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Caron E, Gienapp AJ, Files H, Ridley-Pryor T. Brachial Plexus Birth Injury: A Single-Center Study. Clin Pediatr (Phila) 2023; 62:1489-1496. [PMID: 36964689 DOI: 10.1177/00099228231163698] [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: 03/26/2023]
Abstract
Infants can sustain traction injury to brachial plexus nerves during birth, called brachial plexus birth injury (BPBI). While spontaneous recovery is possible, upper extremity weakness can linger. We report our experience at a brachial plexus clinic from a retrospective chart review of infants with BPBI from September 2017 to September 2019. We determined Narakas Classification (NC) and Active Movement Scale (AMS) at predetermined follow-up points. Of 15 patients, 8 presented with NC-I, 5 with NC-II, and 2 with NC-III without Horner's syndrome. By 7 months, 3 had spontaneous recovery, and 4 achieved all and another 4 achieved most AMS5-7 scores. Eleven patients undergoing surgery had little-to-no improvement of shoulder abduction and shoulder external rotation AMS categories by 6 months. Our small sample size prevents us from making definitive conclusions but gave beneficial insight into our clinic barriers to follow-up, data collection, and collaboration with physical and occupational therapy.
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Affiliation(s)
- Elena Caron
- Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
- University of Tennessee Le Bonheur Pediatric Specialists, Memphis, TN, USA
- Division of Pediatric Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew J Gienapp
- Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
- Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Helen Files
- Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
- Rhodes College, Memphis, TN, USA
| | - Tracee Ridley-Pryor
- Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, TN, USA
- University of Tennessee Le Bonheur Pediatric Specialists, Memphis, TN, USA
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Singh A, Orozco V, Balasubramanian S. In vivo biomechanical responses of neonatal brachial plexus when subjected to stretch. PLoS One 2023; 18:e0290718. [PMID: 37647327 PMCID: PMC10468090 DOI: 10.1371/journal.pone.0290718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023] Open
Abstract
Neonatal brachial plexus palsy (NBPP) results from over-stretching of the neonatal brachial plexus during complicated birthing scenarios. The lack of information on the biomechanical response of the neonatal brachial plexus complex when subjected to stretch limits our understanding of the NBPP injury mechanism. This study aims to fill that critical gap by using a neonatal piglet animal model and providing the in vivo biomechanical properties of the neonatal brachial plexus complex when subjected to stretch. Forty-seven brachial plexus levels (identified by the four brachial plexus terminal nerve branches namely musculocutaneous, median, ulnar, and radial), obtained from 16 neonatal Yorkshire piglets (3-5 days old), were subjected to stretch-induced failure. The average maximum load and corresponding strain were reported to be 16.6 ± 1.3 N and 36.1 ± 1.6%, respectively. Maximum loads reported at the musculocutaneous level were significantly lower than the median and radial levels. No differences in strains at failure were reported at all four tested levels. Proximal or distal failure locations were reported in 83% of the tests with 17% mid-length ruptures that were primarily reported at the bifurcation of the median and ulnar brachial plexus levels. Histological studies reported an overall loss of wavy pattern of the nerve fibers, an increase in nerve spacing, fiber disruptions, and blood vessel ruptures in the stretched tissue. This in vivo piglet animal study offers insight into the NBPP mechanism by reporting biomechanical, injury location, and structural damage responses in neonatal brachial plexus when subjected to stretch.
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Affiliation(s)
- Anita Singh
- Bioengineering Department, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Virginia Orozco
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, United States of America
| | - Sriram Balasubramanian
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, United States of America
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Domingo B, Terroso N, Eckert M. Personalized Use of an Adjustable Movement-Controlled Video Game in Obstetric Brachial Plexus Palsy during Physiotherapy Sessions at School: A Case Report. Healthcare (Basel) 2023; 11:2008. [PMID: 37510449 PMCID: PMC10379120 DOI: 10.3390/healthcare11142008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
This case study explores the use of a personalized, adjustable Kinect exergame in 10 physiotherapy sessions for a 10-year-old girl with incomplete right-sided obstetric brachial plexus palsy (OBPP). The aim was to observe the impact on the patient's upper limb mobility that could be achieved through maximization of the player's motivation, possibly due to continuous game parameter adjustments. It had been achieved that the patient was playing 87% of the total gaming time with a personally challenging setting that increased her arm speed from one to four movements. Strength in abduction and flexion were increased by 8 N and 7 N, respectively. Furthermore, the patient showed better muscular balance and an increase of 50% in speed of the Jebsen-Taylor hand function test (JTHFT). The patient reported high levels of motivation, low perception of fatigue, and just slight discomfort. The study found that the use of personalized video games as a complement to conventional physiotherapy can be successful in OBPP patients when the game allows for the adjustment of the difficulty level as a response to personal performance. Predefined difficulty levels and automatic performance analysis can be helpful. Results are promising; however, further research is needed to confirm the results.
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Affiliation(s)
- Beatriz Domingo
- Department of Physical Therapy, CEIP Pinar de San José, 28054 Madrid, Spain
| | - Noelia Terroso
- Department of Physical Therapy, CEIP Pinar de San José, 28054 Madrid, Spain
| | - Martina Eckert
- Research Center for Software Technologies and Multimedia Systems for Sustainability (CITSEM), Universidad Politécnica de Madrid (UPM), Alan Touring St. 3, 28031 Madrid, Spain
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Jaufuraully S, Lakshmi Narasimhan A, Stott D, Attilakos G, Siassakos D. A systematic review of brachial plexus injuries after caesarean birth: challenging delivery? BMC Pregnancy Childbirth 2023; 23:361. [PMID: 37198580 DOI: 10.1186/s12884-023-05696-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 05/10/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI. METHODS Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies. MAIN RESULTS 39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions. CONCLUSIONS In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors.
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Affiliation(s)
- Shireen Jaufuraully
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK.
| | | | - Daniel Stott
- Elizabeth Garrett Anderson Wing, University College Hospital, London, UK
| | - George Attilakos
- Elizabeth Garrett Anderson Wing, University College Hospital, London, UK
| | - Dimitrios Siassakos
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, London, UK
- National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre (BRC), London, UK
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Sakka SA, Haddad W, Mansor J. Neonatal Iatrogenic Calcinosis Cutis and Heterotopic Calcification Causing Peripheral Brachial Palsy: Case Report and Review of Literature. JBJS Case Connect 2023; 13:01709767-202306000-00018. [PMID: 37093983 DOI: 10.2106/jbjs.cc.22.00591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
CASE Iatrogenic heterotopic calcification and calcinosis cutis secondary to extravasations of intravenous calcium is very rare. We report a case of a neonate treated with intravenous calcium resulting in extravasations causing heterotrophic calcification and calcinosis cutis with subcutaneous mass causing perinatal peripheral brachial palsy. CONCLUSION We highlight these rare potential complications of calcium extravasations and recommend conservative treatment and the avoidance of the temptation of surgical excision of any bony lumps as they resolve spontaneously in time. These complications should not be confused as a fracture with callus formation and periosteal reaction.
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Affiliation(s)
- Samir Akram Sakka
- Department of Special Surgery, Faculty of Medicine, Al-Balqa Applied University, Al-Salt, Jordan
| | - Waleed Haddad
- Department of Special Surgery, Faculty of Medicine, Al-Balqa Applied University, Al-Salt, Jordan
| | - Jeihad Mansor
- Department of Orthopaedic Surgery, Al Hussein Hospital, Al-Salt, Jordan
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Lubelski D, Feghali J, Hersh A, Kopparapu S, Al-Mistarehi AH, Belzberg AJ. Differences in the surgical treatment of adult and pediatric brachial plexus injuries among peripheral nerve surgeons. Clin Neurol Neurosurg 2023; 228:107686. [PMID: 36963285 DOI: 10.1016/j.clineuro.2023.107686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 03/17/2023] [Accepted: 03/18/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVES Peripheral nerve surgeons disagree on the optimal timing and treatment of brachial plexus injuries (BPI). This study aims to survey peripheral nerve surgeons on their management of BPI, including disagreement. METHODS Surgeons responded to a case-based survey involving traumatic and birth injuries leading to BPI involving the upper and lower trunks, and pre- and post-ganglionic injuries. RESULTS Out of 255 invited surgeons, 154 participated, with specialties of Neurosurgery (33.7%), Plastic surgery (32.5%), and Orthopedics (32.5%). For the adult C5-6 avulsion injury, 97.4% agreed they would operate. There was 46.2% disagreement regarding the pediatric upper trunk neuroma-in-continuity case, and similar disagreement (50.0%) was recorded on exploring the brachial plexus for a pediatric lower trunk injury case. High percentages of surgeons were more likely to explore the plexus, such as at upper BPI. Also, most participants reported nerve transfer for the upper and lower trunk avulsion injuries, but there was 55.6% disagreement regarding nerve transfer for the infant with the upper trunk neuroma-in-continuity. Among those elected to perform nerve transfer, most (70.0%-84.5%) would perform an accessory-to-suprascapular nerve transfer for upper BPI, while brachialis-to-anterior interosseous and supinator branch of the radial nerve-to-posterior interosseous were preferred for lower BPI (30.0%-55.9%). CONCLUSIONS Substantial disagreement exists among peripheral nerve surgeons in managing adult and pediatric BPI. In adult BPI, most prefer to operate at the time of the presentation and perform extensive nerve transfers. The accessory-suprascapular transfer was recommended for upper BPI, while brachialis and radial nerves were preferred for lower BPI. The most significant disagreements exist in operation and nerve transfer for pediatric upper BPI and brachial plexus explorations. Geography, specialty, and operative volume contribute to the differences seen.
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Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Andrew Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Srujan Kopparapu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | | | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Kossambe S, Kamath L, Diwakar KK. Descriptive Study of Obstetric Brachial Plexus Palsy (OBPP) at a Tertiary Care Hospital. J Obstet Gynaecol India 2022; 72:542-544. [PMID: 36506894 PMCID: PMC9732160 DOI: 10.1007/s13224-021-01520-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/18/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To study the incidence and risk factors for obstetric brachial plexus palsy and assess the functional outcome. Material and Methods Five-year data of infants with OBPP were reviewed. Case-control study was performed using matched controls to identify the risk factors. Infants with OBPP were followed up to assess functional outcome. Results Of the 14,184 live births over a period of 5 years from 2013 to 2017, 23 (11 males, 12 females) had OBPP. Incidence of OBPP was 1.6 per 1000 live births. Higher birth weight (p-value 0.002) and instrumental delivery (p-value 0.02) were independent risk factors for obstetric brachial plexus palsy by multivariate logistic regression analysis. No cases of obstetric brachial plexus palsy were seen in babies born by cesarean section. 95% of the infants with obstetric brachial plexus palsy had complete recovery by 4 months of age. Conclusion Higher birth weight and instrumental vaginal delivery are independent risk factors for obstetric brachial plexus palsy. Cesarean section may have a protective effect against OBPP. Most infants with obstetric brachial plexus palsy have complete recovery.
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Affiliation(s)
- Sarvesh Kossambe
- Department of Neonatology, MOSC Medical College Hospital, Kolenchery, Kochi, 682311 Kerala India
| | - Leela Kamath
- Department of Neonatology, MOSC Medical College Hospital, Kolenchery, Kochi, 682311 Kerala India
| | - K. K. Diwakar
- Department of Neonatology, MOSC Medical College Hospital, Kolenchery, Kochi, 682311 Kerala India
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Hardie C, Brooks J, Wade R, Teh I, Bourke G. Diagnostic accuracy of magnetic resonance imaging for nerve injury in obstetric brachial plexus injury: protocol for systematic review and meta-analysis. Syst Rev 2022; 11:173. [PMID: 35987695 PMCID: PMC9392905 DOI: 10.1186/s13643-022-02037-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 07/28/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Early and accurate clinical diagnosis of the extent of obstetric brachial plexus injury (OBPI) is challenging. The current gold standard for delineating the nerve injury is surgical exploration, and synchronous reconstruction is performed if indicated. Magnetic resonance imaging (MRI) is a non-invasive method of assessing the anatomy and severity of nerve injury in OBPI but the diagnostic accuracy is unclear. The primary objective of this review is to determine the diagnostic accuracy of MRI in comparison to surgical brachial plexus exploration for detecting root avulsion in children under 5 with OBPI. The secondary objectives are to determine its' diagnostic accuracy for detecting nerve abnormality and detecting pseudomeningocele(s) in this group. METHODS This review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).We will include studies reporting the accuracy of MRI (index test) compared to surgical exploration (reference standard) in detecting any of the three target conditions (root avulsion, any nerve abnormality and pseudomeningocele) in children under five with OBPI. Case reports and studies where the number of true positives, false positives, true negatives and false negatives cannot be derived will be excluded. We plan to search PubMed, Embase and CENTRAL for relevant studies from database inception to 15 June 2022. We will also search grey literature (medRxiv, bioRxiv and Google Scholar) and perform forward and backward citation chasing. Screening and full-text assessment of eligibility will be conducted by two independent reviewers, who will then both extract the relevant data. The QUADAS-2 tool will be used to assess methodological quality and risk of bias of included studies by two reviewers independently. The following test characteristics for the target conditions will be extracted: true positives, false positives, true negatives and false negatives. Estimates of sensitivity and specificity with 95% confidence intervals will be shown in forest plots for each study. If appropriate, summary sensitivities and specificities for target conditions will be obtained via meta-analyses using a bivariate model. DISCUSSION This study will aim to clarify the diagnostic accuracy of MRI for detecting nerve injury in OBPI and define its clinical role. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021267629.
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Affiliation(s)
- Claire Hardie
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK. .,Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK.
| | - James Brooks
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Ryckie Wade
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK.,Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Irvin Teh
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Grainne Bourke
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK.,Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK.,Department of Integrative Medical Biology, University of Umea, Umeå, Sweden
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Girard AO, Suresh V, Lopez CD, Seal SM, Tuffaha SH, Redett RJ, Halsey JN. Radiographic imaging modalities for perinatal brachial plexus palsy: a systematic review. Childs Nerv Syst 2022; 38:1241-1258. [PMID: 35536348 DOI: 10.1007/s00381-022-05538-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Perinatal brachial plexus palsy (PBPP) has a wide spectrum of clinical symptoms that can range from incomplete paresis of the affected extremity to flaccid arm paralysis. Although there is a high rate of spontaneous recovery within the first two years of life, it remains challenging to determine which patients will benefit most from surgical intervention. The diagnostic and predictive use of various imaging modalities has been described in the literature, but there is little consensus on approach or algorithm. The anatomic, pathophysiological, and neurodevelopmental characteristics of the neonatal and infant patient population affected by PBPP necessitate thoughtful consideration prior to selecting an imaging modality. METHODS A systematic review was conducted using six databases. Two reviewers independently screened articles published through October 2021. RESULTS Literature search produced 10,329 publications, and 22 articles were included in the final analysis. These studies included 479 patients. Mean age at time of imaging ranged from 2.1 to 12.8 months and investigated imaging modalities included MRI (18 studies), ultrasound (4 studies), CT myelography (4 studies), and X-ray myelography (1 study). Imaging outcomes were compared against surgical findings (16 studies) or clinical examination (6 studies), and 87.5% of patients underwent surgery. CONCLUSION This systematic review addresses the relative strengths and challenges of common radiologic imaging options. MRI is the most sensitive and specific for identifying preganglionic nerve injuries such as pseudomeningoceles and rootlet avulsion, the latter of which has the poorest prognosis in this patient population and often dictates the need for surgical intervention.
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Affiliation(s)
- Alisa O Girard
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Visakha Suresh
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher D Lopez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stella M Seal
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sami H Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jordan N Halsey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, 601 5th Street South, St. Petersburg, FL, 33701, USA.
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Delioğlu K, Seyhan Bıyık K, Uzumcugil A, Kerem Günel M. "How Well" and "How Often" questions for birth brachial plexus injury: a validity and reliability of the pediatric upper extremity motor activity log-revised. Disabil Rehabil 2022:1-7. [PMID: 35737641 DOI: 10.1080/09638288.2022.2085333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE The pediatric upper extremity motor activity log-revised (PMAL-R) is a structured interview that measures use of the affected arm in daily life in children with unilateral pathologies like hemiparetic cerebral palsy (CP) or birth brachial plexus injury (BBPI). This study investigated validity and test-retest reliability of the PMAL-R in children with BBPI. MATERIALS AND METHODS The PMAL-R was administered to parents of 132 children with BBPI between 5 and 9 years for validity, also 98 parents were re-interviewed after 3 weeks to establish test-retest reliability. Its concurrent validity was examined by correlating scores on the PMAL-R How Well (HW) and How Often (HO) scales with Brachial Plexus Outcome Measure (BPOM) and Pediatric Outcomes Data Collection Instrument (PODCI) scores. RESULTS PMAL-R scores were strongly correlated with BPOM scores (HW, r = 0.943, p < 0.001; HO, r = 0.897, p < 0.001), also strongly correlated with PODCI (HW, r = 0.799, p < 0.001; HO, r = 0.797, p < 0.001). PMAL-R test-retest reliability (intraclass correlation; HO = 0.997, HW = 0.998) and internal consistency (Cronbach's a; HO = 0.99, HW = 0.99) were high. CONCLUSIONS The PMAL-R has good reliability and validity for measuring everyday use of the affected arm with "how often" and "how well" questions in children with BBPI. Implications for rehabilitationThe pediatric upper extremity motor activity log-revised (PMAL-R) is the first tool to assess both "how often" and "how well" the affected arm is used in unimanual activities in children with BBPI.PMAL-R is a real-world measure providing valuable information about "how often" and "how well" the affected arm is used to guide treatment.PMAL-R is valid in both concurrent and discriminative validity in children with BBPI.PMAL-R is reliable in children with BBPI.
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Affiliation(s)
- Kıvanç Delioğlu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Kübra Seyhan Bıyık
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Akin Uzumcugil
- Medicine Faculty, Department of Orthopedics and Traumaology, Hacettepe University, Ankara, Turkey
| | - Mintaze Kerem Günel
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
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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]
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Long term outcome in obstetric brachial plexus injury at a tertiary care center. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1011145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Yan D, Vassar R. Neuromuscular electrical stimulation for motor recovery in pediatric neurological conditions: a scoping review. Dev Med Child Neurol 2021; 63:1394-1401. [PMID: 34247385 DOI: 10.1111/dmcn.14974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 12/31/2022]
Abstract
AIM To explore the breadth of pediatric neurological conditions for which neuromuscular electrical stimulation (NMES) has been studied. METHOD Databases (PubMed, Google Scholar, Scopus, and Embase) were searched from 2000 to 2020, using the search terms 'neuromuscular electrical stimulation' OR 'functional electrical stimulation' with at least one of the words 'pediatric OR child OR children OR adolescent', and without the words 'dysphagia OR implanted OR enuresis OR constipation'. Articles focused on adults or individuals with cerebral palsy (CP) were excluded. RESULTS Thirty-five studies met the inclusion criteria, with a total of 353 pediatric participants (293 unique participants; mean age 7y 4mo, range 1wk-38y). NMES was applied in a range of pediatric conditions other than CP, including stroke, spinal cord injury, myelomeningocele, scoliosis, congenital clubfoot, obstetric brachial plexus injury, genetic neuromuscular diseases, and other neuromuscular conditions causing weakness. INTERPRETATION All 35 studies concluded that NMES was well-tolerated and most studies suggested that NMES could augment traditional therapy methods to improve strength. Outcome measurements were heterogeneous. Further research on NMES with larger, randomized studies will help clarify its potential to improve physiology and mobility in pediatric patients with neuromuscular conditions. What this paper adds Neuromuscular electrical stimulation (NMES) appears to be tolerated by pediatric patients. NMES shows potential for augmenting recovery in pediatric patients with a range of rehabilitation needs.
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Affiliation(s)
- Derek Yan
- Winston Churchill High School, Potomac, MD, USA
| | - Rachel Vassar
- Department of Neurology, Division of Pediatric Neurology, University of California San Francisco, San Francisco, CA, USA
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Orozco V, Magee R, Balasubramanian S, Singh A. A Systematic Review of the Tensile Biomechanical Properties of the Neonatal Brachial Plexus. J Biomech Eng 2021; 143:110802. [PMID: 34091659 PMCID: PMC8299814 DOI: 10.1115/1.4051399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/30/2021] [Indexed: 11/08/2022]
Abstract
Brachial plexus (BP) birth injury has a reported incidence of 1 to 4 per 1000 live births. During complicated deliveries, neonatal, maternal, and other birth-related factors can cause over-stretching or avulsion of the neonatal brachial plexus leading to injury. Understanding biomechanical responses of the neonate brachial plexus when subjected to stretch can offer insight into the injury outcomes while guiding the development of preventative maneuvers that can help reduce the occurrence of neonatal brachial plexus injuries. This review article aims to offer a comprehensive overview of existing literature reporting biomechanical responses of the brachial plexus, in both adults and neonates, when subjected to stretch. Despite the discrepancies in the reported biomechanical properties of the brachial plexus, available studies confirm the loading rate and loading direction dependency of the brachial plexus tissue. Future studies, possibly in vivo, that utilize clinically relevant neonatal large animal models can provide translational failure values of the biomechanical parameters for the neonatal brachial plexus when subjected to stretch.
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Affiliation(s)
- Virginia Orozco
- School of Biomedical Engineering, Science and Health Systems, Drexel University, 3140 Market St., BOSSONE 718, Philadelphia, PA 19104
| | - Rachel Magee
- School of Biomedical Engineering, Science and Health Systems, Drexel University, 3140 Market St., BOSSONE 718, Philadelphia, PA 19104
| | - Sriram Balasubramanian
- School of Biomedical Engineering, Science and Health Systems, Drexel University, 3140 Market St., BOSSONE 718, Philadelphia, PA 19104
| | - Anita Singh
- Department of Biomedical Engineering, Widener University, One University Place, Chester, PA 19013
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Delioğlu K, Ozal C, Seyhan Bıyık K, Unes S, Tuncdemir M, Uzumcugil A, Kerem Gunel M. Requirements for tele-health in children with obstetric brachial plexus palsy during Covid-19-like situations. HAND SURGERY & REHABILITATION 2021; 41:78-84. [PMID: 34655823 PMCID: PMC8531202 DOI: 10.1016/j.hansur.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/23/2021] [Accepted: 09/20/2021] [Indexed: 11/20/2022]
Abstract
The purpose of the study was to investigate families’ concerns and service requirements during the Covid-19 lockdown. In case of tele-consultation, we also aimed to assess the effects of this service on coping and the family’s worries. At end of lockdown, we contacted the parents of 67 obstetric brachial plexus palsy patients (0–10 years age) by e-mail. During lockdown, 42 of the families had had a tele-consultation with our team, while 25 reported that not receiving any service. A questionnaire consisting of 6 questions was sent to the families, and data were analyzed according to 4 age-groups. Parents' concerns varied according to the children’s age group (p = 0.001). All families replied that their children should receive remote services during Covid-19-like situations (p = 0.173). Parents of the 42 children who had tele-consultations reported that this had alleviated their worries, independently of age-group (p = 0.160). The usefulness of tele-consultation to manage the lockdown situation differed according to age-group (p = 0.002). The parents of under-3-year-olds experienced more worry during lockdown, but all respondents reported needing remote services. Although the tele-consultation alleviated the worries of almost all families, it was most useful in managing lockdown in families with under-3-year-olds.
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Affiliation(s)
- K Delioğlu
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Adnan Saygun Street, Altındağ, 06230, Ankara, Turkey.
| | - C Ozal
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Adnan Saygun Street, Altındağ, 06230, Ankara, Turkey.
| | - K Seyhan Bıyık
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Adnan Saygun Street, Altındağ, 06230, Ankara, Turkey.
| | - S Unes
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Adnan Saygun Street, Altındağ, 06230, Ankara, Turkey.
| | - M Tuncdemir
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Adnan Saygun Street, Altındağ, 06230, Ankara, Turkey.
| | - A Uzumcugil
- Hacettepe University, Faculty of Medicine, Department of Orthopedics and Traumatology, Adnan Saygun Street, Altındağ, 06230, Ankara, Turkey.
| | - M Kerem Gunel
- Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Adnan Saygun Street, Altındağ, 06230, Ankara, Turkey.
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The outcome of soft-tissue release and tendon transfer in shoulders with brachial plexus birth palsy. JSES Int 2021; 5:905-911. [PMID: 34505104 PMCID: PMC8411056 DOI: 10.1016/j.jseint.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Shoulder involvement in brachial plexus birth palsy is common, and the adduction, internal rotation contracture deformity often requires some form of surgical treatment. There are very few long-term reports on release of contracted muscles and tendon transfers, especially in older children. We are reporting the single-center results of such a surgery with detailed outcome analysis. Methods The prospectively collected data from brachial plexus birth palsy cases who had undergone contracture release and tendon transfer were retrospectively studied and examined. The new Mallet and functional scores were compared with the original data forms and then analyzed. The radiographic evidence of glenoid dysplasia and its correlation with age and functional outcome was assessed. Results A total of 82 cases with surgery at mean age of 9.5 ± 5.09 years and a follow-up of 8 ± 3.8 (3-20) years entered the study. Of these, 56% of cases had 7 to 20 years of age at surgery. Fifty-four (66%) patients had only shoulder surgery, and 28 (34%) required additional reconstructive surgeries for hand and wrist. Moderate to severe glenohumeral dysplasia was present in 38%. The preoperative Mallet score of 10.6 ± 2.97 improved to 19.3 ± 3.39 (P < .001). Eighty-one percent of patients showed improvement in “reaching face” functions, 71% in “above head” functions, and 74% in “midline functions.” The cases with lack of improvement in midline function mostly belonged to pan-plexus injuries. Noticeable subjective and objective improvement was also observed in cases with glenohumeral dysplasia in their Mallet and functional scores (P < .001). The improvement in function and subjective satisfaction of 92% was observed irrespective of age at surgery. Conclusion Soft-tissue release and tendon transfer for brachial plexus birth palsy shoulder can improve function and limb appearance even in older children and young adults and even in the presence of glenohumeral dysplasia.
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Eldridge B, Alexander N, McCombe D. Recommendations for management of neonatal brachial plexus palsy: Based on clinical review. J Hand Ther 2021; 33:281-287.e1. [PMID: 32151504 DOI: 10.1016/j.jht.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/06/2019] [Accepted: 12/31/2019] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Descriptive report. INTRODUCTION Neonatal brachial plexus palsy (NBPP) involves a partial or total injury of the nerves that originate from spinal roots C5-C8 and T1. The reported incidence of NBPP is between 0.38 and 5.1 in 1000 births. PURPOSE OF THE STUDY This study describes the management NBPP in the first 3 years of life and to develop an assessment framework for infants with NBPP and postoperative guidelines for those undergoing primary surgery. METHODS Retrospective medical record audit from 2012 to 2017. RESULTS Of 187 children referred to brachial plexus clinic (BPC), 138 were new referrals and included in the audit. The average number of new referrals per annum was 37; average age at referral was 6.61 week; average age at first appointment was 16.9 weeks. Of the 138 infants, 104 were initially assessed by a physiotherapist before attending BPC. The most common comorbidity was plagiocephaly. DISCUSSION From 2012 to 2017, birth location, birth facility, referral source, and time between referral and initial assessment have remained stable. The age at referral, age at which the child was first assessed, and the number of children who received services externally before attending the hospital all decreased. The number of children seen by a physiotherapist before attending BPC increased. An NBPP assessment framework, including critical time points for assessment, and postoperative guidelines for infants and children undergoing primary surgery were created. CONCLUSIONS Early referral is essential for effective management of NBPP and ideally infants should be assessed and management implemented before 3 months of age.
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Affiliation(s)
- Beverley Eldridge
- La Trobe University, Level 4, The Alfred Centre, Melbourne, Victoria, Australia.
| | - Nicole Alexander
- The Royal Children's Hospital, Parkville Melbourne Victoria, Australia
| | - David McCombe
- The Royal Children's Hospital, Parkville Melbourne Victoria, Australia
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Could Subtle Obstetrical Brachial Plexus Palsy Be Related to Unilateral B Glenoid Osteoarthritis? J Clin Med 2021; 10:jcm10061196. [PMID: 33809287 PMCID: PMC7999215 DOI: 10.3390/jcm10061196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
Background: Several factors associated with B glenoid are also linked with obstetrical brachial plexus palsy (OBPP). The purpose of this observational study was to determine the incidence of OBPP risk factors in type B patients. Methods: A cohort of 154 patients (68% men, 187 shoulders) aged 63 ± 17 years with type B glenoids completed a questionnaire comprising history of perinatal characteristics related to OBPP. A literature review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to estimate the incidence of OBPP risk factors in the general population. Results: Twenty-seven patients (18%) reported one or more perinatal OBPP risk factors, including shoulder dystocia (n = 4, 2.6%), macrosomia >4 kg (n = 5, 3.2%), breech delivery (n = 6, 3.9%), fetal distress (n = 8, 5.2%), maternal diabetes (n = 2, 1.3%), clavicular fracture (n = 2, 1.3%), and forceps delivery (n = 4, 2.6%). The comparison with the recent literature suggested that most perinatal OBPP risk factors were within the normal range, although the incidence of shoulder dystocia, forceps and vaginal breech deliveries exceeded the average rates. Conclusion: Perinatal factors related to OBPP did not occur in a higher frequency in patients with Walch type B OA compared to the general population, although some of them were in the high normal range.
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Karas HE, Atıcı E, Aydın G, Demirsöz M. The Effects of Virtual Reality on Upper Extremity in Patients with Obstetric Brachial Plexus Injury. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1724100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AbstractThe present study aimed to examine the effects of playing Nintendo Wii games on upper extremity functions compared with conventional physiotherapy, in children with obstetric brachial plexus injury (OBPI). Twenty-two patients with brachial plexus injuries were enrolled. The patients were divided into two groups by simple randomization. The control group (conventional physiotherapy group [CTG]: n = 11) received conventional physiotherapy for 6 weeks (40 minutes per day, for 4 days per week). The study group, called Nintendo Wii group (NWG; n = 11), received conventional physiotherapy as well as tennis, baseball, and boxing games with Nintendo Wii on days when there was no physical therapy. The upper extremity range of motion (ROM) was evaluated using a digital goniometer, motor function was assessed using the Active Movement Scale (AMS), and shoulder functions were assessed with the Mallet Scoring System (MSS). Virtual reality treatment had a positive effect on shoulder flexion, forearm pronation, wrist flexion, ROM, and functionality (p < 0.05). There was a significant improvement in shoulder abduction and shoulder external rotation in the CTG (p < 0.05). There was no significant difference in the MSS values of either groups (p > 0.05). As per the AMS, in the NWG, the shoulder internal rotation increased significantly (p < 0.05). Nintendo Wii treatment used in addition to conventional physiotherapy may be effective in increasing upper extremity functions in children with OBPI.
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Affiliation(s)
- Havva Ezgi Karas
- Occupational Therapy Program, Health Services Vocational School, Avrasya University, Trabzon, Turkey
| | - Emine Atıcı
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul Okan University, Istanbul, Turkey
| | - Gamze Aydın
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul Okan University, Istanbul, Turkey
- Department of Physiotherapy and Rehabilitation, Institute of Graduate Education, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Mert Demirsöz
- Department of Biostatistics, Faculty of Veterinary Medicine, Selçuk University, Konya, Turkey
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A Rare Case of Contralateral Diaphragm Paralysis following Birth Injury with Brachial Plexus Palsy: A Case Report and Review of the Literature. Case Rep Pediatr 2020; 2020:8844029. [PMID: 33274099 PMCID: PMC7676972 DOI: 10.1155/2020/8844029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 10/05/2020] [Accepted: 10/23/2020] [Indexed: 11/29/2022] Open
Abstract
Clinical History. A 4.4 kg male was born to a 25-year-old, G2P1, nondiabetic woman at 39 and 5/7 weeks. Delivery was complicated by shoulder dystocia requiring forceps-assisted vaginal delivery, resulting in left arm Erb's palsy secondary to left brachial plexus injury. He was born with low muscle tone and bradycardia and subsequently required intubation for poor respiratory effort. He was extubated on day one of life but continued to be tachypneic and have borderline oxygen saturation, requiring intensive care. Chest radiographs demonstrated a progressive clearing of his lung fields, consistent with presumptively diagnosed meconium aspiration. However, a persistent elevation of the right hemidiaphragm was noted, and his tachypnea and increased work of breathing continued. Focused ultrasound of the diaphragm was performed, confirming decreased motion of the right hemidiaphragm. Following a multidisciplinary discussion, thoracoscopic right diaphragm plication was performed on the 33rd day of life. He was extubated postoperatively and subsequently weaned to room air with a notable decrease in tachypnea over 48 hours. He was discharged on postoperative day 12 and continues to thrive at 6 months of age without respiratory embarrassment. Purpose. Ipsilateral phrenic nerve injury with diaphragm paralysis from shoulder dystocia during vaginal delivery is a recognized phenomenon. Herein, we present a case of contralateral diaphragm paralysis in order to draw attention to the clinician that this discordance is possible. Key Points. According to Raimbault et al., clinical management of newborns who experience birth injury is a multidisciplinary effort. According to Fitting and Grassino, though most cases of phrenic nerve injuries are ipsilateral to shoulder dystocia brachial plexus palsy, contralateral occurrence is possible and should be considered. According to Waters, diaphragm plication is a safe and effective operation.
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Orozco V, Balasubramanian S, Singh A. A Systematic Review of the Electrodiagnostic Assessment of Neonatal Brachial Plexus. NEUROLOGY AND NEUROBIOLOGY (TALLINN, ESTONIA) 2020; 3. [PMID: 33043293 PMCID: PMC7546533 DOI: 10.31487/j.nnb.2020.02.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite improvements in obstetric care, neonatal brachial plexus palsy continues to significantly impact infants’ lives worldwide, with an incidence of 1 to 4 per 1000 live births. While a majority of affected infants recover spontaneously by three months, 20-30% suffer permanent functional deficits that significantly impair their quality of life. Anatomical complexity of the brachial plexus results in varying degrees of injury and pathological changes at multiple levels within the plexus. Current clinical diagnosis relies on electrodiagnostic techniques such as nerve conduction (i.e., motor and sensory) and electromyography studies. These techniques not only aid clinicians to differentiate between axonal and demyelinating lesions, evident by changes in signal shape and conduction, but also provide prognostic information in cases of brachial plexus injuries. The presented study offers a comprehensive review of existing literature on electrodiagnostic techniques employed for assessing neonatal brachial plexus injuries.
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Affiliation(s)
- Virginia Orozco
- Drexel University, School of Biomedical Engineering, Science and Health Systems, Philadelphia, Pennsylvania, USA
| | - Sriram Balasubramanian
- Drexel University, School of Biomedical Engineering, Science and Health Systems, Philadelphia, Pennsylvania, USA
| | - Anita Singh
- Widener University, School of Engineering, Chester, Pennsylvania, USA
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Longo E, Nishiyori R, Cruz T, Alter K, Damiano DL. Obstetric Brachial Plexus Palsy: Can a Unilateral Birth Onset Peripheral Injury Significantly Affect Brain Development? Dev Neurorehabil 2020; 23:375-382. [PMID: 31906763 PMCID: PMC7550966 DOI: 10.1080/17518423.2019.1689437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Purpose: Examine brain structure and function in OBPP and relate to clinical outcomes to better understand the effects of decreased motor activity on early brain development. Methods: 9 OBPP, 7 controls underwent structural MRI scans. OBPP group completed evaluations of upper-limb function and functional near-infrared spectroscopy (fNIRS) during motor tasks. Results: Mean primary motor area volume was lower in both OBPP hemispheres. No volume differences across sides seen within groups; however, Asymmetry Ratio in supplementary motor area differed between groups. Greater asymmetry in primary somatosensory area correlated with lower ABILHAND-Kids scores. fNIRS revealed more cortical activity in both hemispheres during affected arm reach. Conclusion: Cortical volume differences or asymmetry were found in motor and sensory regions in OBPP that related to clinical outcomes. Widespread cortical activity in fNIRS during affected arm reach suggests reorganization in both hemispheres and is relevant to rehabilitation of those with developmental peripheral and brain injuries.
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Affiliation(s)
- Egmar Longo
- Federal University of Rio Grande do Norte/Faculty of Health Sciences of Trairi - UFRN/FACISA, Health of Children, Santa Cruz, Brazil
| | - Ryota Nishiyori
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, US
| | - Theresa Cruz
- National Center for Medical Rehabilitation Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, US
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, US
| | - Diane L. Damiano
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, US.,Corresponding author: D. L. Damiano, National Institutes of Health, 10 Center Drive, Room 1-1469, Bethesda, MD 20892, United States.,
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Elnaggar RK. Integrated Electromyography: Discriminant Analysis and Prediction of Recovery 3 to 6 Years After Brachial Plexus Birth Injury. Pediatr Phys Ther 2020; 32:120-128. [PMID: 32150027 DOI: 10.1097/pep.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the recovery likelihood, 3 to 6 years after brachial plexus birth injury (BPBI), and predict the functional recovery from integrated electromyography (IEMG). METHODS Thirty children with BPBI limited to C5-C6 lesion participated. Maximal electromyography activity of deltoid and biceps brachii was measured at entry. Shoulder and elbow functions were assessed at the baseline and at 4 intervals across 2 years. RESULTS Shoulder and elbow function significantly changed across the follow-up period. Shoulder and elbow functions were significantly dependent on deltoid and biceps brachii muscles' IEMG level, respectively, with the groups showing higher IEMG achieving better recovery. The deltoid and biceps IEMG explained a portion of the improvement in shoulder and elbow function over 2 years. CONCLUSION Recovery of the shoulder and elbow function continues 3 to 6 years after BPBI. IEMG may partially explain variation in the prognosis for children with BPBI.
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Affiliation(s)
- Ragab K Elnaggar
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt
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Danilov C, Ihle C, Fernandez FF, Blumenstock G, Wirth T, Eberhardt O. Pseudo paralysis of the shoulder and increased C-reactive protein are predictive factors for septic shoulder in children superior to other clinical symptoms: a retrospective case series of 25 patients. J Child Orthop 2020; 14:85-90. [PMID: 32165985 PMCID: PMC7043127 DOI: 10.1302/1863-2548.14.190126] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The aim of the study was to evaluate predictable parameters with the highest sensitivity used in the diagnosis of children septic shoulder arthritis. METHODS All children treated in our paediatric orthopaedic hospital between 2000 and 2017 with intraoperative verified septic arthritis of the shoulder were included in this retrospective study. Diagnostic procedures e.g. ultrasound, MRI, radiograph or blood samples as well as typical clinical symptoms were evaluated as predictable parameters for septic shoulder arthritis in paediatric patients. Descriptive statistics as well as sensitivity analysis were performed. RESULTS In all, 25 children, 20 boys and five girls, aged from eight days to 15 years, were included for further statistical analysis. All parameters included were tested for sensitivity with binomial confidence intervals (Cis) of 95%. Predictive parameters with highest sensitivity were pseudo paralysis (100%, CI 0.86 to 1.00) and C-reactive protein (CRP) (96%, CI 0.79 to 0.99) superior to temperature (52%, CI 0.3 to 0.73), white blood count (11%, CI 0.01 to 0.34), radiograph (21%, CI 0.04 to 0.50), ultrasound (71%, CI 0.47 to 0.88) or MRI (100%, CI 0.78 to 1.00). CONCLUSION The diagnosis of a septic arthritis of the shoulder in children can be challenging for the clinician and especially for the resident doctor. Clinical symptoms such as pseudo paralysis and increased CRP level must be considered as predictive markers not to delay further diagnostics and treatment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Christoph Ihle
- BG Trauma Center Tuebingen, Siegfried-Weller-Institute for Trauma Research, Eberhard-Karls-University, Tuebingen, Germany,Correspondence should be sent to Christoph Ihle, Department of Traumatology, Siegfried-Weller-Institute for Trauma Research, Eberhard-Karls-University Tuebingen, Tuebingen, Germany. E-mail:
| | | | - Gunnar Blumenstock
- Institute for Clinical Epidemiology and Applied Biometry, Eberhard Karls University, Tuebingen, Tuebingen, Germany
| | - Thomas Wirth
- Orthopaedic Department Olgahospital Stuttgart, Germany
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Mohasseb DF, Hassan MM, Semaya AE, Abdelghany HM, Hassan SN. Evaluation of surgical outcomes of obstetric brachial plexus birth injury: clinical and electrophysiological study. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2019. [DOI: 10.4103/err.err_4_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Yarfi C, Elekusi C, Banson AN, Angmorterh SK, Kortei NK, Ofori EK. Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: a five year retrospective study. Pan Afr Med J 2019; 32:211. [PMID: 31312323 PMCID: PMC6620083 DOI: 10.11604/pamj.2019.32.211.17914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/27/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Brachial plexus birth injury is one of the challenges associated with maternal delivery, with varying prevalence between countries. Brachial plexus birth injury poses negative health implications to children and also has socio-economic implications on families and the community as a whole. To treat brachial plexus birth injury, a multi-disciplinary treatment approach is recommended. Brachial plexus birth palsy (BPBP) is categorised into two-upper plexus injury (Erb's palsy) and lower plexus injury (Klumpke's palsy). These categories present with various degrees of injuries, with less severe injuries responding well to treatment and in most instances may resolve on their own, but serious and complicated injuries will require a multi-disciplinary treatment approach to treat and/or manage. Effective treatment and management depends on adequate knowledge of the disease condition. These include the risk factors and prevalence of brachial plexus birth palsy within a particular population at a specific period in time. The aim of this study was to determine the risk factors and the prevalence of a hospital based brachial plexus birth palsy within a five-year period (2013-2017). Methods A five-year retrospective study design was used. The study involved selection of all clients' diagnosed with brachial plexus birth palsy, where their gender, birth weight, complications at birth, type of brachial plexus suffered, mothers' diabetes status, mother's age, birth attendant, side of affectation, presentation at birth and mode of delivery were recorded. Results The prevalence rate of brachial plexus birth palsy was 14.7% out of a total of three hundred and twenty (320) cases reviewed over the study period in the Volta Regional Hospital. Erb's palsy was found to be the modal type of BPBP in this population (93.6%). Conclusion There is the need to provide a nationwide education on the risk factors that predispose babies to brachial plexus birth palsy. There is also the need for frequent antenatal visit by pregnant women; this will help in the provision of best antenatal history, diagnostic investigation in determining the birth weight and safe mode of delivery.
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Affiliation(s)
- Cosmos Yarfi
- Department of Physiotherapy and Rehabilitation Sciences, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana
| | - Cephas Elekusi
- Department of Physiotherapy and Rehabilitation Sciences, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana
| | - Adjoa Nkrumah Banson
- Department of Physiotherapy and Rehabilitation Sciences, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana
| | - Seth Kwadjo Angmorterh
- Department of Medical Imaging, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana
| | - Nii Korley Kortei
- Department of Nutrition and Dietetics, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana
| | - Eric Kwasi Ofori
- Department of Medical Imaging, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana
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Obstetric brachial plexus palsy - A prospective, population-based study of incidence, recovery and long-term residual impairment at 10 to 12 years of age. Eur J Paediatr Neurol 2019; 23:87-93. [PMID: 30458977 DOI: 10.1016/j.ejpn.2018.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/28/2018] [Accepted: 06/21/2018] [Indexed: 11/23/2022]
Abstract
AIM To assess the long-term outcome and evaluate prognostic factors in obstetric brachial plexus palsy (OBPP). METHODS Of all 114 children with OBPP born in western Sweden in 1999-2001, 98 (61 males, 37 females) were invited to participate. A questionnaire on the symptoms of the OBPP was sent out and those with persisting symptoms were examined in terms of muscle strength, range of motion (ROM), activities of daily living (ADL), pain and sensibility at the age of 10-12 years. Contact was made by 87 children. RESULTS The incidence of persisting OBPP at 10-12 years of age was calculated as 19 per 38,749 live births or 0.49 per 1000. Symptoms were reduced muscle strength and ROM in the arm. Eight children reported pain, four had impaired sensibility and ten children described some difficulties in ADL. Muscle strength in forearm supination, shoulder external rotation and elbow flexion at three months of age can be used to predict outcome. INTERPRETATION Most children with an OBPP recover completely, but one in five has symptoms of the injury at 10-12 years of age. Muscle strength in the arm at three months of age can be used to predict outcome.
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Pegu S, Deb B, Kalapesi Z. Rare case of a newborn baby with left-sided Erb's palsy and a contralateral/right-sided paralysis of the diaphragm. BMJ Case Rep 2018; 2018:bcr-2018-225373. [PMID: 30413438 DOI: 10.1136/bcr-2018-225373] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Brachial plexus birth injury (BPBI) and phrenic nerve injury can sometimes occur concurrently in neonates following difficult deliveries like breech presentation, shoulder dystocia, forceps or vacuum extraction. Phrenic nerve palsy should be suspected in a newborn with respiratory distress and an elevated hemidiaphragm on the imaging studies in presence of the associated risk factors. The right side is affected more often than the left side and most of it is associated with BPBI. We present here a rare case of a newborn baby with a left-sided Erb's palsy and a contralateral/right-sided diaphragmatic paralysis who recovered from the persistent respiratory distress and feeding difficulties following plication of the diaphragm. The left-sided Erb's palsy also fully recovered at follow-up examination.
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Affiliation(s)
- Satyaranjan Pegu
- Department of Pediatrics, Division of Neonatology, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Bakul Deb
- Department of Pediatrics, Division of Neonatology, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Zarin Kalapesi
- Department of Pediatrics, Division of Neonatology, Regina General Hospital, Regina, Saskatchewan, Canada
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El-Shamy S, Alsharif R. Effect of virtual reality versus conventional physiotherapy on upper extremity function in children with obstetric brachial plexus injury. JOURNAL OF MUSCULOSKELETAL & NEURONAL INTERACTIONS 2017; 17:319-326. [PMID: 29199193 PMCID: PMC5749040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVES The objective was to evaluate the effects of virtual reality versus conventional physiotherapy on upper extremity function in children with obstetric brachial plexus injury. METHODS Forty children with Erb's palsy were selected for this randomized controlled study. They were assigned randomly to either group A (conventional physiotherapy program) or group B (virtual reality program using Armeo® spring for 45 min three times/week for 12 successive weeks). Mallet system scores for shoulder function and shoulder abduction, and external rotation range of motion (ROM) were obtained; shoulder abductor, and external rotators isometric strength were evaluated pre-and post-treatment using Mallet scoring system, standard universal goniometer, and handheld dynamometer. RESULTS The results of this study indicate that the children in both groups showed improvement in shoulder functions post-treatment with greater improvements in group B. The abduction muscle strength after treatment was 8.53 and 11.3 Nm for group A and group B, respectively. The external rotation muscle strength after treatment was 5.88 and 7.45 Nm for group A and group B, respectively. CONCLUSIONS The virtual reality program is a significantly more effective than conventional physiotherapy program in improving the upper extremity functions in children with obstetric brachial plexus injury.
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Affiliation(s)
- Shamekh El-Shamy
- Department of Physical Therapy for Paediatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt,Corresponding author: Dr. Shamekh M. El-Shamy, Faculty of Physical Therapy, Cairo University, Giza, Egypt. E-mail:
| | - Rabab Alsharif
- Physiotherapy and Rehabilitation Department, Maternity and Children Hospital, Makkah, KSA
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Frich LH, Schmidt PH, Torfing T. Glenoid morphology in obstetrical brachial plexus lesion: a three-dimensional computed tomography study. J Shoulder Elbow Surg 2017; 26:1374-1382. [PMID: 28412107 DOI: 10.1016/j.jse.2017.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 02/12/2017] [Accepted: 02/13/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Obstetric brachial plexus lesion (OBPL) frequently leads to glenohumeral dysplasia, and excessive retroversion of the glenoid is among the best known developmental disturbances. Most analyses of the glenoid are based on 2-dimensional (D) imaging and do not address glenoid inclination or provide information on the glenoid in the sagittal plane. We aim to describe the 3-D deformity of the glenoid in children with OBPL. METHODS Preoperative computed tomography (CT) scans of the nonaffected and the affected scapula of 24 children (aged 5 to 12 years) with developmental disturbances after OBPL years were analyzed. The dimensions of the scapula and the deformation of the glenoid were visualized in 3-D. RESULTS The retroversion of the glenoid fossa was greater in all affected shoulders, and 2-D measurements significantly overestimated retroversion compared with angles measured in 3-D. The inclination of the glenoid fossa was altered, and a distal bony edge loss was observed on 3-D reformations in the sagittal plane. The reliability of the measured angles was excellent, and the κ agreement for the description of the glenoid form was substantial. Furthermore, the dimensions of the scapula were significantly smaller on the affected shoulders. CONCLUSION OBPL is indeed a 3-D disorder. Our measurements revealed excessive retroversion of the glenoid fossa, and the reliability of the 3-D CT measurements was superior to their 2-D counterparts. 3-D CT reformations of the glenoid in the coronal and the sagittal plane added further to 3-D understanding of glenoid morphology in OBPL. These new findings legitimatize a 3-D CT-based description of the glenoid deformities connected with OPBL.
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Affiliation(s)
- Lars H Frich
- Department of Orthopaedics, Odense University Hospital, Odense, Denmark; Orthopaedic Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | | | - Trine Torfing
- Department of Radiology, Odense University Hospital, Odense, Denmark
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Zaami S, Busardò FP, Signore F, Felici N, Briganti V, Baglio G, Marinelli E, Fineschi V. Obstetric brachial plexus palsy: a population-based retrospective case-control study and medicolegal considerations. J Matern Fetal Neonatal Med 2017; 31:1412-1417. [PMID: 28504029 DOI: 10.1080/14767058.2017.1317737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Paolo Busardò
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Fabrizio Signore
- Department of Obstetrics and Gynecology, San Camillo Forlanini Hospital, Rome, Italy
| | - Nicola Felici
- Unit of Reconstructive Surgery of the Limbs, San Camillo Forlanini Hospital, Rome, Italy
| | - Vito Briganti
- Pediatric Surgery and Urology Unit, San Camillo Forlanini Hospital, Rome, Italy
| | - Giovanni Baglio
- Migration and Poverty (NIHMP), National Institute for Health, Roma, Italy
| | - Enrico Marinelli
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
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Coroneos CJ, Voineskos SH, Christakis MK, Thoma A, Bain JR, Brouwers MC. Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline. BMJ Open 2017; 7:e014141. [PMID: 28132014 PMCID: PMC5278272 DOI: 10.1136/bmjopen-2016-014141] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise. SETTING The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries. PARTICIPANTS The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres. OUTCOME MEASURES An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed. RESULTS 7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery. CONCLUSIONS The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.
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Affiliation(s)
- Christopher J Coroneos
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sophocles H Voineskos
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Marie K Christakis
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Achilleas Thoma
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - James R Bain
- Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Melissa C Brouwers
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Björkman A, Weibull A, Svensson H, Dahlin L. Cerebral Reorganization in Patients with Brachial Plexus Birth Injury and Residual Shoulder Problems. Front Neurol 2016; 7:240. [PMID: 28066323 PMCID: PMC5179561 DOI: 10.3389/fneur.2016.00240] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/12/2016] [Indexed: 11/22/2022] Open
Abstract
The functional outcome after a brachial plexus birth injury (BPBI) is based on changes in the peripheral nerve and in the central nervous system. Most patients with a BPBI recover, but residual deficits in shoulder function are not uncommon. The aim of this study was to determine cerebral activation patterns in patients with BPBI and also residual symptoms from the shoulder. In seven patients (six females and one male, aged 17–23 years) with a BPBI and residual shoulder problems (Mallet score IV or lower), the cerebral response to active movement of the shoulder and elbow of the injured and healthy arm was monitored using functional magnetic resonance imaging at 3 T. Movements, i.e., shoulder rotation or elbow flexion and extension, of the injured side resulted in a more pronounced and more extended activation of the contralateral primary sensorimotor cortex compared to the activation seen after moving the healthy shoulder and elbow. In addition, moving the shoulder or elbow on the injured side resulted in increased activation in ipsilateral primary sensorimotor areas an also increased activation in associated sensorimotor areas, in both hemispheres, located further posterior in the parietal lobe, which are known to be important for integration of motor tasks and spatial aspects of motor control. Thus, in this preliminary study based on a small cohort, patients with BPBI and residual shoulder problems show reorganization in sensorimotor areas in both hemispheres of the brain. The increased activation in ipsilateral sensorimotor areas and in areas that deal with both integration of motor tasks and spatial aspects of motor control in both hemispheres indicates altered dynamics between the hemispheres, which may be a cerebral compensation for the injury.
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Affiliation(s)
- Anders Björkman
- Department of Hand Surgery, Skåne University Hospital , Malmö , Sweden
| | - Andreas Weibull
- Department of Radiation Physics, Skåne University Hospital , Malmö , Sweden
| | - Hampus Svensson
- Department of Hand Surgery, Skåne University Hospital , Malmö , Sweden
| | - Lars Dahlin
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden; Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden
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Tang M, Gorbutt KA, Peethambaran A, Yang L, Nelson VS, Chang KWC. High prevalence of cranial asymmetry exists in infants with neonatal brachial plexus palsy. J Pediatr Rehabil Med 2016; 9:271-277. [PMID: 27935564 DOI: 10.3233/prm-160396] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study aimed to: 1) evaluate the prevalence of cranial asymmetry (positional plagiocephaly) in infants with neonatal brachial plexus palsy (NBPP); 2) examine the association of patient demographics, arm function, and NBPP-related factors to positional plagiocephaly; and 3) determine percentage of spontaneous recovery from positional plagiocephaly and its association with arm function. METHODS Infants < 1 year of age with NBPP and no previous exposure to plagiocephaly cranial remolding therapy or surgical intervention were recruited for this prospective cross-sectional study. Positional plagiocephaly (diagonal difference) measurements were captured using a fiberglass circumferential mold of the cranium. Included infants were divided into 2 groups: 1) those with positional plagiocephaly at most recent evaluation (plagio group), including infants with resolved positional plagiocephaly (plagio-resolved subgroup); and 2) those who never had positional plagiocephaly (non-plagio group). Standard statistics were applied. RESULTS Eighteen of 28 infants (64%) had positional plagiocephaly. Delivery type might be predictive for plagiocephaly. Infants in the non-plagio group exhibited more active range of motion than infants in the plagio group. All other factors had no significant correlations. CONCLUSIONS A high prevalence of positional plagiocephaly exists among the NBPP population examined. Parents and physicians should encourage infants to use their upper extremities to change position and reduce chance of cranial asymmetry.
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Affiliation(s)
- Megan Tang
- South Georgia Orthopedic Resources, Hiram, GA, USA
| | | | | | - Lynda Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Virginia S Nelson
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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Obstetrical brachial plexus palsy: Can excision of upper trunk neuroma and nerve grafting improve function in babies with adequate elbow flexion at nine months of age? J Plast Reconstr Aesthet Surg 2016; 69:629-33. [DOI: 10.1016/j.bjps.2015.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/28/2015] [Accepted: 12/31/2015] [Indexed: 11/18/2022]
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Elnaggar RK. Shoulder Function and Bone Mineralization in Children with Obstetric Brachial Plexus Injury After Neuromuscular Electrical Stimulation During Weight-Bearing Exercises. Am J Phys Med Rehabil 2016; 95:239-47. [DOI: 10.1097/phm.0000000000000449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Carsi MB, Clarke AM, Clarke NP. Transient neonatal radial nerve palsy. A case series and review of the literature. J Hand Ther 2016; 28:212-5; quiz 216. [PMID: 25835250 DOI: 10.1016/j.jht.2014.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/13/2014] [Accepted: 10/14/2014] [Indexed: 02/03/2023]
Abstract
Transient neonatal radial nerve palsy manifests at birth by wrist drop and intact elbow and shoulder function. Spontaneous resolution is universal. We present a case series, including two bilateral cases, and a review of the cases found in the English literature, hypothesizing how this condition is probably misdiagnosed as brachial plexus injury.
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Affiliation(s)
- M Belen Carsi
- University Hospital of Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.
| | - Anna M Clarke
- University Hospital Bristol NHS Foundation Trust, Upper Maudlin St, Bristol BS2 8HW, UK
| | - Nicholas P Clarke
- University Hospital of Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK; Faculty of Medicine, University of Southampton, Tremona Road, Southampton SO16 6HW, UK
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Coroneos CJ, Voineskos SH, Coroneos MK, Alolabi N, Goekjian SR, Willoughby LI, Farrokhyar F, Thoma A, Bain JR, Brouwers MC. Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system. J Neurosurg Pediatr 2016; 17:222-229. [PMID: 26496634 DOI: 10.3171/2015.6.peds14703] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada's 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group's guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, "good" if assessed by the time the patient was 1 month of age, "satisfactory" if by 3 months of age, and "poor" if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%-60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was "good" in 28%, "satisfactory" in 66%, and "poor" in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.
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Affiliation(s)
| | - Sophocles H Voineskos
- Division of Plastic Surgery and.,Departments of 2 Clinical Epidemiology & Biostatistics
| | - Marie K Coroneos
- Department of Obstetrics and Gynecology, University of Toronto, Ontario, Canada
| | | | | | | | | | - Achilleas Thoma
- Division of Plastic Surgery and.,Departments of 2 Clinical Epidemiology & Biostatistics
| | | | - Melissa C Brouwers
- Departments of 2 Clinical Epidemiology & Biostatistics.,Oncology, McMaster University, Hamilton, Ontario, Canada; and
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Cortez M, Silva RFD, Gilbert A, Brandt CT, Valenti P. NOSOLOGY OF HAND DISEASES IN CHILDREN AND ADOLESCENTS OPERATED IN PROVISIONAL FACILITIES IN A MODEL HOSPITAL - PERNAMBUCO STATE, BRAZIL. Rev Bras Ortop 2015; 45:445-52. [PMID: 27022593 PMCID: PMC4799119 DOI: 10.1016/s2255-4971(15)30434-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
To report the frequencies of congenital hand diseases in patients who underwent surgery on a collective mobilization basis at SOS Hand, Recife, Pernambuco, between 2005 and 2009. Methods: Information was collected from 833 children and adolescents who were examined in eight missions. Results: Among the patients, 306 (36.7%) underwent surgery: 240 (78.4%) because of congenital malformation and 66 (21.6%) because of acquired lesions. The most frequent congenital malformations were: syndactyly, 72 cases (30.0%); polydactyly, 30 cases (12.5%); bifid thumb, 19 cases (7.9%); complex hand malformation, 14 cases (5.8%); cleft hand, 13 cases (5.4%); trigger finger, 12 cases (5.0%); camptodactyly, 11 cases (4.6%); and brachysyndactyly, 9 cases (3.7%). The most frequently acquired injuries were: obstetric traumatic lesions, 26 cases (39.4%); hand trauma sequelae, 18 cases (27.3%); cerebral paralysis sequelae, 7 cases (10.6%); electric shock sequelae, 5 cases (7.6%); and burn sequelae, 4 cases (6.1%). Conclusion: The nosology of hand diseases is similar to that of large series of elective surgery, especially regarding congenital deformities. The frequency of acquired hand lesions seems to be higher than the frequency in international series. The collective mobilization system for hand surgery is important for decreasing the need for this activity in public institutions, and it has been shown to be very efficient. The success of the project may provide support for the Brazilian National Health System to enroll hand surgeons in the on-call system, in emergency units.
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Affiliation(s)
- Mauri Cortez
- Adjunct Professor in the Federal University of Pernambuco; Director of SOS Hand, Recife, PE
- Correspondence: Rua Minas Gerais 147, Ilha do Leite, 50070-700 Recife, PECorrespondence: Rua Minas Gerais 147Ilha do LeiteRecifePE50070-700
| | | | - Alain Gilbert
- Hand Surgeon, La Chaîne de L'Espoir, Hand Institute, Jouvenet Clinic, 6 Square Jouvenet, Paris
| | | | - Philippe Valenti
- Hand Surgeon, La Chaîne de L'Espoir, Hand Institute, Jouvenet Clinic, 6 Square Jouvenet, Paris
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Eliason S, Bursac I, Bates AR, Huntsman RJ. Case 1: Arm immobility in an infant. Paediatr Child Health 2015; 20:345-7. [DOI: 10.1093/pch/20.7.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Stokes V, Fertleman C. Late neonatal presentation of reduced arm movement due to painful infective lymphadenopathy. BMJ Case Rep 2015; 2015:bcr-2015-210966. [PMID: 26153292 DOI: 10.1136/bcr-2015-210966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report two cases of 21-day-old male infants, Baloo and Bagheera, both admitted with unilateral reduced arm movement secondary to painful lymphadenopathy, which is a presentation previously unreported in the paediatric literature. The only abnormal finding following investigations in both neonates was infective lymphadenopathy; we hypothesise that the inflamed lymph nodes were tender when the surrounding muscles, fascia or skin were moved, so that the infants learnt to reduce arm movement to minimise pain. This report explores the differential diagnoses for reduced arm movement in neonates, and highlights the importance of sepsis with painful lymphadenopathy as a differential diagnosis in neonates presenting with reduced arm movement.
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Affiliation(s)
- Victoria Stokes
- Department of Paediatrics, The Whittington Hospital, Basildon, UK
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Oktay F, Cömert D, Gökkaya NKO, Ozbudak SD, Uysal H. Bone age in children with obstetrical brachial plexus palsy: effect of peripheral nerve injury on skeletal maturation. J Child Neurol 2014; 29:203-9. [PMID: 23611885 DOI: 10.1177/0883073813484089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this retrospective study was to analyze the effect of peripheral nerve injury on the skeletal maturation process. The bone ages of the affected and unaffected hand-wrists of 42 children with obstetrical brachial palsy were determined according to the Greulich and Pyle atlas. In 23 patients, the bone ages of the both sides were identical (bone-age-symmetrical group), in 19 patients the bone age of the affected side was delayed (bone-age-delayed group). The mean bone age of the affected side was delayed 0.48 ± 0.25 years that of the unaffected side (P = .000), and the delay of bone age was inversely correlated with chronological age (R (2) = .45, P < .02) in the bone-age-delayed group. Skeletal retardation can be recognized after appearance of ossification centers by plain radiography, dating from the third month of life, in early infancy. Thus, bone age determination method might be helpful for predicting potential future limb shortness.
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Affiliation(s)
- Fügen Oktay
- 1Department of Physical Medical and Rehabilitation, Zekai Tahir Burak Women's Health Education and Research Hospital, Talatpaşa Bulvarı Samanpazarı, Ankara, Turkey
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Allagui M, Bellaaj Z, Zrig M, Abid A, Koubaa M. [Acute osteomyelitis of the clavicle in the newborn infant: a case report]. Arch Pediatr 2013; 21:211-3. [PMID: 24290180 DOI: 10.1016/j.arcped.2013.09.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 05/28/2013] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
Abstract
Acute osteomyelitis of the clavicle accounts for less than 3% of osteomyelitis cases, with its usual location in the middle third. It may be hematogenous, due to contiguity, or secondary to catheterization of the subclavian vein or neck surgery. The diagnosis is often delayed, and clinical symptoms may simulate obstetric brachial plexus palsy in young children. We report a new case of osteomyelitis of the clavicle in a 30-day-old newborn.
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Affiliation(s)
- M Allagui
- Service de traumatologie et d'orthopédie, université Fattouma Bourguiba hôpital, Monastir, Tunisie.
| | - Z Bellaaj
- Service de traumatologie et d'orthopédie, université Fattouma Bourguiba hôpital, Monastir, Tunisie
| | - M Zrig
- Service de traumatologie et d'orthopédie, université Fattouma Bourguiba hôpital, Monastir, Tunisie
| | - A Abid
- Service de traumatologie et d'orthopédie, université Fattouma Bourguiba hôpital, Monastir, Tunisie
| | - M Koubaa
- Service de traumatologie et d'orthopédie, université Fattouma Bourguiba hôpital, Monastir, Tunisie
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Neonatal brachial plexus palsy with vaginal birth after cesarean delivery: a case-control study. Am J Obstet Gynecol 2013; 208:229.e1-5. [PMID: 23211545 DOI: 10.1016/j.ajog.2012.11.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 11/13/2012] [Accepted: 11/30/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective was to determine the rate of neonatal brachial plexus palsy (NBPP) among women with vaginal birth after cesarean delivery (VBAC) and to compare the peripartum characteristics with control subjects. STUDY DESIGN The Maternal-Fetal Medicine Unit cesarean registry data were used to identify nonanomalous singleton pregnancies with VBAC and NBPP at gestational age of ≥37 weeks (term) and 4 control subjects (matched for gestational age and diabetes mellitus status but without brachial injury). Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. RESULTS Among 11,313 VBACs at term, there were 23 women with NBPP (rate of 2.0/1000 women). Newborn infants with NBPP, compared with control infants, were significantly more likely to weigh ≥4000 g (48% vs 10%, respectively; OR, 8.45; 95% CI, 2.58-28.44) and to require admission to the neonatal intensive care unit (30% vs 13%; OR, 12.98; 95% CI, 2.61-72.18). CONCLUSION Women who desire VBAC should be informed about the low rate of NBPP and, if eligible, encouraged to have a trial of labor after cesarean delivery.
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ElKhatib RS, ElNegmy EH, Salem AH, Sherief AA. Kinesio arm taping as prophylaxis against the development of Erb's Engram. J Adv Res 2012; 4:485-91. [PMID: 25685456 PMCID: PMC4294788 DOI: 10.1016/j.jare.2012.08.006] [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] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 08/13/2012] [Accepted: 08/17/2012] [Indexed: 11/16/2022] Open
Abstract
An Erb’s Engram is a common debility that develops in recovering children with Erb’s palsy. The purpose of this study was to investigate the effect of kinesiotaping over the deltoid and the forearm on the development of proper upper extremity function in children recovering from Erb’s palsy. Thirty patients with Erb’s palsy participated for 3 months in this study and were equally divided into two groups; control group A and study group B. The two groups received the same designed physical therapy program, while group B along the program, received kinesiotaping over the deltoid and the forearm. The subjects were evaluated, pre and post-treatment, and scored functionally, using the Toronto Active Motion Scale, and objectively, using an EMG device utilized to obtain the percentages of degeneration of the deltoid and the biceps muscles. Post-treatment values of six out of nine measured variables, between the two groups, revealed significant difference in favor of group B. The obtained results strongly support the introduction of kinesiotaping of the deltoid and the forearm as an adjunct to the treatment program of Erb’s palsied children.
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Affiliation(s)
- Radwa S ElKhatib
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt
| | - Emam H ElNegmy
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt
| | - Amina H Salem
- Department of Pediatrics, Faculty of Medicine, Cairo University, Egypt
| | - AbdelAziz A Sherief
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Egypt
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Abstract
OBJECTIVE To estimate the modalities of management of post-term neonates. METHODS This study is based on PubMed search, Cochrane library and HAS recommendations. RESULTS Medical team should be able to provide neonatal resuscitation in delivery room in case of meconium-stained fluid or perinatal asphyxia according to the international guidelines ILCOR 2010. The glycaemia of the post-term newborn with macrosomia should be evaluated. The initial clinical examination should search complications such as shoulder dystocia or clavicular fracture. Full blood count should be performed in symptomatic newborn post-term. Developmental assessment should be performed in post-term newborn in case of associated pathology. CONCLUSIONS The risk of perinatal complications is increased in newborn post-term in delivery room and during hospitalization. Medical team should be able to manage these complications.
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Affiliation(s)
- E Lopez
- Service de médecine néonatale de Port-Royal, groupe hospitalier Cochin-Broca, Hôtel-Dieu, AP-HP, 123, boulevard de Port-Royal, 75014 Paris, France.
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Gurewitsch ED, Allen RH. Reducing the risk of shoulder dystocia and associated brachial plexus injury. Obstet Gynecol Clin North Am 2011; 38:247-69, x. [PMID: 21575800 DOI: 10.1016/j.ogc.2011.02.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Despite persisting controversy over shoulder dystocia prediction, prevention, and injury causation, the authors find considerable evidence in recent research in the field to recommend additional guidelines beyond the current American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynecologists guidelines to improve clinical practice in managing patients at risk for experiencing shoulder dystocia. In this article, the authors offer health care providers information, practical direction, and advice on how to limit shoulder dystocia risk and, more importantly, to reduce adverse outcome risk.
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Affiliation(s)
- Edith D Gurewitsch
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Ibrahim AI, Hawamdeh ZM, Alsharif AA. Evaluation of bone mineral density in children with perinatal brachial plexus palsy: effectiveness of weight bearing and traditional exercises. Bone 2011; 49:499-505. [PMID: 21640214 DOI: 10.1016/j.bone.2011.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 04/25/2011] [Accepted: 05/13/2011] [Indexed: 11/16/2022]
Abstract
PURPOSE (1) To investigate any evidence of bone mineral density (BMD) changes in children with Perinatal Brachial Plexus Palsy (PBPP). (2) To detect any relationship between these changes and the child age, weight, height, BMI, power index, gender, ethnicity, and the side affected. (3) To determine any possible effects of a designed weight bearing exercise program and the traditional one upon BMD of those children. STUDY DESIGN Randomized single blind controlled trial. METHOD A convenience sampling strategy was used to obtain 45 children with unilateral PBPP. Their ages ranged from 3 to 10 years. They were randomly divided to three equal groups. Groups were, then, randomly assigned to either interventions [Weight Bearing Exercises Program (WBEP) or Traditional Exercises Program (TEP)] or to the control treatment. Dual Energy X-Ray Absorptiometry (DXA) was used to evaluate BMD for all children at entry and approximately after six months treatment period. RESULTS We detected significant low entry level measurements of all BMD parameters of the affected side when compared to that of the unaffected sides (p=0.000). The mean value of the entry level calculated Z score for the affected side of all study children was equal to -1.12 ± 0.327 being in the osteopenic risk range. Furthermore, thirty children (66.7%) recorded less than (-1) Z score being in this risky range. Also, we recorded a significant improvement of all BMD parameters of the affected side after treatment in favor of the WBEP group when compared to that of the control and TEP groups (p=0.02, p=0.03 respectively for the affected both bones BMD parameter). CONCLUSIONS BMD is significantly reduced in PBPP children. The retardation of bone accrual increases as the child height and weight decreases and the degree of paralysis increases. WBEP significantly promoted BMD improvement when compared to the TEP.
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Affiliation(s)
- A I Ibrahim
- Department of Physical Therapy, College of Applied Medical Sciences, University of Dammam, Dammam, Saudi Arabia.
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Abstract
In subsequent pregnancies after a cesarean delivery, women must choose between attempting to deliver vaginally or undergoing another cesarean delivery. Information relevant to this choice includes the long-term benefits and harms to the baby. In this article we discuss the relationship of mode of delivery (planned trial of labor, either with or without vaginal delivery, or elective repeat cesarean delivery) and long-term outcomes, including brachial plexus palsy, neurodevelopmental impairment, and asthma. No randomized trials are available that relate directly to the choice of delivery method after previous cesarean. Observational studies suggest that cesarean delivery might be associated with a greater risk of asthma, caused perhaps by altered gut colonization, increased risk of neonatal respiratory disease, decreased gestational age at birth or decreased likelihood of breastfeeding. By contrast, vaginal delivery after a previous cesarean delivery is associated with greater risks of neurodevelopmental impairment and upper-extremity motor impairment, caused, respectively, by greater risks of perinatal hypoxic-ischemic encephalopathy and brachial plexus injury. Available information does not provide a precise estimate of the relative risks for infants delivered after a trial of labor versus elective cesarean delivery.
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Affiliation(s)
- T Michael O'Shea
- Department of Pediatrics (Neonatology), Wake Forest University, Health Sciences, Winston-Salem, NC 27157, USA.
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Borna H, Rad SMBA, Borna S, Mohseni SM. Incidence of and Risk Factors for Birth Trauma in Iran. Taiwan J Obstet Gynecol 2010; 49:170-3. [DOI: 10.1016/s1028-4559(10)60036-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2009] [Indexed: 11/28/2022] Open
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