A Review of Brachial Plexus Birth Palsy: Injury and Rehabilitation

Brachial plexus injuries during the birthing process can leave infants with upper extremity deficits corresponding to the location of the lesion within the complex plexus anatomy. Manifestations can range from mild injuries with complete resolution to severe and permanent disability. Overall, patients have a high rate of spontaneous recovery (66-92%).1,2 Initially, all lesions are managed with passive range motion and observation. Prevention and/or correction of contractures with occupational therapy and serial splinting/casting along with encouraging normal development are the main goals of non-operative treatment. Surgical intervention may be war- ranted, depending on functional recovery. [Full article available at http://rimed.org/rimedicaljournal-2017-11.asp].

Shoulder and elbow kinematics during the Mallet score in obstetrical brachial plexus palsy

BACKGROUND

The physical signs of obstetrical brachial plexus palsy range from temporary upper-limb dysfunction to a lifelong impairment and deformity in one arm. The aim of this study was to analyze the kinematics of the upper limb and to evaluate the contribution of glenohumeral and scapulothoracic joints of obstetrical brachial plexus palsy children.

METHODS

Six children participated in this study: 2 males and 4 females with a mean age of 11.7years. Three patients had a C5, C6 lesion and 3 had a C5, C6, C7 lesion. They were asked to perform five tasks based on the Mallet scale and the kinematic data were collected using the Fastrak electromagnetic tracking device.

FINDINGS

The scapulothoracic protraction and posterior tilt were significantly increased in the involved limb during the hand to mouth task (p=0.006 and p=0.015 respectively). The scapulothoracic Protraction/glenohumeral Elevation ratio was significantly increased in the involved limb during the hand to neck task (p=0.041) and the elevation task (p=0.015). The ratios of scapulothoracic Tilt on the three glenohumeral excursion angles were significantly increased during the hand to mouth task (p≤0.041). The scapulothoracic Mediolateral/glenohumeral Elevation ratio was significantly increased in the involved limb during the elevation task (p=0.038). The glenohumeral elevation excursion was significantly decreased in the involved limb during the hand to neck task (p<0.001) and the elevation task (p=0.0003).

INTERPRETATION

This study gives us information about the greater contribution of the scapulothoracic joint to shoulder motion for affected arm of obstetrical brachial plexus palsy patients compared to their unaffected arm. Kinematic analysis could be useful in shoulder motion evaluation during the Mallet score and to evaluate outcomes after surgery.

The Towel Test: A Useful Technique for the Clinical and Electromyographic Evaluation of Obstetric Brachial Plexus Palsy

The towel test consists of covering an infant’s face with a towel and seeing if he/she can remove it with either arm. In this study it has been used to aid the clinical and electromyographic assessment of 21 infants with obstetric brachial plexus palsy. At 2 to 3 months, none of the 21 infants succeeded in removing the towel, either with their normal or affected arm. At 6 months, all the infants succeeded in removing the towel with their normal arm, but 11 could not with their affected arm, and the same was observed at a further assessment at 9 months. The towel test is a reliable technique for evaluating children with obstetric brachial plexus injuries.

Obstetrical brachial plexus palsy: lessons in functional neuroanatomy

Obstetrical branchial plexus paralysis is a serious and possibly disabling disorder. While thoroughly described as a clinical entity, much concerning its pathogenesis is still unknown. Basic science studies alongside with studies on functional neuroanatomy of peripheral and central nervous system and their interactions lead to deeper understanding of its pathology. Research concentrates on the consequences of branchial plexus traction to peripheral nerves and muscles function and viability and rehabilitation options. Changes obstetrical branchial plexus paralysis causes to central nervous systems organisation have been, to some extent, investigated. It seems that central nervous system is not "blind" after obstetrical branchial plexus paralysis but instead proceeds to remodelling so to adapt to new needs. Research indicates that both this entity and organism's response are much more complicated than previously believed. Current treatment options include microsurgery and palliative surgery but their improvement is possible by focusing on central nervous system. Current report discusses these topics and tries to reach useful conclusions.

A five-year retrospective review of infants with Erb-Duchenne's palsy at a teaching hospital in North Trinidad

Birth injuries are devastating to parents and carers alike. They carry the possibility of residual loss of function to the infant and thus the potential for litigation. The aim of this study was to determine the incidence of Erb-Duchenne's palsy and the identification of any contributing factors. A retrospective review over a five-year period, 2005-2009, was performed and an incidence of 0.94 per 1000 live births was noted. An association between both macrosomia and shoulder dystocia and the development of Erb-Duchenne palsy in the newborn was noted. The authors recommended the use of partograms and improved note documentation in the management of labour.

Motor Evoked Potentials After Transcranial Magnetic Stimulation Support Hypothesis of Coexisting Central Mechanism in Obstetric Brachial Palsy

Six infants with obstetric brachial palsy, ranging from 4 to 7 months of age, were investigated. One was suspected of having extensive brachial plexus lesions and five were suspected of having a unilateral lesion of both roots C5 and C6. All were referred to our center to investigate the possibility for reconstructive surgery. In all infants, even at this age, transcranial magnetic stimulation resulted in motor evoked potentials (MEP) in the biceps (in one, in the brachioradial) muscles. Averaging could not be done because of the intraindividual variation in latency. The MEP was easier to recognize if evoked when the infant had the arm bent. In all five infants suspected of upper brachial plexus lesion with avulsion of both roots C5 and C6 and/or complete rupture of the upper trunk, proven in four, an MEP on the lesioned side could be evoked. Combined with earlier investigations showing (almost) normal EMG and somatosensory evoked potentials in infants with upper plexus lesion, this leads us to the conclusion that the paralysis of these infants cannot only be attributed to the peripheral axonal damage alone but that central plasticity must also play an important role. As this is a slow process, some infants might not yet be able to use the paralytic muscles. Some theoretic issues are discussed.

Outcome of subscapularis muscle release for shoulder contracture secondary to brachial plexus palsy at birth

Children with unresolved brachial plexus palsy frequently develop a disabling internal rotation contracture of the shoulder. Several surgical options, including soft tissue procedures such as muscle releases and/or transfers, and bone operations such as humeral osteotomy are available to correct this deformity. This study describes the effect of subscapularis muscle release performed in isolation. Thirteen patients (5 boys, 8 girls) were reviewed at an average of 3.5 years after their surgery (range, 2-7 years). Their mean age at operation was 4.7 years (range, 1-8 years). Three children had C5-C6 palsies, 8 had C5-C7 palsies, and 2 had C5-C8 palsies. Postoperatively, patients presented significant gains in shoulder active lateral rotation (+49 degrees, from 5 to 54 degrees), active abduction (+30 degrees, from 63 to 93 degrees), active flexion (+46 degrees, from 98 to 144 degrees), and active extension (+23 degrees, from 7 to 30 degrees). Gains were also observed in passive range of motion, but of a lesser degree. Subscapularis muscle release is a procedure we found to have few significant complications and was highly effective in increasing active range of motion and restoring shoulder function.

Interobserver reliability of the Mallet score

The interobserver reliability of the Mallet score for active shoulder function was assessed by three experienced observers in a group of 30 children with an obstetric brachial plexus lesion (mean age 7.1 years, range 4.5-10 years). Interobserver reliability, measured using weighted kappa, was good. Kappa varied between 0.37 and 0.84 and differed between the different aspects of the Mallet score and different pairs of observers. In decreasing order, mean weighted kappa was 0.75 for abduction, 0.73 for hand to neck, 0.67 for hand to spine, 0.6 for external rotation and 0.53 for hand to mouth.

Role of intraoperative neurophysiology in primary surgery for obstetrical brachial plexus palsy (OBPP)

OBJECTIVE

Management of conducting neuroma-in-continuity in primary surgery for obstetrical brachial plexus palsy (OBPP) is still discussed controversially. We present our experience with intraoperative neurophysiological recordings in the management of lesions in continuity in OBPP.

METHODS

A series of ten children with lesions in continuity of the upper brachial plexus is presented. Due to recordable compound nerve action potentials (CNAPs) and muscle response to motor stimulation across the neuroma, five children underwent external neurolysis of neuroma only (neurolysis group). Due to lack of recordable CNAPs or muscle response, resection of neuroma and interpositional nerve grafting were performed in another five children (resection and grafting group). Functional recovery after at least 30 months of follow-up was assessed.

RESULTS

There was a marked difference in functional recovery between the neurolysis and the resection and grafting group. Especially, recovery of shoulder function was disappointing after external neurolysis of conducting neuroma-in-continuity. At the end of follow-up, results of shoulder and elbow function after resection of neuroma followed by interpositional nerve grafting were better without exception.

CONCLUSION

Intraoperative neurophysiological recordings face certain difficulties when used in small children with OBPP. Due to overoptimistic assessment of prognosis after intraoperative CNAP recordings and motor stimulation, the functional results after neurolysis of conducting neuroma-in-continuity are disappointing. Resection of neuroma-in-continuity, conducting or not, offers the best opportunity for maximal functional recovery of the compromised upper limb in OBPP. The role of intraoperative neurophysiological techniques should be confined to the diagnosis of root avulsions.

What factors are associated with neonatal injury following shoulder dystocia?

OBJECTIVE

To identify factors associated with the development of neonatal injury in the setting of shoulder dystocia.

STUDY DESIGN

Medical record ICD-9 codes and a computerized perinatal database were reviewed to identify cases of shoulder dystocia from January 1996 to January 2001 in a tertiary care center. For confirmation of the diagnosis and collection of data, both maternal and neonatal charts were then reviewed and neonatal injuries categorized as either neurological (brachial plexus injury) or skeletal (clavicular fracture, humeral fracture). Shoulder dystocia cases were divided into groups based on the presence of neonatal injury at delivery or at discharge (with or without Erb's palsy). The group with neonatal injury was compared for demographic and obstetrical factors to the group without injury (control). chi (2) test, Mann-Whitney test and logistic regression were used as appropriate.

RESULTS

During this 5-year period, there were 25,995 deliveries and 206 (0.8%) confirmed cases of shoulder dystocia. Of these cases, 36 (17.5%) had neonatal injury diagnosed at delivery and 25 (12%) remained with significant residual injury at discharge. Of these there were 19 cases of Erb's palsy and six cases of clavicular fracture. No association was found between neonatal injury and maternal age, ethnicity, diabetes, operative vaginal delivery or number of obstetrical maneuvers. However, maternal body mass index >30 kg/m2, a second stage of labor >20 min and a birth weight >4500 g were all associated with an increased risk of neonatal injury at delivery and at discharge, including Erb's palsy. After logistic regression analysis, only a second stage of delivery >20 min remained significantly associated with neonatal injury at discharge.

CONCLUSION

In our population, maternal obesity was associated with an increased risk of neonatal injury after shoulder dystocia. In addition, a short second stage of labor (<20 min) was associated with a lower rate of neonatal injury.

Pediatric Evaluation of Disability Inventory: its application to children with obstetric brachial plexus palsy

PURPOSE

A standardized method of measurement of self-care ability in children with obstetric brachial plexus palsy (OBPP) has not been universally adopted. A study was conducted to determine if the Pediatric Evaluation of Disability Inventory (PEDI) was able to discriminate between the self-care ability of children with OBPP and their peers and distinguish between those with differing severities of OBPP.

METHODS

The PEDI self-care domain results for 45 children with OBPP (30 without hand impairment, 15 with hand impairment) were reviewed retrospectively.

RESULTS

The group performance of children without hand impairment was within 1 SD above the mean. The group performance of children with hand impairment was more than 2 SDs below the mean. The difference between the 2 groups was statistically significant.

CONCLUSIONS

In this study children without hand impairment did not have a self-care activity limitation as measured by the PEDI. A deficit in self-care ability was found in those with hand impairment. The PEDI was able to differentiate between the performances of reported self-care activities of children with differing severities of OBPP; however, it was unable to discriminate between those without hand impairment and their peers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic, Level II.

Elbow flexion reconstruction by Steindler flexorplasty in obstetric brachial plexus palsy

The results of Steindler flexorplasty in nine patients with obstetric brachial plexus palsy are reported. There were 5 girls and 4 boys with a mean age of 6 (range 2-13) years. Selection criteria for the procedure included strong (at least M4) grip strength and wrist and elbow extension, as well as the presence of the "Steindler effect". Pre-operatively, elbow flexion was rated as M0 or M1 in three patients and M2 in the remaining six patients. Intra-operatively, the detached common flexor origin was advanced 5 to 7 cm and fixation was done to the anterior humerus either with direct suture to the periosteum (in younger children) or suturing into a drill hole in the humerus (in older children). Postoperatively, the elbow was immobilized in flexion and supination for 6 weeks. At a mean follow-up of 5 years, the results in eight patients were good with mean active elbow flexion against resistance of 110 degrees and a mean elbow flexion contracture of 35 degrees. The result in the remaining patient was poor (unsuccessful transfer). It is concluded that the results of the Steindler flexorplasty in obstetric brachial plexus palsy patients are good and reliable, provided patient selection is careful.

[A case-control study on the risk factors related to obstetric brachial plexus palsy]

OBJECTIVE

To identify the risk factors and related degrees associated to obstetric brachial plexus palsy(OBPP).

METHODS

A case-control study was performed. Neonatal records of thirty-one cases with OBPP and their corresponding maternal records from the Department of Gynecology and Obstetrics of eight hospitals in Shanghai city from 1988 to 2002 were reviewed. Four controls, all living in Shanghai were selected to match each case and were born within the same year at the same hospital. The control group also included 124 cases without OBPP. According to the uniformed data and tables used were from medical records and from pregnant women. Epidemiological study was carried out on both case group and control group. Variables for analyses would include: (1) race, age, height, family history, pre-pregnancy weight, body mass index at the pre-pregnancy (weight/height2) on those pregnant women as well as on parity of their mothers; (2) the process of delivery which includeing clinic pelvis evaluation, height of uterus, abdomen circumference,antepartum weight,body mass index before delivery, mode of delivery,the duration of active phase and 2nd stage of labor, shoulder dystocia; (3) on neonates: sex, gestational age, birth weight,affected limb, Apgar scores of 1 and 5 minutes, other birth trauma and resuscitation of infant. Statistical tests applied to these data would include Student's T test for continuous variables and chi2 analysis for discrete data. Risk calculation of OBPP was performed by univariable and multivariable conditional logistic regression analysis.

RESULTS

12 factors related to expsure were identified for OBPP through univariable conditional logistic regression analysis. When multivariable conditional logistic regression model at P = 0.1 was applied, four factors such as cesarean (OR = 0.060), forceps (OR = 65.237), birth weight (OR = 35.468), and pre-pregnancy body mass index (OR = 23.901) were selected.

CONCLUSION

Forceps delivery,macrosomia, and increase of pre-pregnancy body mass index (> or = 21) were risk factors of OBPP in the order of degrees to risk while cesarean seemed to serve as a protective factor.

Repair of obstetric brachial plexus palsy

This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations.

Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired.

The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer.

Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury.

Update on management of pediatric brachial plexus palsy

This manuscript will review the literature and focus on the present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery in infants with brachial plexus birth palsies. Surgical indications, expected outcomes and complications will be addressed. The controversy regarding microsurgery timing in extra-foraminal ruptures will be addressed in detail. The developments in assessment and care of glenohumeral deformity with magnetic resonance imaging scans, arthroscopic and open reductions, and tendon transfers about the shoulder will be discussed. Recommendations for microsurgery and shoulder reconstruction will be based on the present evidence from the literature.

Temporary Erb-Duchenne Palsy Without Shoulder Dystocia or Traction to the Fetal Head

BACKGROUND

Although many retrospective studies report that brachial plexus palsies occur after vaginal delivery in the absence of recorded shoulder dystocia, there are no known prospective reports by a treating clinician (PubMed, English language only, 1952-June 2004, search terms: shoulder dystocia, nonshoulder dystocia, obstetric brachial plexus injury, Erb's palsy, Erb-Duchenne palsy, spontaneous vaginal delivery).

CASE

A multiparous patient presented with a birth plan requesting that the baby be allowed to deliver on its own, without traction on the head and without suctioning. Although induced at term for elevated blood pressure, the otherwise healthy patient experienced a normal labor with a 30-minute second stage. At delivery, which was videotaped by the father, the fetal head presented over an intact perineum in a right-occiput-anterior position. Without traction, the anterior shoulder delivered spontaneously with the next contraction and Valsalva, followed by the posterior shoulder. The trunk followed routinely. The average-weight for gestational age neonate exhibited an Erb-Duchenne palsy of the right (posterior) arm that resolved on the fourth day of life.

CONCLUSION

Temporary Erb-Duchenne palsy can occur in the posterior arm after normal labor and spontaneous delivery without shoulder dystocia or traction on the fetal head.

Long-term results on abduction and external rotation of the shoulder after latissimus dorsi transfer for sequelae of obstetric palsy

Transfer of the latissimus dorsi to the rotator cuff is widely used for restoring shoulder abduction and external rotation in sequelae of brachial plexus palsy; however, its long-term results are not well known. Because persistence of clinical benefits is crucial for children with brachial plexus palsy, the aim of our study was to evaluate retrospectively the long-term results of this transfer in 203 children. Patients were classified according to type of paralysis (C5-C6, C5-C6-C7, and complete), degree of preoperative shoulder function according to Gilbert, and age at surgery. Active abduction and external rotation were measured at 1, 3, 6, 10, and 15 years and the results were analyzed statistically. Children with sequelae of C5-C6 palsy gained in abduction and external rotation more than children with C5-C6-C7 or complete palsy. Patients with mild preoperative shoulder dysfunction achieved the best results. The data showed the clinical results were related to the type of paralysis and to preoperative shoulder function, but not to age at surgery. They also showed progressive deterioration of abduction began at 6 years despite preserved active external rotation.

Does preoperative abduction value affect functional outcome of combined muscle transfer and release procedures in obstetrical palsy patients with shoulder involvement?

Background

Obstetric palsy is the injury of the brachial plexus during delivery. Although many infants with plexopathy recover with minor or no residual functional deficits, some children don't regain sufficient limb function because of functional limitations, bony deformities and joint contractures. Shoulder is the most frequently affected joint with internal rotation contracture causing limitation of abduction, external rotation. The treatment comprises muscle release procedures such as posterior subscapularis sliding or anterior subscapularis tendon lengtening and muscle transfers to restore the missing external rotation and abduction function.

Methods

We evaluated whether the preoperative abduction degree affects functional outcome. Between 1998 and 2002, 46 children were operated on to restore shoulder abduction and external rotation. The average age at surgery was 7.6 years and average follow up was 40.8 months. We compared the postoperative results of the patients who had preoperative abduction less than 90° (Group I: n = 37) with the patients who had preoperative abduction greater than 90° (Group II: n = 9), in terms of abduction and external rotation function with angle measurements and Mallet classification. We inquired whether patients in Group I needed another muscle transfer along with latissimus dorsi and teres major transfers.

Results

In Group I the average abduction improved from 62.5° to 131.4° (a 68.9° ± 22.9°gain) and the average external rotation improved from 21.4° to 82.6° (a 61.1° ± 23°gain). In Group II the average abduction improved from 99.4°to 140°(a40.5° ± 16°gain) and the average external rotation improved from 33.2°to 82.7° (a 49.5° ± 23.9° gain). Although there was a significant difference between Group I and II for preoperative abduction (p = 0.000) and abduction gain in degrees (p = 0.001), the difference between postoperative values of both groups was not significant (p = 0.268). There was also no significant difference between the two groups in the preoperative external rotation, the external rotation gain and the postoperative external rotation (p = 0.163, p = 0.181 and p = 0.803, respectively).

Conclusions

Obstetric palsy patients with shoulder sequela who had a preoperative abduction less than 90°hadas good functional results using latissimus dorsi, teres major muscle transfer and subscapularis muscle release as the patients who hada preoperative abduction greater than 90°.

A surgical technique for pediatric forearm pronation: brachioradialis rerouting with interosseous membrane release

PURPOSE

In this study we used a tendon transfer technique (consisting of rerouting of the brachioradialis with interosseous membrane release) to restore active forearm pronation in patients with supination deformity secondary to brachial plexus birth palsy.

METHODS

Four children (3 with flexible supination deformities, 1 with a fixed supination deformity) whose ages ranged between 5 and 9 years had brachioradialis rerouting with interosseous membrane release.

RESULTS

Mean active forearm rotation was improved from 28 degrees supination before surgery to 49 degrees pronation after surgery. No patient developed elbow contracture during a minimum of 12 months of follow-up evaluation (40 months in 2 patients, 14 months in 1 patient, 12 months in 1 patient).

CONCLUSIONS

These results suggest that brachioradialis rerouting combined with interosseous membrane release may be a successful means to correct supination deformity of the forearm.

Classification of secondary shoulder deformities in obstetric brachial plexus palsy

Shoulder deformities are the most frequent sequelae of birth palsy. In this paper, previous classification systems for secondary shoulder deformities are reviewed and a new classification is offered.

Reliability of three classification systems measuring active motion in brachial plexus birth palsy

BACKGROUND

Several classification systems for the categorization of function in patients with brachial plexus birth palsy have been proposed. The purpose of this investigation was to determine the intraobserver and interobserver reliability of the modified Mallet Classification, Toronto Test Score, and Hospital for Sick Children Active Movement Scale in the evaluation of these patients.

METHODS

Eighty children with brachial plexus birth palsy were evaluated by two trained examiners on two different occasions. Intraobserver and interobserver reliability was determined with use of the kappa statistic.

RESULTS

On the basis of the kappa statistic, intraobserver reliability was good to excellent for individual elements of the modified Mallet Classification, Toronto Test Score, and Active Movement Scale in all age-groups. Interobserver reliability for individual elements of these three systems ranged from fair to excellent. When aggregate Toronto Test and modified Mallet scores were assessed, positive intraobserver and interobserver correlations were noted (Pearson r = 0.70 to 0.98, p < 0.001). Internal consistency (test-retest reliability) as determined by the Cronbach alpha for the aggregate Toronto Test and modified Mallet scores was excellent for each age-group (alpha > 0.90, p < 0.001).

CONCLUSIONS

The modified Mallet Classification, Toronto Test Score, and Active Movement Scale are reliable instruments for assessing upper-extremity function in patients with brachial plexus birth palsy. The natural history and surgical outcomes of these patients can now be conducted with use of these reliable outcomes instruments.

High spatial resolution electromyography and video-assisted movement analysis in children with obstetric brachial plexus palsy

Two tools developed at the Institute for Biomedical Technologies and their use in children with obstetric brachial plexus lesions, a rather complex upper limb movement disorder, have been presented in this article. The authors have given examples of useful patterns correlated to defined clinical situations, such as the reinnervation process in a voluntary muscle, the coactivation of antagonistic muscles, and the ill-defined individual motion pattern in an affected limb. The authors believe these dynamic descriptions combining electrophysiologic and video techniques offer excellent clinical possibilities for the future. Further attempts will be made to adapt them to clinical situations and thus contribute to a more objective and better scientific understanding of upper limb movement.

Aspects of activities and participation in daily life related to body structure and function in adolescents with obstetrical brachial plexus palsy: a descriptive follow-up study

AIM

To analyse whether activities and participation in daily life differed between adolescents with obstetrical brachial plexus palsy (OBPP) and their able-bodied peers.

METHOD

Fifty-one teenagers born in 1985-1987 with OBPP and a comparison group consisting of 116 age-matched adolescents in a socioeconomically and socioculturally representative area answered a self-report questionnaire concerning their daily life, school performance and friendships. The OBPP group was divided into three functional groups according to the degree of severity of the OBPP.

RESULTS

Subjects with OBPP had interests, activities and a social life very similar to those of the teenagers in the comparison group. Differences were, however, found in self-esteem for sport/motor activities, with self-esteem being significantly lower in teenagers with the most severe type of OBPP. The OBPP groups were concerned about the risks for their affected and unaffected limb.

CONCLUSION

In our society, adolescents with OBPP report a typical teenage life today. However, the indications for distress and worry related to the disability have to be considered.

Neurophysiological prediction of outcome in obstetric lesions of the brachial plexus

Seventy-three children with slow recovery after obstetric lesion of the brachial plexus (biceps function returning after 3 months of age) and with relatively favourable neurophysiological investigation were followed until a mean age of 4.3 years. Predictions for C6 and C7 were confirmed in 92% and 96% of the cases, respectively. Predictions for C5 were confirmed in a smaller proportion of cases (78%). The inability to record nerve action potentials for C5, and the high frequency of secondary shoulder pathology are reasons for this. In all, 33 of the 73 children came to operation for medial rotation contracture (11) or posterior subluxation/dislocation (21); there was one case operated for inferior contracture.

Shoulder deformities in obstetric brachial plexus paralysis: a computed tomography study

Obstetric brachial plexus palsy invariably involves the upper roots. If left untreated, characteristic deformities of the shoulder are common sequelae. The most objective way to investigate these shoulder deformities is computed tomographic (CT) scanning of bilateral upper limbs. In this study, specific measurements on CT scans of bilateral upper extremities were performed in a population of patients with obstetric brachial plexus palsy before and after reconstruction (nerve repairs and secondary procedures). The measurements showed that the restoration of external rotation and the scapula stabilization procedure correct the inclination of the humeral head, improve the joint congruency significantly, and decrease the winging of the scapula, thus improving the kinetics of the shoulder. Periodic CT measurement is an objective method of measuring the changes at the shoulder joint that occur over time during the natural evolution of the obstetric brachial plexus palsy lesion and of documenting the benefits of microsurgical intervention.

Obstetric brachial plexus lesions: a study of 74 children registered with the British Paediatric Surveillance Unit (March 1998-March 1999)

Seventy-four children with obstetric brachial plexus palsy registered with the British Paediatric Surveillance Unit were prospectively followed for a minimum of 2 years. Thirty-nine (52.7%) spontaneously recovered to normal or nearly normal levels and a further 29 (39.3%) regained good function in the upper limb. The most important secondary deformity involved the gleno-humeral joint and 20 patients (27%) needed surgical correction. Two more children await operation for shoulder deformity. The brachial plexus was explored in nine patients (12.2%) and repaired in seven.

Assessment of the motor power in older children with obstetric brachial plexus palsy

The King Saud University (KSU) muscle grading system used for assessing the upper limb in older children with obstetric brachial plexus palsy is presented and compared to other muscle grading systems.

Obstetric brachial plexus palsy: a clinical and electrophysiologic evaluation

BACKGROUND

Obstetrical brachial plexus palsy (OBPP) occurs as sequelae of birth-related trauma, antenatal and parturition related complications. It is associated with varying degrees of functional disability. Electrodiagnostic studies (EDS) are an adjunctive tool and help to localise and prognosticate the outcome of OBPP.

METHODS

Fourteen children, presenting with OBPP to the Clinical Neurophysiology Lab, were analyzed. Details of birth history were obtained, and EDS were performed to characterize the lesion.

RESULTS

The age ranged from one month to one year. Ten had unilateral and four bilateral brachial palsy. On EDS, five had pan-plexus, six predominantly upper plexus and three lower plexus involvement. A poor re-innervation pattern on EMG correlated with inadequate recovery.

CONCLUSION

OBPP, a condition associated with considerable disability, needs to be prevented. Electrodiagnostic studies are a useful adjunctive tool for characterizing the site of injury and prognostication.

Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy

For the purpose of treatment, obstetric brachial plexus palsy can be subdivided into two distinct phases: initial obstetric brachial plexus palsy, and late obstetric brachial plexus palsy. In the latter, nerve surgery is no longer practical, and treatment often requires palliative surgery to improve function of the shoulder, elbow, forearm, and hand. Late obstetric brachial plexus palsy in the forearm and hand includes weakness or absence of wrist or metacarpophalangeal or interphalangeal joint extension; weakness or absence of finger flexion; forearm supination, or less commonly pronation contracture; ulnar deviation of the wrist; dislocation of the radial or ulnar head; thumb instability; or sensory disturbance of the hand. Palliative reconstruction for these forearm and hand manifestations is more difficult than for the shoulder or elbow because of the lack of powerful regional muscles for transfer. This report reviews the authors' experience performing more than 100 surgical procedures in 54 patients over a 9-year period (between 1988 and 1997) with a minimum of 2 years' follow-up. Surgical treatment is highly individualized, but the optimal age for forearm and hand reconstruction is usually later than for shoulder and elbow reconstruction because of the requirement for a preoperative exercise program. Multiple procedures for forearm and hand function were often performed on any given patient. Frequently, these were done simultaneously with reconstructive procedures for improving shoulder and/or elbow function. Traditional tendon transfer techniques do not provide satisfactory reconstruction for those deformities. Many of the authors' patients required more complex techniques such as nerve transfer and functioning free-muscle transplantation to augment traditional techniques of tendon and/or bone management. Sensory disturbance of the forearm and hand in late obstetric brachial plexus palsy seems a minor problem and further sensory reconstruction is unnecessary.

The "beggar's" hand and the "unshakable" hand in children with total obstetric brachial plexus palsy

A total 12 consecutive children with secondary deformities following total obstetric brachial plexus palsy were included in this retrospective study. In all patients, the main complaints were two socially disabling hand postures: the "beggar's" hand and/or the "unshakable" hand. All children had a supinated forearm with no active pronation and were teased by their friends, who called them "beggars." When the impairment was severe and involved the right hand and wrist, children also complained that they were not able to shake hands. The management approach to these children was described, with the main aim of surgery being the correction of the abnormal posture. Other simultaneous tendon transfers were also performed to improve hand function if there were suitable musculotendinous units. Successful reconstruction was accomplished in all patients. Preoperatively, some children refused to go to school because of teasing, and most did not want to interact socially. After surgery, all children attended school regularly, and parents reported much better social interaction. However, the functional gain was never enough to dramatically improve the daily use of the limb. The contralateral normal limb remained the dominant one for all daily activities, including writing and eating.

Obstetrical brachial plexus palsy. Prediction of outcome in upper root injuries

Thirty obstetrical brachial plexus palsies involving the upper roots were retrospectively reviewed. There were 20 C5-C6 palsies and ten C5-C6-C7 palsies in which recovery of C7 occurred by the end of the first month. Recovery of elbow flexion at 3 months, C7 involvement and high birthweight were the best early predictors of outcome, but all were unreliable when used separately. In combination, recovery of elbow flexion and birthweight predicted the final outcome reasonably satisfactorily, particularly when elbow flexion at 9 months, and not 3 months was considered (risk of error = 13%). Brachial plexus reconstruction may therefore be justified when there was initial C7 involvement associated with increased birthweight and poor elbow flexion at 6-9 months.

Assessment of the method and timing of repair of a brachial plexus traction injury in an animal model for obstetric brachial plexus palsy

A Sunderland type IV traction injury to the C6 root of adult sheep or newborn lamb brachial plexus was used as a model for obstetric traction injury to the C5 root in humans. In one experimental cohort the injury was created and repaired using interfascicular nerve autografts or coaxially aligned freeze-thawed skeletal muscle autografts in a group of adult sheep and in a group of newborn lambs. In a second cohort a similar injury was created and repaired either immediately or after a delay of 30 days, using either interfascicular nerve autografts or coaxially aligned freeze-thawed skeletal muscle autografts in four groups of six newborn lambs. In all cases both functional and morphometric indices of nerve regeneration were poorer in the injured and repaired nerves than in normal nerves. In lambs the method of repair made no difference and no significant differences were found for any of the indices of nerve function or morphology. In sheep the use of muscle grafts was associated with a poorer outcome than the use of nerve autografts. Where a delay of 30 days had elapsed between injury and repair, the results using nerve autografts were not significantly different. Where freeze-thawed muscle autografts had been used, the maturation of the regenerated nerve fibres after delay was significantly poorer than after immediate repair. The electrophysiological variables CV(max) and jitter, which may be applied clinically, were found to be good discriminators of recovery in all of the animals and in respect of all procedures.

The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy

Children with previously untreated obstetric brachial plexus palsy frequently have abnormal elbow function because of motor recovery with aberrant reinnervation, or because of paresis or paralysis. From 1988 to 1997 (9-year period), 62 children with obstetric brachial plexus palsy with resulting elbow deformity underwent various methods of palliative reconstruction to improve elbow function. For motor recovery with aberrant reinnervation, release of aberrantly reinnervated antagonistic muscles and augmentation of paretic muscles form the basis of surgical intervention. The surgical procedures included triceps-to-biceps transfer, biceps-to-triceps transfer, brachialis-to-triceps transfer, or combined biceps- and brachialis-to-triceps transfer. Choice of procedures was individualized and randomly determined on the basis of the degree and pattern of aberrant reinnervation between elbow flexors and extensors. In patients' motor recovery with paresis or paralysis, persistently weak elbow flexion was salvaged with a functioning free muscle transplantation or Steindler's flexorplasty, or regional shoulder muscle transfer. In addition, patients with aberrant reinnervation between shoulder abductors and elbow flexors underwent anterior deltoid-to-biceps transfer with a fascia lata graft. All patients had a minimum follow-up of 2 years. Results are assessed and discussed and a reconstructive algorithm is recommended. In general, reconstruction of elbow extension should precede that of elbow flexion. Biceps-to-triceps transfer with preservation of an intact brachialis muscle, or brachialis-to-triceps transfer with preservation of an intact biceps, allows 50 percent of these patients to achieve acceptable elbow flexion and extension in a single-stage procedure.

Function of the upper limb after surgery for obstetric brachial plexus palsy

We reviewed a consecutive series of 33 infants who underwent surgery for obstetric brachial plexus palsy at a mean age of 4.7 months. Of these, 13 with an upper palsy and 20 with a total palsy were treated by nerve reconstruction. Ten were treated by muscle transfer to the shoulder or elbow, and 16 by tendon transfer to the hand. The mean postoperative follow-up was 4 years 8 months. Ten of the 13 children (70%) with an upper palsy regained useful shoulder function and 11 (75%) useful elbow function. Of the 20 children with a total palsy, four (20%) regained useful shoulder function and seven (35%) useful elbow function. Most patients with a total palsy had satisfactory sensation of the hand, but only those with some preoperative hand movement regained satisfactory grasp. The ability to incorporate the palsied arm and hand into a co-ordinated movement pattern correlated with the sensation and prehension of the hand, but not with shoulder and elbow function.

Focal upper extremity neuropathy in neonates

Focal upper extremity neuropathies are common in neonates. The brachial plexus is the most common site involved. Brachial plexus injuries may involve different structures, thus producing different clinical presentations: complete brachial plexus palsy, Duchenne-Erb palsy, upper-middle trunk brachial plexus palsy, Klumpke palsy, fascicular brachial plexus palsy, and bilateral brachial plexus palsy. The causes of brachial plexus palsy are obstetric injury, intrauterine compression, humeral osteomyelitis, hemangioma, exostosis of the first rib, neck compression, and neoplasm. The differential diagnosis of brachial plexus palsy includes pseudoparesis, amyoplasia congenita, congenita varicella syndrome, and neurological lesions at other neuroanatomical levels. The cause and the degree of injury dictate the prognosis. The prognosis of obstetric brachial plexus injury is usually good.

The findings in paediatric obstetric brachial palsy differ from those in older patients: a suggested explanation

An EMG and nerve-conduction-study protocol has been developed and used in all patients with brachial plexus lesions since 1985. The findings of EMG and nerve-conduction studies in obstetric brachial palsy (OBP) mostly suggest a falsely optimistic prognosis. To analyse this, all subjects were selected with complete avulsion of both roots C5 and C6 and/or complete rupture of the upper trunk verified during operation from a group of 162 infants with OBP (aged 4 to 14 months) and a group of 184 child and adult patients (aged 6 to 74 years) with a traumatic brachial plexus lesion. Fourteen infants, approximately 4 months old, with OBP, and 19 adults (aged 16 to 30 years) met the selection criteria. The infants from the group with OBP had at 4 months a nearly normal recruitment pattern of motor units in the biceps brachii and deltoid muscles, with little or no denervation. However, in the older group with traumatic brachial palsy, the same lesion caused complete denervation of both muscles. From the group with OBP, a third group (N=3) with the same lesion plus an additional lesion of C7 or a rupture of the middle trunk was selected. This additional lesion resulted in nearly complete denervation of both muscles. This means that C7 largely contributes to the innervation of both muscles at the time of birth, but this innervation is lost during later life in normally developing individuals (apoptosis). A central mechanism might be responsible for the clinical palsy and later spontaneous improvement which is always found in the infants with OBP.

Improving shoulder and elbow function in children with Erb's palsy

Many children who sustain birth injuries to the brachial plexus suffer significant functional limitations due to various sequelae affecting the shoulder and elbow or forearm. The maintenance of full passive mobility during the period of neurological recovery is essential for normal joint development. Early surgical correction of shoulder contractures and subluxations reduces permanent deformity. Reconstruction of forearm rotation contractures significantly improves the appearance and use of the extremity for many basic activities. Each child must be carefully evaluated, therapy maximized, and the surgical approach individualized to obtain the best result.

Neurophysiological evaluation of children with traumatic radiculopathy, plexopathy, and peripheral neuropathy

Neurophysiological evaluation of children with traumatic peripheral nervous system injury is accomplished with electromyography, motor and sensory nerve conduction studies, and somatosensory and motor-evoked potentials. Preoperative neurophysiological tests are performed if motor deficits persist for more than 3 months. Evidence of reinnervation on these neurophysiological tests predates clinical recovery by weeks, hence they help determine the site of the lesion and provide objective measures for selecting candidates for surgical exploration. Intraoperative neurophysiological tests help to identify and confirm the integrity of nerves and to develop the optimal surgical strategy. Postoperative evaluations every 3 to 6 months may determine efficacy of treatment.

Functional outcome at 5 years in children with obstetrical brachial plexus palsy with and without microsurgical reconstruction

Between 1987 and 1998, 470 patients visited the national clinic for obstetrical brachial plexus palsies at the Karolinska Hospital, Stockholm, Sweden. This study reports on 247 children examined at 5 years of age using a special protocol for testing the sensory and motor function of the hand. The children were distributed in various groups depending on the number of injured nerves, whether they had some muscle activity in their biceps or deltoid muscles at 3 months of age, and whether any operations with nerve reconstruction had been performed. The shoulder range of movement in C5-6 palsies was significantly better in the group which had been operated on (operated group), but otherwise there were no differences between children who had been operated on (non-operated group) and those who had not. A decrease in grip strength and bimanual function in level C5-6 palsies was found, though these roots should not innervate the distal hand. Outcome was not influenced by the number of avulsions in upper-plexus palsies or whether the operation took place before or after the age of 6 months. The group with extensive lesions (C5-Th1) had the most root avulsions, showing a correlation between increased avulsions and decreased hand function. This study does not support operating on children with no activity of the biceps and deltoid muscles at 3 months of age, as other authors have concluded. Rather, it favours waiting for a late recovery.

Functional scoring system for obstetric brachial plexus palsy

We suggest a new scoring system that measures the upper limb function both as a unit and in separate parts. Our system was designed to study the recovery in patients with obstetric brachial plexus palsy (OBPP). It measures active limb movements and compares them with the normal side to obtain a ratio, which is then converted to a score. Fifty-two patients with OBPP were studied with a follow-up of 2 years. The progress of the patients was monitored using the system. Thirty-seven patients (71%) achieved very good recovery, eight patients (15%) achieved a good score, and five patients (10%) achieved a poor score. Most of the recovery occurred before the age of 6 months.

Perinatal brachial plexus palsy

Perinatal brachial plexus palsy (PBPP) has been traditionally classified into three types: upper plexus palsy (Erb's) affecting the C5, C6, and +/- C7 nerve roots, lower plexus palsy (Klumpke's) affecting the C8 and T1 nerve roots, and total plexus palsy. Although most cases will resolve spontaneously, the natural history of the remaining cases is influenced by contractures of uninvolved muscle groups and subluxation or dislocation of the shoulder and elbow. Microsurgical nerve repair has demonstrated to provide improved outcomes compared to conservative treatment, while advancements in secondary reconstruction have offered significant improvements in the performance of activities of daily living for older children with unresolved plexus palsy.

Developmental and behavioural outcome in obstetric brachial plexus palsy

Forty-four children with obstetric brachial plexus palsy were assessed for both developmental attainment and behavioural problems. Analysis of the resulting data revealed developmental and behavioural problems previously not identified, particularly in those with more severe injuries. These effects were independent of the general condition of the child at birth, as indicated by their Apgar scores. Further studies are required to provide clarification of these children's difficulties, the mechanisms by which they occur and effective strategies to address them.

Classification of impairment of shoulder abduction in obstetric brachial plexus palsy and its clinical significance

Shoulder abduction was studied in 25 cases of obstetric brachial plexus palsy (OBPP). According to muscle function, electromyographic features and X-ray examination, impairment of shoulder abduction could be classified into dynamic, resistant or combined types. Five cases were the dynamic type, which was characterized by paralysis of the shoulder abductors. Fifteen cases were categorized as the resistant type, with contracture of the subscapularis muscle, co-contraction of latissimus dorsi and teres major muscles and secondary disorders of the shoulder joint. Five cases were classified as the combined type in which there were both dynamic and resistant factors. Appropriate management and surgical procedures in the shoulder affected by OBPP depend on the pathological classification.

Obstetric brachial plexus palsy: a large animal model for traction injury and its repair. Part 1: age of the recipient

A Sunderland type IV traction injury to the C6 root of the sheep or lamb brachial plexus was used as a model for obstetric traction injury to the C5 root in humans. The injury was created and immediately repaired using interfascicular nerve autografts in a group of adult sheep and a group of newborn lambs. The animals were examined using electrophysiological and morphometric techniques 1 year after operation. It was found that the recovery of neuromuscular function was superior in the lambs. The implication is that nerves in newborn animals have a better potential for regeneration than that seen in older individuals. This is discussed with reference to the management of obstetric brachial plexus palsy.

[Pseudo-paralysis of the brachial biceps in obstetrical brachial plexus lesions (OBPL):concerning the "overly optimistic" EMG in OBPL]

In birth palsy of the brachial plexus, the mixed interference pattern recorded for the brachial biceps on the electromyogram often conflicts with the muscle's inability to flex the elbow. We report our observations of a six-month-old infant who presented paralysis of the upper and medial elements of the brachial plexus, in whom we demonstrated early biceps-triceps co-contractions, which may explain this discrepancy and 'pseudo-paralysis' of the biceps. We analyse and discuss the practical consequences of these findings, and notably the possible therapeutic use of triceps-to-biceps surgical transposition.

Management of peripheral nerve problems in the upper and lower extremity using quantitative sensory testing

Elective microsurgery of the peripheral nervous system concerns nerve decompression, neurolysis, nerve repair, and forms of nerve reconstruction with grafts or tubes. Management skills for the peripheral nerve too often rely on antiquated assessment techniques and depend upon traditional electrodiagnostic testing. Quantitative sensory testing is an approach to the evaluation of peripheral nerve function that is available now to all physicians interested in managing peripheral nerve problems. This article introduces quantitative sensory testing, with particular regard to the management of peripheral nerve problems.