Navigating the gray zone: a guideline for surgical decision making in obstetrical brachial plexus injuries

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

How Institution of the Sup-ER Protocol in a Clinic Changed Procedure Patterns in Upper Brachial Plexus (Erb's Type) Birth Injuries

BACKGROUND

For children with upper brachial plexus birth injury (BPBI; C5, C6, ±C7 roots), most clinics first recommend nonsurgical treatment followed by primary and/or secondary surgical interventions in selected patients. Since 2008, we have used an infant shoulder repositioning protocol (supination-external rotation [Sup-ER]) designed to prevent shoulder internal rotation contracture and its potential effects on the shoulder joint. This study characterizes our clinic's current choice, number, and timing of primary and secondary procedural interventions (including Botox) and compares Sup-ER protocol patients with those of our historical controls.

METHODS

The records of all patients with upper BPBI who underwent procedures from 2001 to 2018 were retrospectively reviewed and grouped into a historical (2001-2007, n = 20) and recent (2008-2018, n = 23) cohort. Patient demographics, procedure types and timing, and functional outcomes were collected and analyzed.

RESULTS

Since the 2008 institution of the Sup-ER protocol, fewer brachial plexus exploration and grafting (BPEG) surgeries were performed and none in later infancy, where nerve transfers were preferred. There were more and earlier Botox injections. There were fewer tendon transfers, and the preoperative indications were from a higher level of function.

CONCLUSIONS

We now see fewer indications for BPEG surgeries overall. After the 3-month-age group, more direct nerve transfers are indicated instead of the BPEG surgery if nerve surgery is required at all. Shoulder tendon transfer rates have decreased. Humeral osteotomies are not seen in our recent group. Glenoid osteotomies within tendon transfers are rare in both groups.

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.

Surgical Innovations to Restore Function in Pediatric Peripheral Nerve Conditions

Peripheral nerve injuries in children can result in devastating lifelong deficits. Because of the time-sensitive nature of muscle viability and the limited speed of nerve regeneration, early recognition and treatment of nerve injuries are essential to restore function. Innovative surgical techniques have been developed to combat the regenerative length and speed; these include nerve transfers. Nerve transfers involve transferring a healthy, expendable donor nerve to an injured nerve to restore movement and sensation. Nerve transfers are frequently used to treat children affected by conditions, including UE trauma, brachial plexus birth injury, and acute flaccid myelitis. Pediatricians play an important role in the outcomes of children with these conditions through early diagnosis and timely referrals. With this review, we aim to provide awareness of state-of-the-art surgical treatment options that significantly improve the function of children with traumatic nerve injuries, brachial plexus birth injury, and acute flaccid myelitis.

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.

Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury

The majority of children with obstetric brachial plexus injury show some degree of spontaneous recovery. This review explores the available evidence for the use surgical brachial plexus repair to improve outcome. So far, no randomized trial has been performed to evaluate the usefulness of nerve repair. The evidence level of studies comparing surgical treatment with non-surgical treatment is Level IV at best. The studies on natural history that are used for comparison with surgical series are also, unfortunately, of too low quality. Among experts, however, the general agreement is that nerve reconstruction is indicated when spontaneous recovery is absent or severely delayed at specific time points. A major obstacle in comparing or pooling obstetric brachial plexus injury patient series, either surgical or non-surgical, is the use of many different outcome measures. A requirement for multicentre studies is consensus on how to assess and report outcome, both concerning motor performance and functional evaluation.

Neonatal brachial plexus injuries and their impact on growing bone. An experimental study

Neonatal brachial plexus palsy remains a problem, even in light of current advances in perinatal care. While many cases resolve spontaneously, the concern remains on the best means of surgical management for restoration of elbow flexion and shoulder reanimation. The present experimental study in an animal model examines the evidence that supports that neonatal brachial plexus injuries result in structural changes in the affected bone. The study suggests that if the microsurgical reinnervation takes place early enough, these changes may be diminished. On the other hand there is no way to identify at birth, which injuries will be permanent and will need surgical repair and which will spontaneously improve.

Integrated Electromyography: Discriminant Analysis and Prediction of Recovery 3 to 6 Years After Brachial Plexus Birth Injury

PURPOSE

To assess the recovery likelihood, 3 to 6 years after brachial plexus birth injury (BPBI), and predict the functional recovery from integrated electromyography (IEMG).

METHODS

Thirty children with BPBI limited to C5-C6 lesion participated. Maximal electromyography activity of deltoid and biceps brachii was measured at entry. Shoulder and elbow functions were assessed at the baseline and at 4 intervals across 2 years.

RESULTS

Shoulder and elbow function significantly changed across the follow-up period. Shoulder and elbow functions were significantly dependent on deltoid and biceps brachii muscles' IEMG level, respectively, with the groups showing higher IEMG achieving better recovery. The deltoid and biceps IEMG explained a portion of the improvement in shoulder and elbow function over 2 years.

CONCLUSION

Recovery of the shoulder and elbow function continues 3 to 6 years after BPBI. IEMG may partially explain variation in the prognosis for children with BPBI.

Health-care use and information needs of children with neonatal brachial plexus palsy: A cross-sectional survey among 465 Dutch patients

To investigate health-care use (HCU) and information needs of children aged 0-18 years with neonatal brachial plexus palsy (NBPP), a cross-sectional study was performed. Patients and/or parents seen in our NBPP clinic were invited to complete a survey comprising questions on HCU due to NBPP and current information needs. Outcomes were described for three age-groups (0-1/2-9/10-18 years), based on follow-up status (early/late/no-discharge). Four hundred sixty-five parents/patients participated (59 in the 0-1, 226 in the 2-9, and 180 in the 10-18-year group). Two hundred ninety-three patients had C5-C6 lesions, 193 were discharged from follow-up, 83 of whom categorized as 'early discharged' (<1 year of age). Over the past year, 198 patients had contact with the expert team (49 in the 0-1, 81 in the 2-9, and 68 in the 10-18-year group) and 288 with at least one other health-care professional (53 in the 0-1, 133 in the 2-9, and 102 in the 10-18-year group). Of the 83 patients discharged early, 34 reported health-care use. Two hundred twenty-eight participants reported current information needs of whom 23 were discharged early. HCU and information needs of Dutch children with NBPP remains considerable even in children who were discharged. Stricter follow-up and information provision for these patients is needed.

Adjunctive Dorsal Scapular Nerve Transfer to Suprascapular Nerve for Brachial Plexus Birth Injuries: Case Series

PURPOSE

Brachial plexus birth injury (BPBI) may result in permanent functional deficits. Brachial plexus birth injury involving the suprascapular nerve (SSN) is conventionally treated using accessory nerve transfer or excision and nerve grafting. This study analyzed shoulder function in patients with BPBI undergoing dorsal scapular nerve (DSN) to SSN transfer.

METHODS

We performed a retrospective review of all infants referred to the McMaster University Children's Hospital for BPBI between 1999 and 2012. Patients were included if they underwent SSN reconstruction with DSN transfer and functional outcomes were recorded as measured by the active movement scale (AMS).

RESULTS

Of the 266 patients referred, 16 met inclusion criteria. From the initial assessment to final follow-up, average AMS scores improved by 4.1 and 4.4 points for shoulder abduction and external rotation, respectively. In addition, 50% of patients had shoulder abduction greater than half of full range of motion and 43% had external rotation greater than half of full range of motion (AMS scores of 6 or greater). No patient had a secondary surgery; however, 9 of 16 had subsequent botulinum toxin injections.

CONCLUSIONS

Although DSN to SSN nerve transfers were combined with other interventions and the outcomes cannot be attributed solely to this nerve transfer alone, it presents an alternative approach to SSN reinnervation under circumstances in which the accessory nerve is unavailable, damaged, or suboptimal. Successful results were achieved; thus, further exploration and study are warranted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children

PURPOSE

The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years.

METHODS

We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months.

RESULTS

The majority of cases were complete lesions (56/53.8%). Erb's palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb's palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases.

CONCLUSIONS

There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).

Surgical Technique and Anatomical Considerations for the Modified L'Episcopo Tendon Transfer

BACKGROUND

Birth brachial plexus injury usually affects the upper trunks of the brachial plexus and can cause substantial loss of active shoulder external rotation and abduction. Due to the unbalanced rotational forces acting at the glenohumeral joint, the natural history of the condition involves progressive glenohumeral joint dysplasia with associated upper limb dysfunction. Surgical reconstruction methods have been described previously by Sever and L'Episcopo, and modified by Hoffer and Roper to release the adduction contracture and to restore external rotation and shoulder abduction.

METHODS

The authors describe their preferred technique for contracture release and tendon transfer to improve external rotation and shoulder abduction. Pertinent anatomy and highlights of surgical exposure are reviewed.

RESULTS

The senior author has utilized this technique with consistent clinical outcomes to improve shoulder function for patients with persisting nerve palsy associated with birth brachial plexus injury. A review of the literature supports utilization of this technique.

CONCLUSIONS

Transfer of the latissimus dorsi and teres major to the posterior rotator cuff for reanimation of shoulder abduction and external rotation deficits associated with birth brachial plexus injury is a safe and reliable technique. Careful patient selection and attention to surgical detail are critical for optimal outcomes.

Neonatal Magnetic Resonance Imaging Without Sedation Correlates With Injury Severity in Brachial Plexus Birth Palsy

PURPOSE

Which infants with brachial plexus birth palsy (BPBP) should undergo microsurgical plexus reconstruction remains controversial. The current gold standard for the decision for plexus reconstruction is serial clinical examinations, but this approach obviates the possibility of early surgical treatment. We hypothesize that a new technique using 3-dimensional volumetric proton density magnetic resonance imaging (MRI) without sedation can evaluate the severity of BPBP injury earlier than serial clinical examinations.

METHODS

Infants were prospectively enrolled prior to 12 weeks of age and imaged using 3 Tesla MRI without sedation. Clinical scores were collected at all visits. The imaging findings were graded based on the number of injured levels and the severity of each injury, and a radiological score was calculated. All infants were followed at least until the decision for surgery was made based on clinical examination.

RESULTS

Nine infants completed the MRI scan and clinical follow-up. The average Toronto score at presentation was 4.4 out of 10 (range, 0-8.2); the average Active Movement Scale score was 50 out of 105 (range, 0-86). Four infants required surgery: 2 because of a flail limb and Horner syndrome and 2 owing to failure to recover antigravity elbow flexion by age 6 months. Radiological scores ranged from 0 to 18 out of a maximum score of 25. The average radiological score for those infants who required surgery was 12 (range, 6.5-18), whereas the average score for infants who did not require surgery was 3.5 (range, 0-8).

CONCLUSIONS

Three-dimensional proton density MRI can evaluate spinal nerve roots in infants without the need for radiation, contrast agents, or sedation. These data suggest that MRI can help determine the severity of injury earlier than clinical examination in infants with BPBP, although further study of a larger sample of infants with varying severity of disease is necessary.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline

OBJECTIVE

The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise.

SETTING

The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries.

PARTICIPANTS

The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres.

OUTCOME MEASURES

An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed.

RESULTS

7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery.

CONCLUSIONS

The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.

The natural history and management of brachial plexus birth palsy

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

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Birth brachial plexus palsy: a race against time

A 5-year-old child presented to us with weakness of the left upper limb since birth. With the given history of obstetric trauma and limb examination, a diagnosis of birth brachial plexus palsy was made. Brachial plexus exploration along with microsurgery was performed at the same time which included extrinsic neurolysis of the roots and trunks and nerve transfer for better shoulder external rotation and elbow flexion. Both the movements were severely restricted previously due to co-contractures with the shoulder internal rotators and triceps. The problem of birth brachial plexus palsy is proving to be a global health burden both in developed countries and in developing countries such as India. The lack of awareness among the general public and primary healthcare providers and inadequate orthopaedic and neurosurgeons trained to treat the condition have worsened the prognosis. This case lays stress on the delayed complications in birth brachial palsy and its effective management.

Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system

OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada's 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group's guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, "good" if assessed by the time the patient was 1 month of age, "satisfactory" if by 3 months of age, and "poor" if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%-60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was "good" in 28%, "satisfactory" in 66%, and "poor" in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.

Primary Nerve Repair for Obstetrical Brachial Plexus Injury: A Meta-Analysis

BACKGROUND

Nerve repair may be effective in improving function following obstetrical brachial plexus injury. No previous review has directly compared nerve repair to nonoperative management for similar patients, and no previous analysis has been adequately powered to determine whether nerve repair reduces impairment.

METHODS

Electronic databases were searched (MEDLINE, Embase, CINAHL, and Cochrane Central). Eligible studies were randomized controlled trials, observational studies, and case series (n > 9); included patients younger than 2 years undergoing nerve repair or nonoperative management of obstetrical brachial plexus injury; and reported functional impairment. Two reviewers independently screened articles using objective a priori criteria. Bias was assessed for each study. Overall quality of evidence was evaluated for each outcome.

RESULTS

Among nine cohort studies including 222 patients, nerve repair significantly reduced functional impairment compared with nonoperative management (relative risk, 0.58; 95 percent CI, 0.43 to 0.79; p < 0.001; I = 0 percent; absolute risk reduction, 19 percent; number needed to treat, six). Findings are consistent with comparison of similar patients from case series. With operative management, no deaths were reported; major adverse events were reported in 1.5 percent, and minor adverse events were reported in 5.0 percent of cases. Among demographic (all severities) samples managed nonoperatively, residual impairment remains in 27 percent (19 to 36 percent).

CONCLUSIONS

Nerve repair reduces functional impairment in obstetrical brachial plexus injury. Nonoperative management in patients with a deficit at 3 months of age leads to a high proportion of functional impairment. Mortality is not a common risk of modern pediatric microsurgical nerve repair. Residual impairment with nonoperative management is underestimated in the reported literature.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

"Popeye muscle" morphology in OBPI elbow flexion contracture

BACKGROUND

The pathophysiology of elbow flexion contracture (EFC) in obstetrical brachial plexus injury (OBPI) is not established. In basic science models, neonatal denervation leads to impaired muscle growth. In clinical studies, diminished growth is correlated with extent of denervation, and improved with surgical repair. In EFC, the biceps are clinically short and round vs the contralateral size, termed the "Popeye muscle". The objective of this study was to determine if the biceps morphology (muscle belly and tendon length) in arms with EFC secondary to OBPI is different vs the contralateral.

METHODS

This is a retrospective matched-cohort study. Patients with unilateral EFC (>20°) secondary to OBPI were identified (median = 6.6 years, range = 4.7-16.8). A blinded radiologist used computed tomography to measure length of the biceps short head muscle belly, and tendon bilaterally using standardised anatomical landmarks.

RESULTS

Twelve patients were analyzed. The biceps muscle belly in the injured arm was shorter in all patients vs contralateral, mean difference = 3.6 cm (80%), p < 0.001. The biceps tendon in the injured arm was longer in all patients vs contralateral, mean difference = 1.13 cm (127%), p < 0.001. The total biceps length in the injured arm was shorter in all patients vs contralateral, mean difference = 2.5 cm (89%), p < 0.001.

CONCLUSIONS

This is the first human study confirming growth discrepancy of an elbow flexor in EFC. Distinct biceps morphology is demonstrated, with a significantly shorter muscle belly and overall length, but longer tendon vs normal. This is termed the "Popeye muscle" for its irregular morphology. Findings are consistent with impaired limb growth in denervation.

Late reconstruction of brachial plexus birth palsy

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

Results of nerve reconstructions in treatment of obstetrical brachial plexus injuries

BACKGROUND

The aim of this study was to evaluate the results achieved using various surgical techniques in patients with partial and total obstetrical brachial plexus palsy.

METHODS

From 2000 to 2013, 33 patients with obstetrical brachial plexus injury underwent surgery. Twenty had follow-up periods greater than 24 months and met the criteria for inclusion in the study. All patients were evaluated using the Active Movement Scale.

RESULTS

The outcomes of different nerve reconstructive procedures including nerve transfers, nerve grafting after neuroma resection and end-to-side neurorrhaphy are presented. The overall success rate in upper plexus birth injury was 80 % in shoulder abduction, 50 % in external rotation and 81.8 % in elbow flexion with median follow-ups of 36 months. Success rate in complete paralysis was 87 % in finger and thumb flexion, 87 % in shoulder abduction and 75 % in elbow flexion; the median follow-up was 46 months. Useful reanimation of the hand was obtained in both patients who underwent end-to-side neurotization.

CONCLUSION

Improved function can be obtained in infants with obstetrical brachial plexus injury with early surgical reconstruction.

Clinical assessment of the infant and child following perinatal brachial plexus injury

STUDY DESIGN

Literature review.

INTRODUCTION

After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome.

PURPOSE

To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians.

METHODS

We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians.

DISCUSSION

With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.

Evaluation and management of brachial plexus birth palsy

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

Utility of delayed surgical repair of neonatal brachial plexus palsy

OBJECT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy

OBJECT

The debate addressed in this article is that of surgical treatment methods for a neuroma-in-continuity. The authors of this study chose to test the hypothesis that more severe nerve injuries, as distinguished by < 50% conduction across a neuroma-in-continuity, could be treated with neuroma resection and grafting, whereas less severe nerve injuries, with > 50% conduction across the neuroma, could be treated with neurolysis alone.

METHODS

The goal of this study was to compare preoperative and postoperative Active Movement Scale (AMS) scores in children with upper trunk brachial plexus birth injuries treated with neurolysis alone if the neuroma's conductivity was > 50% on intraoperative nerve testing. Seventeen patients (7 male, 10 female) met the criteria for inclusion in this study. Surgery was done when the patients were an average of 10 months old (range 6-19 months). The authors analyzed AMS scores from the preoperative assessment, 1-year postoperative follow-up visit, and subsequent follow-up assessment as close to 3 years after surgery as possible (referred to in this paper as > 2-year postoperative scores).

RESULTS

Comparison of preoperative and 1-year follow-up data showed significant improvement in shoulder abduction, flexion, external rotation, and internal rotation; elbow flexion and supination; and wrist extension. Comparison of preoperative findings and results of assessment at > 2-year follow-up showed significant improvement in shoulder abduction, flexion, external rotation; and elbow flexion and supination. At final follow-up, useful function (AMS score of 6 or 7) was achieved for elbow flexion in 14 of 16 patients, shoulder flexion in 11 of 15 patients, shoulder abduction in 11 of 16 patients, and shoulder external rotation in 5 of 15 patients.

CONCLUSIONS

This report indicates that there is a subgroup of patients who can benefit clinically, with functional improvement of shoulder and elbow function, from treatment with neurolysis alone for upper trunk lesions demonstrating more than 50% conduction across the neuroma on intraoperative nerve testing. Patients with less than 50% conduction, indicating more severe disease, are treated with nerve resection and grafting in the authors' treatment algorithm.

The evidence for nerve repair in obstetric brachial plexus palsy revisited

Strong scientific validation for nerve reconstructive surgery in infants with Obstetric Brachial Plexus Palsy is lacking, as no randomized trial comparing surgical reconstruction versus conservative treatment has been performed. A systematic review of the literature was performed to identify studies that compare nerve reconstruction to conservative treatment, including neurolysis. Nine papers were identified that directly compared the two treatment modalities. Eight of these were classified as level 4 evidence and one as level 5 evidence. All nine papers were evaluated in detail to describe strong and weak points in the methodology, and the outcomes from all studies were presented. Pooling of data was not possible due to differences in patient selection for surgery and outcome measures. The general consensus is that nerve reconstruction is indicated when the result of nerve surgery is assumedly better than the expected natural recovery, when spontaneous recovery is absent or severely delayed. The papers differed in methodology on how the cut-off point to select infants for nerve reconstructive surgical therapy should be determined. The justification for nerve reconstruction is further discussed.

Psychometric properties of outcome measures for children and adolescents with brachial plexus birth palsy: a systematic review

AIM

The aim of this review was to evaluate the psychometric properties of outcome measures used to quantify upper limb function in children and adolescents with brachial plexus birth palsy (BPBP).

METHOD

Eleven electronic databases were searched to identify studies on the effects of conservative management to improve upper limb function in young people with BPBP. Outcome measures used in these studies were extracted and used in a subsequent search to identify studies that evaluated the psychometric properties of these measures. The methodological quality of these studies was rated using a standardized critical appraisal tool.

RESULTS

Thirty-three outcome measures and 12 psychometric studies were identified. Nine outcome measures had some psychometric evidence, which was variable in quality. The outcome measures which seem to have the most robust psychometric properties include the Active Movement Scale, Assisting Hand Assessment, Pediatric Evaluation of Disability Index, and the Pediatric Outcomes Data Collection Instrument.

INTERPRETATION

Further research is required to determine the psychometric properties of outcome measures used for children and adolescents with BPBP. Caution is required when interpreting the results of commonly used outcome measures in this population owing to their relatively unknown psychometric properties.

Current concepts in the management of brachial plexus birth palsy

Brachial plexus birth palsy, although rare, may result in substantial and chronic impairment. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed to help the child maximize function in the affected upper extremity. Many present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery remain unresolved in infants with brachial plexus birth palsies. Recent literature has enhanced our understanding of the pathoanatomy and natural history of the injury as well as the surgical indications, expected outcomes, and complications; this literature has led to improved care of these patients. Based on the present evidence, recommendations for both microsurgery and shoulder reconstruction with tendon transfer and arthroscopic and open reductions are presented.