Loss of Midline Function in Brachial Plexus Birth Palsy Patients

The Pericoracoid Tissue Release in Children With Brachial Plexus Birth Injury

PURPOSE

In brachial plexus birth injury (BPBI), children with upper trunk injuries have multidirectional movement deficits, including global abduction and hand-to-neck, hand-to-abdomen, and hand-to-spine movements. The aim of this study was to evaluate the results of pericoracoid tissue release and postoperative structured physiotherapy as a first-step intervention to reduce the multidirectional movement deficit in children with BPBI.

METHODS

Thirty-four children with BPBI underwent pericoracoid tissue release, including coracohumeral and coracoacromial ligament release, pectoralis minor release, and coracoid process osteotomy. Patients were followed up with regular physiotherapy and a home exercise program for 1 year after surgery. Before surgery and at 3 and 12 months after surgery, upper-extremity function was measured using the modified Mallet classification and Active Movement Scale, passive shoulder and elbow joint movements were measured using goniometry, and the difference in the distance between the treatment table and the acromion was measured.

RESULTS

There was an improvement in all movement tasks evaluated with modified Mallet classification, and there was increased shoulder flexion, abduction, and external and internal rotation movements as evaluated with Active Movement Scale. Increased passive joint movements were noted in abduction, external rotation, and internal rotation movements with the arm next to the body and with the limb in 90° abduction. There was a decrease in the distance difference between the acromion and the treatment table between both sides.

CONCLUSIONS

Pericoracoid tissue release provided multidirectional improvement in shoulder joint movements in children with BPBI.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Reduced Clavicle Length Indicates the Severity of Scapular Misalignment in Obstetric Brachial Plexus Lesions

(1) Background: Although most brachial plexus birth palsies show some spontaneous recovery, secondary operations are likely to follow. Accordingly, due to the loss of muscle innervation, the growth of the affected limb and the shoulder girdle is reduced. This is associated with pathological scapula positioning and rotation. The objective of this work was to clarify the relationship between length differences of the two clavicles and different types of scapular dyskinesia. (2) Methods: Twenty-five patients suffering from brachial plexus birth palsy were included in this retrospective study. There were eighteen female and seven male patients with a mean age of 10 years (2 to 23 years). CT scans of the thoracic cage, including both shoulder joints and both clavicles, were obtained preoperatively between 2010 and 2012. Radiographic measurements were taken of the axial plane and 3D reconstructions were produced. Functional evaluations of possible movement and scapular dyskinesia were performed. (3) Results: We found an increasing difference in the length of the clavicle (both in absolute and relative terms) in the children with more pronounced scapular dyskinesia. Additionally, with increasing clavicle length differences, the scapula was positioned in a deteriorated angle compared to the healthy side. Significant positive correlations were identified for the age and absolute difference of the clavicle length and the length and width of the scapula on the affected side. (4) Conclusion: Scapular dyskinesia, which is a common finding in brachial plexus birth palsy, is strongly related to reduced clavicle growth. Reduced clavicle length (which is a relatively easily examinable parameter) compared to the healthy side can be used to estimate the extent of scapular malpositioning on the thoracic cage. The extent and severity of scapular dyskinesia increases with augmented differences in the length of the clavicle.

Glenohumeral Dysplasia Following Brachial Plexus Birth Injuries: A Review

BACKGROUND AND OBJECTIVES

Despite the high morbidity associated with glenohumeral dysplasia (GHD) in children with brachial plexus birth injuries, the progression of this condition often remains unnoticed, even after correcting for the underlying brachial plexus birth injuries. GHD, driven by a multifactorial process involving disruptions in both direct and indirect neural regulation of bony and muscular structures, can lead to intermittent or permanent shoulder mobility imbalances, significantly impacting the quality of life of those affected. Recent research efforts are increasingly directed toward identifying the root causes, managing the deformity, and determining effective treatment options for correcting GHD.

METHODS

A comprehensive search strategy was used by the authors to identify relevant literature relating to the progression, pathoanatomy, clinical presentation, and management of GHD following brachial plexus birth injuries across various search engines, such as PubMed, Scopus, and Embase. Considering the topic's interdisciplinary nature, articles were retrieved from both neurosurgical and orthopaedic journals to enrich the review.

RESULTS

Given the challenges in managing patients with brachial plexus birth injuries, a multidisciplinary care team consisting of certified occupational hand therapists, neurosurgeons, plastic surgeons, and orthopedic surgeons, specializing in brachial plexus injuries should be advocated for. The aim of this collaborative effort is to correct brachial plexus birth injuries and prevent the persistence of GHD.

CONCLUSION

As research continues to focus on understanding the complexities of this condition, the aim of this review article is to summarize the current literature on the course of brachial plexus birth injury and the development of GHD. By doing so, we hope to provide neurosurgeons with the necessary knowledge and essential tools needed to identify and effectively treat GHD during management of brachial plexus birth injuries.

Shoulder external rotation contracture following neonatal brachial plexus injury

BACKGROUND

Glenohumeral posterior external rotation contractures and scapular winging are frequently overlooked problems in residual neonatal brachial plexus injury (NBPI). Recent attention has emphasized their impact on vital functions such as feeding and hygiene. This study aims to present the epidemiology of posterior glenohumeral contractures in a significant pediatric NBPI population and explore contributing factors.

METHODS

We conducted a retrospective analysis of data collected from January 2019 to November 2022, involving a case series of 262 children with residual NBPI. The data included demographics, palsy level, prior surgical history, and the modified Mallet scale. Glenohumeral passive internal rotation in abduction and cross-body adduction angles were measured bilaterally. Subjects were categorized into "Belly-" (Mallet hand-to-belly <3) and "Belly+" (Mallet hand-to-belly ≥3) groups.

RESULTS

The median participant age was 7.9 years (range: 3.5-21 years). Extension injury patterns included Erb's palsy (56.5%), extended Erb's palsy (28.6%), and global palsy (14.9%). Contractures exceeding 10°, 20°, and 30° were prevalent in both internal rotation in abduction and cross-body adduction angles. The "Belly-" group (9.5%) demonstrated a significant reduction in both angles compared to the "Belly+" group. Weak correlations were found between internal rotation in abduction (r = 0.390, P < .0001) or cross-body adduction (r = 0.163, P = .0083) angles and Mallet hand-to-abdomen item. Glenohumeral reduction and Hoffer procedures led to a notable decrease in cross-body adduction angle, without affecting "Belly-" prevalence. Global injuries exhibited decreased angles compared to Erb's group.

CONCLUSIONS

External rotation glenohumeral contractures are prevalent in residual NBPI, impacting midline access. Surprisingly, the history of glenohumeral procedures or extensive injuries did not increase the likelihood of losing the ability to reach the belly. Receiver operating characteristic analysis suggests specific thresholds for maintaining this ability.

Bimanual ability for brachial plexus birth injury: a validity and reliability study of the ABILHAND-Kids

PURPOSE

ABILHAND-Kids is a structured parent report that assesses manual ability in activities of daily living in children with cerebral palsy, and also brachial plexus birth injury (BPBI). This study investigated the validity, test-retest reliability, and internal consistency of the ABILHAND-Kids in children with BPBI.

MATERIALS AND METHODS

The ABILHAND-Kids was administered to parents of 119 children with BPBI between 6 and 15 years for validity and internal consistency, also 92 parents were re-interviewed after two weeks to establish test-retest reliability. Its concurrent validity was examined by correlating scores on the ABILHAND-Kids with Active Movement Scale-Total Score.

RESULTS

ABILHAND-Kids were strongly correlated with AMS-Total score (p < 0.001, r = 0.87) ABILHAND-Kids test-retest reliability was excellent (ICC: 0.93, %95 CI: 0.90-0.95). The internal consistency for the total score of ABILHAND-Kids was excellent (alpha = 0.94). For 20 items, item-total correlations were adequate (corrected item-total correlations, 0.27-0.85), one item which was "switching on a bedside lamb" had no adequate correlation (corrected item-total correlations, 0.011). The ABILHAND-Kids score showed a statistically significant difference between the Narakas types (p < 0.001).

CONCLUSION

The ABILHAND-Kids has excellent reliability and strong validity for measuring manual ability or bimanual performance in activities of daily living in children with BPBI.

Cut-off values of internal rotation in the glenohumeral joint for functional tasks in children with brachial plexus birth injury

The aim of this study was to determine the cut-off values of the range of internal rotation motion in the isolated glenohumeral joint that is required for functional tasks in children with an upper root injury of the brachial plexus. Internal rotation motion was measured using a universal goniometer in 97 participants. The Mallet Hand to Spine and Mallet Hand to Belly tasks were assessed as functional tasks that require internal rotation of the shoulder. For the Hand to Spine task, 41° passive and 30° active internal rotation were necessary to reach the S1 level. For the Hand to Belly task, 42° passive and 29° active internal rotation were required to place the palm on the belly without wrist flexion. Of our participants, 97% could touch the belly with or without wrist flexion, but 28% could not reach S1 in the Hand to Spine task. The results of this study show the necessary amount of internal rotation of the shoulder that should be considered in treatment strategies.Level of evidence: III.

Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes

BACKGROUND

Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation.

METHODS

From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery.

RESULTS

The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations.

CONCLUSION

Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.

Scapulothoracic and Glenohumeral Contributions to Humerothoracic Kinematics in Single Versus Double Tendon Transfers in Patients With Brachial Plexus Birth Injury

PURPOSE

Evidence suggests that patients with brachial plexus birth injury are more likely to retain midline function following a teres major tendon transfer without a concomitant latissimus dorsi transfer. Both procedures increase shoulder external rotation and abduction, but whether increased loss of midline frequency following double transfer is due to glenohumeral (GH) joint motion or scapulothoracic (ST) compensation is unknown. We hypothesized that double tendon transfers would exhibit greater GH external rotation than single tendon transfers, thus requiring greater ST rotation to internally rotate the shoulder, while GH and ST contributions to elevation remained equivalent between both groups.

METHODS

Twenty-six postsurgical children with C5/C6 brachial plexus birth injuries participated in this study. Thirteen patients with single tendon transfers were matched with 13 with double tendon transfer. Coordinate systems of the thorax, scapula, and humerus were measured utilizing motion capture in 6 arm positions. Joint angles were calculated by the helical (ST) and modified globe method (GH and humerothoracic [HT]). Differences between groups were compared with repeated measures of multivariate analyses of variance for each position. Pending significant multivariate analyses of variance, univariate analyses of variance determined joint differences between transfer groups.

RESULTS

Joint rotations from neutral were similar between groups in 5 of 6 tested positions, with double tendon transfers consistently demonstrating 15°-20˚ more internal rotation at the GH and HT joints. Still, only the internal rotation position showed statistically significant differences in GH and HT joint angles. The ST joint angles were similar in this position (45.2˚ and 48.5˚).

CONCLUSIONS

The arc of motion for patients with double tendon transfer was more internally rotated than in patients with single tendon transfer at the GH and HT joints for all positions. However, both groups demonstrated little active rotation from neutral. Based on this data, teres major-only tendon transfers may not reduce the risk of loss of midline function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Single Versus Double Tendon Transfer to Improve Shoulder External Rotation During the Treatment of Brachial Plexus Birth Palsy

Background: Tendon transfers are commonly performed in patients with brachial plexus birth palsy (BPBP) to improve function. Transferring 2 tendons in patients with C5-7 injury has the potential complication of loss of midline function. The purpose of this study was to investigate whether a single tendon transfer (1TT) as opposed to the traditional double tendon transfer (2TT) resulted in any differences in functional outcomes in patients with C5-7 BPBP. Methods: A retrospective review of all patients with C5-7 BPBP who underwent tendon transfers to improve shoulder external rotation over a 5-year period was performed at 2 institutions. Outcomes were assessed using the modified Mallet (MM) classification scores. Results: Twenty-two C5-7 patients had complete records of preoperative and postoperative MM scores, including 11 sex-matched patients in both the 1TT and 2TT groups. When comparing preoperative and postoperative MM categories, there were significant improvements in both the 1TT and 2TT groups for global abduction (P < .05 and P < .01, respectively) and external rotation (P < .00001 for both). Modified Mallet (MM) hand to neck scores were significantly improved in the 2TT group (P < .05) but not in the 1TT group (P = .053). Internal rotation scores significantly decreased in both groups (P < .001). Both groups demonstrated significant increases in total scores from the preoperative MM scores (P < .01). Conclusion: The 1TT and 2TT procedures result in substantial gains in upper extremity functions for patients with C5-7 BPBP as measured by the MM score, specifically within the global abduction and external rotation subcategories. However, a significant loss occurs in internal rotation for both groups.

Effect of arthroscopic shoulder release on shoulder mobility and bone deformity following brachial plexus birth injury: a systematic review and meta-analysis

BACKGROUND

Specific information to guide clinical practice is lacking for the effects of arthroscopic release on bone and joint deformities, as well as the additional benefits of tendon transfer, in children with brachial plexus birth injury. The aims of this study were (1) to evaluate changes in shoulder mobility and bone and joint deformity, (2) to evaluate the effect of release with and without tendon transfer on the same outcomes, and (3) to evaluate the perioperative and long-term complications.

METHODS

We conducted a systematic review and meta-analysis. Four databases were searched using relevant inclusion and exclusion criteria from inception until May 2020. The quality of articles was evaluated using the Methodological Index for Non-randomized Studies (MINORS) scale. Data regarding patients, interventions, and clinical and radiologic outcomes were reported.

RESULTS

Thirteen articles were included: 6 of low quality and 7 of moderate quality separated into 17 studies (266 children). The mean follow-up duration was 32.4 months (standard deviation, 15.2 months). Arthroscopic release significantly improved the Mallet score (standardized mean difference [SMD], 3.1 [95% confidence interval (CI), 1.5-4.7]; P < .001) and passive external rotation (SMD, 3.6 [95% CI, 2.3-4.9]; P = .02). The percentage of humeral head anterior (SMD, 1.3 [95% CI, 0.7-1.9]; P = .003) and glenoid retroversion (SMD, 1.4 [95% CI, 0.9-2]; P = .01) also improved. Descriptive analysis of the data suggested that concomitant tendon transfer further improved mobility. Recurrence of internal-rotation contracture was reported in 8 of 157 children.

DISCUSSION

This systematic review showed that arthroscopic release effectively improves both shoulder mobility and bone deformity, with few complications in young children with brachial plexus birth injury. As such, it seems reasonable to propose a stepwise approach starting with a release without transfer.

Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function

BACKGROUND

Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach.

METHODS

Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05).

RESULTS

Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation.

CONCLUSIONS

Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.