantly upper plexus and three lower plexus involvement. A poor re-innervation pattern on EMG correlated with inadequate recovery.

CONCLUSION

OBPP, a condition associated with considerable disability, needs to be prevented. Electrodiagnostic studies are a useful adjunctive tool for characterizing the site of injury and prognostication.

The "beggar's" hand and the "unshakable" hand in children with total obstetric brachial plexus palsy

A total 12 consecutive children with secondary deformities following total obstetric brachial plexus palsy were included in this retrospective study. In all patients, the main complaints were two socially disabling hand postures: the "beggar's" hand and/or the "unshakable" hand. All children had a supinated forearm with no active pronation and were teased by their friends, who called them "beggars." When the impairment was severe and involved the right hand and wrist, children also complained that they were not able to shake hands. The management approach to these children was described, with the main aim of surgery being the correction of the abnormal posture. Other simultaneous tendon transfers were also performed to improve hand function if there were suitable musculotendinous units. Successful reconstruction was accomplished in all patients. Preoperatively, some children refused to go to school because of teasing, and most did not want to interact socially. After surgery, all children attended school regularly, and parents reported much better social interaction. However, the functional gain was never enough to dramatically improve the daily use of the limb. The contralateral normal limb remained the dominant one for all daily activities, including writing and eating.

Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy

For the purpose of treatment, obstetric brachial plexus palsy can be subdivided into two distinct phases: initial obstetric brachial plexus palsy, and late obstetric brachial plexus palsy. In the latter, nerve surgery is no longer practical, and treatment often requires palliative surgery to improve function of the shoulder, elbow, forearm, and hand. Late obstetric brachial plexus palsy in the forearm and hand includes weakness or absence of wrist or metacarpophalangeal or interphalangeal joint extension; weakness or absence of finger flexion; forearm supination, or less commonly pronation contracture; ulnar deviation of the wrist; dislocation of the radial or ulnar head; thumb instability; or sensory disturbance of the hand. Palliative reconstruction for these forearm and hand manifestations is more difficult than for the shoulder or elbow because of the lack of powerful regional muscles for transfer. This report reviews the authors' experience performing more than 100 surgical procedures in 54 patients over a 9-year period (between 1988 and 1997) with a minimum of 2 years' follow-up. Surgical treatment is highly individualized, but the optimal age for forearm and hand reconstruction is usually later than for shoulder and elbow reconstruction because of the requirement for a preoperative exercise program. Multiple procedures for forearm and hand function were often performed on any given patient. Frequently, these were done simultaneously with reconstructive procedures for improving shoulder and/or elbow function. Traditional tendon transfer techniques do not provide satisfactory reconstruction for those deformities. Many of the authors' patients required more complex techniques such as nerve transfer and functioning free-muscle transplantation to augment traditional techniques of tendon and/or bone management. Sensory disturbance of the forearm and hand in late obstetric brachial plexus palsy seems a minor problem and further sensory reconstruction is unnecessary.

Obstetrical brachial plexus palsy. Prediction of outcome in upper root injuries

Thirty obstetrical brachial plexus palsies involving the upper roots were retrospectively reviewed. There were 20 C5-C6 palsies and ten C5-C6-C7 palsies in which recovery of C7 occurred by the end of the first month. Recovery of elbow flexion at 3 months, C7 involvement and high birthweight were the best early predictors of outcome, but all were unreliable when used separately. In combination, recovery of elbow flexion and birthweight predicted the final outcome reasonably satisfactorily, particularly when elbow flexion at 9 months, and not 3 months was considered (risk of error = 13%). Brachial plexus reconstruction may therefore be justified when there was initial C7 involvement associated with increased birthweight and poor elbow flexion at 6-9 months.

Assessment of the method and timing of repair of a brachial plexus traction injury in an animal model for obstetric brachial plexus palsy

A Sunderland type IV traction injury to the C6 root of adult sheep or newborn lamb brachial plexus was used as a model for obstetric traction injury to the C5 root in humans. In one experimental cohort the injury was created and repaired using interfascicular nerve autografts or coaxially aligned freeze-thawed skeletal muscle autografts in a group of adult sheep and in a group of newborn lambs. In a second cohort a similar injury was created and repaired either immediately or after a delay of 30 days, using either interfascicular nerve autografts or coaxially aligned freeze-thawed skeletal muscle autografts in four groups of six newborn lambs. In all cases both functional and morphometric indices of nerve regeneration were poorer in the injured and repaired nerves than in normal nerves. In lambs the method of repair made no difference and no significant differences were found for any of the indices of nerve function or morphology. In sheep the use of muscle grafts was associated with a poorer outcome than the use of nerve autografts. Where a delay of 30 days had elapsed between injury and repair, the results using nerve autografts were not significantly different. Where freeze-thawed muscle autografts had been used, the maturation of the regenerated nerve fibres after delay was significantly poorer than after immediate repair. The electrophysiological variables CV(max) and jitter, which may be applied clinically, were found to be good discriminators of recovery in all of the animals and in respect of all procedures.

The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy

Children with previously untreated obstetric brachial plexus palsy frequently have abnormal elbow function because of motor recovery with aberrant reinnervation, or because of paresis or paralysis. From 1988 to 1997 (9-year period), 62 children with obstetric brachial plexus palsy with resulting elbow deformity underwent various methods of palliative reconstruction to improve elbow function. For motor recovery with aberrant reinnervation, release of aberrantly reinnervated antagonistic muscles and augmentation of paretic muscles form the basis of surgical intervention. The surgical procedures included triceps-to-biceps transfer, biceps-to-triceps transfer, brachialis-to-triceps transfer, or combined biceps- and brachialis-to-triceps transfer. Choice of procedures was individualized and randomly determined on the basis of the degree and pattern of aberrant reinnervation between elbow flexors and extensors. In patients' motor recovery with paresis or paralysis, persistently weak elbow flexion was salvaged with a functioning free muscle transplantation or Steindler's flexorplasty, or regional shoulder muscle transfer. In addition, patients with aberrant reinnervation between shoulder abductors and elbow flexors underwent anterior deltoid-to-biceps transfer with a fascia lata graft. All patients had a minimum follow-up of 2 years. Results are assessed and discussed and a reconstructive algorithm is recommended. In general, reconstruction of elbow extension should precede that of elbow flexion. Biceps-to-triceps transfer with preservation of an intact brachialis muscle, or brachialis-to-triceps transfer with preservation of an intact biceps, allows 50 percent of these patients to achieve acceptable elbow flexion and extension in a single-stage procedure.

Function of the upper limb after surgery for obstetric brachial plexus palsy

We reviewed a consecutive series of 33 infants who underwent surgery for obstetric brachial plexus palsy at a mean age of 4.7 months. Of these, 13 with an upper palsy and 20 with a total palsy were treated by nerve reconstruction. Ten were treated by muscle transfer to the shoulder or elbow, and 16 by tendon transfer to the hand. The mean postoperative follow-up was 4 years 8 months. Ten of the 13 children (70%) with an upper palsy regained useful shoulder function and 11 (75%) useful elbow function. Of the 20 children with a total palsy, four (20%) regained useful shoulder function and seven (35%) useful elbow function. Most patients with a total palsy had satisfactory sensation of the hand, but only those with some preoperative hand movement regained satisfactory grasp. The ability to incorporate the palsied arm and hand into a co-ordinated movement pattern correlated with the sensation and prehension of the hand, but not with shoulder and elbow function.

Focal upper extremity neuropathy in neonates

Focal upper extremity neuropathies are common in neonates. The brachial plexus is the most common site involved. Brachial plexus injuries may involve different structures, thus producing different clinical presentations: complete brachial plexus palsy, Duchenne-Erb palsy, upper-middle trunk brachial plexus palsy, Klumpke palsy, fascicular brachial plexus palsy, and bilateral brachial plexus palsy. The causes of brachial plexus palsy are obstetric injury, intrauterine compression, humeral osteomyelitis, hemangioma, exostosis of the first rib, neck compression, and neoplasm. The differential diagnosis of brachial plexus palsy includes pseudoparesis, amyoplasia congenita, congenita varicella syndrome, and neurological lesions at other neuroanatomical levels. The cause and the degree of injury dictate the prognosis. The prognosis of obstetric brachial plexus injury is usually good.

The findings in paediatric obstetric brachial palsy differ from those in older patients: a suggested explanation

An EMG and nerve-conduction-study protocol has been developed and used in all patients with brachial plexus lesions since 1985. The findings of EMG and nerve-conduction studies in obstetric brachial palsy (OBP) mostly suggest a falsely optimistic prognosis. To analyse this, all subjects were selected with complete avulsion of both roots C5 and C6 and/or complete rupture of the upper trunk verified during operation from a group of 162 infants with OBP (aged 4 to 14 months) and a group of 184 child and adult patients (aged 6 to 74 years) with a traumatic brachial plexus lesion. Fourteen infants, approximately 4 months old, with OBP, and 19 adults (aged 16 to 30 years) met the selection criteria. The infants from the group with OBP had at 4 months a nearly normal recruitment pattern of motor units in the biceps brachii and deltoid muscles, with little or no denervation. However, in the older group with traumatic brachial palsy, the same lesion caused complete denervation of both muscles. From the group with OBP, a third group (N=3) with the same lesion plus an additional lesion of C7 or a rupture of the middle trunk was selected. This additional lesion resulted in nearly complete denervation of both muscles. This means that C7 largely contributes to the innervation of both muscles at the time of birth, but this innervation is lost during later life in normally developing individuals (apoptosis). A central mechanism might be responsible for the clinical palsy and later spontaneous improvement which is always found in the infants with OBP.

Improving shoulder and elbow function in children with Erb's palsy

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.

Neurophysiological evaluation of children with traumatic radiculopathy, plexopathy, and peripheral neuropathy

Neurophysiological evaluation of children with traumatic peripheral nervous system injury is accomplished with electromyography, motor and sensory nerve conduction studies, and somatosensory and motor-evoked potentials. Preoperative neurophysiological tests are performed if motor deficits persist for more than 3 months. Evidence of reinnervation on these neurophysiological tests predates clinical recovery by weeks, hence they help determine the site of the lesion and provide objective measures for selecting candidates for surgical exploration. Intraoperative neurophysiological tests help to identify and confirm the integrity of nerves and to develop the optimal surgical strategy. Postoperative evaluations every 3 to 6 months may determine efficacy of treatment.

Functional outcome at 5 years in children with obstetrical brachial plexus palsy with and without microsurgical reconstruction

Between 1987 and 1998, 470 patients visited the national clinic for obstetrical brachial plexus palsies at the Karolinska Hospital, Stockholm, Sweden. This study reports on 247 children examined at 5 years of age using a special protocol for testing the sensory and motor function of the hand. The children were distributed in various groups depending on the number of injured nerves, whether they had some muscle activity in their biceps or deltoid muscles at 3 months of age, and whether any operations with nerve reconstruction had been performed. The shoulder range of movement in C5-6 palsies was significantly better in the group which had been operated on (operated group), but otherwise there were no differences between children who had been operated on (non-operated group) and those who had not. A decrease in grip strength and bimanual function in level C5-6 palsies was found, though these roots should not innervate the distal hand. Outcome was not influenced by the number of avulsions in upper-plexus palsies or whether the operation took place before or after the age of 6 months. The group with extensive lesions (C5-Th1) had the most root avulsions, showing a correlation between increased avulsions and decreased hand function. This study does not support operating on children with no activity of the biceps and deltoid muscles at 3 months of age, as other authors have concluded. Rather, it favours waiting for a late recovery.

Functional scoring system for obstetric brachial plexus palsy

We suggest a new scoring system that measures the upper limb function both as a unit and in separate parts. Our system was designed to study the recovery in patients with obstetric brachial plexus palsy (OBPP). It measures active limb movements and compares them with the normal side to obtain a ratio, which is then converted to a score. Fifty-two patients with OBPP were studied with a follow-up of 2 years. The progress of the patients was monitored using the system. Thirty-seven patients (71%) achieved very good recovery, eight patients (15%) achieved a good score, and five patients (10%) achieved a poor score. Most of the recovery occurred before the age of 6 months.

Perinatal brachial plexus palsy

Perinatal brachial plexus palsy (PBPP) has been traditionally classified into three types: upper plexus palsy (Erb's) affecting the C5, C6, and +/- C7 nerve roots, lower plexus palsy (Klumpke's) affecting the C8 and T1 nerve roots, and total plexus palsy. Although most cases will resolve spontaneously, the natural history of the remaining cases is influenced by contractures of uninvolved muscle groups and subluxation or dislocation of the shoulder and elbow. Microsurgical nerve repair has demonstrated to provide improved outcomes compared to conservative treatment, while advancements in secondary reconstruction have offered significant improvements in the performance of activities of daily living for older children with unresolved plexus palsy.

Developmental and behavioural outcome in obstetric brachial plexus palsy

Forty-four children with obstetric brachial plexus palsy were assessed for both developmental attainment and behavioural problems. Analysis of the resulting data revealed developmental and behavioural problems previously not identified, particularly in those with more severe injuries. These effects were independent of the general condition of the child at birth, as indicated by their Apgar scores. Further studies are required to provide clarification of these children's difficulties, the mechanisms by which they occur and effective strategies to address them.

Classification of impairment of shoulder abduction in obstetric brachial plexus palsy and its clinical significance

Shoulder abduction was studied in 25 cases of obstetric brachial plexus palsy (OBPP). According to muscle function, electromyographic features and X-ray examination, impairment of shoulder abduction could be classified into dynamic, resistant or combined types. Five cases were the dynamic type, which was characterized by paralysis of the shoulder abductors. Fifteen cases were categorized as the resistant type, with contracture of the subscapularis muscle, co-contraction of latissimus dorsi and teres major muscles and secondary disorders of the shoulder joint. Five cases were classified as the combined type in which there were both dynamic and resistant factors. Appropriate management and surgical procedures in the shoulder affected by OBPP depend on the pathological classification.

Obstetric brachial plexus palsy: a large animal model for traction injury and its repair. Part 1: age of the recipient

A Sunderland type IV traction injury to the C6 root of the sheep or lamb brachial plexus was used as a model for obstetric traction injury to the C5 root in humans. The injury was created and immediately repaired using interfascicular nerve autografts in a group of adult sheep and a group of newborn lambs. The animals were examined using electrophysiological and morphometric techniques 1 year after operation. It was found that the recovery of neuromuscular function was superior in the lambs. The implication is that nerves in newborn animals have a better potential for regeneration than that seen in older individuals. This is discussed with reference to the management of obstetric brachial plexus palsy.

[Pseudo-paralysis of the brachial biceps in obstetrical brachial plexus lesions (OBPL):concerning the "overly optimistic" EMG in OBPL]

In birth palsy of the brachial plexus, the mixed interference pattern recorded for the brachial biceps on the electromyogram often conflicts with the muscle's inability to flex the elbow. We report our observations of a six-month-old infant who presented paralysis of the upper and medial elements of the brachial plexus, in whom we demonstrated early biceps-triceps co-contractions, which may explain this discrepancy and 'pseudo-paralysis' of the biceps. We analyse and discuss the practical consequences of these findings, and notably the possible therapeutic use of triceps-to-biceps surgical transposition.

Management of peripheral nerve problems in the upper and lower extremity using quantitative sensory testing

Elective microsurgery of the peripheral nervous system concerns nerve decompression, neurolysis, nerve repair, and forms of nerve reconstruction with grafts or tubes. Management skills for the peripheral nerve too often rely on antiquated assessment techniques and depend upon traditional electrodiagnostic testing. Quantitative sensory testing is an approach to the evaluation of peripheral nerve function that is available now to all physicians interested in managing peripheral nerve problems. This article introduces quantitative sensory testing, with particular regard to the management of peripheral nerve problems.