Management of infant brachial plexus injuries

Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy

PURPOSE

Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP.

METHODS

This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity).

RESULTS

Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients.

CONCLUSION

Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.

Long-term functional outcome of secondary shoulder surgery in brachial plexus birth palsy patients

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options. A systematic literature search in healthcare databases (PubMed, Embase, the Cochrane library, CINAHL, and Web of Science) was performed from January 2000 to July 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The quality of the included studies was assessed with the Cochrane ROBINS-I risk of bias tool. Relevant trials studying BPBP with at least five years of follow-up and describing functional outcome were included. Of 5,941 studies, 19 were included after full-text screening. A total of 15 surgical techniques were described. All studies described an improvement in active external rotation (range 12° to 128°). A decrease in range of motion and Mallet score after long-term (five to 30 years) follow-up compared to short-term follow-up was seen in most studies. The literature reveals that functional outcome increases after different secondary procedures, even in the long term. Due to the poor methodological quality of the included studies and the variations in indication for surgery and surgical techniques described, a consensus on the long-term functional outcome after secondary surgical procedures in BPBP patients cannot be made.

Neonatal brachial plexus palsy: a permanent challenge

Neonatal brachial plexus palsy (NBPP) has an incidence of 1.5 cases per 1000 live births and it has not declined despite recent advances in obstetrics. Most patients will recover spontaneously, but some will remain severely handicapped. Rehabilitation is important in most cases and brachial plexus surgery can improve the functional outcome of selected patients. This review highlights the current management of infants with NBPP, including conservative and operative approaches.

Late reconstruction of brachial plexus birth palsy

Brachial plexus birth palsy (BPBP) presents to the physician on a clinical spectrum, and may substantially impair the child. Potential interventions to improve function for the child with BPBP include physical therapy, microsurgical nerve reconstruction and nerve transfers, soft-tissue balancing and reconstruction with musculotendinous transfers, and osteotomies. Some interventions, such as nerve reconstruction, are best performed in infancy; others, such as muscle transfers and osteotomies, are performed to treat manifestations of this condition that appear later in childhood. Although controversy continues to exist regarding the natural history and surgical management of these patients, recent literature has improved our understanding of surgical indications, anticipated outcomes, and potential complications. On the basis of current evidence, we present here the recommendations for surgical intervention in the upper extremity of children with BPBP, and encourage early referral to a brachial plexus specialist to establish care.

Neonatal brachial plexus palsy--management and prognostic factors

Successful treatment of patients with neonatal brachial plexus palsy (NBPP) begins with a thorough understanding of the anatomy of the brachial plexus and of the pathophysiology of nerve injury via which the brachial plexus nerves stretched in the perinatal period manifest as a weak or paralyzed upper extremity in the newborn. NBPP can be classified by systems that can guide the prognosis and the management as these systems are based on the extent and severity of nerve injury, anatomy of nerve injury, and clinical presentation. Serial physical examinations, supplemented by a thorough maternal and perinatal history, are critical to the formulation of the treatment plan that relies upon occupational/physical therapy and rehabilitation management but may include nerve reconstruction and secondary musculoskeletal surgeries. Adjunctive imaging and electrodiagnostic studies provide additional information to guide prognosis and treatment. As research improves not only the technical aspects of NBPP treatment but also the ability to assess the activity and participation as well as body structure and function of NBPP patients, the functional outcomes for affected infants have an overall optimistic prognosis, with the majority recovering adequate functional use of the affected arm. Of importance are (i) early referral to interdisciplinary specialty clinics that can provide up-to-date advances in clinical care and (ii) increasing research/awareness of the psychosocial and patient-reported quality-of-life issues that surround the chronic disablement of NBPP.

Microsurgical outcome in posttraumatic brachial plexus injuries in children

PURPOSE

The purpose of the study was to analyze the surgical outcomes in children (≤18 years) with brachial plexus injury operated between April 2008 and March 2012 at our center.

METHODS

All children <18 years of age admitted to our center and surgically treated with a diagnosis of posttraumatic brachial plexus injury were included in the study. The demographic details of these patients were retrieved from the computerized database of our hospital. The results were analyzed in terms of the mode of injury, type of injury, surgical procedure performed, and motor recovery after the surgery (MRC Grading). Motor recovery with MRC >3/5 was termed as good outcome.

OBSERVATIONS

A total of 33 patients were surgically treated. The mean age at presentation was 15.1 (range 4-18) years. Boys constituted 79% (n = 26) of our patient population. High-velocity injury was the commonest mode of injury. Panbrachial injury was the commonest seen in 82% (n = 27) of patients. Mean duration between injury and surgical intervention was 6 (range 2-13, SD ± 2.6) months. Majority of patients underwent neurotization procedure. Mean follow-up was 32 (range 6-51) months.

CONCLUSIONS

High-velocity trauma is the most common mode on injury. Global palsy involving all the plexal elements was present in 82% of the children. Neurotization was the most commonly performed surgical procedure. Good motor outcome (MRC grade ≥3/5) was seen in 62% of patients.

Three-dimensional humeral morphologic alterations and atrophy associated with obstetrical brachial plexus palsy

BACKGROUND

Obstetrical brachial plexus palsy (OBPP) is a common birth injury, resulting in severe functional losses. Yet, little is known about how OBPP affects the 3-dimensional (3D) humeral morphology. Thus, the purpose of this study was to measure the 3D humeral architecture in children with unilateral OBPP.

METHODS

Thirteen individuals (4 female and 9 male patients; mean age, 11.8 ± 3.3 years; mean Mallet score, 15.1 ± 3.0) participated in this institutional review board approved study. A 3D T1-weighted gradient-recalled echo magnetic resonance image set was acquired for both upper limbs (involved and noninvolved). Humeral size, version, and inclination were quantified from 3D humeral models derived from these images.

RESULTS

The involved humeral head was significantly less retroverted and in declination (medial humeral head pointed anteriorly and inferiorly) relative to the noninvolved side. Osseous atrophy was present in all 3 dimensions and affected the entire humerus. The inter-rater reliability was excellent (intraclass correlation coefficient, 0.96-1.00).

DISCUSSION

This study showed that both humeral atrophy and bone shape deformities associated with OBPP are not limited to the axial plane but are 3D phenomena. Incorporating information related to these multi-planar, 3D humeral deformities into surgical planning could potentially improve functional outcomes after surgery. The documented reduction in retroversion is an osseous adaptation, which may help maintain glenohumeral congruency by partially compensating for the internal rotation of the arm. The humeral head declination is a novel finding and may be an important factor to consider when one is developing OBPP management strategies because it has been shown to lead to significant supraspinatus inefficiencies and increased required elevation forces.

Bone discrepancy as a powerful indicator for early surgery in obstetric brachial plexus palsy

OBJECTIVES

One of the unfortunate sequelae in obstetric brachial plexus palsy (OBPP) is upper limb length discrepancy. However, the influence of primary nerve reconstruction remains undetermined. In this study, the resultant discrepancy in children with OBPP who underwent primary reconstruction was analyzed in relation to the severity of the lesion, the timing of surgery, and the functional outcome following surgery.

METHODS

Fifty-four patients that met the inclusion criteria were included in this study. Preoperative and postoperative bilateral scanograms were obtained to document the effect of reinnervation on bone growth. The length of the humerus, ulna, third metacarpal, third proximal phalange, and total limb length were measured and the percentage between the affected and normal side were accessed. Correlations between all the measures of limb length and measures of active motion (i.e., three different classification systems) were performed.

RESULTS

Spearman's rank correlation coefficients revealed significant correlations between limb length discrepancies and nearly all measures of active upper extremity movement. The timing of surgery and the severity of the lesion significantly influenced the resultant limb length discrepancy.

CONCLUSIONS

The prevention of a non-acceptable upper limb discrepancy is fundamental for both the patient and family. The extent of the resultant discrepancy appeared to be strongly related to the time between injury and surgery, degree of severity, and the outcome of surgery. Patients with better functional recoveries of the affected upper extremities showed smaller differences in limb length.

Obstetric brachial plexus palsy: a prospective, population-based study of incidence, recovery, and residual impairment at 18 months of age

AIM

The aim of this investigation was to study the incidence of obstetric brachial plexus palsy (OBPP), to prospectively follow the recovery process, to assess the functional outcome at 18 months of age, and to find early prognostic indicators.

METHOD

Of the 38 749 children born between 1999 and 2001 in western Sweden, 114 (70 males, 44 females) had an OBPP. Ninety-eight children were examined on six occasions at up to 18 months of age. Muscle strength, range of motion, hand preference, and functional abilities were noted, and the severity of the OBPP was classified.

RESULTS

The incidence of OBPP was 2.9 per 1000 live births, and the incidence of persisting OBPP was 0.46 per 1000. At 3 months of age, the predictive value of regained elbow flexion for complete recovery was 100%, 99% of shoulder external rotation, and 96% of forearm supination. Most of the 18 children with persisting OBPP could perform functional activities but asymmetries were noted. Five children had a mild, 11 had a moderate, and two had a severe impairment. Three had undergone nerve surgery, one with a mild and two with a severe persisting impairment.

INTERPRETATION

Most children with an OBPP recover completely. Muscle strength at 3 months of age can be used to predict outcome.

Prognosis following neonatal brachial plexus palsy: an evidence-based review

PURPOSE

The spontaneous recovery rate of neonatal brachial plexus palsy (NBPP) is often cited as 75-95%. However, recent reports have found the recovery rate to be much lower. The purpose of this study was to perform an evidence-based review aimed at summarizing the available English language information regarding prognosis following NBPP based on the Narakas classification.

METHODS

A Medline database search was performed to identify articles that focused on the natural history, outcome, prognosis, or conservative treatment of neonatal brachial plexus birth injury from 1966 to 2006. Twenty-four articles were identified. The articles were graded according to the Oxford Evidence Based Grading Scale and data regarding sample size, follow up, study purpose, Narakas grouping, Mallet scale, and recovery of function at 3 and 6 months were extracted. Of the 24 articles, 11 were included for review. Data analysis included odds ratios and percent recovery.

RESULTS

Of the 11 studies, only one was given a grade of a Level I study, three were given a grade of Level II, and seven were given a grade of Level IV. Sixty-four percent of infants classified as Narakas I and II had spontaneous recovery of biceps function at 3 months of age and only 9% of the Narakas III and IV group had recovery. Sixty-five percent of the Narakas I and II group had complete recovery at 6 months of age and only 14% of the Narakas III and IV group had recovery. The odds of biceps recovery at 3 months of age for the Narakas I and II group was 19 times higher compared to the III and IV group. The odds of complete recovery were 11 times higher for the Narakas I and II group compared to the III and IV group.

CONCLUSION

The quality of the literature regarding the prognosis of neonatal brachial plexus injury is poor. Based on the Narakas classification, recovery better for NBPP classified as Narakas I and II.

Lack of effectiveness of primary conservative management for infants with brachial plexus birth palsy

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.

The epidemiology of neonatal brachial plexus palsy in the United States

BACKGROUND

The nationwide incidence of neonatal brachial plexus palsy in the United States is unknown. The purpose of this study was to determine the incidence of this condition in the United States and to identify potential risk factors for neonatal brachial plexus palsy.

METHODS

Data from the 1997, 2000, and 2003 Kids' Inpatient Database data sets were utilized for this study. Patients were identified with use of the International Classification of Diseases, Ninth Revision (ICD-9), code 767.6 for neonatal brachial plexus palsy. Previously reported risk factors for this condition, including shoulder dystocia, instrumented delivery, breech delivery, an exceptionally large baby (>4.5 kg), heavy infant weight for gestational dates, multiple birth mates, and cesarean delivery, were also identified with use of ICD-9 codes. Multivariate logistic regression analysis was utilized to assess the association of neonatal brachial plexus palsy with its risk factors, after adjusting for sociodemographic characteristics, such as gender, race, and payer status; hospital-based characteristics, such as number of hospital beds, hospital location, region, type, and teaching status; and the effect of time.

RESULTS

Over eleven million births were recorded in the database, and 17,334 had a documented brachial plexus injury in the total of three years, yielding a nationwide mean and standard error of incidence of neonatal brachial plexus palsy in the United States of at least 1.51 +/- 0.02 cases per 1000 live births. The incidence of this condition has shown a significant decrease over the years (p < 0.01). In the multivariate analysis, shoulder dystocia had a 100 times greater risk, an exceptionally large baby (>4.5 kg) had a fourteen times greater risk, and forceps delivery had a nine times greater risk for injury. Having a twin or multiple birth mates and delivery by cesarean section had a protective effect against the occurrence of neonatal brachial plexus palsy. Forty-six percent of all children with neonatal brachial plexus palsy had one or more known risk factors, and fifty-four percent had no known risk factors.

CONCLUSIONS

This nationwide study of neonatal brachial plexus palsy in the United States demonstrates a decreasing incidence over time. Shoulder dystocia poses the greatest risk for brachial plexus injury, and having a twin or multiple birth mates and delivery by cesarean section are associated with a protective effect against injury. Most children with neonatal brachial plexus palsy did not have known risk factors.