Relationships Between 3 Classification Systems in Brachial Plexus Birth Palsy

Brachial Plexus Birth Injury: Trends in Early Surgical Intervention over the Last Three Decades

Early surgical management of brachial plexus birth injury has advanced owing to targeted surgical techniques and increases in specialty-centers and multi-institutional collaboration. This study seeks to determine trends in the early surgical management of BPBI over the last 30 years.

Methods

A systematic review was performed through MEDLINE (PubMed) identifying studies limited to the early surgical management of BPBI from 1990 to current. Patients treated after 1 year of age (ie, tendon transfers and secondary reconstructive efforts) were excluded. Diagnostic tests, age of intervention, surgical treatment modalities, and outcome scoring systems were extrapolated and compared so as to determine trends in management over time.

Results

Seventeen studies met criteria, summating a total of 883 patients. The most commonly reported physical examination classifications were the Mallet and AMS scoring systems. Most patients underwent neuroma excision and sural nerve autografting (n = 618, 70%) when compared with primary nerve transfers (148, 16.8%), primary nerve transfer with autografting combinations (59, 6.7%), or neurolysis alone (58, 6.6%). There was no significant change in the proportion of patients treated with sural nerve grafting, combination graft and transfer procedures, or isolated neurolysis over time. However, there has been a significant increase in the proportion of patients treated with primary nerve transfer procedures (τ _b = 0.668, P < 0.01) over time.

Conclusion

Although neuroma excision and sural nerve autografting has been the historic gold-standard treatment for brachial plexus birth injury, peripheral nerve transfers have become increasingly utilized for surgical management.

Brachial Plexus Birth Injuries

Brachial plexus birth injuries (BPBIs) are typically traction type injuries to the newborn that occur during the delivery process. Although the incidence of these injuries has overall decreased from 1.5 to around 0.9 per 1000 live births in the United States over the past 2 decades, these injuries remain common, with incidence holding fairly steady from 2008 to 2014. Shoulder dystocia is the strongest identified risk factor, imparting a 100-fold greater risk. The newborn's shoulder is caught behind the mother's pubic bone, and traction performed on the child during delivery results in injury to the brachial plexus. Other risk factors associated with BPBI include macrosomia (birthweight > 4.5 kg), heavy for gestational age infants, birth hypoxia, gestational diabetes, and forceps or vacuum-assisted delivery. Breech presentation has also been described as a risk factor in the past, but there have been more recent data that challenge this association.

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.

Long-Term Hand Function Outcomes of the Surgical Management of Complete Brachial Plexus Birth Injury

PURPOSE

Hand function outcomes of primary nerve reconstruction for total brachial plexus birth injury (BPBI) are confounded by nerve roots left in continuity, inclusion of secondary procedures, and no assessment of the ability to perform activities of daily living. The purpose of this study was to evaluate the long-term hand function outcomes in a cohort of patients with a complete BPBI who had no nerve root in continuity prior to primary nerve reconstruction targeting the lower trunk.

METHODS

This single-center retrospective case series of complete BPBI included patients who underwent primary nerve reconstruction. The outcomes were assessed using the active movement scale (AMS) and brachial plexus outcome measure preoperatively and at the age of 4 and 8 years.

RESULTS

Fifty patients with a complete BPBI, of whom 82% (41/50) had an avulsion of C8-T1, underwent primary nerve reconstruction at a mean age of 4.1 months. Compared with the preoperative AMS scores, a statistically significant increase of AMS scores was observed at 4 and 8 years of age for all movements except forearm pronation. Between 4 and 8 years of age, there was a statistically significant improvement of external rotation of the shoulder and elbow flexion as well as diminution of thumb flexion. In the brachial plexus outcome measure assessment, there were 83% (24/29) at 4 years and 81% (21/26) at 8 years who had sufficient functional movement to perform wrist, finger, and thumb activities.

CONCLUSIONS

Functional hand outcome was restored to sufficiently perform bimanual activity tasks in 81% (21/26) of patients with a complete BPBI at 8 years of age. This affirmed that primary nerve reconstruction reinnervating the lower trunk can result in a functional extremity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Brachial Plexus Birth Injuries: A Critical Analysis Review

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The incidence of brachial plexus birth injury (BPBI) in the United States is declining and now occurs in <1 per 1,000 births.

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The gold standard for predicting the need for early intervention remains serial examination.

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Early treatment of BPBI with reconstructive surgery requires the ability to perform both interposition nerve grafting and nerve transfers.

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Given the heterogeneity of lesions, the evidence is largely limited to retrospective comparative studies and case series.

Therapeutic Implementation of a Custom Dynamic Elbow Brace for Children With Neonatal Brachial Plexus Palsy: A Case Report

PURPOSE

The objective of this analysis is to present the benefits and functional outcomes when using a custom dynamic elbow brace as an adjunct to therapeutic interventions for a child with neonatal brachial plexus palsy.

SUMMARY OF KEY POINTS

Impairments associated with neonatal brachial plexus palsy can cause lifelong limitations of mobility, dexterity, and functional use of the involved upper extremity. The functional design of the custom dynamic elbow brace provided therapeutic versatility including immobilization, active-assisted controlled movement, and resistance exercise. These features facilitated efficient and functional muscle activation patterns, negating compensatory or substitute movements.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

The brace provided opportunities for focused muscle activation and subsequent improvements in strength, development of motor control, and functional mobility. Using a custom dynamic elbow brace was an effective therapeutic tool, used in conjunction with a comprehensive treatment program, and contributed to a successful outcome.

Radiographic and Clinical Outcomes of the Shoulder in Long-Term Follow-Up of Brachial Plexus Birth Injury

PURPOSE

The purpose of this study was to examine radiographic and functional outcomes of the shoulder in brachial plexus birth injury (BPBI) patients at long-term follow-up.

METHODS

Medical records were reviewed at the Shriners Hospital in St. Louis to identify patients older than 18 years with a diagnosis of BPBI. Twenty-five patients were included in this study. Evaluations included radiographic examination, clinical examination, and outcome measures including the Mallet classification, visual analog scale (VAS) for shoulder pain, American Shoulder and Elbow Shoulder score (ASES), quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Simple Shoulder Test (SST), and Patient-Reported Outcomes Measurement Information System (PROMIS) domain measures.

RESULTS

The mean age of the patients included was 44 years. Average follow-up was 37 years. No patient had primary nerve reconstruction surgery. Thirteen patients had a history of shoulder surgery at an average age of 6 years. There was a wide spectrum of deformity seen radiographically. Fifty-five percent of patients had evidence of glenoid retroversion, posterior humeral translation, or a biconcave glenoid. An additional 20% of patients had complete posterior dislocation of the humeral head. Despite the degenerative changes seen on radiographs, the mean VAS for pain was low, at 2. The mean ASES shoulder score was 54. The mean QuickDASH score was 30. Mean PROMIS Physical Function, Pain Interference, Depression, and Anxiety scores were near the means for the general population, with similar outcomes in patients treated with shoulder surgery compared with those treated without surgery.

CONCLUSIONS

Adult BPBI patients experience minimal shoulder pain despite deformity and degenerative changes on shoulder radiographs. Whereas there are significant deficits in range of motion and function, PROMIS scores in adult BPBI patients are normal.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Team Approach: Management of Brachial Plexus Birth Injury

Brachial plexus birth injury is an upper-extremity paralysis that occurs from a traction injury to the brachial plexus during birth. Approximately 10% to 30% of children with a brachial plexus birth injury have residual neurologic deficits with associated impact on upper-limb function. Management of brachial plexus birth injuries with a multidisciplinary team allows optimization of functional recovery while avoiding unnecessary intervention. Early occupational therapy should be initiated with a focus on range of motion and motor learning. The need for microsurgical reconstruction of the brachial plexus can be predicted based on early physical examination findings, and reconstruction is generally performed at 3 to 9 months of age. The majority of children with residual neurologic deficits develop associated glenohumeral dysplasia. These children may require secondary procedures, including botulinum toxin injection, subscapularis and pectoralis lengthening, shoulder capsular release, shoulder tendon transfer, and humeral osteotomy.

Outcomes of Spinal Accessory-to-Suprascapular Nerve Transfers for Brachial Plexus Birth Injury

PURPOSE

The results of a spinal accessory nerve-to-suprascapular (SAN-SSN) nerve transfer for brachial plexus birth injuries (BPBIs) have thus far been presented only in limited case series. Our study evaluates the recovery of shoulder function of patients who underwent an SAN-SSN for BPBI as an isolated procedure or as part of a multinerve reconstruction (MNR) surgery.

METHODS

We retrospectively reviewed the medical records of patients at a single institution who underwent an SAN-SSN after BPBI. Inclusion criteria were patients with both preoperative and a minimum 12-months postoperative active movement scale (AMS) scores. Patients for whom the primary surgery involved tendon transfers were excluded. The primary outcome measures were AMS scores for shoulder abduction, forward flexion, and external rotation and secondary outcomes included the need for further shoulder surgery to improve function.

RESULTS

Seventy-three patients met the inclusion criteria. Forty-three patients (58.9%) obtained functional shoulder motion (AMS ≥ 6) of at least 1 of 3 planes (abduction/flexion/external rotation) following surgery, with 13 patients (17.8%) achieving full recovery of 1 of these shoulder motions against gravity (AMS = 7). Fifty-six patients (76.7%) did not undergo subsequent tendon transfers or corrective osteotomies to augment shoulder function. The MNR procedures were performed in 46 patients (63%), of whom 45.7% gained a functional recovery. In 27 patients for whom SAN-SSN nerve transfer was conducted in isolation, 81.5% gained functional shoulder motion. However, isolated SAN-SSNs were conducted at a later age than MNR procedures (13.2 vs 4.8 months) and had higher preoperative AMS scores. The anterior and posterior approaches for SAN-SSN were both found to be effective when used for SAN-SSN in BPBI. When the follow-up duration cutoff was set to 3 years, the outcomes were found to be superior.

CONCLUSIONS

In 76.7% of the patients, SAN-SSN was able to recover function that was sufficient to prevent tendon transfers and corrective osteotomies. A cutoff of 3 postoperative years should be used as a benchmark for analyzing the results of this procedure.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey

There is no consensus regarding strategies to optimally treat children with a brachial plexus birth injury (BPBI). Comparison of outcome data presented by different centers is impossible due to the use of (1) many different outcome measures to evaluate results; (2) different follow-up periods after interventions; and (3) different patient ages at the time of assessment. The goal of iPluto (international PLexus oUtcome sTudy grOup) was to define a standardized dataset which should be minimally collected to evaluate upper limb function in children with BPBI. This dataset must enable comparison of the treatment results of different centers if prospectively used. Three rounds of internet surveys were used to reach consensus on the dataset. A Delphi-derived technique was applied using a nine point Likert scale. Consensus was defined as having attained a rating of 7/8/9 by > = 75% of the participants. A total of 59 participants from five continents participated in the Second and Third Rounds of the survey. Consensus was reached regarding four elements: (1) evaluation should take place at the age of 1/3/5/7 years; range of motion in degrees should be measured for (2) passive joint movement; (3) active range of motion; and (4) the Mallet score should be determined. Consensus on how to asses and report outcome for BPBI was only reached on motor items from the "Body Function and Structure" domain. Consensus regarding additional ICF domains to obtain a more elaborate set of outcome items, should be addressed in future research. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:2533-2541, 2018.

Postoperative Loss of Midline Function in Brachial Plexus Birth Palsy

PURPOSE

To identify the rate of and predictive variables for functionally limited shoulder internal rotation in postoperative patients with brachial plexus birth palsy.

METHODS

Records of patients with brachial plexus birth palsy who had surgery on the affected upper extremity during a 10-year period were retrospectively reviewed. Patient demographics, physical examinations, and all upper extremity procedures were recorded. Loss of midline function (LOM) was defined as a Modified Mallet Scale or Active Movement Scale (AMS) internal rotation score <3. Exclusion criteria were <1-year follow-up after the most recent procedure, insufficient documentation, or preexisting LOM. Multivariable logistic regression was performed on 3 different scenarios of candidate variables to identify those associated with LOM. All scenarios included each procedure as a candidate variable. Scenario A additionally analyzed preprocedural AMS scores. Scenario B additionally analyzed preprocedural Modified Mallet Scale scores. Scenario C isolated the surgical pathway without preprocedural examination scores.

RESULTS

Among 172 included patients, 34 (19.8%) developed LOM. Predictive variables associated with LOM included severity of initial palsy (C5-7, odds ratio 3.6; C5-T1, odds ratio 4.9), poor recovery of upper trunk motor function before the patient's first surgery (specifically Modified Mallet Scale abduction < 4, AMS elbow flexion < 3, and AMS wrist extension < 3), and patients who ultimately required surgical glenohumeral reduction (odds ratio 3.6). Age, number of procedures, closed shoulder reduction with casting, shoulder tendon transfers, and external rotation humeral osteotomies were not predictive of LOM.

CONCLUSIONS

Approximately 1 in every 5 patients with brachial plexus birth palsy will develop LOM after entering a surgical algorithm designed to improve shoulder external rotation. Patients with a more severe initial palsy (C5-7 or global), poor spontaneous recovery of upper trunk motor function (elbow flexion or wrist extension) before their first procedure, and those who ultimately require surgical glenohumeral joint reduction should be counseled as having a higher odds of LOM development.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.