1
|
Delioğlu K, Uzumcugil A, Öztürk E, Bıyık KS, Ozal C, Gunel MK. Cut-off values of internal rotation in the glenohumeral joint for functional tasks in children with brachial plexus birth injury. J Hand Surg Eur Vol 2023; 48:738-746. [PMID: 36788751 DOI: 10.1177/17531934231154362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The aim of this study was to determine the cut-off values of the range of internal rotation motion in the isolated glenohumeral joint that is required for functional tasks in children with an upper root injury of the brachial plexus. Internal rotation motion was measured using a universal goniometer in 97 participants. The Mallet Hand to Spine and Mallet Hand to Belly tasks were assessed as functional tasks that require internal rotation of the shoulder. For the Hand to Spine task, 41° passive and 30° active internal rotation were necessary to reach the S1 level. For the Hand to Belly task, 42° passive and 29° active internal rotation were required to place the palm on the belly without wrist flexion. Of our participants, 97% could touch the belly with or without wrist flexion, but 28% could not reach S1 in the Hand to Spine task. The results of this study show the necessary amount of internal rotation of the shoulder that should be considered in treatment strategies.Level of evidence: III.
Collapse
Affiliation(s)
- Kıvanç Delioğlu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Akin Uzumcugil
- Faculty of Medicine, Department of Orthopedics and Traumatology, Hacettepe University, Ankara, Turkey
| | - Ebru Öztürk
- Faculty of Medicine, Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Kubra Seyhan Bıyık
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Cemil Ozal
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Mintaze Kerem Gunel
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| |
Collapse
|
2
|
Cui Z, Liu L, Chen X, Zeng H, Zheng S, Wu D. Single Blind Randomized Controlled Trial of Modified Constraint-Induced Movement Therapy in Infants With the Sequelas of Unilateral Brachial Plexus Injury. Front Hum Neurosci 2022; 16:900214. [PMID: 35706479 PMCID: PMC9189277 DOI: 10.3389/fnhum.2022.900214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo explore the effect of modified constraint-induced movement therapy (mCIMT) on upper limbs residual dysfunction for infancy with the sequelas of unilateral brachial plexus injury (uBPI).MethodsSingle blind randomized controlled trial of mCIMT vs. standard care. An enrolling 31 infants with a uBPI exhibiting residual dysfunction of the affected upper limb for over 6 months was conducted. And functional outcomes pertaining to the affected upper limb were assessed via AMS, GRES, RHS, and MSS at 0, 3, and 6 months after treatment.ResultsNo differences were found in baseline (acquisition phase) AMS, MSS, GRES, or RHS between the control and mCIMT groups [F(1, 14) = 0.062, P = 0.086; F(1, 14) = 0.483, P = 0.499; F(1, 14) = 0.272, P = 0.610; Z = −0.336, P = 7.373]. At the 3- and 6-month follow-up time points, AMS, MSS, and GRES scores were significantly improved over baseline in both groups [mCIMT: F(2, 30) = 183.750, 128.614, 110.085, P < 0.05; Control: F(2, 28) = 204.007, 75.246, 51.070, P < 0.05]. No significant differences were found between two treatment groups at the 3-month follow-up time point [F(1, 14) = 0.565, P = 0.465; F(1, 14) = 0.228, P = 0.641; F(1, 14) = 0.713, P = 0.413; Z = −0.666, P = 0.505]. However, at the 6-month follow-up time point, AMS and MSS scores were significantly improved in the mCIMT group relative to the control group [F(1, 14) = 8.077, P = 0.013; F(1, 14) = 18.692, P = 0.001].ConclusionmCIMT may benefit the rehabilitation of residual upper limb dysfunction associated with a uBPI in infants.Clinical Trial Registration[www.chictr.org.cn], identifier [ChiCTR1900022119].
Collapse
Affiliation(s)
- Zhenzhen Cui
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Le Liu
- Department of Pediatric, Anhui Province Maternity and Child Health Hospital, Hefei, China
| | - Xi Chen
- Pediatric Neurorehabilitation Center, Hefei Changxing Rehabilitation Hospital, Hefei, China
| | - Haiyan Zeng
- Pediatric Neurorehabilitation Center, Hefei Changxing Rehabilitation Hospital, Hefei, China
| | - Shizhu Zheng
- Pediatric Neurorehabilitation Center, Lu’an Rehabilitation Hospital, Lu’an, China
| | - De Wu
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Pediatric Neurorehabilitation Center, Hefei Changxing Rehabilitation Hospital, Hefei, China
- *Correspondence: De Wu,
| |
Collapse
|
3
|
Delioğlu K, Uzumcugil A, Gunel M. Activity-based hand-function profile in preschool children with obstetric brachial plexus palsy. HAND SURGERY & REHABILITATION 2022; 41:487-493. [DOI: 10.1016/j.hansur.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/03/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
|
4
|
Bachy M, Lallemant P, Grimberg J, Fitoussi F. Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy. HAND SURGERY & REHABILITATION 2021; 41S:S63-S70. [PMID: 34058395 DOI: 10.1016/j.hansur.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 08/29/2018] [Accepted: 05/08/2020] [Indexed: 11/26/2022]
Abstract
Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.
Collapse
Affiliation(s)
- M Bachy
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France.
| | - P Lallemant
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| | - J Grimberg
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| | - F Fitoussi
- Service de Chirurgie Orthopédique et Réparatrice de l'Enfant, Hôpital Armand Trousseau, APHP, 26, Avenue du Dr Arnold Netter, 75012 Paris, France
| |
Collapse
|
5
|
Siqueira MG, Heise CO, Pessa M, Zacariotto M, Martins RS. Long-term evaluation of hand function in children undergoing Oberlin and Oberlin-like procedures for reinnervation of the biceps muscle. Childs Nerv Syst 2020; 36:3071-3076. [PMID: 32399802 DOI: 10.1007/s00381-020-04634-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/16/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Long-term evaluation of hand function in children who underwent transfer procedures to reinnervate the biceps muscle, using fascicles from the ulnar and median nerves as donors. METHODS In the last follow-up evaluation, the children underwent a neurological examination, and their hand status was classified according to the Raimondi grading system for hand function. Two physical measurements, the child health assessment questionnaire (CHAQ) and the Sollerman hand function test, were applied to assess upper extremity function. RESULTS Eight children were re-evaluated. In four the donor fascicle was from the ulnar nerve and in four from the median nerve. The average interval between surgery and the last evaluation was 8.3 years (range 6-10 years). Five patients scored 5 points in the Raimondi grading system, and 3 patients scored 4 points. The results from the CHAQ ranged from 0.03 to 0.41. The results from the Sollerman test were between 60 and 77 for the affected upper limb and between 65 and 79 for the dominant upper limb. CONCLUSION Nerve transfer of a fascicle from the ulnar or median nerve to the biceps motor branch in children with neonatal brachial plexus palsy does not result in hand dysfunction.
Collapse
Affiliation(s)
- Mario G Siqueira
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, SP, Brazil.
| | - Carlos Otto Heise
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, SP, Brazil
- Clinical Neurophysiology, Department of Neurology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Mariana Pessa
- Occupational Therapy, Department of Orthopedic Surgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Monise Zacariotto
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Roberto S Martins
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, SP, Brazil
| |
Collapse
|
6
|
Socolovsky M, Bonilla G, Lovaglio AC, Masi GD. Differences in strength fatigue when using different donors in traumatic brachial plexus injuries. Acta Neurochir (Wien) 2020; 162:1913-1919. [PMID: 32556814 DOI: 10.1007/s00701-020-04454-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/08/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The purpose of this study was to assess the results of elbow flexion strength fatigue, rather than the maximal power of strength, after brachial plexus re-innervation with phrenic and spinal accessory nerves. We designed a simple but specific test to study whether statistical differences were observed among those two donor nerves. METHOD We retrospectively reviewed patients with severe brachial plexus palsy for which either phrenic nerve (PN) or spinal accessory nerve (SAN) to musculocutaneous nerve (MCN) transfer was performed. A dynamometer was used to determine the maximal contraction strength. One and two kilograms circular weights were utilized to measure isometrically the duration of submaximal and near-maximal contraction time. Statistical analysis was performed between the two groups. RESULTS Twenty-eight patients were included: 21 with a PN transfer while 7 with a SAN transfer for elbow flexion. The mean time from trauma to surgery was 7.1 months for spinal accessory nerve versus 5.2 for phrenic nerve, and the mean follow-up was 57.7 and 38.6 months, respectively. Statistical analysis showed a quicker fatigue for the PN, such that patients with the SAN transfer could hold weights of 1 kg and 2 kg for a mean of 91.0 and 61.6 s, respectively, while patients with transfer of the phrenic nerve could hold 1 kg and 2 kg weights for just a mean of 41.7 and 19.6 s, respectively. Both differences were statistically significant (at p = 0.006 and 0.011, respectively). Upon correlation analysis, endurances at 1 kg and 2 kg were strongly correlated, with r = 0.85 (p < 0.001). CONCLUSIONS Our results suggest that phrenic to musculocutaneous nerve transfer showed an increased muscular fatigue when compared with spinal accessory nerve to musculocutaneous transfer. Further studies designed to analyze this relation should be performed to increase our knowledge about strength endurance/fatigue and muscle re-innervation.
Collapse
Affiliation(s)
- Mariano Socolovsky
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina.
| | - Gonzalo Bonilla
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina
| | - Ana Carolina Lovaglio
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina
| | - Gilda di Masi
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina
| |
Collapse
|
7
|
Pondaag W, Malessy MJ. Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey. J Orthop Res 2018; 36:2533-2541. [PMID: 29566312 PMCID: PMC6175006 DOI: 10.1002/jor.23901] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 03/18/2018] [Indexed: 02/04/2023]
Abstract
There is no consensus regarding strategies to optimally treat children with a brachial plexus birth injury (BPBI). Comparison of outcome data presented by different centers is impossible due to the use of (1) many different outcome measures to evaluate results; (2) different follow-up periods after interventions; and (3) different patient ages at the time of assessment. The goal of iPluto (international PLexus oUtcome sTudy grOup) was to define a standardized dataset which should be minimally collected to evaluate upper limb function in children with BPBI. This dataset must enable comparison of the treatment results of different centers if prospectively used. Three rounds of internet surveys were used to reach consensus on the dataset. A Delphi-derived technique was applied using a nine point Likert scale. Consensus was defined as having attained a rating of 7/8/9 by > = 75% of the participants. A total of 59 participants from five continents participated in the Second and Third Rounds of the survey. Consensus was reached regarding four elements: (1) evaluation should take place at the age of 1/3/5/7 years; range of motion in degrees should be measured for (2) passive joint movement; (3) active range of motion; and (4) the Mallet score should be determined. Consensus on how to asses and report outcome for BPBI was only reached on motor items from the "Body Function and Structure" domain. Consensus regarding additional ICF domains to obtain a more elaborate set of outcome items, should be addressed in future research. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:2533-2541, 2018.
Collapse
Affiliation(s)
- Willem Pondaag
- Department of NeurosurgeryLeiden University Medical CenterLeidenThe Netherlands
| | | |
Collapse
|
8
|
Madura T, Doi K, Hattori Y, Sakamoto S, Shimoe T. Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children. J Hand Surg Eur Vol 2018; 43:596-608. [PMID: 29547071 DOI: 10.1177/1753193418762950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED The purpose of this study was to evaluate long-term outcomes of the free functioning gracilis transfer in children with traumatic total brachial plexus palsy. We used the free functioning gracilis transfer to reconstruct elbow flexion and prehension in 17 children with a mean age of 13.4 years (range 3-17) who were followed-up over a mean period of 6 years (range 2-16). The transferred gracilis delivered a stable elbow flexion with a useful power, as well as reconstructed active finger motion. In 3-11-year-old patients we noted a tendency towards developing a progressive flexion contracture of the elbow. The limb length discrepancy observed in our patients was not different from the brachial plexus palsy patients treated without the free functioning gracilis transfer. In conclusion, the free functioning gracilis transfer is a reliable reconstructive technique for reanimating upper extremity in children of all ages capable of delivering stable function over a long period of time. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Tomas Madura
- 1 Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, Ogori, Japan.,2 West Midlands Peripheral Nerve Injury Service, University Hospitals Birmingham, Birmingham, UK
| | - Kazuteru Doi
- 1 Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, Ogori, Japan
| | - Yasunori Hattori
- 1 Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, Ogori, Japan
| | - Sotetsu Sakamoto
- 1 Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, Ogori, Japan
| | - Takashi Shimoe
- 1 Department of Orthopaedic Surgery, Ogori Daiichi General Hospital, Ogori, Japan
| |
Collapse
|
9
|
|
10
|
Duff SV, DeMatteo C. Clinical assessment of the infant and child following perinatal brachial plexus injury. J Hand Ther 2015; 28:126-33; quiz 134. [PMID: 25840493 PMCID: PMC4425986 DOI: 10.1016/j.jht.2015.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/05/2015] [Accepted: 01/07/2015] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Literature review. INTRODUCTION After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome. PURPOSE To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians. METHODS We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians. DISCUSSION With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.
Collapse
Affiliation(s)
- Susan V. Duff
- Thomas Jefferson University, Department of Physical Therapy, 901 Walnut St., Suite 510, Philadelphia, PA 19107,
| | - Carol DeMatteo
- McMaster University, School of Rehabilitation Science, 1400 Main St West, Hamilton, Ontario, Canada, L8S 1C7,
| |
Collapse
|
11
|
External Rotation Osteotomy of the Humerus to Salvage the Failed Latissimus Dorsi Transfer in Children With Erb Birth Palsy and Supple Congruent Shoulders. Ann Plast Surg 2014; 75:625-8. [PMID: 25180949 DOI: 10.1097/sap.0000000000000331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Management of the failed latissimus dorsi muscle transfer to restore shoulder external rotation has received little attention in the literature. We report on 6 children with Erb birth palsy and supple congruent shoulders and who underwent external rotation osteotomy to salvage a failed latissimus dorsi transfer. It is standard of care to do humerus osteotomies only to children with significant deformities of the glenohumeral joint. In the current article, the osteotomy was performed despite the presence of supple congruent shoulders because the osteotomy seemed the best and simplest option available. The functional outcome was satisfactory; with all patients reaching the occiput easily. Furthermore, there were improvement of the standing posture and improvement of the elbow flexion contracture. We conclude that the osteotomy procedure is a simple and effective option of management after a failed latissimus dorsi transfer.
Collapse
|
12
|
The use of the phrenic nerve communicating branch to the fifth cervical root for nerve transfer to the suprascapular nerve in infants with obstetric brachial plexus palsy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:153182. [PMID: 24800206 PMCID: PMC3988910 DOI: 10.1155/2014/153182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 03/05/2014] [Accepted: 03/12/2014] [Indexed: 12/02/2022]
Abstract
Traditionally, suprascapular nerve reconstruction in obstetric brachial plexus palsy is done using either the proximal C5 root stump or the spinal accessory nerve. This paper introduces another potential donor nerve for neurotizing the suprascapular nerve: the phrenic nerve communicating branch to the C5 root. The prevalence of this communicating branch ranges from 23% to 62% in various anatomical dissections. Over the last two decades, the phrenic communicating branch was used to reconstruct the suprascapular nerve in 15 infants. Another 15 infants in whom the accessory nerve was used to reconstruct the suprascapular nerve were selected to match the former 15 cases with regard to age at the time of surgery, type of palsy, and number of avulsed roots. The results showed that there is no significant difference between the two groups with regard to recovery of external rotation of the shoulder. It was concluded that the phrenic nerve communicating branch may be considered as another option to neurotize the suprascapular nerve.
Collapse
|
13
|
Gosk J, Wnukiewicz W, Urban M. The effect of perinatal brachial plexus lesion on upper limb development. BMC Musculoskelet Disord 2014; 15:116. [PMID: 24694070 PMCID: PMC3976457 DOI: 10.1186/1471-2474-15-116] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Deficiency in upper limb development is a sequel of the perinatal brachial plexus palsy. The purpose of this study was to evaluate the effect of brachial plexus birth lesion on upper limb development. METHODS Forty-four patients with unilateral obstetric brachial plexus palsy underwent measurements of both upper extremities. The average age at the time of evaluation was 6.8 years. Active motion was assessed using Gilbert-Raimondi, the modified MRC, and Al-Qattan scales. Paired t test was used for statistical analysis. Correlation between limb length / circumference discrepancy and age / time of surgery was assessed using Pearson correlation coefficient. RESULTS A decrease in the circumference and length was observed in all limbs with brachial plexus lesion. We found a statistically significant difference between degree of hand length and width decrease and its useful and useless function. We observed a statistically significant difference in measurement: forearm length, hand length and width dependent on the type of surgical procedure (neurolysis, reconstruction). We observed no correlation between age and limb length / circumference discrepancy. We also observed no correlation between time of surgery and limb length / circumference discrepancy. CONCLUSIONS The decrease in dimensions of the affected limbs occurred predominantly during the period of early childhood. Disparities in dimensions are observed in both cases of deficiency of useful function of upper limb and cases in which functional efficiency appears.
Collapse
Affiliation(s)
- Jerzy Gosk
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wroclaw Medical University, ul, Borowska 213, 50-556 Wrocław, Poland.
| | | | | |
Collapse
|
14
|
Obstetric brachial plexus palsy: the mallet grading system for shoulder function--revisited. BIOMED RESEARCH INTERNATIONAL 2014; 2014:398121. [PMID: 24527447 PMCID: PMC3909974 DOI: 10.1155/2014/398121] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/27/2013] [Accepted: 12/28/2013] [Indexed: 11/26/2022]
Abstract
The Mallet grading system is a commonly used functional scoring system to assess shoulder abduction/external rotation deficits in children with obstetric brachial plexus palsy. One feature of the Mallet score is that each grade is translated into certain degrees of deficiencies in both shoulder abduction and external rotation. The aim of the current study is to investigate the percentage of children in which the Mallet score could not be applied because of a discrepancy between the deficiency of shoulder abduction and shoulder external rotation. The study group included 50 consecutive unoperated older children (over 5 years of age) with Erb's palsy and deficits in shoulder movements. The Mallet score could be applied in 40 cases (80%). In the remaining 10 cases (20%), the Mallet score could not be applied either because shoulder abduction had a better grade than the grade of shoulder external rotation (n = 7) or vice versa (n = 3). It was concluded that documenting the deficits in shoulder abduction and external rotation are best done separately and this can be accomplished by using other grading systems.
Collapse
|
15
|
Amorim S, Heise CO, Santos S, Macedo-Souza LI, Zatz M, Kok F. Nerve conduction studies in spastic paraplegia, optic atrophy, and neuropathy (SPOAN) syndrome. Muscle Nerve 2013; 49:131-3. [PMID: 24123118 DOI: 10.1002/mus.24087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 01/07/2023]
Abstract
INTRODUCTION SPOAN (spastic paraplegia, optic atrophy, and neuropathy) syndrome is an autosomal recessive neurodegenerative disorder identified in a large consanguineous Brazilian family. METHODS Twenty-seven patients with SPOAN syndrome (20 women), aged 4-58 years, underwent nerve conduction studies (NCS) of the median, ulnar, tibial, and fibular nerves, and sensory NCS of the median, ulnar, radial, sural, and superficial fibular nerves. RESULTS Sensory nerve action potentials were absent in the lower limbs and absent in >80% of upper limbs. Motor NCS had reduced amplitudes and borderline velocities in the upper limbs and absent compound muscle action potentials (CMAPs) in the lower limbs. CONCLUSIONS The neuropathy in SPOAN syndrome is a severe, early-onset sensory-motor axonal polyneuropathy. Normal NCS seem to rule-out this condition.
Collapse
Affiliation(s)
- Simone Amorim
- Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | | | | | | |
Collapse
|
16
|
Duijnisveld BJ, Saraç C, Malessy MJA, Brachial Plexus Advisory Board TI, Vliet Vlieland TPM, Nelissen RGHH. Developing core sets for patients with obstetricbrachial plexus injury based on the International Classificationof Functioning, Disability and Health. Bone Joint Res 2013; 2:116-21. [PMID: 23836476 PMCID: PMC3693181 DOI: 10.1302/2046-3758.26.2000153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Symptoms of obstetric brachial plexus injury (OBPI) vary widely
over the course of time and from individual to individual and can
include various degrees of denervation, muscle weakness, contractures,
bone deformities and functional limitations. To date, no universally
accepted overall framework is available to assess the outcome of patients
with OBPI. The objective of this paper is to outline the proposed
process for the development of International Classification of Functioning,
Disability and Health (ICF) Core Sets for patients with an OBPI. Methods The first step is to conduct four preparatory studies to identify
ICF categories important for OBPI: a) a systematic literature review
to identify outcome measures, b) a qualitative study using focus
groups, c) an expert survey and d) a cross-sectional, multicentre
study. A first version of ICF Core Sets will be defined at a consensus
conference, which will integrate the evidence from the preparatory
studies. In a second step, field-testing among patients will validate this
first version of Core Sets for OBPI. Discussion The proposed method to develop ICF Core Sets for OBPI yields
a practical tool for multiple purposes: for clinicians to systematically
assess and evaluate the individual’s functioning, for researchers
to design and compare studies, and for patients to get more insight
into their health problems and their management.
Collapse
Affiliation(s)
- B J Duijnisveld
- Leiden University Medical Center, Departmentof Orthopaedics, P.O. Box 9600, 2300RC Leiden, the Netherlands
| | | | | | | | | | | |
Collapse
|
17
|
Gosk J, Hendrich B, Wiącek R, Sąsiadek M, Rutowski R. Assessment of the usefulness of X-ray myelography and magnetic resonance myelography, performed with an open low-field device, in diagnosing perinatal preganglionic injuries of the brachial plexus. Arch Med Sci 2012; 8:678-83. [PMID: 23056080 PMCID: PMC3460489 DOI: 10.5114/aoms.2012.28597] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 10/14/2011] [Accepted: 01/01/2012] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION The goal is to assess the usefulness of diagnostic imaging in diagnosing perinatal preganglionic injuries of the brachial plexus. MATERIAL AND METHODS The clinical material included 40 children of both genders, aged 2 to 35 months. The authors analysed the results of diagnostic imaging examinations (myelography in 20 cases and magnetic resonance [MR] myelography in 20 cases), intraoperative view and clinical course. RESULTS In 13 out of 40 (32.5%) examined children, no evidence of avulsion of the roots of the spinal nerves was found either by diagnostic imaging or during the surgery. In 3 cases (7.5%) with avulsed roots of the spinal nerves, the diagnostic imaging and intraoperative appearance were in agreement. Total agreement of the diagnostic imaging and intraoperative view was found in 40% of cases. In 9 patients (22.5%) suspected avulsion of roots of the spinal nerves was not confirmed during the surgery. However, the further clinical course of the disease in these cases indicated high probability of avulsion of roots without their pull-out from the intervertebral foramens. In the remaining cases, the findings were as follows: false positive results - 7 (17.5%), false negative results - 1 (2.5%), results underestimating injury - 3 (7.5%), results overestimating injury - 2 (5%). CONCLUSIONS It was determined that the usefulness of pre-operative diagnostic imaging is limited. Due to the risk of occurrence of false positive and false negative results, final decisions concerning selection of the surgical technique must be based on the analysis of the intraoperative view and preoperative clinical symptoms.
Collapse
Affiliation(s)
- Jerzy Gosk
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wroclaw Medical University, Poland
| | - Barbara Hendrich
- Department of General and Interventional Radiology and Neuroradiology, Academic Teaching Hospital, Wroclaw, Poland
| | - Roman Wiącek
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wroclaw Medical University, Poland
| | - Marek Sąsiadek
- Department of General and Interventional Radiology and Neuroradiology, Academic Teaching Hospital, Wroclaw, Poland
- Chair of Radiology, Wroclaw Medical University, Poland
| | - Roman Rutowski
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wroclaw Medical University, Poland
- Department of Biostructure, Department of Sport Medicine and Nutrition, University of Physical Education, Wroclaw, Poland
| |
Collapse
|
18
|
Siqueira MG, Socolovsky M, Heise CO, Martins RS, Di Masi G. Efficacy and Safety of Oberlin's Procedure in the Treatment of Brachial Plexus Birth Palsy. Neurosurgery 2012; 71:1156-60; discussion 1161. [PMID: 23037815 DOI: 10.1227/neu.0b013e318271ee4a] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
In brachial plexus injuries, when there are no available roots to use as a source for graft reconstruction, nerve transfers emerge as an elective technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. Despite the high rate of good to excellent results in adults, this technique is seldom used in children.
OBJECTIVE:
To evaluate the efficacy and safety of Oberlin's procedure in the surgical treatment of brachial plexus birth palsy.
METHODS:
Striving to restore elbow flexion, we performed Oberlin's procedure in 17 infants with brachial plexus birth palsy. After follow-up of at least 19 months, primary outcomes were the strength of elbow flexion (modified British Medical Research Council Scale), hand function measured using Al-Qattan's Scale, and comparative x-rays of both hands to detect altered growth.
RESULTS:
Good to excellent results related to biceps contraction were obtained in 14 patients (82.3%) (3/MRC3, 11/MRC4). The preoperative Al-Qattan Scale score for the hand was maintained at final follow-up. Comparing the treated and normal limb, no difference was observed in hand development by x-ray.
CONCLUSION:
Oberlin's procedure is an effective and safe option for the surgical treatment of upper brachial plexus birth palsy.
Collapse
Affiliation(s)
- Mario G. Siqueira
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Mariano Socolovsky
- Peripheral Nerve and Plexus Surgery Program, Division of Neurosurgery, University of Buenos Aires, Buenos Aires, Argentina
| | - Carlos Otto Heise
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Roberto S. Martins
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Gilda Di Masi
- Peripheral Nerve and Plexus Surgery Program, Division of Neurosurgery, University of Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
19
|
Andersen J, Watt J, Olson J, Van Aerde J. Perinatal brachial plexus palsy. Paediatr Child Health 2011; 11:93-100. [PMID: 19030261 DOI: 10.1093/pch/11.2.93] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births. OBJECTIVES To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions. METHODS A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included 'brachial plexus', 'brachial plexus neuropathy', 'brachial plexus injury', 'birth injury' and 'paralysis, obstetric'. RESULTS There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm function in children with serious impairments. CONCLUSIONS It is not possible to predict which infants are at risk for PBPP, and therefore amenable to preventive measures. Twenty-five per cent of affected infants will experience permanent impairment and injury. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary. Further research into prediction, prevention and best mode of treatment needs to be done.
Collapse
|
20
|
Gosk J, Rutowski R, Wiącek R, Urban M, Mazurek P. Preganglionic injuries in perinatal brachial plexus palsies - results of surgical treatment. Neurol Neurochir Pol 2011; 45:140-7. [PMID: 21574118 DOI: 10.1016/s0028-3843(14)60025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE The authors report their experience in surgical treatment of preganglionic injuries in perinatal brachial plexus palsies. MATERIAL AND METHODS Clinical material consisted of 16 children, of both sexes, aged from 2.5 to 33 months (mean 6.2 months), treated surgically between 1994 and 2006. The clinical view of the injury and location of preganglionic lesions was analysed and the description of the performed microsurgical techniques is provided. Control clinical examinations included a group of 14 children. The shortest postoperative observation period was 3 years. The currently accepted scales of evaluation of function of particular joints of the upper limb were used. RESULTS The following outcome was noted after surgical treatment of perinatal brachial plexus palsies with signs of pre- and postganglionic injuries: good shoulder function in 6 cases, and average in 2 others; good elbow function in 4 cases, and average in 7 patients; functional position of the forearm in 9 cases, and good range of pronation and supination in 1 patient; useful function of wrist (flexion/extension) in 4 cases; good motor hand function in 3 cases, and fair in 6 patients. CONCLUSIONS In preganglionic perinatal brachial plexus injuries located in the upper-middle part, spinal nerve C7 roots avulsion is the most frequently observed, and in the lower part of the brachial plexus, spinal nerve C8 roots avulsion is the most frequently observed. In preganglionic injuries of the brachial plexus, the number of avulsed spinal nerves has an influence on technical possibilities of performing reconstruction procedures, and then the results of the surgical treatment.
Collapse
Affiliation(s)
- Jerzy Gosk
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wroclaw Medical University, Poland.
| | | | | | | | | |
Collapse
|
21
|
Total obstetric brachial plexus palsy in children with internal rotation contracture of the shoulder, flexion contracture of the elbow, and poor hand function: improving the cosmetic appearance of the limb with rotation osteotomy of the humerus. Ann Plast Surg 2010; 65:38-42. [PMID: 20548233 DOI: 10.1097/sap.0b013e3181a72f9e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rotation osteotomy of the humerus has been described by several authors to treat the internal rotation contracture of the shoulder in Erb palsy. The main aim of the osteotomy in Erb patients is to bring the functioning hand to the face which greatly improves function. The author has performed the rotation humeral osteotomy in children with total obstetric brachial plexus palsy aiming for the improvement of the cosmetic appearance of the limb rather than improvement function. This article specifically reports on this group of patients.Over the last 15 years, the author has performed rotation humeral osteotomy in 13 children (mean age 6 years; range, 4.5-9 years) with total obstetric brachial plexus palsy aiming for improvement of the cosmetic appearance of the limb rather than improvement of function. All children had a triad of severe internal rotation contracture of the shoulder, severe flexion contracture of the elbow, and poor hand function.After a mean follow-up of 2 years following the humeral osteotomy, all patients/parents were satisfied with the result and a panel of plastic surgeons confirmed the significant improvement in aesthetics. Reasons for this improvement following the osteotomy were as follows: the child no longer needed to stand with shoulder slightly abducted, the antecubital fossa became visible in the standing position, and the forearm no longer appeared excessively pronated. Of more importance, was the improvement in elbow flexion contracture which had major contribution in improving limb appearance and the perception of length discrepancy between the affected and the contralateral normal limb.The humeral osteotomy improves the cosmetic appearance of children with total palsy and the triad of severe internal rotation contracture of the shoulder, severe flexion contracture of the elbow and poor hand function.
Collapse
|
22
|
The Results of Surgical Treatment of the Forearm Deformity in Perinatal Brachial Plexus Palsy. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0092-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
23
|
The Results of Neurolysis In Perinatal Brachial Plexus Lesions Treatment. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0080-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
24
|
Al-Qattan MM, Al-Husainan H, Al-Otaibi A, El-Sharkawy MS. Long-term results of low rotation humeral osteotomy in children with Erb's obstetric brachial plexus palsy. J Hand Surg Eur Vol 2009; 34:486-92. [PMID: 19675029 DOI: 10.1177/1753193409104552] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Seventeen children with Erb's (C5/6 and C5/6/7 types) obstetric brachial plexus palsy who underwent low rotation humeral osteotomy to treat internal rotation contracture of the shoulder were recalled back to the clinic at a mean of 10 (range 8-14) years after surgery. Eight were male and nine female with mean age of 16 (range 13-20) years. The osteotomy procedure was done at a mean age of 6 (range 5-8) years. Preoperative, early postoperative, and late postoperative motor assessments were compared. There was no recurrence of the internal rotation posturing of the shoulder and there was maintenance of the improvements in elbow extension deficit and forearm rotation. The most surprising finding was a significant (P = 0.003) decrease in shoulder abduction on long-term follow-up (the mean shoulder abduction was 135 degrees , 146 degrees and 109 degrees measured pre-, early post- and late postoperatively, respectively). There was no correlation between changes in shoulder abduction and the radiological score of the shoulder.
Collapse
Affiliation(s)
- M M Al-Qattan
- Department of Surgery, King Saud University, Riyadh, Saudi Arabia.
| | | | | | | |
Collapse
|
25
|
Al-Qattan MM. An obstetric brachial plexus data sheet. J Hand Microsurg 2009; 1:32-8. [PMID: 23129929 DOI: 10.1007/s12593-009-0005-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 03/15/2009] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Several reputed obstetric brachial plexus clinics use their own protocols and indications for surgery. This study is to present and explain the obstetric brachial plexus data sheet used at our institution. METHODS The data sheet is composed of 5 main parts: (1) the basic database which includes the name, age, type and side of palsy, maternal history, birth history and other complications of the traumatic delivery; (2) motor assessment of the limb; (3) preoperative investigations; (4) description of intraoperative brachial plexus findings and type of nerve procedure performed; and (5) secondary surgery to the shoulder, elbow, forearm, wrist and hand. RESULTS The data sheet was found useful in documenting the assessment and events in infants and older children. CONCLUSION An obstetric brachial plexus data sheet is presented and it may be modified and used by other centers.
Collapse
|
26
|
Pondaag W, de Boer R, van Wijlen-Hempel MS, Hofstede-Buitenhuis SM, Malessy MJA. External Rotation as a Result of Suprascapular Nerve Neurotization in Obstetric Brachial Plexus Lesions. Neurosurgery 2005; 57:530-7; discussion 530-7. [PMID: 16145533 DOI: 10.1227/01.neu.0000170557.13788.d2] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACTOBJECTIVE:Obstetric brachial plexus lesions may cause lifelong limitations of upper limb function. Nerve repair is widely advocated in infants who do not show spontaneous recovery. Typically, the suprascapular nerve (SSN) is involved in the lesion. Neurotization of the SSN routinely is performed, aiming at reinnervation of the infraspinatus muscle to restore external rotation. The results after SSN neurotization have not, as yet, been studied in detail; therefore, this study was undertaken. Of special interest was the comparison of two commonly applied SSN neurotization procedures: nerve grafting from C5 versus nerve transfer of the accessory nerve.METHODS:Infants with obstetric brachial plexus lesions after nerve grafting of C5 to the SSN (n = 65) or nerve transfer of the accessory nerve to the SSN (n = 21) were selected for retrospective analysis after a mean follow-up period of 3 years. Outcome was expressed in degrees of true glenohumeral external rotation. This was defined as the angle between the position of the 90 degrees (actively or passively) flexed elbow resting against the abdomen and the position of the flexed elbow after external rotation with the upper arm held in adduction by the investigator. This movement can be executed only by infraspinatus muscle contraction. In addition, functional external rotation was evaluated by testing the ability to reach the mouth and the back of the head.RESULTS:Only 17 (20%) of the 86 patients reached more than 20 degrees of external rotation, whereas 35 (41%) were unable to perform true external rotation. There was no statistically significant difference between nerve grafting from C5 and extraplexal nerve transfer using the accessory nerve. Functional scores showed that 88% can reach the mouth and that 75% can reach the head.CONCLUSION:The restoration of a fair range of true glenohumeral external rotation after neurotization of the SSN in infants with obstetric brachial plexus lesions, whether by grafting from C5 or by nerve transfer of the accessory nerve, is disappointingly low. However, it seems that compensatory techniques contribute to effectuate a considerable range of movement.
Collapse
Affiliation(s)
- Willem Pondaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.
| | | | | | | | | |
Collapse
|
27
|
|