Forensic Identification and Evaluation of 25 Obstetric Brachial Plexus Palsy Medical Damage Cases.

OBJECTIVES: To analyze the high risk factors of obstetric brachial plexus palsy (OBPP), and to explore how to evaluate the relationship between fault medical behavior and OBPP in the process of medical damage forensic identification. METHODS: A retrospective analysis was carried out on 25 cases of medical damage liability disputes related to OBPP from 2017 to 2021 in Beijing Fayuan Judicial Science Evidence Appraisal Center. The shortcomings of hospitals in birth weight assessment, delivery mode selection, labor process observation and shoulder dystocia management, and the causal relationship between them and the damage consequences of the children were summarized. RESULTS: Fault medical behavior was assessed as the primary cause in 2 cases, equal cause in 10 cases, secondary cause in 8 cases, minor cause in 1 case, no causal relationship in 1 case, and unclear causal force in 3 cases. CONCLUSIONS: In the process of forensic identification of OBPP, whether medical behaviors fulfill diagnosis and treatment obligations should be objectively analyzed from the aspects of prenatal evaluation, delivery mode notification, standardized use of oxytocin, standard operation of shoulder dystocia, etc. Meanwhile, it is necessary to fully consider the objective risk of different risk factors and the difficulty of injury prevention, and comprehensively evaluate the causal force of fault medical behavior in the damage consequences.

Altered evoked responses for motor-related words in children with upper limb motor impairments.

OBJECTIVE: Obstetric brachial plexus palsy (OBPP) and amyoplasia, the classical type of arthrogryposis multiplex congenita, manifest themselves as highly limited mobility of the upper limb. At the same time, according to the embodiment cognition theories, the motor impairments might lead to the alteration of cognitive functions in OBPP/amyoplasia patients. In the current study, we examined whether OBPP/amyoplasia children exhibit altered processing of motor-related verbs. METHODS: We conducted a case-control study using clinical population and control children. Oddball series were used to elicit mismatch negativity (MMN) EEG responses. The series consisted of limb-related verbs (deviant stimuli) and matched pseudowords (standard stimuli). 27 patients and 32 control children were included in the analysis. RESULTS: We showed that MMN waveforms differed between OBPP/amyoplasia children and their control peers in the frontal and temporal electrodes when the stimuli contained hand-related verbs. In particular, the MMN peak latency in the OBPP/amyoplasia children was significantly delayed as compared with the healthy controls. At the same time, neither series with leg-related verbs nor series of pseudowords resulted in statistically significant differences. CONCLUSIONS: Our findings suggest altered processing of hand-related verbs in OBPP/amyoplasia children with hand-related disabilities. SIGNIFICANCE: Our results contribute to the growing evidence in support of the theory of embodied cognition, which proposes that various domains of cognition are shaped by bodily interactions with the environment.

Rethinking surgical strategy in the management of obstetrical palsy.

The widespread use of the operating microscope for nerve repairs has inspired operative treatment for obstetric paralysis. For a long time, the standard treatment has been based on early nerve surgery. However, the generally accepted strategy for treating obstetric paralysis is far from satisfactory. The main sequels we have observed are due to incorrect treatment of the deficits or due to devastating early nerve surgery. Therefore, a different approach should be considered and designed to prevent and treat the main deficits. After examining over 1000 non-operated patients over almost four decades and in three different countries, I have never encountered anyone who has not recovered active contraction of shoulder muscles or relatively strong elbow flexion. Therefore, I recommend not to have early nerve surgery.

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.

[Physiotherapy applied to the upper extremity in 0 to 10-year-old children with obstetric brachial palsy: a systematic review]. / Fisioterapia aplicada en la extremidad superior a niños de 0 a 10 años con parálisis braquial obstétrica: revisión sistemática.

INTRODUCTION: Obstetric brachial palsy is involved with affected upper limb, resulting in permanent structural and function sequelae that limit the motion articular range and reduce independence in daily activities, as well as the children participation in their natural environment. AIM: To describe the physiotherapy treatments currently used to increase the affected upper limb functionality in children from 0 to 10 years diagnosed with obstetric brachial palsy. PATIENTS AND METHODS: A bibliographic search of published studies between 2009 and 2018 was carried out in the PubMed, PEDro, ScienceDirect and The Cochrane Library databases. RESULTS: After applying the inclusion/exclusion criteria, ten studies were obtained with favorable results for the affected upper limb functionality and bone mineralization density, regardless of the technique of choice used during the intervention. The used physiotherapy programs in the different studies such as Constraint Induced movement therapy, kinesiotape, electrotherapy, virtual reality and use of splints or orthotics were analyzed. CONCLUSION: All the described techniques suggest favorable results for the affected upper limb functionality in obstetric brachial palsy from 0 to 10 years.

TITLE: Fisioterapia aplicada en la extremidad superior a niños de 0 a 10 años con parálisis braquial obstétrica: revisión sistemática.Introducción. La parálisis braquial obstétrica cursa con afectación del miembro superior y da lugar a secuelas estructurales y de la función permanentes que limitan el rango articular de movimiento y reducen la independencia en las actividades cotidianas, así como la participación del niño dentro de su entorno natural. Objetivo. Describir los tratamientos de fisioterapia empleados en la actualidad para incrementar la funcionalidad de la extremidad superior afectada en niños de 0 a 10 años diagnosticados de parálisis braquial obstétrica. Pacientes y métodos. Se realizó una búsqueda bibliográfica de los trabajos publicados entre 2009 y 2018 en las bases de datos PubMed, PEDro, ScienceDirect y Cochrane Library. Resultados. Tras aplicar los criterios de inclusión/exclusión, se obtuvieron diez estudios con resultados favorables para la funcionalidad de la extremidad superior afectada y la densidad de mineralización ósea, independientemente de la técnica de elección utilizada durante la intervención. Se analizaron los programas de fisioterapia empleados en los diferentes estudios, como la terapia de movimiento inducido por restricción, el kinesiotape, la electroterapia, la realidad virtual y el uso de férulas u ortesis. Conclusión. Todas las técnicas descritas sugieren resultados favorables para la funcionalidad del miembro superior en niños de 0 a 10 años con parálisis braquial obstétrica.

Anatomical study of the brachial plexus in human fetuses and its relation with neonatal upper limb paralysis.

OBJECTIVE: To study the anatomy of the brachial plexus in fetuses and to evaluate differences in morphology during evolution, or to find anatomical situations that can be identified as the cause of obstetric paralysis. METHODS: Nine fetuses (12 to 30 weeks of gestation) stored in formalin were used. The supraclavicular and infraclavicular parts of the brachial plexus were dissected. RESULTS: In its early course, the brachial plexus had a cord-like shape when it passed through the scalene hiatus. Origin of the phrenic nerve in the brachial plexus was observed in only one fetus. In the deep infraclavicular and retropectoralis minor spaces, the nerve fibers of the brachial plexus were distributed in the axilla and medial bicipital groove, where they formed the nerve endings. CONCLUSION: The brachial plexus of human fetuses presents variations and relations with anatomical structures that must be considered during clinical and surgical procedures for neonatal paralysis of the upper limbs.

Diaphragmatic paralysis after phrenic nerve injury in newborns.

BACKGROUND: Phrenic nerve injury (PNI) from birth trauma is a recognized phenomenon, generally occurring with ipsilateral brachial plexus palsy (BPP). In severe cases, PNI results in diaphragm paresis (DP) and respiratory insufficiency. Surgical diaphragmatic plication (SDP) is a potential management strategy for patients with PNI and DP, but timing and outcomes associated with SDP have not been rigorously studied. METHODS: Records from 49 tertiary United States pediatric hospitals in the Pediatric Health Information System from 2004 to 2018 were analyzed. The study cohort included patients diagnosed with BPP from birth trauma who were documented to have PNI or DP. Patients who underwent congenital cardiac operations were excluded. RESULTS: A total of 5832 patients were identified with BPP from birth trauma during the study period, 122 (2%) of whom were found to have concomitant DP. Of those, 65 (53%) were male, 39 (32%) were infants of diabetic mothers, 80 (65%) required mechanical ventilation, and 33 (27%) underwent SDP. SDP was performed at a median (range) age of 36 (7-95) days. Median (range) total and postoperative hospital lengths of stay (LOS) were 34 (6-180) and 15 (4-132) days, respectively. There was also an observed increase in post-operative LOS with increase in age at operation. CONCLUSION: Neonatal DP is rare and is managed with SDP in a minority of instances. Age at repair affects total and postoperative length of stay, proxies for resource utilization and morbidity. Repair prior to 45 days of life appears to result in a shorter postoperative hospital stay. This analysis will help guide surgeons with respect to indications and operative timing for infant DP. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Intercostal Nerve Transfer in Management of Biceps and Triceps Cocontraction in Spontaneously Recovered Obstetric Brachial Plexus Palsy.

BACKGROUND: Obstetric brachial plexus palsy is caused by traction during birth. Most patients regain useful function with spontaneous recovery. In some cases, cross reinnervation occurs between the biceps and triceps muscles. In these cases, smooth active motion of the elbow joint is impaired by simultaneous biceps and triceps muscle contraction. The biceps and triceps muscle cocontraction could be treated by botulinum toxin type A injection, tendon transfer of the triceps to biceps, and intercostal nerves transfer to the musculocutaneous nerve (MCN) or to the motor branch of the radial nerve to the triceps muscle. PATIENTS AND METHODS: We present 16 cases (10 males and 6 females) with biceps and triceps cocontraction in spontaneously recovered obstetric brachial plexus palsy patients. They were treated by 3 intercostal nerves transfer to MCN without exploration of the remaining plexus. The mean age at surgery was 40.6 months (range, 24-65 months). Preoperative electromyography was done in all cases to confirm biceps and triceps cocontraction and to assess the contractile status of both muscles. RESULTS: The mean postoperative follow-up period was 51.7 months (range, 27-64 months). At the final follow-up, elbow flexion was graded 3 in 1 patient, grade 4 in 3 patients, grade 6 in 9 patients, and grade 7 in 3 patients using the 7-point Toronto scale. The mean active range of motion of the elbow (against gravity) increased from 38 degrees preoperatively (range, 0-75 degrees) to 96.8 °[Combining Ring Above] at the final follow-up (range, 60-140 degrees). CONCLUSIONS: Intercostal nerves transfer to MCN for management of biceps, and triceps cocontraction in spontaneously recovered obstetric brachial plexus injury is a good option with minimal morbidity and high success rate.

Function in unaffected arms of children with obstetric brachial plexus palsy.

OBJECTIVE: The objective is to compare the fine and gross motor function of unaffected arms of children with obstetric brachial plexus palsy (OBBP) with typically developing children's dominant upper extremities. METHODS: Fifty-three patients with OBBP and fifty-one typically developing children between the age of 4 and 13 were included in the study. For gross motor function evaluation in the upper extremity box-block test (BBT), for fine motor skill nine-hole peg (9HP) test was used. For grasp and pinch strength measurements, a Jamar dynamometer is used. RESULTS: The patient group performed significantly worse in 9HP and BBT tests. When further divided into age groups, 4-8 age patient group performed significantly worse in 9HP and BBT tests, while there were no differences in children in the 9-13 age group. CONCLUSIONS: The fine and gross motor functions of the unaffected arms of children with OBPP are significantly worse in children between the ages of four and eight but this deficit improves with age, and possibly with ongoing therapy.

Arthroscopic isolated capsular release for shoulder contracture after brachial plexus birth palsy: clinical outcomes in a prospective cohort of 28 children with 2 years' follow-up.

BACKGROUND: The primary objective of this study was to evaluate improvements in external rotation after isolated arthroscopic capsular release in children with shoulder contracture due to brachial plexus birth palsy. MATERIALS AND METHODS: This study included all children older than 2 years with a range of active external rotation limited to 30° or less and/or active anterior elevation (AE) limited to 90° or less secondary to brachial plexus palsy treated between 2011 and 2015. Passive glenohumeral motion, passive global (glenohumeral plus scapulothoracic) motion, active global motion for external rotation with the elbow at the side (ER1), AE, and internal rotation with the elbow at the side were recorded before and 2 years after surgery. Improvement was evaluated by comparing the preoperative and follow-up values. The operation performed was subscapularis-sparing arthroscopic capsular release. RESULTS: Thirty-five patients were included, and 28 completed 2 years of follow-up. The average changes in active global ER1, passive glenohumeral ER1, and passive global ER1 were +35° (range, -20° to +100°; P <.0001), +35° (range, +0° to +75°; P <.0001), and +26° (range, -15° to +60°; P <.0001), respectively. There were no significant changes in internal rotation with the elbow at the side or AE. The mean improvement in the aggregate Mallet score was 3.9 points (range, -3 to +9 points; P <.0001). CONCLUSIONS: For children with shoulder contracture secondary to brachial plexus palsy, subscapularis-sparing isolated capsular release improves external rotation and functional scores and avoids any loss of active internal rotation but does not improve AE.

Late treatment of obstetrical brachial plexus palsy by humeral rotational osteotomy and lengthening with an intramedullary elongation nail.

To date, all the authors who have recommended external rotation osteotomy (ERO) in the late treatment of obstetrical brachial plexus palsy (OBPP), have neglected upper limb length discrepancy, which is an another sequelae of OBPP. In this paper, a new technique is reported for the late treatment of OBPP patients with upper limb length discrepancy, in which both humeral external rotation osteotomy (ERO) and lengthening are applied with an intramedullary elongation nail. With this technique, upper limb function is improved through re-orientation of the shoulder arc to a more functional range, and further improvements will be seen in the appearance of the upper limb with the elimination of length discrepancy. It is also advocated that there is a potentiating effect of the humeral lengthening on shoulder movements gained by ERO when the osteotomy is applied above the deltoid insertion, as this allows more lateralized placement of the deltoid insertion.

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].

The components of shoulder and elbow movements as goals of primary reconstructive operation in obstetric brachial plexus lesions.

Most of the cases of obstetric brachial plexus lesions (OBPL) show satisfactory improvement with conservative management, but in about 25% some surgical treatment is indicated. The present paper analyzes the effects of primary reconstructive surgeries in aspect of achieving delineated intraoperatively goals. Children operated before the age of 18 months with follow-up period longer than 1 year were selected. Therapeutic goals established during the operation were identified by analysis of initial clinical status and operative protocols. The elementary movement components in shoulder and elbow joints were classified by assessing range of motion, score in Active Movement Scale and modified British Medical Research Council scale of muscle strength. The effect was considered satisfactory when some antigravity movement was possible, and good when strength exceeded M3 or antigravity movement exceeded half of range of passive movement. In 13 of 19 patients most of established goals were achieved at good level, in 2 at satisfactory level. Remaining 4 patients showed improvement only in some aspects of extremity function. In 2 patients improvement in some movements was accompanied by worsening of other movements. The analysis of results separated into individual components of movements showed that goals were achieved in most of the cases, simultaneously clearly indicating which damaged structures failed to provide satisfactory function despite being addressed intraoperatively. The good results were obtained mainly by regeneration through grafts implanted after resection of neuroma in continuity, which proves that this technique is safe in spite of unavoidable temporary regression of function postoperatively.

Ultrasound Screening for Posterior Shoulder Dislocation in Infants with Persistent Brachial Plexus Birth Palsy.

BACKGROUND: Early detection of posterior shoulder dislocation in infants with brachial plexus birth palsy (BPBP) is essential, but it may be difficult to accomplish with physical examination alone. The aim of this study was to determine the prevalence of shoulder dislocation in patients with BPBP using ultrasound and to identify which physical examination measurements correlated most with dislocation in these patients. METHODS: This study was a retrospective review of data obtained in an ultrasound screening program of infants with BPBP born from January 2011 to April 2014. Physical examination included the use of the Active Movement Scale (AMS) and measurement of passive external rotation of the shoulder. Ultrasound measurements included PHHD (percentage of the humeral head displaced posterior to the axis of the scapula) and the alpha angle (intersection of the posterior scapular margin with a line tangential to the humeral head through the glenoid). Shoulder dislocation was defined as both a PHHD of >0.5 and an alpha angle of >30°. RESULTS: Of sixty-six infants who had undergone a total of 118 ultrasound examinations (mean, 1.8; range, 1 to 5), 19 (29%) demonstrated shoulder dislocation with the shoulder positioned in internal rotation; the dislocation was first detected between 2.1 and 10.5 months of age. Infants with a dislocated shoulder demonstrated significantly less mean passive external rotation in adduction (mean, 45.8° versus 71.4°, p < 0.001) and a greater difference between internal rotation and external rotation AMS scores (mean, 5.5-point versus 3.3-point difference, p < 0.001) than those without shoulder dislocation. Passive external rotation in adduction was a better measure for discriminating between dislocation and no dislocation (area under receiver operating characteristic curve [AUC] = 0.89) than was the difference between internal and external rotation AMS scores (AUC = 0.73). A cutoff of 60° of passive external rotation in adduction (≤60° versus° >60) yielded a sensitivity of 94% and a specificity of 69%. CONCLUSIONS: Shoulder dislocation is common in infants with BPBP; 29% of the infants presenting to our tertiary care center had a dislocation during their first year of life. Ultrasound shoulder screening is appropriate for infants with BPBP. If passive external rotation in adduction is used to determine which infants should undergo ultrasound, ≤60° should be utilized as the criterion to achieve appropriate sensitivity. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

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.

[Palsy of the upper limb: Obstetrical brachial plexus palsy, arthrogryposis, cerebral palsy]. / Les paralysies du membre supérieur : plexus brachial obstétrical, arthrogrypose, paralysie cérébrale.

"Palsy of the upper limb" in children includes various diseases which leads to hypomobility of the member: cerebral palsy, arthrogryposis and obstetrical brachial plexus palsy. These pathologies which differ on brain damage or not, have the same consequences due to the early achievement: negligence, stiffness and deformities. Regular entire clinical examination of the member, an assessment of needs in daily life, knowledge of the social and family environment, are key points for management. In these pathologies, the rehabilitation is an emergency, which began at birth and intensively. Splints and physiotherapy are part of the treatment. Surgery may have a functional goal, hygienic or aesthetic in different situations. The main goals of surgery are to treat: joints stiffness, bones deformities, muscles contractures and spasticity, paresis, ligamentous laxity.