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

Forearm Deformities in Birth Brachial Plexus Palsy - Patient Profile and Management Algorithm

Forearm deformities are often seen in children with severe birth brachial plexus palsy (BBPP). They may be either a supination or a pronation deformity and both hinder normal use of the hand and parents often request for corrective surgery. However, the correction of these deformities can be challenging due to a paucity of options. Also, there is less information in literature on the management of forearm deformities in BBPP compared to the information with regard to nerve surgery or correction of shoulder deformities. This article presents a synopsis of incidence, pathogenesis, clinical presentation and parental concerns related to these deformities. The decision-making considerations, management strategies and outcome expectations are also discussed. Patient selection is very crucial, and the treatment plan must be individualised depending on the disability, parental expectations and existing motor power in the involved limb. Correction of both the deformities have different considerations; however, effective correction of these deformities is immensely satisfactory to the patient/parents in terms of improved function and appearance of the limb. Level of Evidence: Level V (Therapeutic).

Clinical and psychosocial outcomes following correction of supination deformity in obstetrical brachial plexus palsy patients: A retrospective study

Background

Forearm supination contracture is the mostAQ common deformity of the forearm following obstetric brachial plexus palsy (OBPP). Supination deformities in OBPP may be corrected by performing forearm osteotomy; however, the high recurrence rate limits patient satisfaction. Apart from the cosmetic impairment of this deformity, there are no previous reports on the clinical and psychosocial outcomes of forearm osteotomy in patients with supination deformities secondary to OBPP. Therefore, our study aimed to assess the clinical, functional, and psychosocial outcomes following forearm pronation osteotomy in OBPP patients with supination deformity.

Methods

This retrospective study was conducted after a chart review of all OBPP sequelae with supination forearm deformity in patients who underwent forearm pronating osteotomy from 2006 to 2018. Data relating to OBPP were gathered, and functional and psychosocial outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire through interviews

Results

This study included 60 patients with a mean age of 8.7 years at the time of surgery. A total of 46 patients had lesions involving C5-T1 (76.7%). The mean preoperative supination deformity position was 68.5°, the mean amount of correction was 98.9°, and the mean forearm position was 30.5°, postoperatively. In the DASH assessment scale used postoperatively, 24 patients (42.9%) reported no restrictions on their daily activities, 25 patients (44.6%) believed that their social activities were unaffected, and 20 patients (35.7%) strongly disagreed with feeling less capable or less confident due to arm, shoulder, or hand problems. The factors significantly affecting position at the final follow-up were the amount of correction (p = 0.011), postoperative position (p = 0.005), and degree of pronation achieved (p = 0.02). The amount of correction significantly affected both self-confidence (p = 0.049) and activities of daily living (p = 0.033).

Conclusion

In conclusion, our study showed that the position at the final follow-up, the degree of pronation achieved intraoperatively, and the postoperative position significantly affected the position at follow-up and the outcome assessment. The amount of intraoperative correction was significantly associated with higher self-confidence and normal activities of daily living.

Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy

Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.

'Switch' technique to restore pronation and radial deviation in 17 patients with brachial plexus birth palsy

We report outcomes of 17 children with brachial plexus birth palsy that underwent extensor carpi ulnaris to brachioradialis and brachioradialis to abductor pollicis longus transfers to correct supination and ulnar deviation deformity. Mean age at the time of surgery was 8.7 years and mean follow-up time was 21 months (8-44). These patients had marked increases in active forearm rotation and Canadian Occupational Performance Measure scores. Activity performance score on the measure increased from 1.1 to 6.7 and satisfaction score increased from 0.8 to 8.7 at final follow-up. We conclude from our patient series that these tendon transfers are effective in correction of the supination and ulnar deviation deformities in brachial plexus birth palsy. Level of evidence: IV.

Rehabilitation of Neonatal Brachial Plexus Palsy: Integrative Literature Review

This integrative literature review has been carried out with the aim of analyzing the scientific literature aimed at identifying and describing existing rehabilitation treatments/therapies for neonatal brachial plexus palsy (NBPP). NBPP is a frequent consequence of difficult birthing, and it impairs the function of the brachial plexus in newborns. This is why knowledge on rehabilitation strategies deserves special attention. The data collection was carried out in January 2019, in the EBSCOhost and BVS (Biblioteca Virtual em Saúde) platforms, in the CINAHL Complete, MEDLINE Complete, LILACS and PubMed databases. Thirteen articles were included in this integrative literature review, based on a literature search spanning title, abstract and full text, and considering the inclusion criteria. Two main treatments/therapies for NBPP rehabilitation were identified: conservative treatment and surgical treatment. Conservative treatment includes teamwork done by physiatrists, physiotherapists and occupational therapists. These professionals use rehabilitation techniques and resources in a complementary way, such as electrostimulation, botulinum toxin injection, immobilizing splints, and constraint induced movement therapy of the non-injured limb. Professionals and family members work jointly. Surgical treatment includes primary surgeries, indicated for children who do not present any type of spontaneous rehabilitation in the first three months of life; and secondary surgeries, recommended in children who after primary surgery have some limitation of injured limb function, or in children who have had some spontaneous recovery, yet still have significant functional deficits. Treatment options for NBPP are defined by clinical evaluation/type of injury, but regardless of the type of injury, it is unanimous that conservative treatment is always started as early as possible. It should be noted that there was no evidence in the literature of other types of rehabilitation and techniques used in clinical practice, such as preventive positioning of contractures and deformities, hydrotherapy/aquatic therapy, among others, so we consider there is a need for further studies at this level in this area.

Clavicle Fracture Is Not Predictive of the Need for Microsurgery in Brachial Plexus Birth Palsy

BACKGROUND

Brachial plexus birth palsy (BPBP) and clavicle fractures occur concurrently as well as in isolation during difficult deliveries. The concept that concurrent clavicle fracture may spare nerve injury has been advocated. Our aim was to compare those children with BPBP presenting to a tertiary care center with and without concurrent clavicle fractures and assess the utility of the presence of a clavicle fracture as a predictor of injury severity in children with BPBP.

METHODS

Records of all patients belonging to a large prospective multicenter cohort study of infants with BPBP (Treatment and Outcomes of Brachial Plexus Injuries study) were analyzed for demographic information and birth information including risk factors, comorbidity, presence of clavicle fracture, and injury severity.

RESULTS

The records of 639 children with BPBP were examined. Thirteen patients were excluded for incomplete data. Ninety-six children who sustained concurrent birth fracture and BPBP were identified (15%). Of these, 57 sustained clavicle fractures (9%), 44 sustained humerus fractures, and 4 sustained other fractures. Of the demographic factors analyzed, only the presence of gestational diabetes was found to be significantly higher in those children with fractures versus those without. The presence of a clavicle fracture did not change the rate of microsurgical intervention, nor did clavicle fracture rates differ by Toronto score, suggesting that there was no difference in injury severity between the 2 groups.

CONCLUSIONS

In a large multicenter prospective study, 9% of children presenting with BPBP also sustained a clavicle fracture at birth. The presence of a clavicle fracture did not correlate with the severity of brachial plexus injury. We suggest that in study populations of children with severe enough BPBP to present to a tertiary care center, compared with studies collected in the obstetric population, the presence of a clavicle fracture is neither protective from nerve injury nor predictive of injury severity.

LEVEL OF EVIDENCE

Level 2-prognostic.

Evaluation of Self-Concept and Emotional-Behavioral Functioning of Children with Brachial Plexus Birth Injury

Background The reported incidence of brachial plexus birth injury (BPBI) is 0.87 to 2.2 per 1,000 live births. The psychological functioning, including self-concept and emotional-behavioral functioning, of children with BPBI has only been examined to a limited extent. Objective The purpose of this study was to describe the self-concept and emotional-behavioral functioning in children with BPBI from both the child's and parent's perspective. Methods Thirty-one children with BPBI, mean age 11 years 1 month, completed the Draw A Person: Screening Procedure for Emotional Disturbance (DAP:SPED) and Piers Harris Children's Self-Concept Scale (PHCSCS). The parents answered questions from the Behavior Assessment System for Children, Parent Rating Scales (BASC-2 PRS). Results The scores from the DAP:SPED drawings showed further evaluation was not strongly indicated in the majority of the children. The PHCSCS Total score demonstrated that the children had a strongly positive self-concept. The parental responses to the BASC-2 PRS indicated that few children were at risk or in the clinically significant range for the four composite scores and all of the component clinical or adaptive scales. Gender comparison revealed females exhibited greater anxiety than males. Conclusion Both children and parents reported a positive psychological well-being for the majority of the children. Parents had greater concerns about their child's social-emotional functioning, particularly anxiety. An interdisciplinary approach (occupational therapy evaluation, clinical observation, and parental interview) is necessary to determine the need for mental health referral.

Neonatal brachial plexus palsy: a permanent challenge

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

The brachial plexus outcome measure: development, internal consistency, and construct validity

PURPOSE

The purpose of this article was to report the development of a new assessment tool, the Brachial Plexus Outcome Measure (BPOM) and the evaluation of its internal consistency and construct validity.

METHODS

A retrospective case series of children aged 4-19 years with obstetrical brachial plexus palsy (OBPP) was conducted. Intraclass coefficients were calculated for the BPOM Activity Scale items. Correlation between the Active Movement Scale (AMS) and BPOM Activity Scale scores were conducted to determine the convergent validity.

RESULTS

The BPOM Activity Scale items (N=306) had good internal consistency (Cronbach's α=0.87). A strong correlation between the BPOM Activity Scale and AMS (n=284) was found (r=0.71, p=0.001, α=0.05).

CONCLUSIONS

The BPOM Activity Scale demonstrates good internal consistency and construct validity as a discriminative functional outcome measure in children with OBPP.

LEVEL OF EVIDENCE

IV.

Hand function in children with an upper brachial plexus birth injury: results of the nine-hole peg test

AIM

The aim of this study was to evaluate hand function in children with Erb upper brachial plexus palsy.

METHOD

Hand function was evaluated in 25 children (eight males; 17 females) with a diagnosed upper (C5/C6) brachial plexus birth injury. Of these children, 22 had undergone primary nerve reconstruction and 13 of the 25 had undergone simultaneous and/or secondary shoulder procedures. Hand function was evaluated using the nine-hole peg test at a mean age of 9 years (SD 2y 2mo), and compared with the contralateral, uninvolved hand. Results were compared with age- and sex-matched population norms, and correlated with shoulder outcomes using the Gilbert and Miami scores.

RESULTS

Although shoulder function was graded as good or excellent in 24 of 25 children, hand function as measured by the nine-hole peg test was significantly altered in the involved hand in 80% (p=0.008). On average the participants took 18.8% longer to complete the task with the involved hand; this was significantly different from the expected difference of 7.2% (p=0.008).

INTERPRETATION

Hand function is impaired in individuals with upper brachial plexus birth injury. These results suggest that from the initiation of treatment in this population, attention should be paid to recognizing and focusing therapy on subtle limitations of hand function.

Total obstetric brachial plexus palsy in children with internal rotation contracture of the shoulder, flexion contracture of the elbow, and poor hand function: improving the cosmetic appearance of the limb with rotation osteotomy of the humerus

Rotation osteotomy of the humerus has been described by several authors to treat the internal rotation contracture of the shoulder in Erb palsy. The main aim of the osteotomy in Erb patients is to bring the functioning hand to the face which greatly improves function. The author has performed the rotation humeral osteotomy in children with total obstetric brachial plexus palsy aiming for the improvement of the cosmetic appearance of the limb rather than improvement function. This article specifically reports on this group of patients.Over the last 15 years, the author has performed rotation humeral osteotomy in 13 children (mean age 6 years; range, 4.5-9 years) with total obstetric brachial plexus palsy aiming for improvement of the cosmetic appearance of the limb rather than improvement of function. All children had a triad of severe internal rotation contracture of the shoulder, severe flexion contracture of the elbow, and poor hand function.After a mean follow-up of 2 years following the humeral osteotomy, all patients/parents were satisfied with the result and a panel of plastic surgeons confirmed the significant improvement in aesthetics. Reasons for this improvement following the osteotomy were as follows: the child no longer needed to stand with shoulder slightly abducted, the antecubital fossa became visible in the standing position, and the forearm no longer appeared excessively pronated. Of more importance, was the improvement in elbow flexion contracture which had major contribution in improving limb appearance and the perception of length discrepancy between the affected and the contralateral normal limb.The humeral osteotomy improves the cosmetic appearance of children with total palsy and the triad of severe internal rotation contracture of the shoulder, severe flexion contracture of the elbow and poor hand function.

Outcomes of hand reconstruction in obstetric brachial plexus palsy

BACKGROUND

In children with global obstetric brachial plexus palsy, prioritization should be first focused on hand reinnervation and then directed to shoulder and elbow function. In this study, the surgical strategy for restoration of hand function and the methods and outcomes are analyzed.

METHODS

Between 1979 and 2005, 59 patients (61 extremities) underwent reconstruction for hand reanimation. The mean follow-up was 7.7 years (range, 2 to 22 years). Of these, 16 cases underwent primary reconstruction alone, 35 underwent both primary and secondary procedures, and 10 late cases underwent palliative surgery. Hand function was evaluated with a modified Gilbert- Raimondi hand scale (grades 4 to 6 were considered useful outcomes).

RESULTS

Grade 4 or better functional recovery was observed in six of six cases (100 percent) that underwent primary reconstruction within the first 3 months of life. These patients did not require any secondary procedures. Multiple secondary procedures were necessitated to maximize the functional outcome in late cases or in patients with incomplete recovery following primary reconstruction. Overall, 46 of 61 cases (75.4 percent) achieved grade 4 or greater. The long-term results were better; 23 of 26 cases (88 percent) with a follow-up of more than 8 years achieved grade 4 or greater.

CONCLUSIONS

When primary reconstruction was performed within 3 months, functional return to the hand was the greatest and the need for palliative surgery was dramatically reduced. For older patients (>or=4 months), secondary procedures can significantly enhance hand function. The best results were seen when a combination of tendon transfers and free muscles transfers was performed.

An obstetric brachial plexus data sheet

BACKGROUND

Several reputed obstetric brachial plexus clinics use their own protocols and indications for surgery. This study is to present and explain the obstetric brachial plexus data sheet used at our institution.

METHODS

The data sheet is composed of 5 main parts: (1) the basic database which includes the name, age, type and side of palsy, maternal history, birth history and other complications of the traumatic delivery; (2) motor assessment of the limb; (3) preoperative investigations; (4) description of intraoperative brachial plexus findings and type of nerve procedure performed; and (5) secondary surgery to the shoulder, elbow, forearm, wrist and hand.

RESULTS

The data sheet was found useful in documenting the assessment and events in infants and older children.

CONCLUSION

An obstetric brachial plexus data sheet is presented and it may be modified and used by other centers.

The supination deformity and associated deformities of the upper limb in severe birth lesions of the brachial plexus

We reviewed 42 consecutive children with a supination deformity of the forearm complicating severe birth lesions of the brachial plexus.

The overall incidence over the study period was 6.9% (48 of 696). It was absent in those in Narakas group I (27.6) and occurred in 5.7% of group II (13 of 229), 9.6% of group III (11 of 114) and 23.4% of group IV (18 of 77).

Concurrent deformities at the shoulder, elbow, wrist and hand were always present because of muscular imbalance from poor recovery of C5 and C7, inconsistent recovery of C8 and T1 and good recovery of C6. Early surgical correction improved the function of the upper limb and hand, but there was a tendency to recurrence. Pronation osteotomy placed the hand in a functional position, and increased the arc of rotation of the forearm. The supination deformity recurred in 40% (17 of 42) of those treated by pronation osteotomy alone, probably because of remodelling of the growing bone.

Children should be followed up until skeletal maturity, and the parents counselled on the likelihood of multiple operations.

Forearm rotational profile in obstetric brachial plexus injury

Children with obstetric brachial plexus palsy (OBPP) most commonly have weakness of supination. There is little previous information on later progress of forearm rotation movements, although severe supination contracture has been reported in a small proportion of children. The aims of this study were to evaluate forearm rotation after initial recovery from OBPP, to define the relationship with the severity of disease, and to assess which factors might limit rotation. Measurements of active and passive pronation and supination were recorded in 56 children (37 boys and 19 girls) who had had OBPP and did not have full recovery. The mean age was 8 years (minimum, 2.5 years). Care was taken to measure forearm rotation in isolation from shoulder movements. According to the Narakas classification for severity of the original brachial plexus lesion, there were 23 group I cases, 16 group II cases, 11 group III cases, and 6 group IV cases. Twenty-one children underwent reconstructive procedures for shoulder deformity. Mallet scores for shoulder function were available for all patients. Overall pronation was more limited than supination. Active movements were more limited than passive movements. Active pronation was less than normal in 48 children, active supination was less than normal in 36, passive pronation was less than normal in 22, and passive supination was less than normal in 9. Active pronation and active and passive supination were significantly limited in children with worse Mallet scores and in Narakas group IV children. Both active supination and passive supination were decreased in children with more severe elbow flexion contractures. No significant relationship was found between forearm rotation movements and the time of biceps recovery. Many children have persisting limitation of forearm rotation after OBPP. Despite the initial weakness of supination, pronation is more often reduced in the longer term. Patients with more severe OBPP and poorer recovery of shoulder function have greater limitation of forearm rotation.