Brachial plexus birth palsy: a 10-year report on the incidence and prognosis

Surgical treatment of a nonunion following clavicle osteotomy in a child with a history of Erb's palsy: A case report

INTRODUCTION AND IMPORTANCE

Erb's palsy defined as muscle weakness and loss of motion caused by a nerve condition in the shoulder and arm. Children with Erb's palsy might underwent clavicle osteotomy as an appropriate surgical treatment method. However, few number of these patients who underwent clavicle osteotomy experienced nonunion and complained of shoulder deformity and pain. The aim of the present case report was to present new surgical treatment of a nonunion following clavicle osteotomy in a child affected by Erb's palsy.

CASE PRESENTATION

A six years old boy with a history of Erb's palsy who underwent clavicle osteotomy at age of 6 months was referred to hospital. There was a nonunion following clavicle osteotomy. The patient had right shoulder deformity and complained of its-related pain. To correct a nonunion following clavicle osteotomy in this case, middle third fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was used. After five months of follow-up, a clavicle nonunion and shoulder deformity was thoroughly corrected.

CLINICAL DISCUSSION

As clavicle osteotomy, the most commonly surgical method for Erb's palsy, has been demonstrated to not work effectively and cause nonunion in some cases, a new surgical method for correcting clavicle nonunion other than repeated clavicle osteotomy is needed. In the present case report, fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was applied and demonstrated remarkable improvement.

CONCLUSION

Totally, use of fibula auto grafting and fixing it to the cite of clavicle nonunion by pins might be an effective surgical treatment for such cases.

Recovery of Shoulder, Elbow, and Forearm Movement After Nerve Reconstruction for Neonatal Brachial Plexus Palsy

BACKGROUND AND OBJECTIVES

There is a relative dearth of published data with respect to recovery of upper extremity movement after nerve reconstruction for neonatal brachial plexus palsy (NBPP). This study aimed to demonstrate long-term recovery of active range of motion (AROM) at the shoulder, elbow, and forearm after nerve reconstruction for NBPP and to compare that with patients managed nonoperatively.

METHODS

We interrogated a prospectively collected database of all patients evaluated for NBPP at a single institution from 2005 to 2020. AROM measurements for shoulder, elbow, and forearm movements were collected at every visit up to 5 years of follow-up and normalized between 0 and 1. We used generalized estimated equations to predict AROM for each movement within local age windows over 5 years and compared the operative and nonoperative cohorts at each age interval.

RESULTS

In total, >13 000 collected datapoints representing 425 conservatively and 99 operatively managed children were included for analysis. At 5 years, absolute recovery of AROM after nerve reconstruction was ∼50% for shoulder abduction and forward flexion, ∼65% for shoulder external rotation, and ∼75% for elbow flexion and forearm supination, with ∼20% loss of elbow extension AROM. Despite more limited AROM on presentation for the operative cohort, at 5 years, there was no significant difference between the groups in AROM for shoulder external rotation, elbow extension, or forearm supination, and, in Narakas grade 1-2 injury, shoulder abduction and forward flexion.

CONCLUSION

We demonstrate recovery of upper extremity AROM after nerve surgery for NBPP. Despite more severe presenting injury, operative patients had similar recovery of AROM when compared with nonoperative patients for shoulder external rotation, elbow extension, forearm supination, and, for Narakas grade 1-2 injury, shoulder abduction and forward flexion.

Subscapularis Z-plasty With Coracoidectomy for Internal Rotation Contracture in Children With Brachial Plexus Birth Injury

OBJECTIVES

Brachial plexus birth injury (BPBI) is a rare dystocia complication. Although it has a good prognosis, a significant number retain functional impairment to varying degrees. The data concerning shoulder function improvement and complication rates are conflicting due to variations in outcome measures between the studies. Therefore, we report our experience with this approach.

METHODS

It was a retrospective study conducted at King Faisal Specialist Hospital and Research Center in Riyadh (FSH&RC), Saudi Arabia. Data such as patient demographics, Mallet scores, and passive external rotation (PER) in adduction and abduction were retrieved from the medical records.

RESULTS

In active shoulder function, Mallet score significantly improved (P=0.00). The improvement was most remarkable in active external rotation movement (P=0.00) followed by hand to the neck. However, no significant gain was observed in active abduction and hand-to-back. At the final follow-up, with a mean of 2.9 years, the improvement in PER in adduction and abduction was maintained. Compared to six months postoperative, no significant difference was found in hand-to-neck, hand-to-back, and total Mallet score.

CONCLUSION

Subscapularis z-lengthening with coracoidectomy was consistently effective in correcting internal rotation contraction in a patient with BPBI. Significant improvements were observed in the Mallet score and PER in adduction and abduction.

Risk factors for brachial plexus injury and permanent sequelae due to shoulder dystocia

AIM

The primary aim of this study was to determine the risk factors for the occurrence of brachial plexus injury in cases of shoulder dystocia. Secondly, it was aimed to determine the factors affecting the occurrence of permanent sequelae in cases with brachial plexus injury.

SUBJECTS AND METHODS

ICD-10 codes were scanned from the records of patients who gave birth between 2012 and 2018, and the records of patients with brachial plexus injury and shoulder dystocia were reached. Shoulder dystocia cases with brachial plexus damage were accepted as the study group, and shoulder dystocia cases without brachial plexus damage were considered the control group. Shoulder dystocia patients with brachial plexus injury and without injury were compared for 2-year orthopedics clinic follow-up reports, surgical intervention, permanent sequelae status as well as birth data, maternal characteristics, and maneuvers applied to the management of shoulder dystocia.

RESULTS

Five hundred sixty births with shoulder dystocia were detected. Brachial plexus injury was observed in 88 of them, and permanent sequelae were detected in 12 of these patients. Maneuvers other than McRobert's (advanced maneuvers) were used more and clavicle fracture was seen more in the group with plexus injury (P < 0.05, P < 0.05, respectively). Logistic regression analysis was performed to determine the risk factors of brachial plexus injury. Brachial plexus injury was observed 4.746 times more in infants who were delivered with advanced maneuvers and 3.58 times more in infants with clavicle fractures at birth.

CONCLUSION

In patients with shoulder dystocia, the risk of brachial plexus injury increased in deliveries in which advanced maneuvers were used and clavicle fracture occurred.

Reliability of Towel Test for Elbow Flexion Assessment in Brachial Plexus Birth Palsy

Background and Objectives The towel test is a reliable and straightforward technique to find elbow flexion in brachial plexus birth palsy. This study evaluates the role and reliability of towel test in children at 6 and 9 months of age.

Materials and Methods We conducted the towel test in 30 consecutive children at 6 and 9 months of their ages between 2015 and 2020. We recorded the results along with the side involved in these children and the mother’s handedness. Based on the results of towel tests, we did a statistical correlation.

Results Sixteen of the 30 children were boys. Twelve of the 30 children had left-side involvement. Four mothers were left handed. Four (13%) infants (male = 3; female = 1) had false-negative towel test at 6 and 9 months. There is a significant correlation between the left-hand mother’s and infant who had false-negative towel test (p < 0.01)

Conclusion The towel test is reliable and straightforward to assess the elbow flexion at 6 and 9 months. It can be falsely negative in 13% of children because of handedness. Mother’s handedness is crucial and should be recorded during the children assessment. Alternate tests will further evaluate the elbow flexion in such false-negative towel-tested brachial plexus birth palsy children.

Conjoint muscle transfer and subscapularis slide in brachial plexus birth palsy: Clinical outcomes in shoulder functions

Background

Shoulder deformity and inadequate shoulder function in brachial plexus birth palsy (BPBP) occur due to imbalance between the shoulder abductors, external rotators, adductors and internal rotators. This is due to cross innervation of the regenerating axons and subsequent target muscle innervation. These lead to internal rotation deformity along with glenohumeral dysplasia. Conjoint muscle transfer in the form of latissimus dorsi and teres major muscle combined with release and slide of subscapularis muscle improves shoulder functions. This study aims to evaluate the outcomes of shoulder function after a simultaneous conjoint muscle transfer and subscapularis slide in the management of BPBP.

Methods

18 children with BPBP, who presented with shoulder deformity and inadequate shoulder functions, underwent conjoint muscle transfer along with subscapularis muscle slide. At 18 months, shoulder functions were assessed preoperatively and postoperatively using Mallet score system and range of motions. Statistical analysis was performed to ascertain if the outcomes were statistically significant.

Results

Mean age was 4.64 years with a mean preoperative Mallet score of 10.89 ± 1.60 and mean postoperative Mallet score of 16.22 ± 1.86. At 18 months, mean gain in shoulder abduction at 18 months was 57.22 ± 16.11° with external rotation of 26.66 ± 7.67°. All children showed improvement in shoulder functions. There was no correlation between the clinical outcomes and age of the child.

Conclusion

This procedure was effective in improving shoulder functions in a cohort of patients. The long-term effect of this procedure, however, remains to be evaluated by further follow-up and with similar such studies.

Follow-up Study on the Effects of Tendon Transfers and Open Reduction on Moderate Glenohumeral Joint Deformity in Brachial Plexus Birth Injury

BACKGROUND

Soft-tissue contractures about the shoulder in patients with brachial plexus birth injury are common and can lead to progressive shoulder displacement and glenohumeral dysplasia. Open or arthroscopic reduction with musculotendinous lengthening and tendon transfers have become the standard of care. The clinical function and radiographic joint remodeling beyond the first 2 years after surgery are not well understood.

METHODS

We performed a follow-up study of 20 patients with preexisting mild to moderate glenohumeral joint deformity who had undergone open glenohumeral joint reduction with latissimus dorsi and teres major tendon transfers and concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis. Prospective collection of Modified Mallet and Active Movement Scale (AMS) scores and radiographic analysis of cross-sectional imaging for glenoid version, humeral head subluxation, and glenohumeral joint deformity classification were analyzed for changes over time.

RESULTS

The average duration of radiographic follow-up was 4.2 years (range, 2 to 6 years). The mean glenoid version improved from -31.8° to -15.4° (p < 0.0001). The mean percentage of the humeral head anterior to the middle of the glenoid (PHHA) improved from 9.6% to 30.4% (p < 0.0001). The mean glenohumeral joint deformity score improved from 3.7 to 2.1 (p < 0.0001).

CONCLUSIONS

All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. There were no significant changes beyond the 1-year time point in the Mallet scores, AMS scores, or radiographic outcome measures, possibly because of insufficient power, although trends of improvement were noted for some outcomes. No decline in outcome measures was found during the study period.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk factors associated with neonatal brachial plexus palsy in the United States

Neonatal brachial plexus palsy (NBPP) is a birth injury that can cause severe functional loss in the affected limb. The purpose of this study was to determine the temporal changes in the national incidence of this condition and whether associated risk factors have changed over time. Children born via vaginal delivery were identified in the Kids' Inpatient Database (KID) from 1997 to 2012, and those with NBPP were identified. The trend in incidence and risk factors were assessed through the study period. The nationwide incidence of NBPP decreased during the study period. Infants with shoulder dystocia, fetal macrosomia, and gestational diabetes had the highest risk of developing NBPP, while multiple birth mates during delivery had a protective effect. Multiple risk factors, including shoulder dystocia, macrosomia, and heavy for dates became less predictive of the development of NBPP over time. Several risk factors predispose children to the development of NBPP, and the effect of these risk factors has been changing. This information can guide obstetric treatment to help prevent NBPP. Level of evidence is diagnostic, level 3.

Preoperative multislice computed tomography evaluation of shoulder deformities in brachial plexus birth palsy patients undergoing tendon transfer

BACKGROUND

Brachial plexus birth palsy (BPBP) refers to a birth related paralysis of the upper extremity. The current study was designed to evaluate the efficacy of computed tomography (CT) in the assessment of humeral head posterior subluxation and glenoid retroversion preoperatively and to evaluate whether or not bony deformity correlates with functional improvement (based on Modified Mallet Score) following tendon transfer in brachial plexus birth palsy patients.

PATIENTS AND METHODS

This prospective study included 30 patients, 15 below 4 years and 15 above 4 years old, with a mean age 3.65 ± 1.39 (range 2-8) years old. Thirteen patients were males (43.3%) and 17 were females (56.6%). The left side was affected in 13 patients (43.3%), while the right in 17 (56.7%). The Modified Mallet Score was used for clinical assessment of the shoulder function. A multislice CT scan with 3D reconstruction was used as a preoperative radiological assessment of the shoulder. An electromyography (EMG) of the muscles around the shoulder was performed. All patients were operated upon by anterior release of the internal rotators to improve the external rotation range of motion and by transfer of teres major and latissimus dorsi to improve the abduction motion through one anterior deltopectoral incision and a small posterosuperior incision. Postoperatively, the range of shoulder abduction and external rotation had been assessed after shoulder spica removal and till the end of follow up.

RESULTS

Fourteen patients (46.7%) had a normal glenoid version angle (normal range from -12° to 2°) and normal range of articulation with the glenoid (42.3%-71.4%) and 16 patients (53.3%) had an abnormal glenoid version angle and abnormal range of articulation with the glenoid. According to the Modified Mallet Score, there was a statistically significant difference in the mean value of global abduction (P = 0.04), external rotation (P = 0.03), hand to mouth (P = 0.02), hand to neck (P = 0.03) and hand to spine (P = 0.02) between the pre- and post-operative assessment of all patients. There was a statistically significant difference in the mean value of postoperative Modified Mallet Score between the patients under the age of 4 years and those above the age of 4 years. There was no statistically significant difference between the patients with normal CT angles and those with abnormal CT angles. There was no statistically significant difference in the mean value of glenoid version angle and percentage of humeral head articulation between the patients below the age of 4 years and those above 4 years (P = 0.845).

CONCLUSION

The study concluded that the glenoid version angle and humeral head articulation percentage do not negatively affect results of the tendon transfer around the shoulder in patients of upper brachial plexus birth palsy.

LEVEL OF EVIDENCE

IV.

The Pathogenesis of Glenohumeral Deformity and Contracture Formation in Obstetric Brachial Plexus Palsy-A Review

Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.

Assessment of Current Epidemiology and Risk Factors Surrounding Brachial Plexus Birth Palsy

PURPOSE

Brachial plexus birth palsy (BPBP) is common; however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known risk factors, and evaluate hypotonia as a new risk factor, as well as estimate the length of stay (LOS) and direct costs of children with an associated BPBP injury.

METHODS

Data from the 1997 to 2012 Kids' Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and direct costs was also performed. Multivariable logistic regression analysis was utilized to assess the association of BPBP with its known and previously undescribed risk factors.

RESULTS

The incidence of BPBP has steadily decreased from 1997 to 2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number 1 risk factor for the development of a BPBP injury. Hypotonia is a newly recognized risk factor for the development of BPBP. Fifty-five percent of infants with BPBP have no known perinatal risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay direct costs are approximately 40% higher.

CONCLUSIONS

The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the most common risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer LOSs and hospital direct costs compared with children without a BPBP injury.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

10-year Follow-up of Mod Quad and Triangle Tilt Surgeries in Obstetric Brachial Plexus Injury

Aim:

To evaluate whether obstetric brachial plexus injury (OBPI) children who had mod Quad and triangle tilt surgeries maintained their recovered upper extremity functional movements over 10 years.

Background:

The short-term outcomes of surgery in OBPI patients are well documented. However, only a few publications with results over 10-year postoperative follow-up exist. We have previously reported the outcomes of these 2 surgeries in OBPI after 1, 2, and 5 years. Here, we report the successful outcomes in 17 of these patients over 10 years.

Methods:

Seventeen OBPI patients, who had mod Quad, a modified muscle release operation and triangle tilt, a bony surgical procedure with us between 2005 and 2008, had postoperative follow-up of 10 years and met the inclusion criteria. Patients who had multiple surgeries and did not have 10-year follow-up are excluded in this study.

Results:

Fifteen of 17 children maintain their recovered upper extremity functions for extended long period (mean, 10 years; range, 9–13 years). There was statistically significant improvement in total functional Mallet score after 3 years (mean, 18.8 ± 2.1; P ≤ 0.01) from the preoperative mean total Mallet score of 14.5 ± 1.2. This improvement was not only maintained for extended period but also improved (mean total Mallet score, 20.35 ± 2.3; P ≤ 0.01) in some patients.

Conclusions:

Overall, all upper extremity functions improved greatly after mod Quad and triangle tilt surgeries in OBPI children, and they were able to maintain their recovered functional movements over extended period of 10 years.

Brachial Plexus Ultrasound and MRI in Children with Brachial Plexus Birth Injury

BACKGROUND AND PURPOSE

Brachial plexus birth injury is caused by traction on the neck during delivery and results in flaccid palsy of an upper extremity commonly involving C5-C6 nerve roots. MR imaging and MR myelography help to assess the anatomic location, extent, and severity of brachial plexus injuries which influence the long-term prognosis along with the surgical decision making. Recently, sonography has been increasingly used as the imaging modality of choice for brachial plexus injuries. The aim of this study was to assess the degree of correlation among brachial plexus sonography, MR imaging, and surgical findings in children with brachial plexus birth injury.

MATERIALS AND METHODS

This prospective study included 55 consecutive patients (girls/boys = 32:23; mean age, 2.1 ± 0.8 months) with brachial plexus birth injury between May 2014 and April 2017. The patients were classified according to the Narakas classification and were followed up at 4- to 6-week intervals for recovery by the Modified Mallet system and sonography without specific preparation for evaluation. All patients had MR imaging under general anesthesia. Nerve root avulsion-retraction, pseudomeningocele, and periscalene soft tissue were accepted brachial plexus injury findings on imaging. Interobserver agreement for MR imaging and the agreement between imaging and surgical findings were estimated using the κ statistic. The diagnostic accuracy of sonography and MR imaging was calculated on the basis of the standard reference, which was the surgical findings.

RESULTS

Forty-three patients had pre- and postganglionic injury, 12 had only postganglionic injury findings, and 47% of patients underwent an operation. On sonography, no patients had preganglionic injury, but all patients had postganglionic injury findings. For postganglionic injury, the concordance rates between imaging and the surgical findings ranged from 84% to 100%, and the diagnostic accuracy of sonography and MR imaging was 89% and 100%, respectively. For preganglionic injury, the diagnostic accuracy of MR imaging was 92%. Interobserver agreement and the agreement between imaging and the surgical findings were almost perfect for postganglionic injury (κ = 0.81-1, P < .001).

CONCLUSIONS

High-resolution sonography can identify and locate the postganglionic injury associated with the upper and middle trunks. The ability of sonography to evaluate pre- and the postganglionic injury associated with the lower trunk was quite limited. Sonography can be used as a complement to MR imaging; thus, the duration of the MR imaging examination and the need for sedation can be reduced by sonography.

Prompt Referral in the Nonoperative Treatment of Obstetrical Brachial Plexus Injuries

Background

Prompt physical and occupational therapy is crucial in managing nonsurgical candidates with obstetrical brachial plexus injuries (OBPI). The objective of our study was to identify newborns suffering from nonoperative OBPI in need of a "fast-track" evaluation by a multidisciplinary team.

Methods

This is a retrospective review of patients with OBPI from June 1995 to June 2015. All nonsurgical candidates (Narakas class 1) were included in the study. The Gilbert score and the Medical Research Council grading system were used to measure shoulder and elbow function, respectively. The relationship between shoulder and elbow functional outcomes and time delay to consultation was studied using analysis of variance and Welch's tests. Various subgroups were studied based on OBPI risk factors: maternal diabetes, birth weight >4 kg, use of forceps, asphyxia, multiple comorbidities, and Apgar score at 1 and 5 minutes.

Results

A total of 168 patients were included in this study. Mean follow-up time was 313.8 weeks (minimum: 52; maximum: 1072; SD: 228.1). A total of 19 patients had an Apgar scores <7 at 5 minutes. Time delay between birth and the first consult to our clinic had an impact on shoulder outcome in the subgroup of newborns with Apgar scores <7 at 5 minutes.

Conclusions

The subgroup of newborns with an Apgar score <7 at 5 minutes shows improved long-term shoulder function when promptly examined by an OBPI clinic. We recommend a "fast-track" referral for this time-sensitive population.

Derotational Pronation-producing Osteotomy of the Radius and Biceps Tendon Rerouting for Supination Contractures in Neonatal Brachial Plexus Palsy Patients

Forearm supination contractures can occur as a result of neurological derangement of the upper extremity. Primarily, this is observed in patients with neonatal brachial plexus birth palsy. The contractures develop slowly over time and become problematic in childhood as the patients begin requiring forearm pronation for activities of daily living including typing on a keyboard and writing. Although supination contracture is a well-described sequelae of neonatal brachial plexus birth palsy, there is a paucity of literature describing techniques and outcomes for reconstruction and restoration of forearm pronation. The initially described technique included release of the interosseous membrane for flexibility combined with rerouting of part of the biceps tendon to change its biomechanical pull from supination to pronation. More recently, bone and soft tissue procedures have been combined with various forearm osteotomies. We present a combined derotational radial osteotomy and biceps rerouting to realign the forearm in resting pronation and convert the biceps from a supinator to a pronator. This novel surgical technique has not been described as a solution for supination contracture to restore pronation and provide biomechanical advantage of the biceps insertion.

Transfer of Pectoralis Major to Subscapularis in the Management of Brachial Plexus Birth Palsy Sequels

BACKGROUND

Limitations in abduction and external rotation are the sequel of brachial palsy. The purpose of this study was to evaluate functional outcomes of modified L'Episcopo procedure in children with brachial palsy who do not have gross shoulder joint subluxation.

METHODS

From 2002 to 2012, a continuous series of 22 patients with brachial plexus birth palsy underwent a modified L'Episcopo procedure. Through an axillary approach, subscapularis release with latissimus dorsi rerouting and transfer of pectoralis major to subscapularis footprint was performed.

RESULTS

The mean age of patients at surgery was 49 months. The mean follow-up time was 51 months (range, 24 to 90 mo). Preoperatively, the mean active abduction and external rotation were 77.5 and 2.5 degrees, respectively. The mean active abduction and external rotation were 135.6 and 32 degrees, respectively, at the final follow-up (P<0.001).

CONCLUSIONS

This modified L'Episcopo technique is an effective and reproducible procedure that improves shoulder function significantly.

LEVEL OF EVIDENCE

Level III.

Relationships Between 3 Classification Systems in Brachial Plexus Birth Palsy

BACKGROUND

The Mallet scale, Active Movement Scale (AMS), and Toronto Test are validated for use in children with brachial plexus birth palsy (BPBP). However, the inability to compare these evaluation systems has led to difficulty gauging treatment efficacy and interpreting available literature in which multiple scoring systems are reported. Given the critical importance of physical examination, we compared 3 scoring systems to clarify statistical relationships between current validated evaluation methods.

METHODS

The medical records of children with BPBP treated at a single institution over a 14-year period were retrospectively reviewed. Modified Mallet, AMS, and Toronto scores were recorded throughout the entire period. Data were included if at least 2 complete scoring systems were documented during the same examination session. Spearman correlation coefficients were calculated for all composite and subscore combinations. A concordance table was constructed for select variables found to be highly correlated.

RESULTS

Total single-session score combinations were as follows: 157 Mallet and AMS, 325 AMS and Toronto, and 143 Mallet and Toronto. Composite AMS and Toronto scores were found to have a strong correlation (r=0.928, P<0.001). A concordance table comparing these variables revealed that a Toronto score of 3.5 is concordant to an AMS score of 45. Modified Mallet scores had only a moderate correlation with composite AMS (r=0.512, P<0.001) and Toronto (r=0.458, P<0.001) scores. Specifically regarding the modified Mallet score, maneuvers requiring external rotation had stronger correlations with the composite modified Mallet score than maneuvers highlighting internal rotation.

CONCLUSIONS

Modified Mallet scores do not correlate well with AMS or Toronto scores and should be utilized separately when managing children with BPBP. Similarly, AMS and Toronto scores are inadequate to guide clinical decisions for which the literature cites Mallet scores as outcome measures, and vice versa. Lastly, Mallet scores should incorporate an isolated internal rotation component to adequately assess midline function.

LEVEL OF EVIDENCE

Diagnostic level III.

Triplanar Humeral Osteotomy for Restoration of Midline Function in Patients With Brachial Plexus Birth Palsy

Brachial plexus birth palsy resolves spontaneously in a majority of patients, however, others may have serious permanent dysfunction. Although nerve transfers or grafts are early options for treatment, many children have residual deficits or present too late for such procedures. In these patients, rotational osteotomy of the humerus may restore improved function and motion. Unfortunately, traditional humeral osteotomies only provide correction in a single plane, therefore appropriate correction of the typical residual deformity is incomplete. Here, we describe a novel technique for obtaining a calculated correction in 3 planes using a single osteotomy of the humerus on the basis of a mathematical equation. Nine patients are described here with an average of 35.4 months follow-up. Corrections were obtained in adduction, extension, and either internal or external rotation depending on the initial deformity and Modified Mallet scores were collected for each patient. There was 1 case of transient radial nerve palsy with no long-term complications overall.

The natural history and management of brachial plexus birth palsy

Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3-6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.

Non-Sedated Rapid Volumetric Proton Density MRI Predicts Neonatal Brachial Plexus Birth Palsy Functional Outcome

BACKGROUND AND PURPOSE

The current prognostic biomarker of functional outcome in brachial plexus birth palsy is serial clinical examination throughout the first 6 months of age. This can delay surgical treatment and prolong parental anxiety in neonates who will recover spontaneously. A potentially superior biomarker is a volumetric proton density MRI performed at clinical presentation and within the first 12 weeks of life, providing a high spatial and contrast resolution examination in 4 minutes.

METHODS

Nine neonates ranging in age from 4 to 9 weeks who presented with brachial plexus birth palsy were enrolled. All subjects underwent non-sedated 3 Tesla MRI with Cube Proton Density MRI sequence at the same time as their initial clinical visit. Serial clinical examinations were conducted at routine 4 week intervals and the functional performance scores were recorded. MRI findings were divided into pre-ganglionic and post-ganglionic injuries and a radiological scoring system (Shriners Radiological Score) was developed for this study.

RESULTS

Proton Density MRI was able to differentiate between pre-ganglionic and post-ganglionic injuries. Radiological scores (Shriners Radiological Score) correlated better with functional performance at 6 months of age (P = .022) than the initial clinical examinations (Active Movement Scale P = .213 and Toronto P = .320).

CONCLUSIONS

Rapid non-sedated volumetric Cube Proton Density MRI protocol performed at initial clinical presentation can accurately grade severity of brachial plexus birth palsy injury and predict functional performance at 6 months of age.

Nerve Transfers in Birth Related Brachial Plexus Injuries: Where Do We Stand?

This article reviews the assessment and management of obstetrical brachial plexus palsy. The potential role of distal nerve transfers in the treatment of infants with Erb's palsy is discussed. Current evidence for motor outcomes after traditional reconstruction via interpositional nerve grafting and extraplexal nerve transfers is reviewed and compared with the recent literature on intraplexal distal nerve transfers in obstetrical brachial plexus injury.

Functional outcomes of infants with Narakas grade 1 birth-related brachial plexus palsy undergoing neurotization compared with infants who did not require surgery

PURPOSE

This study aimed to investigate the functional outcomes of infants who underwent neurotization for shoulder abduction and elbow flexion in Narakas grade 1 birth-related brachial plexus palsy (BRBPP) and compare this cohort to children who progressed past the point of needing intervention.

METHODS

A cohort study was conducted at a single center between 1999 and 2010. Two-hundred and eight infants were identified with BRBPP that presented for neurosurgical care as infants. Of those, 38 (18 %) received neurosurgical intervention with approximate 2-year follow-up. Only infants undergoing cranial nerve XI to suprascapular nerve neurotization for shoulder abduction (SA) weakness and medial pectoral nerve to musculocutaneous nerve neurotization for elbow flexion (EF) weakness were included. In addition, 30 infants who improved past the need for surgical intervention and had been followed for close to 24 months were identified for comparison. Descriptive statistics and exploratory analysis were performed using SAS 9.2 and JMP 9.0.2.

RESULTS

Shoulder abduction For SA, there were no differences in age at presentation between the operative (6-9 months) and non-operative (5-9 months) groups (p = 0.99). Infants in the operative cohort had significantly worse initial function (p = 0.008). At 2-year follow-up, the two groups had become similar (p = 1.0). Elbow flexion For EF, there were no differences in age at presentation between the operative (6-8 months) and non-operative (5-8.5 months) groups (p = 0.98). Infants in the operative cohort had significantly worse initial function (p = 0.002). At 2-year follow-up, those two groups had become similar (p = 0.26).

CONCLUSIONS

Infants undergoing neurotization for Narakas grade 1 brachial plexus injury had similar long-term function to those who had improved and never required surgery. The preoperative exam findings were significantly different between the intervened and non-intervened groups, while the postoperative exam findings were not.

Brachial plexus birth palsy: Management during the first year of life

Brachial plexus birth palsy (BPBP) is defined as an injury to any nerve root of the brachial plexus during difficult delivery. BPBP is relatively rare; its incidence has remained constant over the last few decades, mostly due to unpredictable risk factors, such as shoulder dystocia. Both diagnosis and assessment of spontaneous recovery is based on clinical examination. Electromyography is difficult to interpret in the newborn and is therefore not meaningful. MRI of the cervical spine requires sedation or general anesthesia. Searching for a pre-ganglion tear prior to surgery is indicted. Prognosis depends on the level of the injury (pre- or post-ganglion), size and severity of the post-ganglion tears, speed of recovery, and quality of initial management. Although spontaneous recovery is frequent, some children suffer various degrees of sequelae, up to complete loss of function of the affected upper limb. Recent publications have improved general knowledge and indications for surgery. However, some aspects, such as indication and timing of nerve repair continue to be debated.

Isolated C5-C6 avulsion in obstetric brachial plexus palsy treated by ipsilateral C7 neurotization to the upper trunk: outcomes at a mean follow-up of 9 years

Cervical root avulsions are the worst pattern of injury in obstetrical brachial plexus injury (OBPI). The prognosis is poor and the treatment is mainly surgical with extraplexual neurotizations or muscle transfers. We present the outcomes of a technique performed in our institution to treat C5-C6 avulsion in obstetrical brachial plexus injury. This technique consists of a total ipsilateral C7 neurotization to the upper trunk. Ten babies with isolated C5-C6 root avulsion were operated on; we were able to review nine of them at over 12 months follow-up. The shoulder and the elbow function were assessed, as well as the Mallet Score. The mean follow-up was 9.2 years (SD 5.7). After a follow-up of 6 years, elbow flexion was restored with a range of motion ⩾130° and a motor function ⩾M3 in all patients. The average Mallet score was 18.1 (SD 1.2). This approach appears to be a viable alternative to extraplexual neurotizations for the treatment of C5-C6 nerve root avulsion.

Neuropathological Characteristics of Brachial Plexus Avulsion Injury With and Without Concomitant Spinal Cord Injury

Neonatal brachial plexus avulsion injury (BPAI) commonly occurs as a consequence of birth trauma and can result in lifetime morbidity; however, little is known regarding the evolving neuropathological processes it induces. In particular, mechanical forces during BPAI can concomittantly damage the spinal cord and may contribute to outcome. Here, we describe the functional and neuropathological outcome following BPAI, with or without spinal cord injury, in a novel pediatric animal model. Twenty-eight-day-old piglets underwent unilateral C5–C7 BPAI with and without limited myelotomy. Following avulsion, all animals demonstrated right forelimb monoparesis. Injury extending into the spinal cord conferred greater motor deficit, including long tract signs. Consistent with clinical observations, avulsion with myelotomy resulted in more severe neuropathological changes with greater motor neuron death, progressive axonopathy, and persistent glial activation. These data demonstrate neuropathological features of BPAI associated with poor functional outcome. Interestingly, in contrast to adult small animal models of BPAI, a degree of motor neuron survival was observed, even following severe injury in this neonatal model. If this is also the case in human neonatal BPAI, repair may permit functional restoration. This model also provides a clinically relevant platform for exploring the complex postavulsion neuropathological responses that may inform therapeutic strategies.

Subscapularis Z-lengthening in children with brachial plexus birth palsy loses efficiency at mid-term follow-up: a retrospective cohort study

PURPOSE

The aim of this study was to evaluate early and mid-term clinical outcomes after isolated subscapularis Z-lengthening in children with shoulder internal rotation contractures resulting from brachial plexus birth palsy.

METHODS

Children with brachial plexus birth palsy treated with subscapularis tendon Z-lengthening from 2001 to 2011 were retrospectively reviewed. Over this period, 31 patients were identified. Primary outcome was improvement in Mallet score after surgery, and secondary outcome measures were active range of motion and Mallet sub-scores. Clinical outcomes were collected at three time intervals: pre-operatively, one-year post-operative and at latest follow-up.

RESULTS

After exclusion, 21 patients remained for further analysis. Mean age at surgery was 3.7 years (range, 1.2-8.7), and mean follow-up length was 6.5 years (2.9-9.7). Moderate improvements were found for mean Mallet score, active external rotation, active abduction and hand-to-mouth movement at one year and latest follow-up. However, improvements in active external rotation and Mallet score were not fully maintained at final follow up.

CONCLUSION

Isolated subscapularis Z-lengthening is effective at early follow-up, but results are not maintained at mid-term follow-up.

EVALUATION OF UPPER-LIMB FUNCTION IN PATIENTS WITH OBSTETRIC PALSY AFTER MODIFIED SEVER-L'EPISCOPO PROCEDURE

Objective: To evaluate upper-limb function by means of the Mallet score, in patients with medial rotation contracture of the shoulder who underwent the modified Sever-L'Episcopo procedure, and to correlate evolution with age and length of postoperative follow-up. Methods: Sixteen patients were assessed by comparing the pre and postoperative Mallet scores and correlating the differences between these scores with age at the time of surgery and length of follow-up. Results: A statistically significant improvement in the postoperative Mallet score was observed. The correlations of the differences in scores with age and length of follow-up were not statistically significant. Conclusion: The modified Sever-L'Episcopo procedure led to improved upper-limb function according to the Mallet score. Limb function did not present correlations with age or length of follow-up.

Obesity in children with brachial plexus birth palsy

Fetal macrosomia is associated with a 14-fold increased risk of brachial plexus birth palsy (BPBP), and is a predictor of childhood obesity. The purpose of this study was to identify the relationships between BPBP, fetal macrosomia, and childhood obesity. We retrospectively reviewed 214 children with BPBP. The average age was 8 years and 53% had a Narakas 1 grade BPBP. Overall, 49% of children were normal weight, 22% overweight, and 29% obese. Of the children with a history of fetal macrosomia, 41% were obese; a statistically significant difference. Overall quality of life scores, however, were not correlated with obesity.

Risk factors for clavicle fracture concurrent with brachial plexus injury

PURPOSE

The aim of this study was to evaluate the risk factors for clavicle fracture concurrent with brachial plexus injuries.

METHODS

A retrospective study was conducted at a tertiary centre. The hospital records of 62,288 vaginal deliveries were evaluated retrospectively. There were 35 cases of brachial plexus injury. Of these patients, nine had brachial plexus injuries with clavicle fracture and 26 without clavicle fracture. The analysed risk factors for clavicle fracture concurrent with brachial plexus injury were gestational diabetes, labour induction and augmentation, prolonged second stage of labour, estimated foetal weight above 4000 g, birth weight above 4000 g, risky working hours, and the requirement of manoeuvres to free the impacted shoulder from behind the symphysis pubis.

RESULTS

Labour augmentation with oxytocin increased the risk of clavicle fracture in cases of brachial plexus injury (OR 6.67; 95% CI 1.26-35.03). A birth weight higher than 4000 g also increased the risk of clavicle fracture. Risky working hours, gestational diabetes, estimated foetal weight higher than 4000 g, and requirement of shoulder dystocia manoeuvres did not increase the risk of clavicle fracture.

CONCLUSIONS

Labour augmentation and actual birth weight higher than 4000 g were identified as risk factors for clavicle fracture in cases of brachial plexus injury.

Shoulder linked arthroplasty in patients with obstetric brachial plexus palsy can improve quality of life and function at short-term follow-up

BACKGROUND

Patients with obstetric brachial plexus palsy (OBPP) are prone to develop degenerative shoulder disease at a younger age than the general population. To date, no reports have been published on the complexities or outcome of shoulder arthroplasty (SA) in this unique patient group.

METHODS

We reviewed of 9 SAs in 9 patients (3 men and 6 women) with OBPP with mean follow-up 5.1 years (range, 2.6-7.6 years). Patients were a mean age of 29 years (range, 16-56 years). Patients had undergone a mean of 3 previous operations (range, 2-6). All patients underwent linked constrained SA.

RESULTS

The mean Oxford Shoulder Score increased from 8 (range, 3-10) preoperatively to 21 (range, 12-32) at the final follow-up (P < .001) predominantly due to pain relief. Mean range of active forward elevation and abduction improved from 35° and 39° to 46° and 45°, respectively. Patients improved significantly in 2 of 8 Short-Form 36-Item health-related quality of life domains, bodily pain (P = .013) and mental health (P = .035), and the overall physical component summary score (P = .006). Range of motion had mild improvements. Three required reoperation (33%), comprising 1 excision of heterotopic ossification, 1 trimming of a prominent screw, and 1 deltoid rupture repair.

CONCLUSIONS

SA is effective at relieving pain and health-related quality of life for young patients with OBPP; however, compared with the general population, the complication rate is high and functional gains are small.

Late reconstruction of brachial plexus birth palsy

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

Role of early shoulder tomography on the obstetric brachial plexus palsy

Objective:

To demonstrate the importance of performing early shoulder tomography in patients with obstetric brachial plexus palsy (OBPP).

Methods:

This series of cases retrospective study with level evidence IV was conducted by consulting 76 patient's medical records with OBPP divided into three age groups: ≤12 months, 13 to 24 months and ≥ 25 months. The patients were classified according to gender, affected side, type of paralysis according to Narakas classification, and by computed tomography, according to the Waters scale.

Results:

The association between the age groups with Waters classification was statistically significant (p=0,006), showing that patients in the group aged less than 12 months and in the group aged between 12 and 24 months had a relevant correlation between the physical examination and Waters > III when compared to patients from groups aged 25 months or older.

Conclusion:

This study shows a correlation between the findings in the physical examination and severe dysplasia on the shoulder of children under 24 months of age, justifying the early tomographic shoulder exam in order to achieve a better follow-up and a consider a more aggressive approach in the treatment of OBPP affected children. Level of Evidence IV, Case Series.

Incidence and prognosis of neonatal brachial plexus palsy with and without clavicle fractures

OBJECTIVE

To report the incidence of neonatal brachial plexus palsy with and without ipsilateral clavicle fracture in a population of newborns and to compare the prognosis between these subgroups.

METHODS

This was a retrospective review of 3,739 clavicle fractures and 1,291 brachial plexus palsies in neonates over a 24-year period from a geographically defined health care system with reference to county-wide population data.

RESULTS

A referral clinic for children with brachial plexus palsies evaluated 1,383 neonates, of whom 320 also had ipsilateral clavicular fracture. As a result of referral patterns within the region, it is likely that this represents nearly all infants from the area with persistent brachial plexus injury after 2 months of age. Among the children evaluated without concomitant clavicular fracture, 72% resolved spontaneously (154/214); among those with concomitant clavicular fracture, 74% healed spontaneously (55/74). Limiting the analysis to neonates delivered at Parkland Memorial Hospital and assuming that those neonates with a discharge diagnosis of brachial plexus injury with or without clavicular fracture who did not present to the referral brachial plexus injury clinic had complete resolution, 94.4% without clavicular fracture resolved and 98.1% with clavicular fracture resolved (P=.005).

CONCLUSIONS

The risk of persistent neurologic deficit from a birth-related brachial plexus palsy is lower than what has been reported, and the presence of a clavicle fracture may improve the likelihood of recovery.

LEVEL OF EVIDENCE

III.

Humeral rotational osteotomy for shoulder deformity in obstetric brachial plexus palsy: which direction should I rotate?

Shoulder internal rotation contracture is the most common deformity affecting the shoulder in patients with Obstetric Brachial Plexus Palsy. With progression of the deformity, the glenohumeral joint starts to subluxate and then dislocates. This is accompanied with bony changes of both the humerus and the glenoid. Two opposite direction humeral osteotomies have been proposed for this condition (internal rotation osteotomy (IRO) and external rotation osteotomy (ERO)). This fact of different direction osteotomies has not adequately been explained in the literature. Most orthopedic surgeons may not be able to fully differentiate between these two osteotomies regarding the indications, outcomes and effects on the joint. This review explains these differences in details.

Total ipsilateral C7 root neurotization to the upper trunk for isolated C5-C6 avulsion in obstetrical brachial plexus palsy: a preliminary technical report

BACKGROUND

C5-C6 root avulsion in obstetrical brachial plexus palsy (OBPP) is a rare injury with poor prognosis usually associated with breech delivery. The treatment is challenging and requires high microsurgical skills. The triple nerve transfer (spinal accessory nerve, ulnar fascicles, and triceps long or lateral head branch) represents the gold standard treatment. The total ipsilateral C7 nerve root neurotization is a promising technique, which has never been described in OBPP.

OBJECTIVE

The total ipsilateral C7 nerve root is used as a neurotizer transferred to the upper trunk as an alternative method to other intra- or extra-plexual reconstruction techniques.

METHODS

During brachial plexus surgical exploration, an intraoperative neurostimulation was performed to confirm the integrity of C7 and the lesion of C5 and C6. The entire C7 nerve root and the upper trunk are cut. The C7 root was transferred to the upper trunk with a fibrin sealant.

RESULT

This technique was easily performed with a single approach and avoided intercalated nerve grafts. The C7 nerve root provided a large number of nerve fibers with an adequate diameter to be transferred to the upper trunk. We illustrated this technique with a typical case of a child at 8 years of follow-up.

CONCLUSION

The total ipsilateral transfer of the C7 root to the upper trunk is a viable alternative procedure for newborns with C5-C6 avulsion.

The developing shoulder has a limited capacity to recover after a short duration of neonatal paralysis

Mechanical stimuli are required for the proper development of the musculoskeletal system. Removal of muscle forces during fetal or early post-natal timepoints impairs the formation of bone, tendon, and their attachment (the enthesis). The goal of the current study was to examine the capacity of the shoulder to recover after a short duration of neonatal rotator cuff paralysis, a condition mimicking the clinical condition neonatal brachial plexus palsy. We asked if reapplication of muscle load to a transiently paralyzed muscle would allow for full recovery of tissue properties. CD-1 mice were injected with botulinum toxin A to paralyze the supraspinatus muscle from birth through 2 weeks and subsequently allowed to recover. The biomechanics of the enthesis was determined using tensile testing and the morphology of the shoulder joint was determined using microcomputed tomography and histology. A recovery period of at least 10 weeks was required to achieve control properties, demonstrating a limited capacity of the shoulder to recover after only two weeks of muscle paralysis. Although care must be taken when extrapolating results from an animal model to the human condition, the results of the current study imply that treatment of neonatal brachial plexus palsy should be aggressive, as even short periods of paralysis could lead to long-term deficiencies in enthesis biomechanics and shoulder morphology.

Evaluation and management of brachial plexus birth palsy

Brachial plexus birth palsy can result in permanent lifelong deficits and unfortunately continues to be relatively common despite advancements in obstetric care. The diagnosis can be made shortly after birth by physical examination, noting a lack of movement in the affected upper extremity. Treatment begins with passive range-of-motion exercises to maintain flexibility and tactile stimulation to provide sensory reeducation. Primary surgery consists of microsurgical nerve surgery, whereas secondary surgery consists of alternative microsurgical procedures, tendon transfers, or osteotomies, all of which improve outcomes in the short term. However, the long-term outcomes of current treatment recommendations remain unknown.

Utility of delayed surgical repair of neonatal brachial plexus palsy

OBJECT

Neonatal brachial plexus palsy (NBPP) represents a significant health problem with potentially devastating consequences. The most common form of NBPP involves the upper trunk roots. Currently, primary surgical repair is performed if clinical improvement is lacking. There has been increasing interest in "early" surgical repair of NBPPs, occurring within 3-6 months of life. However, early treatment recommendations ignore spontaneous recovery in cases of Erb's palsy. This study was undertaken to evaluate the optimal timing of surgical repair in this group with respect to quality of life.

METHODS

The authors formulated a decision analytical model to compare 4 treatment strategies (no repair or repair at 3, 6, or 12 months of life) for infants with persistent NBPPs. The model derives data from a critical review of published studies and projects health-related quality of life and quality-adjusted life years over a lifetime.

RESULTS

When evaluating the quality of life of infants with NBPP, improved outcomes are seen with delayed surgical repair at 12 months, compared with no repair or repair at early and intermediate time points, at 3 and 6 months, respectively. ANOVA showed that the differences among the 4 groups are highly significant (F = 8369; p < 0.0001). Pairwise post hoc comparisons revealed that there are highly significant differences between each pair of strategies (p < 0.0001). Meta-regression showed no evidence of improved outcomes with more recent treatment dates, compared with older ones, for either nonsurgical or for surgical treatment (p = 0.767 and p = 0.865, respectively).

CONCLUSIONS

These data support a delayed approach of primary surgical reconstruction to optimize quality of life. Early surgery for NBPPs may be an overly aggressive strategy for infants who would otherwise demonstrate spontaneous recovery of function by 12 months. A randomized, controlled trial would be necessary to fully elucidate the natural history of NBPP and determine the optimal time point for surgical intervention.

Understanding quality of life and patient expectations among adolescents with neonatal brachial plexus palsy: a qualitative and quantitative pilot study

PURPOSE

To explore the quality of life (QOL) and patient expectations among adolescents with neonatal brachial plexus palsy (NBPP)and their parents using qualitative and quantitative approaches.

METHODS

A total of 18 adolescents (10-17 y) with residual NBPP impairment and their parents under went separate 1-hour tape-recorded semistructured interviews. We also collected quantitative physical examination measures and patient-rated outcome scores, specifically the Pediatric Outcomes Data Collection Instrument and the Child Health Questionnaire, to quantify the severity of each adolescent’s functional deficit and increase our understanding of QOL and patient expectations.

RESULTS

Through qualitative analysis, we identified several patient- and system-dependent factors contributing to QOL, such as social impact and peer acceptance, emotional adjustment,aesthetic concerns and body image, functional limitations, physical and occupational therapy, finances, pain, and family dynamics. Despite residual impairment, most adolescents and their parents reported a good overall QOL according to quantitative outcome measures. Our study results showed that functional and aesthetic factors were responsible for most observed differences in QOL among NBPP adolescents. We also found that the Pediatric Outcomes Data Collection Instrument might be more sensitive than the Child Health Questionnaire in assessing patient expectations and QOL among this patient population.

CONCLUSIONS

Understanding patient expectations and QOL in NBPP adolescents is essential for medical decision making and advancing care. Physical examination measurements alone may not be sufficient for measuring outcome, and knowledge regarding environmental factors and family dynamics is important for clinicians to consider when counseling families of children with NBPP and improving overall outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

A systematic review of evaluation methods for neonatal brachial plexus palsy: a review

OBJECT

Neonatal brachial plexus palsy (NBPP) affects 0.4-2.6 newborns per 1000 live births in the US. Many infants recover spontaneously, but for those without spontaneous recovery, nerve and/or secondary musculoskeletal reconstruction can restore function to the affected arm. This condition not only manifests in a paretic/paralyzed arm, but also affects the overall health and psychosocial condition of the children and their parents. Currently, measurement instruments for NBPP focus primarily on physical ability, with limited information regarding the effect of the disablement on activities of daily living and the child's psychosocial well-being. It is also difficult to assess and compare overall treatment efficacy among medical (conservative) or surgical management strategies without consistent use of evaluation instruments. The purpose of this study is to review the reported measurement evaluation methods for NBPP in an attempt to provide recommendations for future measurement usage and development.

METHODS

The authors systematically reviewed the literature published between January 1980 and February 2012 using multiple databases to search the keywords "brachial plexus" and "obstetric" or "pediatrics" or "neonatal" or "congenital." Original articles with primary patient outcomes were included in the data summary. Four types of evaluation methods (classification, diagnostics, physical assessment, and functional outcome) were distinguished among treatment management groups. Descriptive statistics and 1-way ANOVA were applied to compare the data summaries among specific groups.

RESULTS

Of 2836 articles initially identified, 307 were included in the analysis, with 198 articles (9646 patients) reporting results after surgical treatment, 70 articles (4434 patients) reporting results after medical treatment, and 39 articles (4247 patients) reporting results after combined surgical and medical treatment. Among medical practitioners who treat NBPP, there was equivalence in usage of classification, diagnostic, and physical assessment tools (that focused on the Body Function and Structures measure of the International Classification of Functioning, Disability, and Health [ICF]). However, there was discordance in the functional outcome measures that focus on ICF levels of Activity and Participation. Of the 126 reported evaluation methods, only a few (the Active Movement Scale, Toronto Scale Score, Mallet Scale, Assisting Hand Assessment, and Pediatric Outcomes Data Collection Instrument) are specifically validated for evaluating the NBPP population.

CONCLUSIONS

In this review, the authors demonstrate disparities in the use of NBPP evaluation instruments in the current literature. Additionally, valid and reliable evaluation instruments specifically for the NBPP population are significantly lacking, manifesting in difficulties with evaluating the overall impact and effectiveness of clinical treatments in a consistent and comparative manner, extending across the various subspecialties that are involved in the treatment of patients with NBPP. The authors suggest that all ICF domains should be considered, and future efforts should include consideration of spontaneous (not practitioner-elicited) use of the affected arm in activities of daily living with attention to the psychosocial impact of the disablement.

The 100 classic papers of pediatric orthopaedic surgery: a bibliometric analysis

BACKGROUND

Pediatric orthopaedic surgery owes its development to many pioneering individuals, and the studies that these individuals have undertaken form the basis for the clinical decisions made on the modern pediatric orthopaedic service. The aim of our study was to use citation analysis to identify the top 100 papers in pediatric orthopaedic surgery.

METHODS

Using the Thomson Reuters Web of Knowledge, we searched for citations of all papers relevant to pediatric orthopaedics. The number of citations, authorship, year of publication, journal of publication, and country and institution of origin were recorded for each paper.

RESULTS

The most cited paper was found to be the classic paper from 1963 by Salter and Harris that introduced the now-eponymous classification system for physeal injuries in the skeletally immature patient. The second most cited was Salter's paper describing the widely used osteotomy for the treatment of developmental dysplasia of the hip, and the third most cited was Catterall's description of the natural history of Legg-Calvé-Perthes disease. Most papers originated in the U.S., and most were published in this journal. A number of authors including Salter, Ponseti, Graf, and Loder had more than one paper in the top-100 list.

DISCUSSION

This paper's identification of the classic papers of pediatric orthopaedic surgery gives us a unique insight into the development of pediatric orthopaedic surgery in the twentieth and early twenty-first centuries and identifies those individuals who have contributed the most to the body of knowledge used to guide evidence-based clinical decision-making in pediatric orthopaedics today.

Meta-analysis of function after secondary shoulder surgery in neonatal brachial plexus palsy

BACKGROUND

Shoulder internal rotation contracture, active abduction, and external rotation deficits are common secondary problems in neonatal brachial plexus palsy (NBPP). Soft tissue shoulder operations are often utilized for treatment. The objective was to conduct a meta-analysis and systematic review analyzing the clinical outcomes of NBPP treated with a secondary soft-tissue shoulder operation.

METHODS

A literature search identified studies of NBPP treated with a soft-tissue shoulder operation. A meta-analysis evaluated success rates for the aggregate Mallet score (≥ 4 point increase), global abduction score (≥ 1 point increase), and external rotation score (≥ 1 point increase) using the Mallet scale. Subgroup analysis was performed to assess these success rates when the author chose arthroscopic release technique versus open release technique with or without tendon transfer.

RESULTS

Data from 17 studies and 405 patients were pooled for meta-analysis. The success rate for the global abduction score was significantly higher for the open technique (67.4%) relative to the arthroscopic technique (27.7%, P<0.0001). The success rates for the global abduction score were significantly different among sexes (P=0.01). The success rate for external rotation was not significantly different between the open (71.4%) and arthroscopic techniques (74.1%, P=0.86). No other variable was found to have significant impact on the external rotation outcomes. The success rate for the aggregate Mallet score was 57.9% for the open technique, a nonsignificant increase relative to the arthroscopic technique (53.5%, P=0.63). Data suggest a correlation between increasing age at the time of surgery and a decreasing likelihood of success with regards to aggregate Mallet with an odds ratio of 0.98 (P=0.04).

CONCLUSIONS

Overall, the secondary soft-tissue shoulder operation is an effective treatment for improving shoulder function in NBPP in appropriately selected patients. The open technique had significantly higher success rates in improving global abduction. There were no significant differences in the success rates for improvement in the external rotation or aggregate Mallet score among these surgical techniques.

Medical decision-making among adolescents with neonatal brachial plexus palsy and their families: a qualitative study

BACKGROUND

Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with neonatal brachial plexus palsy and their families when faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process.

METHODS

Eighteen adolescents with residual neonatal brachial plexus palsy deficits between 10 and 17 years and their parents were included. Qualitative research design was used involving separate, 1-hour, in person, semistructured interviews, which were audio recorded and transcribed. Grounded theory was applied by two members of the research team to identify recurrent themes and create a codebook that was applied to the data.

RESULTS

Medical decision-making among adolescents with neonatal brachial plexus palsy and their families is multifaceted and individualized, composed of both patient- and system-dependent factors. Four codes were identified: (1) knowledge acquisition, (2) multidisciplinary care, (3) adolescent autonomy, and (4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system-dependent factors, whereas adolescents largely based their decisions on individual treatment desires to improve function and/or aesthetics.

CONCLUSIONS

There are many areas for improving the delivery of information and health care organization among adolescents with neonatal brachial plexus palsy and their families. The authors recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. The authors believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The influence of GDNF on the timecourse and extent of motoneuron loss in the cervical spinal cord after brachial plexus injury in the neonate

Injuries of the peripheral nerve in the early post-natal period are known to cause massive loss in the motoneuron pools of the spinal cord. However, the exact time frame and extent of motoneuron death in the cervical spinal cord after a brachial plexus lesion and the altered course after neuroprotection with different trophic factors is not known. In the present study, the time course of induced motoneuron death after a neonatal peripheral nerve injury and the effect of GDNF was investigated over a 4 week time period to determine the window of opportunity for possible therapeutic interventions in obstetrical plexus palsy. The brachial plexus of a total of 70 animals was explored within 12 hours after birth and divided at trunc level. The plexus was then labeled with a fluorescent tracer to identify the corresponding motoneuron pool. Two groups were prepared: Group I remained untreated to assess the natural course of induced neuronal death. Group II received GDNF immediately after the lesion. Post-operatively the animals were evaluated sequentially over 29 days. Surviving motoneurons were evaluated quantitatively counting the nucleoli. The entire brachial plexus of the rat is supplied by a total of about 4000 motoneurons. After injury the number of motoneurons steadily diminished within the first 10 days to reach a plateau of about 20% of the original number. At this time the GDNF treated group still had 85% (3330 +/- 247) of motoneurons viable. This further decreased so that at the termination of the experiment at day 29 there were still 2527 +/- 285 motoneurons alive. This study clearly shows that pathology after a brachial plexus injury in the newborn is not restricted to the peripheral nerve alone. In this model 64% of motoneurons underwent apoptosis within the first week after injury, reaching a plateau after 10 days at 20%. GDNF successfully rescued motoneurons so that after 4 weeks still 65% were present. We conclude that GDNF leads to enhanced motoneuron survival so that exogenous trophic support of motoneurons might have a role in the treatment of all types of severe neonatal plexopathies, maintaining the viability of motoneurons until reconstructive surgery provides them with a pathway for regeneration and endogenous trophic support.