The epidemiology of neonatal brachial plexus palsy in the United States

The impact of a soft robotic glove on activity performance and body function for brachial plexus birth injury patients-A longitudinal case series

BACKGROUND

A brachial plexus birth injury (BPBI) can cause reduced ability to use the arm and hand in daily activities due to reduced grip strength and endurance. A soft robotic glove can increase the number of activities performed and improve activity performance for patients with neurological disease. The use of a soft robotic glove for patients with BPBI has not been studied.

PURPOSE

To investigate if a soft robotic glove can improve activity performance and body function for patients with BPBI.

STUDY DESIGN

Longitudinal Case Series.

METHODS

A convenience sample of patients with BPBI, treated by the Brachial plexus injury service in Umeå, Sweden were studied. Eight patients used a soft robotic glove, (Carbonhand®), at home for three months. Data on activity performance and satisfaction with activity performance, active range of motion and strength were collected at baseline, and at three and four months. A patient evaluation form was filled out at three months, all patients kept a diary for three out of 12 weeks.

RESULTS

Six out of eight patients wanted to continue using the device and improved their self-perception of activity performance and satisfaction with the performance due to a more secure grip, compared to when not using the device. All patients had improved maximum strength and endurance in elbow flexion at three months. The device was useful as an assisting device and as a training tool.

CONCLUSION

A soft robotic glove (Carbonhand) may improve activity performance and perceived satisfaction and increase the number of activities that a person with BPBI can perform in everyday life. It is possible to increase strength in elbow flexion after using such a device. Due to this limited material, more research is needed.

Peripheral nerve decompression for pain relief in the setting of previous obstetrical brachial plexus injury: a retrospective case series

PURPOSE

In children with previous obstetrical brachial plexus injury (OBPI), upper extremity pain is present in 45 to 66% of patients. Recent literature reports this as musculoskeletal or neuropathic in nature. The purpose of the study is to demonstrate that peripheral nerve decompression, and neurolysis may be an effective treatment for patients with upper extremity pain in the context of previous OBPI.

METHODS

A retrospective chart review was performed on patients undergoing peripheral nerve decompression and neurolysis after OBPI by senior author. The primary outcome assessed was pain, and secondary outcome measure was range of motion of the wrist and elbow. Outcome measures were assessed preoperatively as well as at their subsequent follow-up.

RESULTS

Six patients were included, with a mean age of 14 years old at time of decompression. Three patients underwent median nerve, two patients underwent ulnar nerve, and one patient underwent posterior interosseous nerve decompression. There was a substantial improvement in pain post-operatively, demonstrated by reduction or resolution of subjective pain in all patients and resolution of Tinel's sign. There was a modest improvement in range of motion.

CONCLUSION

This study demonstrates an improvement in subjective pain and range of motion after decompression and neurolysis in small subset of OBPI patients. It generates the hypothesis that peripheral nerve compression is a source of pain that can be addressed in this population. Future research should focus on confirming this hypothesis and assessing treatment options on a larger scale.

Maternal Epidemiology of Brachial Plexus Birth Injuries in California: 1996 to 2012

OBJECTIVE

 This study aimed to evaluate the incidence of brachial plexus birth injury (BPBI) and its associations with maternal demographic factors. Additionally, we sought to determine whether longitudinal changes in BPBI incidence differed by maternal demographics.

STUDY DESIGN

 We conducted a retrospective cohort study of over 8 million maternal-infant pairs using California's Office of Statewide Health Planning and Development Linked Birth Files from 1991 to 2012. Descriptive statistics were used to determine BPBI incidence and the prevalence of maternal demographic factors (race, ethnicity, age). Multivariable logistic regression was used to determine associations of year, maternal race, ethnicity, and age with BPBI. Excess population-level risk associated with these characteristics was determined by calculating population attributable fractions.

RESULTS

 The incidence of BPBI between 1991 and 2012 was 1.28 per 1,000 live births, with peak incidence of 1.84 per 1,000 in 1998 and low of 0.9 per 1,000 in 2008. Incidence varied by demographic group, with infants of Black (1.78 per 1,000) and Hispanic (1.34 per 1,000) mothers having higher incidences compared with White (1.25 per 1,000), Asian (0.8 per 1,000), Native American (1.29 per 1,000), other race (1.35 per 1,000), and non-Hispanic (1.15 per 1,000) mothers. After controlling for delivery method, macrosomia, shoulder dystocia, and year, infants of Black (adjusted odds ratio [AOR] = 1.88, 95% confidence interval [CI] = 1.70, 2.08), Hispanic (AOR = 1.25, 95% CI = 1.18, 1.32), and advanced-age mothers (AOR = 1.16, 95% CI = 1.09, 1.25) were at increased risk. Disparities in risk experienced by Black, Hispanic, and advanced-age mothers contributed to a 5, 10, and 2% excess risk at the population level, respectively. Longitudinal trends in incidence did not vary among demographic groups. Population-level changes in maternal demographics did not explain changes in incidence over time.

CONCLUSION

 Although BPBI incidence has decreased in California, demographic disparities exist. Infants of Black, Hispanic, and advanced-age mothers are at increased BPBI risk compared with White, non-Hispanic, and younger mothers.

KEY POINTS

· The incidence of BPBI has decreased over time.. · Demographic disparities in BPBI incidence and risk exist.. · Infants of Black, Hispanic, and advanced age mothers are at greatest risk of BPBI..

Surgical Complexity and Physician Compensation: An Analysis of Relative Under-Valuation for Pediatric Brachial Plexus Surgery

BACKGROUND

Brachial plexus reconstruction (BPR) is a rapidly advancing field within hand surgery. BPR procedures are complex, time-intensive, and require microsurgical expertise. As physician reimbursement rates for BPR are poorly defined, relative to more common hand procedures, we sought to analyze compensation for BPR across different payor groups and understand the factors contributing to their reimbursement.

METHODS

A retrospective review was performed of surgeries by a single senior staff member in a 4-year period to evaluate Current Procedural Terminology (CPT) codes from BPR cases. For comparison, all finger fracture fixations and skin graft reconstructions performed by the same surgeon over the same time period were analyzed as well.

RESULTS

A total of 57 BPR cases, 94 finger fracture fixation cases, and 69 skin grafting cases met inclusion criteria. Among the top 5 insurance providers, average work relative value unit (wRVU)/hour was 6.55, 3.49, and 12.67 for BPR, fracture fixation, and skin grafts, respectively. Reimbursements were an average $685.76/hour for BPR, compared to $590.10/hour for fracture fixation and $1,197.94/hour for skin grafts.

CONCLUSIONS

BPR demonstrates a relative undervaluation, in terms of reimbursement per hour, given the time and surgical skill required for such cases, particularly compared to shorter, less complex cases such as skin grafting and fracture fixation. We find that this discrepancy is amplified across multiple levels of coding, billing, and reimbursement. We suggest specific strategies for physician leadership to more directly participate in the financial decisions that affect themselves, their patients, and their specialty.

Correlation between histopathological nerve assessment and clinical recovery in brachial plexus birth injuries

In the management of brachial plexus birth palsies, the quality of the roots eligible for reconstruction is thought to be a key issue. The aim of the present study was to evaluate the correlations between pathological root examination and motor recovery after brachial plexus reconstructions. Quantitative histopathological analysis of intraneural fibrosis was conducted on 72 nerve transections (40 roots, 18 trunks and 14 suprascapular nerves) in 20 patients. Clinical recovery of targeted muscles after surgery was assessed by standardized functional scores. After a mean follow-up of 32 months, patients with a lower fibrosis rate for the suprascapular nerve had greater global Mallet scores (r = -0.57; p = 0.042) as well as a greater active shoulder flexion (r = -0.66; p = 0.015). Correlations were also found between C6 root and upper trunk fibrosis rate and some of the subsections of the Mallet score, active movement scale for the biceps and active elbow flexion. These results seem to confirm the relevance of intraoperative pathological evaluation of the roots and nerves after neuroma resection to optimally define the reconstruction strategy.Level of evidence: IV.

The Relative Efficacy of Available Proteasome Inhibitors in Preventing Muscle Contractures Following Neonatal Brachial Plexus Injury

BACKGROUND

Contractures following neonatal brachial plexus injury (NBPI) are associated with growth deficits in denervated muscles. This impairment is mediated by an increase in muscle protein degradation, as contractures can be prevented in an NBPI mouse model with bortezomib (BTZ), a proteasome inhibitor (PI). However, BTZ treatment causes substantial toxicity (0% to 80% mortality). The current study tested the hypothesis that newer-generation PIs can prevent contractures with less severe toxicity than BTZ.

METHODS

Unilateral brachial plexus injuries were surgically created in postnatal (5-day-old) mice. Following NBPI, mice were treated with either saline solution or various doses of 1 of 3 different PIs: ixazomib (IXZ), carfilzomib (CFZ), or marizomib (MRZ). Four weeks post-NBPI, mice were assessed for bilateral passive range of motion at the shoulder and elbow joints, with blinding to the treatment group, through an established digital photography technique to determine contracture severity. Drug toxicity was assessed with survival curves.

RESULTS

All PIs prevented contractures at both the elbow and shoulder (p < 0.05 versus saline solution controls), with the exception of IXZ, which did not prevent shoulder contractures. However, their efficacies and toxicity profiles differed. At lower doses, CFZ was limited by toxicity (30% to 40% mortality), whereas MRZ was limited by efficacy. At higher doses, CFZ was limited by loss of efficacy, MRZ was limited by toxicity (50% to 60% mortality), and IXZ was limited by toxicity (80% to 100% mortality) and loss of efficacy. Comparisons of the data on these drugs as well as data on BTZ generated in prior studies revealed BTZ to be optimal for preventing contractures, although it, too, was limited by toxicity.

CONCLUSIONS

All of the tested second-generation PIs were able to reduce NBPI-induced contractures, offering further proof of concept for a regulatory role of the proteasome in contracture formation. However, the narrow dose ranges of efficacy for all PIs highlight the necessity of precise proteasome regulation for preventing contractures. Finally, the substantial toxicity stemming from proteasome inhibition underscores the importance of identifying muscle-targeted strategies to suppress protein degradation and prevent contractures safely.

CLINICAL RELEVANCE

Although PIs offer unique opportunities to establish critical mechanistic insights into contracture pathophysiology, their clinical use is contraindicated in patients with NPBI at this time.

A Novel Operation Technique for Forearm Deformities in Patients with Brachial Plexus Birth Injury: Retrospective Analysis of 14 Patients

Background: We aimed to evaluate the effectiveness of our novel operation technique that included radial shaft shortening plus supination producing osteotomy and transfer of the biceps brachii tendon to the brachialis tendon in patients with chronic radial head dislocation secondary to brachial plexus birth injury (BPBI). Methods: Fourteen patients with chronic radial head dislocation resulting from BPBI were included in this study, with a minimum 1-year postoperative follow-up period. All patients underwent the same surgical procedure. The range of motion of affected elbow was measured with a standard goniometer. The Mayo Elbow Performance Score (MEPS) was used to measure for evaluation of functional result of these patients. The affected elbow radiograph also obtained in the last visit for evaluation of compatibility of the radiocapitellar joint. Results: Fourteen patients (10 males and 4 females) were included in the study. The average age at the time of surgery was 7.2 (5-8) years and average follow-up was 73.2 ± 19 (36-131) months. Although the forearm active-passive pronation decreased, active-passive supination significantly improved postoperatively (p < 0.001). Ten patients had excellent MEPS results (90 and above), two patients with good results (75 and 80), one patient with fair (65) and one patient with poor result (55). Radiocapitellar reduction was achieved in 78.5% (11/14) of the patients. Conclusions: The novel surgical techniques that included radial shaft shortening plus supination producing osteotomy and transfer of the biceps brachii tendon to the brachialis tendon improved the functional outcomes of patients with chronic radial head dislocation secondary to BPBI. Level of Evidence: Level IV (Therapeutic).

Evaluation of Infantile Brachial Plexopathy Using 3T MRI and High-Resolution Ultrasound: Experience From a Tertiary Care Centre

BACKGROUND

Currently, clinical assessment is the main tool for the evaluation of brachial plexus injury, complemented by electrophysiologic studies (EPS), and imaging studies whenever available. Imaging plays an important role as it enables the differentiation of pre-ganglionic and postganglionic injuries, and adds objectivity to presurgical evaluation.

OBJECTIVES

The primary objective was to evaluate the utility of magnetic resonance imaging (MRI) and high-resolution ultrasonography (USG) in the localization and characterization of brachial plexus injury in infants.

MATERIALS AND METHODS

In this prospective study, 34 infants with signs and symptoms of brachial plexus injury were evaluated by clinical examination, EPS, MRI, and USG. Imaging findings were correlated with intraoperative findings in infants who underwent surgical management. The association between EPS and MRI findings, and USG and MRI findings were assessed using Fisher's exact test. Semi-quantitative subjective analysis of various MRI sequences was done as well.

RESULTS

The most common findings of preganglionic injury and postganglionic injury, in our study, were pseudomeningocele and nerve thickening, respectively. MRI detection of injuries had a significant association with EPS findings. All MRI-detected injuries had a muscle power of grade 3 or less. muscle. Three-dimensional (3D) short tau inversion recovery (STIR) sequence was found to be superior for detecting postganglionic injuries (P < 0.05).

CONCLUSION

Imaging studies enable localization of the site of injury, determining the extent, and nature/morphology of injury. The gamut of findings obtained from MRI is far wider compared to that from USG. USG can be used as the first-line screening investigation.

Safety of botulinum toxin injections in children less than one year old: A retrospective chart review

PURPOSE

Infants can have muscle hypertonia due to cerebral palsy, muscle strength imbalances due to brachial plexus palsy, refractory clubfoot, and torticollis. These muscle problems can cause significant development impairments. A child with severe sialorrhea and dysphagia from leukodystrophy can aspirate, causing respiratory problems. Botulinum toxin (BoNT) injections can improve these conditions but may lead to adverse effects from the toxin spreading to non-targeted muscles, potentially impacting breathing, swallowing, and overall strength. This is particularly concerning in infants. This study assessed the safety of BoNT injections in children less than one year of age.

METHODS

This was a retrospective cohort study.

RESULTS

Forty-seven patients (22 male, 25 female) received BoNT injections before one year of age (three to 12 months). Thirty-seven received one round of injections and 10 were injected on multiple occasions. Forty-five received onabotulinumtoxinA (15-100 units [U], 1.9-15.2 U/kg), one received abobotulinumtoxinA (70 U, 9.0 U/kg), and one received incobotulinumtoxinA (25 U, 3.5 U/kg). Lower extremities were treated in 15 patients, upper extremities in 38, the sternocleidomastoid in two, and the salivary glands in one. Forty-five patients had no reported complications. One experienced transient fever, vomiting, and diarrhea. The parent of another reported subjective weakness in one muscle.

CONCLUSION

BoNT injections in children less than one year of age appear to be safe.

Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury

OBJECTIVE

To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment.

STUDY DESIGN

Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data.

RESULTS

There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%.

CONCLUSIONS

In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

Brachial Plexus Birth Injury: A Single-Center Study

Infants can sustain traction injury to brachial plexus nerves during birth, called brachial plexus birth injury (BPBI). While spontaneous recovery is possible, upper extremity weakness can linger. We report our experience at a brachial plexus clinic from a retrospective chart review of infants with BPBI from September 2017 to September 2019. We determined Narakas Classification (NC) and Active Movement Scale (AMS) at predetermined follow-up points. Of 15 patients, 8 presented with NC-I, 5 with NC-II, and 2 with NC-III without Horner's syndrome. By 7 months, 3 had spontaneous recovery, and 4 achieved all and another 4 achieved most AMS5-7 scores. Eleven patients undergoing surgery had little-to-no improvement of shoulder abduction and shoulder external rotation AMS categories by 6 months. Our small sample size prevents us from making definitive conclusions but gave beneficial insight into our clinic barriers to follow-up, data collection, and collaboration with physical and occupational therapy.

Association of Parity and Previous Birth Outcome With Brachial Plexus Birth Injury Risk

OBJECTIVE

To evaluate the association of maternal delivery history with a brachial plexus birth injury risk in subsequent deliveries and to estimate the effect of subsequent delivery method on brachial plexus birth injury risk.

METHODS

We conducted a retrospective cohort study of all live-birth deliveries occurring in California-licensed hospitals from 1996 to 2012. The primary outcome was recurrent brachial plexus birth injury in a subsequent pregnancy. The exposure was delivery history (parity, shoulder dystocia in a previous delivery, or previously delivering a neonate with brachial plexus birth injury). Multiple logistic regression was used to model adjusted associations of delivery history with brachial plexus birth injury in a subsequent pregnancy. The adjusted risk and adjusted risk difference for brachial plexus birth injury between vaginal and cesarean deliveries in subsequent pregnancies were determined, stratified by delivery history, and the number of cesarean deliveries needed to prevent one brachial plexus birth injury was determined.

RESULTS

Of 6,286,324 neonates delivered by 4,104,825 individuals, 7,762 (0.12%) were diagnosed with a brachial plexus birth injury. Higher parity was associated with a 5.7% decrease in brachial plexus birth injury risk with each subsequent delivery (adjusted odds ratio [aOR] 0.94, 95% CI 0.92-0.97). Shoulder dystocia or brachial plexus birth injury in a previous delivery was associated with fivefold (0.58% vs 0.11%, aOR 5.39, 95% CI 4.10-7.08) and 17-fold (1.58% vs 0.11%, aOR 17.22, 95% CI 13.31-22.27) increases in brachial plexus birth injury risk, respectively. Among individuals with a history of delivering a neonate with a brachial plexus birth injury, cesarean delivery was associated with a 73.0% decrease in brachial plexus birth injury risk (0.60% vs 2.21%, aOR 0.27, 95% CI 0.13-0.55) compared with an 87.9% decrease in brachial plexus birth injury risk (0.02% vs 0.15%, aOR 0.12, 95% CI 0.10-0.15) in individuals without this history. Among individuals with a history of brachial plexus birth injury, 48.1 cesarean deliveries are needed to prevent one brachial plexus birth injury.

CONCLUSIONS

Parity, previous shoulder dystocia, and previously delivering a neonate with brachial plexus birth injury are associated with future brachial plexus birth injury risk. These factors are identifiable prenatally and can inform discussions with pregnant individuals regarding brachial plexus birth injury risk and planned mode of delivery.

The role of sympathetic innervation in neonatal muscle growth and neuromuscular contractures

Neonatal brachial plexus injury (NBPI), a leading cause of pediatric upper limb paralysis, results in disabling and incurable muscle contractures that are driven by impaired longitudinal growth of denervated muscles. A rare form of NBPI, which maintains both afferent and sympathetic muscle innervation despite motor denervation, protects against contractures. We have previously ruled out a role for NRG/ErbB signaling, the predominant pathway governing antegrade afferent neuromuscular transmission, in modulating the formation of contractures. Our current study therefore investigated the contributions of sympathetic innervation of skeletal muscle in modulating NBPI-induced contractures. Through chemical sympathectomy and pharmacologic modification with a β2 -adrenergic agonist, we discovered that sympathetic innervation alone is neither required nor sufficient to modulate contracture formation in neonatal mice. Despite this, sympathetic innervation plays an intriguing sex-specific role in mediating neonatal muscle growth, as the cross-sectional area (CSA) and volume of normally innervated male muscles were diminished by ablation of sympathetic neurons and increased by β-adrenergic stimulation. Intriguingly, the robust alterations in CSA occurred with minimal changes to normal longitudinal muscle growth as determined by sarcomere length. Instead, β-adrenergic stimulation exacerbated sarcomere overstretch in denervated male muscles, indicating potentially discrete regulation of muscle width and length. Future investigations into the mechanistic underpinnings of these distinct aspects of muscle growth are thus essential for improving clinical outcomes in patients affected by muscle disorders in which both length and width are affected.

Towards comprehensive evaluation of the FLEXotendon glove-III: a case series evaluation in pediatric clinical cases and able-bodied adults

Injuries involving the nervous system, such as a brachial plexus palsy or traumatic brain injury, can lead to impairment in the functionality of the hand. Assistive robotics have been proposed as a possible method to improve patient outcomes in rehabilitation. The work presented here evaluates the FLEXotendon Glove-III, a 5 degree-of-freedom, voice-controlled, tendon-driven soft robotic hand exoskeleton, with two human subjects with hand impairments and four able-bodied subjects. The FLEXotendon Glove-III was evaluated on four unimpaired subjects, in conjunction with EMG sensor data, to determine the quantitative performance of the glove in applied pinch force, perturbation resistance, and exertion reduction. The exoskeleton system was also evaluated on two subjects with hand impairments, using two standardized hand function tests, the Jebsen-Taylor Hand Function Test and the Toronto Rehabilitation Institute Hand Function Test. The subjects were also presented with three qualitative questionnaires, the Capabilities of Upper Extremities Questionnaire, the Quebec User Evaluation of Satisfaction with Assistive Technology, and the Orthotics Prosthetics User Survey-Satisfaction module. From the previous design, minor design changes were made to the exoskeleton. The quick connect system was redesigned for improved performance, the number of motors was reduced to decrease overall footprint, and the entire system was placed into a compact acrylic case that can be placed into a backpack for increased portability.

Examination of Upper Extremity Length Discrepancy in Patients with Obstetric Brachial Plexus Paralysis

Since the natural course of obstetric brachial plexus palsy is variable, several problems are encountered. One important question, in considering patients with OBPP under observation in outpatient clinical settings, is whether children will have length discrepancies in their arms. The aim of this study was to determine differences in the length of the affected extremity, in comparison to the opposite upper extremity. As such, 45 patients, aged 6 months to 18 years, with unilateral brachial plexus palsy developed due to obstetric reasons, were included in the study. Affected and healthy side humerus, ulna, radius, 2nd metacarpal and 5th metacarpal lengths were evaluated according to gender, age, side, Narakas classification, primary and secondary surgery. Statistically significant differences were found in the change rates of affected/healthy humerus, radius, 2nd metacarpal and 5th metacarpal lengths according to age (93%, 95%, 92%, 90% and 90%, respectively). Affected/healthy change rates of ulna, radius, 2nd metacarpal and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to the Narakas classification variable (94%, 92%, 95%, 94% and 94%, respectively). There were no statistically significant differences in the ratios of affected/healthy change in the lengths of the humerus, ulna, radius and 5th metacarpal compared to the primary surgery (p > 0.05). The ratios of affected/healthy change in ulna, radius and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to secondary surgeries (93%, 91%, 91% and 92%, respectively). Joint and bone deformities and bone shortening were observed after changes that occurred in the postnatal and growing periods due to obstetric brachial plexus palsy. Every increase in function to be gained in the upper extremity musculature was also potentially able to reduce problems, such as shortness.

Nerve Transfer Is Superior to Nerve Grafting for Suprascapular Nerve Reconstruction in Obstetrical Brachial Plexus Birth Injury: A Meta-Analysis

BACKGROUND

Restoration of shoulder function in obstetrical brachial plexus injury is paramount. There remains debate as to the optimal method of upper trunk reconstruction. The purpose of this study was to test the hypothesis that spinal accessory nerve to suprascapular nerve transfer leads to improved shoulder external rotation relative to sural nerve grafting.

METHODS

A systematic review of Medline, EMBASE, EBSCO CINAHL, SCOPUS, Cochrane Library, and TRIP Pro from inception was conducted. Our primary outcome was shoulder external rotation.

RESULTS

Four studies were included. Nerve transfer was associated with greater shoulder external rotation relative to nerve grafting (mean difference: 0.82 AMS 95% confidence interval [CI]: 0.27-1.36, P < .005). Patients undergoing nerve grafting were more likely to undergo a secondary shoulder stabilizing procedure (odds ratio [OR]: 1.27, 95% CI: 0.8376-1.9268).

CONCLUSION

In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery.

LEVEL OF EVIDENCE

Level III; Therapeutic.

Permanent Brachial Plexus Birth Injury: Helsinki Shoulder Protocol

Passive shoulder exercises from birth and ultrasound screening from 3 to 12 months. Botox is given to shoulder internal rotators and a bracing commenced, if alpha-angle exceeds 30°, or passive shoulder external rotation is below 70 degrees. Plexus reconstruction is recommended to children with root avulsion(s) on magnetic resonance imaging or 3-month Toronto Test Score < 3.5. Specific neurotization is recommended to children without avulsions, but lack of progress in healing. Shoulder dysplasia was diagnosed in 49% of 270 patients with permanent brachial plexus birth injury in our catchment area from 1995 to 2021. The age at detection of shoulder dysplasia dropped from mean 5.4 years in children born before 2000 to mean 3.9 months in children born after 2009. Botox was given to 57% of the patients born after 2009. Rate of shoulder relocation decreased from 28 to 7% while mean active shoulder external rotation in adduction increased from 2 to 46°.

Effectiveness of Physical Therapy Interventions in Children with Brachial Plexus Birth Injury: A Systematic Review

AIM

To systematically review the effectiveness of physical therapy interventions in infants, children and adolescents with brachial plexus birth injury (BPBI).

METHODS

Systematic review of randomized controlled trials including patients under 18 years old with BPBI was conducted on Medline, Cochrane, Embase, Amed and Pedro databases. Methodological quality was assessed by the PEDro score and quality of evidence by the GRADE system. The primary outcomes measured were range of motion, muscle strength and bone mineral density.

RESULTS

Seven studies were included, two in infant and 5 in children, of 932 title and abstracts screened. The interventions, characteristics of the participants and outcomes were diverse. The largest effect was found when other intervention was combined with conventional physical therapy in the primary outcomes, with low quality of evidence.

CONCLUSION

Physical therapy interventions alone or in combination with other treatment modalities are effective in improving short-term disabilities in children with BPBI.

Long-Term Outcomes of Biceps Rerouting for Flexible Supination Contractures in Children With Brachial Plexus Birth Injuries

PURPOSE

Forearm supination contractures occur in 7% of children with brachial plexus birth injuries (BPBI). Biceps rerouting is proposed when pronation has deteriorated but is passively correctable to at least 0° (neutral). The purpose of this investigation was to evaluate long-term outcomes of biceps rerouting for this indication, including magnitude and maintenance of correction, complications, and subsequent osteotomy.

METHODS

We conducted a retrospective review of all children with BPBI and forearm supination contractures treated with biceps rerouting alone, for the above indications, from 1993 to 2017 with at least 2 years follow-up. Demographic information, BPBI characteristics, surgical details, and ranges of motion were obtained from medical records. Pre- and postoperative active pronation (AP) and supination (AS), elbow flexion contracture, and arc of forearm rotation (Arc) were analyzed using linear mixed-effect models.

RESULTS

Twenty-five children (13 females; 13 left forearms; 15 global BPBI) underwent biceps rerouting at age 7 ± 3 years and were followed for 6 ± 3 years. Before surgery, the mean AP and AS were 6° ± 29° and 62° ± 27°, respectively. At the final follow-up, the mean AP, AS, and Arc were 39° ± 36°, 18° ± 34°, and 57° ± 42°, respectively. AP was significantly improved and AS was significantly decreased by 2 years after surgery and at the final follow-up. Neither Arc nor elbow flexion contracture changed significantly. Two of 25 (8%) children underwent subsequent forearm osteotomy.

CONCLUSIONS

Biceps rerouting in children with BPBI improves the forearm position when pronation is deteriorating by shifting the arc from supination to pronation without decreasing the arc of motion or worsening elbow flexion contractures. There is a low risk of complications and a limited need for subsequent forearm osteotomy. These results are maintained over time. When performed before passive pronation is reduced beyond neutral, this procedure may prevent severe supination contractures and reduce the need for forearm osteotomy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Prevalence of perinatal factors in infants with brachial plexus birth injuries and their association with injury severity

OBJECTIVES

To determine the prevalence of perinatal factors associated with brachial plexus birth injury (BPBI) in affected infants and their relationship with BPBI severity.

STUDY DESIGN

Retrospective study of BPBI infants prospectively enrolled in a multicenter registry. The prevalence of perinatal factors was calculated. Infants were stratified by injury severity and groups were compared to determine the association of severity and perinatal factors.

RESULTS

Seven-hundred-ninety-six BPBI infants had a mean 4.2 ± 1.6 perinatal factors. Nearly all (795/796) reported at least one factor, including shoulder dystocia(96%), no clavicle fracture (91%), difficult delivery(84%), parity >1(61%) and birthweight >4000 g(55%). Ten-percent (74/778) had Horner's syndrome and 28%(222/796) underwent nerve surgery. Birth asphyxia and NICU admission were significantly associated with injury severity.

CONCLUSIONS

NICU admission and asphyxia were associated with BPBI severity. An improved understanding of the relationship between perinatal factors and BPBI severity may be used to guide early referral to BPBI providers and support prevention efforts.

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.

Brachial Plexus Birth Injury: A Review of Neurology Literature Assessing Variability and Current Recommendations

BACKGROUND

Publications regarding the epidemiology and management of brachial plexus birth injury (BPBI) were evaluated to investigate treatment guidelines for children with BPBI.

METHODS

A search of neurology literature from 1990 to 2019 was performed using PubMed, Scopus, and Medline. Data including incidence, risk factors, spontaneous recovery rates, imaging studies, treatment recommendations, and indications and timing for surgery were collected.

RESULTS

A total of 46 total studies were reviewed. Reported incidence rates for BPBI ranged from 0.3 to 3 per 1000 births. Spontaneous recovery rates had an average reported range from 66% to 75%. Physical and occupational therapy were recommended in 37% of articles. Computed tomographic myelogram and magnetic resonance imaging of the brachial plexus were the most commonly recommended imaging studies for BPBI. Timelines for surgical interventions ranged from age three to nine months. Early referral was recommended in 28% of the articles included in the review.

CONCLUSIONS

Given the inconsistencies in spontaneous recovery rates, imaging recommendations, and timing of referral, establishing consistent clinical guidelines for patients with BPBI is crucial for management. Early referral to specialists for evaluation and treatment may improve outcomes in children with BPBI.

Outcomes of Functioning Free Gracilis Muscle Transplantation to Restore Elbow Flexion in Late Brachial Plexus Birth Injury

BACKGROUND

 Restoring elbow function is challenging after late presenting brachial plexus birth injury (BPBI). Free functioning muscle transplantation (FFMT) using the gracilis muscle is a reliable procedure to restore elbow flexion in patients with impaired function after spontaneous recovery or failed surgical reconstruction.

METHODS

 A retrospective review was performed on BPBI patients more than 2 years of age who received a FFMT between January 1993 and January 2018, with the aim of improving elbow flexion as the primary or secondary functional goal. Patients with preoperative elbow flexion Medical Research Council (MRC) grades less than 3 with more than or equal to 18 months of follow-up duration were included in the analysis. Patient demographic information and pre/postoperative clinical parameters including elbow flexion MRC scale, passive elbow range of motion, and complications were recorded. Surgical data including donor nerve choice, site of the FFMT tendon attachment, and necessity of concomitant procedures or reoperation were also analyzed.

RESULTS

 Fifty-six FFMTs were performed for the primary (29 patients) or secondary (26 patients) objective of restoring elbow flexion. The mean age at the time of the procedure was 9.6 years (standard deviation [SD] = 6.29, R = 3-35). Mean follow-up was 7.9 years (SD = 5.2). Elbow flexion improved from a median MRC grade 2 to 4 after a FFMT (p < 0.05). Patients who had a FFMT to restore two functions had 86% lower elbow flexion MRC grades than those who had a FFMT to restore flexion only (p < 0.05). Patients less than 12 years old at the time of surgery had more complications, reoperations, and rates of a flexion contracture more than or equal to 30 degrees than those aged more than 12 years (p < 0.05).

CONCLUSION

 FFMT is a reliable option for upper extremity reanimation. Patients aged less than 12 years old at the time of FFMT had significantly more complications, reoperations, and rates of postoperative elbow flexion contracture more than or equal to 30 degrees, but equivalent elbow flexion MRC grades.

LEVEL OF EVIDENCE

 III.

Transient neonatal shoulder paralysis causes early osteoarthritis in a mouse model

Neonatal brachial plexus palsy (NBPP) occurs in approximately 1.5 of every 1,000 live births. The majority of children with NBPP recover function of the shoulder. However, the long-term risk of osteoarthritis (OA) in this population is unknown. The purpose of this study was to investigate the development of OA in a mouse model of transient neonatal shoulder paralysis. Neonatal mice were injected twice per week for 4 weeks with saline in the right supraspinatus muscle (Saline, control) and botulinum toxin A (BtxA, transient paralysis) in the left supraspinatus muscle, and then allowed to recover for 20 or 36 weeks. Control mice received no injections, and all mice were sacrificed at 24 or 40 weeks. BtxA mice exhibited abnormalities in gait compared to controls through 10 weeks of age, but these differences did not persist into adulthood. BtxA shoulders had decreased bone volume (-9%) and abnormal trabecular microstructure compared to controls. Histomorphometry analysis demonstrated that BtxA shoulders had higher murine shoulder arthritis scale scores (+30%), and therefore more shoulder OA compared to controls. Articular cartilage of BtxA shoulders demonstrated stiffening of the tissue. Compared with controls, articular cartilage from BtxA shoulders had 2-fold and 10-fold decreases in Dkk1 and BMP2 expression, respectively, and 3-fold and 14-fold increases in Col10A1 and BGLAP expression, respectively, consistent with established models of OA. In summary, a brief period of paralysis of the neonatal mouse shoulder was sufficient to generate early signs of OA in adult cartilage and bone.

Elbow flexion contractures in neonatal brachial plexus palsy: A one-year comparison of dynamic orthosis and serial casting

OBJECTIVE

Elbow flexion contractures are common complications of neonatal brachial plexus palsy, but evidence on how to treat these contractures is weak. This study compared the treatment of elbow flexion contractures using a dynamic orthosis or serial circular casting.

METHODS

A randomized controlled trial was conducted with one-year follow-up. Children with an elbow flexion contracture of ≥30° were treated with either a night-worn dynamic orthosis for one year or serial casting for four weeks followed by night splinting. For pragmatic reasons, some participants were included in an open part of this study, this group was also analyzed separately. Degree of contracture and goal attainment scaling was evaluated at baseline and after 8, 20 and 54 weeks.

RESULTS

55 patients were analyzed in this trial, 32 of whom were randomized to treatment. At one-year follow-up of the randomized group, both dynamic splinting (median -8.5°, interquartile range [IQR] -13.5, -5) and serial casting (median -11.0°, IQR -16, -5) resulted in significant reduction of contracture (P < 0.001). The reduction was significantly greater with serial casting in the first 20 weeks, but not at one-year follow-up (P = 0.683). In the entire cohort, the individual functional goals had been reached in 24 out of 32 cases (80%) of dynamic splinting and 18 out of 23 cases (82%) of serial casting, respectively.

CONCLUSION

The dynamic night orthosis is comparable to serial casting for treating elbow flexion contractures in children with brachial plexus birth injury. We recommend selecting one of these treatment modalities in close consultation with parents and patients.

Brachial plexus birth injury and cerebral palsy lead to a common contracture phenotype characterized by reduced functional muscle length and strength

Introduction

Brachial plexus birth injury (BPBI) and cerebral palsy (CP) both cause disabling contractures for which no curative treatments exist, largely because contracture pathophysiology is incompletely understood. The distinct neurologic nature of BPBI and CP suggest different potential contracture etiologies, although imbalanced muscle strength and insufficient muscle length have been variably implicated. The current study directly compares the muscle phenotype of elbow flexion contractures in human subjects with BPBI and CP to test the hypothesis that both conditions cause contractures characterized by a deficit in muscle length rather than an excess in muscle strength.

Methods

Subjects over 6 years of age with unilateral BPBI or hemiplegic CP, and with elbow flexion contractures greater than 10 degrees on the affected side, underwent bilateral elbow flexion isokinetic strength testing to identify peak torque and impulse, or area under the torque-angle curve. Subjects then underwent needle microendoscopic sarcomere length measurement of bilateral biceps brachii muscles at symmetric joint angles.

Results

In five subjects with unilateral BPBI and five with hemiplegic CP, peak torque and impulse were significantly lower on the affected versus unaffected sides, with no differences between BPBI and CP subjects in the percent reduction of either strength measurement. In both BPBI and CP, the percent reduction of impulse was significantly greater than that of peak torque, consistent with functionally shorter muscles. Similarly, in both conditions, affected muscles had significantly longer sarcomeres than unaffected muscles at symmetric joint angles, indicating fewer sarcomeres in series, with no differences between BPBI and CP subjects in relative sarcomere overstretch.

Discussion

The current study reveals a common phenotype of muscle contracture in BPBI and CP, with contractures in both conditions characterized by a similar deficit in muscle length rather than an excess in muscle strength. These findings support contracture treatments that lengthen rather than weaken affected muscles. Moreover, the discovery of a common contracture phenotype between CP and BPBI challenges the presumed dichotomy between upper and lower motor neuron lesions in contracture pathogenesis, instead revealing the broader concept of “myobrevopathy”, or disorder of short muscle, warranting increased investigation into the poorly understood mechanisms regulating muscle length.

Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: an observational study

OBJECTIVE

To study the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI).

DESIGN

Retrospective observational study.

SETTING

Helsinki University Women's Hospital, Finland.

SAMPLE

Deliveries with SD.

METHODS

Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010-2014 were considered the pre-training period and years 2015-2019 were considered the post-training period.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed.

RESULTS

During the study period, 113 085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p < 0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p < 0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p < 0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm.

CONCLUSIONS

Systematic simulation-based training of midwives and doctors can translate into improved individual and team performance and can significantly reduce the incidence of permanent BPBI.

Ultrasound assessment of glenohumeral dysplasia in infants

Brachial plexus birth injury can lead to irreversible neuromuscular dysfunction and skeletal deformity of the upper extremity and shoulder girdle, ultimately resulting in glenohumeral dysplasia. Diagnosis and treatment of affected infants requires a multi-disciplinary approach in which imaging plays a vital role. While MRI is excellent for assessing both the shoulder and spine of these children, it is costly and requires sedation and is thus typically reserved for preoperative planning. US, however, is inexpensive, dynamic and readily available and provides excellent visualization of the largely cartilaginous glenohumeral joint. As such, it has become a highly useful modality during early diagnosis and follow-up of children with brachial plexus birth injuries. In this review, we describe the relevant anatomy of the glenohumeral joint, outlining the normal sonographic appearance as well as providing tips and tricks for identifying and characterizing pathology.

Treatment of obstetrical brachial plexus palsy sequelae: Preliminary results about 18 cases

Background

Severe obstetrical injuries of the brachial plexus lead to a complete or incomplete paralysis resulting in a significant functional handicap of the limb.

This study aimed to assess the preliminary results of our management.

Materials and methods

This prospective study involved 18 patients, with an average age of 7.7 years. The choice of the surgical technique depended on the type of palsy. We evaluated our patients using the Mallet, Gilbert-Raimondi, Brachial plexus World Group Heerlen, and Raimondi scores.

Results

Patients in groups I and II of Narakas had an anterior shoulder release (n = 2) and transfer of the latissimus dorsi (n = 8). For those in group III, we performed 5 biceps rerouting and 2 radius derotation osteotomies, one of which was associated with a Zancolli I and an arthrodesis of the thumb MCP joint. In the wrist and hand, we performed two tendon transfers from the flexor carpi ulnaris to the extensor tendons of the fingers.

After a mean follow-up of 30.52 months, in the first 9 patients, active external rotation of the shoulder increased from a mean value of −22.5°–38.8° and mean active abduction from 78.3° to 141.1°. In Group III, the mean spontaneous supination position of 75.5° was improved to 45° pronation. Regarding the two patients with tendon transfers, active wrist extension increased from 0° to 45° and from −60° to 0°, respectively.

Conclusion

Palliative surgery in the treatment obstetrical brachial plexus palsy sequelae retains an important place in the restoration of upper limb function.

•

Obstetrical brachial plexus palsy lead to a complete or incomplete paralysis.

•

Several techniques are proposed to improve the upper limb functions.

•

Functional results depend on the severity of the injury and the age of the patient.

•

Palliative surgery redistributes remaining muscular forces.

•

Treatment requires a collaboration between doctor, physiotherapist and parents.

Location of brachial plexus birth injury affects functional outcomes in a rat model

Brachial plexus birth injury (BPBI) results in shoulder and elbow paralysis with shoulder internal rotation and elbow flexion contracture as frequent sequelae. The purpose of this study was to develop a technique for measuring functional movement and examine the effect of brachial plexus injury location (preganglionic and postganglionic) on functional movement outcomes in a rat model of BPBI, which we achieved through integration of gait analysis with musculoskeletal modeling and simulation. Eight weeks following unilateral brachial plexus injury, sagittal plane shoulder and elbow angles were extracted from gait recordings of young rats (n = 18), after which rats were sacrificed for bilateral muscle architecture measurements. Musculoskeletal models reflecting animal-specific muscle architecture parameters were used to simulate gait and extract muscle fiber lengths. The preganglionic neurectomy group spent significantly less (p = 0.00116) time in stance and walked with significantly less (p < 0.05) elbow flexion and shoulder protraction in the affected limb than postganglionic neurectomy or control groups. Linear regression revealed no significant linear relationship between passive shoulder external rotation and functional shoulder protraction range of motion. Despite significant restriction in longitudinal muscle growth, normalized functional fiber excursions did not differ significantly between groups. In fact, when superimposed on a normalized force-length curve, neurectomy-impaired muscle fibers (except subscapularis) accessed regions of the curve that overlapped with the control group. Our results suggest the presence of compensatory motor control strategies during locomotion following BPBI. The clinical implications of our findings support emphasis on functional movement analysis in treatment of BPBI, as functional and passive outcomes may differ substantially.

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 Palsy: Practical Concepts for Radiologists

Brachial plexus birth palsy (BPBP) is classified as a preganglionic or postganglionic injury based on the site of injury. Most patients recover spontaneously and are followed up with clinical evaluation; however, permanent sequelae are not uncommon. For patients with persistent neurologic deficits, clinical and radiologic evaluation is crucial. Untreated BPBP can progress to significant sequelae, such as muscle contractures and glenohumeral dysplasia (GHD). Timely characterization of these entities based on different imaging modalities is a high priority for optimal patient outcomes. We describe the anatomy and pathogenesis, as well as the different imaging modalities involved in the evaluation and classification of BPBP and GHD.

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.

Glenohumeral abduction contractures after residual neonatal brachial plexus injury

Glenohumeral abduction contractures are common in patients with neonatal brachial plexus injury, but little has been previously published about them. We conducted a retrospective analysis of data prospectively collected from 205 consecutive children (108 female) of mean age 9.6 years with neonatal brachial plexus injury (C5-C6, 58%; C5-C7, 29%; C5-T1, 14%). Most children (69%) showed a glenohumeral abduction contracture, it being more common in those with upper neonatal brachial plexus injury.Level of evidence: III.

Comparing the Results of External Rotational Humeral Osteotomy in Older Children to the Mod Quad and Triangle Tilt Procedures in Adults with Obstetric Brachial Plexus Injury

BACKGROUND

External Rotational Humeral osteotomy is used to address the external rotation deficit in older children with obstetric brachial plexus Injury (OBPI). Although this procedure improves the cosmetic effect of shoulder subluxation, it has no effect on the underlying structural (glenohumeral deformity and scapular elevation and rotation) and functional problems. In this study, improvements in glenohumeral joint alignment; scapular hypoplasia, elevation, and rotation (SHEAR) deformity; and upper extremity functional movements were demonstrated in adult patients with OBPI 1 year after the mod Quad and/or triangle tilt surgeries.

METHODS AND PATIENTS

The outcome of humeral rotational osteotomy reported in the literature was compared with the results from 43 adult patients with OBPI (21 men and 22 women; 23 right and 20 left sides) with a mean age of 21.3 years (range, 17 to 38 years) who underwent mod Quad and/or triangle tilt surgeries and had over 12 months of postoperative follow-up (mean 22.9 months; range, 12 to 50 months).

RESULTS

The preoperative average modified total Mallet score, including supination, was 14.6 ± 3.5 (P < 0.0001) in the 43 adult patients with OBPI in this report. This total Mallet score was significantly improved to 22 ± 3.9 (P < 0.0001) over 12 months after mod Quad and/or triangle tilt surgeries. Thirty-two (75%) of the patients showed great improvement in all upper extremity functions: shoulder abduction, external rotation, hand-to-mouth, hand-to-neck, hand-to-spine, and supination. The improvement after humeral osteotomy reported in the literature was a cosmetic effect that did not address the underlying structural and functional problems and was found to decrease the improved shoulder abduction in long-term follow-up.

CONCLUSIONS

Thirty-two (75%) of 43 adult patients with OBPI showed great improvement in all upper extremity functions 1 year after mod Quad and/or triangle tilt surgeries. The other 11 patients (25%) showed improvement in hand-to-mouth movement and/or supination. In contrast, humeral osteotomy, as reported in the literature, improved the cosmetic effect of shoulder subluxation but had no effect on the underlying structural and functional problems.

Sex-specific role of myostatin signaling in neonatal muscle growth, denervation atrophy, and neuromuscular contractures

Neonatal brachial plexus injury (NBPI) causes disabling and incurable muscle contractures that result from impaired longitudinal growth of denervated muscles. This deficit in muscle growth is driven by increased proteasome-mediated protein degradation, suggesting a dysregulation of muscle proteostasis. The myostatin (MSTN) pathway, a prominent muscle-specific regulator of proteostasis, is a putative signaling mechanism by which neonatal denervation could impair longitudinal muscle growth, and thus a potential target to prevent NBPI-induced contractures. Through a mouse model of NBPI, our present study revealed that pharmacologic inhibition of MSTN signaling induces hypertrophy, restores longitudinal growth, and prevents contractures in denervated muscles of female but not male mice, despite inducing hypertrophy of normally innervated muscles in both sexes. Additionally, the MSTN-dependent impairment of longitudinal muscle growth after NBPI in female mice is associated with perturbation of 20S proteasome activity, but not through alterations in canonical MSTN signaling pathways. These findings reveal a sex dimorphism in the regulation of neonatal longitudinal muscle growth and contractures, thereby providing insights into contracture pathophysiology, identifying a potential muscle-specific therapeutic target for contracture prevention, and underscoring the importance of sex as a biological variable in the pathophysiology of neuromuscular disorders.

Magnetic resonance imaging of the brachial plexus. Part 2: Traumatic injuries

The most common indications for magnetic resonance imaging (MRI) of the brachial plexus (BP) are traumatic injuries. The role of MRI of the BP has increased because of recent trends favoring earlier surgery. Determining preganglionic vs. postganglionic injury is essential, as different treatment strategies are required. Thus, MRI of the BP should be supplemented with cervical spine MRI to assess the intradural part of the spinal nerves, including highly T2-weighted techniques. Acute preganglionic injuries usually manifest as various combinations of post-traumatic pseudomeningocele, the absence of roots, deformity of nerve root sleeves, displacement of the spinal cord, hemorrhage in the spinal canal, presence of scars in the spinal canal, denervation of the back muscles, and syrinx. Spinal nerve root absence is more specific than pseudomeningocele on MRI. Acute postganglionic injuries can present as lesions in continuity or tears. The following signs indicate injury to the BP: side-to-side difference, swelling, partial, or total BP rupture. Injury patterns and localization are associated with the mechanism of trauma, which implies a significant role for MRI in the work-up of patients.

The identification and description of traumatic lesions involving the brachial plexus need to be systematic and detailed. Using an appropriate MRI protocol, obtaining details about the injury, applying a systematic anatomical approach, and correlating imaging findings to relevant clinical data to make a correct diagnosis. Information about the presence or suspicion of root avulsion should always be provided.

•

Trauma is the most common indication for MRI of the brachial plexus.

•

MRI of the brachial plexus should include cervical spine MRI.

•

Spinal nerve root absence is seen in preganglionic injuries.

•

Determining preganglionic vs. postganglionic injury is essential for treatment planning.

•

Appropriate MRI rapport is crucial in communication with the clinician.

The evaluation and management of neonatal brachial plexus palsy

Neonatal brachial plexus palsy presents at birth and can be a debilitating condition with long-term consequences. Presentation at birth depends on the extent of nerve injury, and can vary from transient weakness to global paresis, with active range of motion affected. Serial clinical examination after birth and during the neonatal period (first month of life) is crucial to assess recovery and predicts long-term outcomes. This position statement guides the evaluation of neonates for risk factors at birth, early referral to a multidisciplinary specialized team, and ongoing communication between community providers and specialists to optimize childhood outcomes.

Knowledge of neonatal brachial plexus palsy among medical professionals in North America

PURPOSE

Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP.

METHODS

A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge.

RESULTS

Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation.

CONCLUSIONS

Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

L'évaluation et la prise en charge de la paralysie néonatale du plexus brachial

La paralysie néonatale du plexus brachial, qui se manifeste à la naissance, peut être débilitante et avoir des conséquences prolongées. La présentation à la naissance dépend de l'importance de la lésion nerveuse et peut varier entre une faiblesse transitoire et une parésie globale qui touche l'amplitude active des mouvements. Il est essentiel de procéder à des examens cliniques sériels après la naissance et pendant la période néonatale (jusqu'à l'âge d'un mois) pour évaluer le rétablissement et prédire le pronostic à long terme. Le présent document de principes décrit l'évaluation des facteurs de risque des nouveau-nés à la naissance, l'orientation précoce vers une équipe multidisciplinaire spécialisée et les communications entre les intervenants communautaires et les spécialistes pour optimiser le pronostic pendant l'enfance.

Neonatal Birth Trauma: Analysis of Yearly Trends, Risk Factors, and Outcomes

OBJECTIVE

To evaluate the trends, proportions, risk factors, resource utilization, and outcomes of neonatal birth trauma in the US.

STUDY DESIGN

This cross-sectional study of in-hospital births used the Nationwide Inpatient Sample for 2006-2014. We divided the cases by type of birth trauma: scalp injuries and major birth trauma. Linear regression for yearly trends and logistic regression were used for risk factors and outcomes. A generalized linear model was used, with a Poisson distribution for the length of stay and a gamma distribution for total spending charges.

RESULTS

A total of 982 033 weighted records with neonatal birth trauma were found. The prevalence rate increased by 23% from (from 25.3 to 31.1 per 1000 hospital births). Scalp injuries composed 80% of all birth traumas and increased yearly from 19.87 to 26.46 per 1000 hospital births. Major birth trauma decreased from 5.44 to 4.67 per 1000 hospital births due to decreased clavicular fractures, brachial plexus injuries, and intracranial hemorrhage. There were significant differences in demographics and risk factors between the 2 groups. Compared with scalp injuries, major birth trauma was associated with higher odds of hypoxic-ischemic encephalopathy, seizures, need for mechanical ventilation, meconium aspiration, and sepsis. Length of stay was increased by 56%, and total charges were almost doubled for major birth trauma.

CONCLUSIONS

Neonatal birth trauma increased over the study period secondary to scalp injuries. Major birth trauma constitutes a significant health burden. Scalp injuries are also associated with increased morbidity and might be markers of brain injury in some cases.

Modified constraint-induced movement therapy during hospitalization in children with perinatal brachial plexus palsy: A randomized controlled trial

STUDY DESIGN

Prospective single-blind, randomized controlled study.

INTRODUCTION

Children with perinatal brachial plexus palsy (PBPP) have motion limitations in the affected upper extremity. Modified constraint-induced movement therapy (mCIMT) is one of the treatment options used for the improvement of the function of the affected limb.

PURPOSE OF THE STUDY

The purpose of this study was to compare the effect of mCIMT and conventional therapy in improving active range of motion (ROM) and functional use of the affected upper extremity in children with PBPP with injuries to upper and middle trunks in the hospital environment.

MATERIALS

26 patients received conventional rehabilitation program (control group) and 13 patients participated in a mCIMT program (study group). Children had a mean age 56.3 months (range 4-10 years). The mCIMT included 1 hour therapy sessions emphasizing the affected arm use for 14 consecutive days during hospitalization. Their normal arm was also constrained for 6 hour per day. All the patients were assessed at the baseline, one day, one month, and three months after completion of therapy using active ROM, active movement scale, hand dynamometer, box and blocks test.

RESULTS

The mCIMT group improved more than the control group in shoulder internal rotation, forearm supination, elbow flexion active ROMs, hand grip strength, and in upper extremity function.

CONCLUSION

mCIMT has a potential to promote functional gains for children with PBPP; this approach should be widely applied within routine clinical practice.

Recommendations for management of neonatal brachial plexus palsy: Based on clinical review

STUDY DESIGN

Descriptive report.

INTRODUCTION

Neonatal brachial plexus palsy (NBPP) involves a partial or total injury of the nerves that originate from spinal roots C5-C8 and T1. The reported incidence of NBPP is between 0.38 and 5.1 in 1000 births.

PURPOSE OF THE STUDY

This study describes the management NBPP in the first 3 years of life and to develop an assessment framework for infants with NBPP and postoperative guidelines for those undergoing primary surgery.

METHODS

Retrospective medical record audit from 2012 to 2017.

RESULTS

Of 187 children referred to brachial plexus clinic (BPC), 138 were new referrals and included in the audit. The average number of new referrals per annum was 37; average age at referral was 6.61 week; average age at first appointment was 16.9 weeks. Of the 138 infants, 104 were initially assessed by a physiotherapist before attending BPC. The most common comorbidity was plagiocephaly.

DISCUSSION

From 2012 to 2017, birth location, birth facility, referral source, and time between referral and initial assessment have remained stable. The age at referral, age at which the child was first assessed, and the number of children who received services externally before attending the hospital all decreased. The number of children seen by a physiotherapist before attending BPC increased. An NBPP assessment framework, including critical time points for assessment, and postoperative guidelines for infants and children undergoing primary surgery were created.

CONCLUSIONS

Early referral is essential for effective management of NBPP and ideally infants should be assessed and management implemented before 3 months of age.

Developing a decision aid for youth with brachial plexus birth injuries facing treatment decisions for an elbow flexion contracture

BACKGROUND

A common sequela of brachial plexus birth injury (BPBI) is an elbow flexion contracture. Youth with BPBI and their families face rehabilitation or surgical decisions that ideally entail careful deliberation of the risks and benefits of treatment within the context of the child's and family's functional and appearance-related goals.

OBJECTIVE

To develop a patient decision aid (PtDA) following International Patient Decision Aid Standards to help these youth and their families make treatment decisions.

DESIGN

Mixed-methods study.

SETTING

Brachial plexus clinic in a pediatric tertiary care center.

PARTICIPANTS

Five young adults (21-24 years), 14 youth (8-19 years) and their parents, 15 families (children 2-16 years), and 19 clinicians from a brachial plexus clinic participated in the PtDA development. Seventeen other youth (8-18 years) facing treatment decisions regarding their elbow contracture field tested the PtDA prototype.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

In-depth interviews and participant observation to conduct a decisional needs assessment of young adults, youth, parents, and health care professionals involved in these shared decisions. Cognitive interviews to field test the PtDA prototype.

RESULTS

Evidence from previously conducted knowledge synthesis and the youth-focused decisional needs assessment qualitative data informed the development of new PtDA prototype, which included a questionnaire-based values clarification method for youth to rate what matters most to them regarding their elbow function, appearance, psychosocial impact, and treatment options. The majority (90%) of youth >11 years who field tested the PtDA prototype understood its content, whereas only 29% of those between 8 and 11 years demonstrated independent comprehension. The majority (69%) responded that they would prefer to use the PtDA on their own either at home or in the clinic waiting room.

CONCLUSIONS

This new PtDA can be used to help youth with BPBI and their families to make a personal value-based informed decision regarding treatment options for their elbow flexion contracture.

Upper limb kinematics after Latissimus Dorsi transfer in children with brachial plexus birth palsy

BACKGROUND

Brachial plexus birth palsy remains a frequent condition and one of its treatments is to transfer the Latissimus Dorsi tendon to the infraspinatus muscle. The aim of this study was to analyse, for the first time, the three-dimensional kinematic effects of this operation on the upper limb joints during the five Mallet tasks and their correlation with clinical parameters.

METHODS

Kinematic analysis was performed using an electromagnetic device. An Index of Improvement taking into account the angle in preop and postop, the reproducibility and the angle of a control group was developed. Three groups of patients were analysed: sixteen patients (mean: 10,5 years) for the reproducibility, thirty children (mean: 9,5 years) for the control group and ten patients (mean: 8 years 7 months) who were operated.

FINDINGS

The humerothoracic and glenohumeral external rotations improved during the external rotation, the neck and the abduction tasks and worsened during the spine task. The glenohumeral external rotation worsened during the mouth task. The Humerothoracic abduction improved during the abduction and the neck tasks. The elbow flexion improved for the neck task. Differences were observed between patients and correlations were obtained between the Index of Improvement and clinical parameters.

INTERPRETATION

Using kinematics allows to better analyse the evolution of joint angles after the latissimus dorsi transfer. The Index of Improvement allows to quickly analyse the effect of the operation for each angle and each patient. This effect depends on clinical parameters.

Muscle elasticity in patients with neonatal brachial plexus palsy using shear-wave ultrasound elastography. Preliminary results

Ultrasound shear wave elastography (SWE) is a noninvasive, reliable and reproducible method, used for the qualitative and quantitative evaluation of tissues. The aim of this study was to compare muscle elasticity between the healthy and the involved sides in children with neonatal brachial plexus palsy (NBPP) using the elastography tool and to assess whether the difference was correlated with the Mallet grading system. We repeatedly measured the shear modulus coefficient of several muscles around the shoulder in stretched or passively relaxed positions on 14 patients. We evaluated the abductor muscles (supraspinatus and deltoid), the infraspinatus, the pectoralis major and the latissimus dorsi. We found a mean shear modulus significantly higher in most studied muscles in the pathologic side (P < 0.001), especially in the stretched position (P < 0.001). Moreover, the shear modulus increases with the degradation of the Mallet score for the abduction and external rotation tasks. SWE seems to be a reliable and reproducible tool to assess muscle elasticity in NBPP.

Brachial plexus birth palsy: incidence, natural-course, and prognostic factors during the first year of life

OBJECTIVE

To evaluate the incidence of brachial plexus birth palsy (BPBP) in a large, single cohort and stratify clinical 1-year outcomes.

STUDY DESIGN

A cohort study of all births occurring at a single institution between 2011 and 2015. Hospital discharge papers were analyzed, and structured telephone interviews were conducted.

RESULTS

Among 76,000 livebirths, 98 (0.13%) cases of BPBP were diagnosed. Of cases who fully responded to interview (66/98), at 3 months of age 77% infants made a complete recovery, and by 1 year of age an additional 20% had recovered completely. Only 3% of infants had residual longer-term neurological deficits.

CONCLUSIONS

Predictors of a longer course of recovery were the presence of shoulder dystocia (p < 0.04) and right-sided palsy (p < 0.02). Birth weight, neonatal head circumference, and sex were not correlated with outcome. Future reports of BPBP should differentiate between infants showing early recovery from those with true BPBP.

Brachial Plexus Birth Injuries: A Critical Analysis Review

»

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

»

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

»

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

»

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