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.

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.

Hemi-hypoglossal nerve transfer for obstetric brachial plexus palsy: report of 3 cases.

Use of the entire hypoglossal nerve for nerve transfer in obstetric palsy is not recommended because of major donor nerve morbidity in terms of feeding and speech problems. We used a hemi-hypoglossal nerve transfer for biceps reinnervation in obstetric palsy in 3 infants with multiple root avulsions. Two of the 3 infants recovered normal or near-normal elbow flexion. There was no donor nerve morbidity in terms of feeding. Speech was assessed at age 20 to 27 months and was appropriate for age, which indicates that early speech development (speech intelligibility and articulation) were not affected. However, phonological development (expected to develop by age 3 y) and full consonant development (expected to be complete by age 5 y) could not be assessed because all children were younger than age 3 years at final follow-up. Our results confirm the relative safety of using a hemi-hypoglossal nerve transfer in infants. The transfer deserves study in a larger series and with longer follow-up, particularly regarding speech development.

Limited glenohumeral cross-body adduction in children with brachial plexus birth palsy: a contributor to scapular winging.

BACKGROUND: Approximately 1 of every 1000 live births results in life-long impairments because of a brachial plexus injury. The long-term sequelae of persistent injuries include glenohumeral joint dysplasia and glenohumeral internal rotation and adduction contractures. Scapular winging is also common, and patients and their families often express concern regarding this observed scapular winging. It is difficult for clinicians to adequately address these concerns without a satisfying explanation for why scapular winging occurs in children with brachial plexus birth palsy. This study examined our proposed theory that a glenohumeral cross-body abduction contracture leads to the appearance of scapular winging in children with residual brachial plexus birth palsy. METHODS: Sixteen children with brachial plexus injuries were enrolled in this study. Three-dimensional locations of markers placed on the thorax, scapula, and humerus were recorded in the hand to mouth Mallet position. The unaffected limbs served as a control. Scapulothoracic and glenohumeral cross-body adduction angles were compared between the affected and unaffected limbs. RESULTS: The affected limbs demonstrated significantly greater scapulothoracic and significantly smaller glenohumeral cross-body adduction angles than the unaffected limbs. The affected limbs also exhibited a significantly lower glenohumeral cross-body adduction to scapulothoracic cross-body adduction ratio. CONCLUSIONS: The results of this study support the theory that brachial plexus injuries can lead to a glenohumeral cross-body abduction contracture. Affected children demonstrated increased scapulothoracic cross-body adduction that is likely a compensatory mechanism because of decreased glenohumeral cross-body adduction. These findings are unique and better define the etiology of scapular winging in children with brachial plexus injuries. This information can be relayed to patients and their families when explaining the appearance of scapular winging. LEVEL OF EVIDENCE: Level II.

Exposure of the retroclavicular brachial plexus by clavicle suspension for birth brachial plexus palsy.

Surgical exploration and reconstruction of the brachial plexus requires adequate exposure beyond the zone of injury. In the case of extensive lesions, some authors advocate clavicle osteotomy for an extensile approach. Such an osteotomy introduces further morbidity and may impact upon the delicate nerve reconstruction. A new simple but effective method of clavicle elevation is described that provides access to the retroclavicular brachial plexus during exploration for birth brachial plexus palsy.

Total ipsilateral C7 root neurotization to the upper trunk for isolated C5-C6 avulsion in obstetrical brachial plexus palsy: a preliminary technical report.

BACKGROUND: C5-C6 root avulsion in obstetrical brachial plexus palsy (OBPP) is a rare injury with poor prognosis usually associated with breech delivery. The treatment is challenging and requires high microsurgical skills. The triple nerve transfer (spinal accessory nerve, ulnar fascicles, and triceps long or lateral head branch) represents the gold standard treatment. The total ipsilateral C7 nerve root neurotization is a promising technique, which has never been described in OBPP. OBJECTIVE: The total ipsilateral C7 nerve root is used as a neurotizer transferred to the upper trunk as an alternative method to other intra- or extra-plexual reconstruction techniques. METHODS: During brachial plexus surgical exploration, an intraoperative neurostimulation was performed to confirm the integrity of C7 and the lesion of C5 and C6. The entire C7 nerve root and the upper trunk are cut. The C7 root was transferred to the upper trunk with a fibrin sealant. RESULT: This technique was easily performed with a single approach and avoided intercalated nerve grafts. The C7 nerve root provided a large number of nerve fibers with an adequate diameter to be transferred to the upper trunk. We illustrated this technique with a typical case of a child at 8 years of follow-up. CONCLUSION: The total ipsilateral transfer of the C7 root to the upper trunk is a viable alternative procedure for newborns with C5-C6 avulsion.

Correlation between clinical findings and CT scan parameters for shoulder deformities in birth brachial plexus palsy.

PURPOSE: The shoulder is the most common site of secondary deformities after birth brachial plexus palsy. The severity and the pattern of deformity vary in patients and have implications for clinical decision making. This study aimed to find the correlation between clinical findings and computed tomography (CT) scan parameters for these deformities. METHODS: This prospective study included 75 patients aged 3 to 23 years. The clinical parameters included age, extent of involvement (nerve roots affected), degree of shoulder abduction, active and passive external rotation, and Mallet score. These were correlated with 3 CT scan parameters: elevation of the scapula above the clavicle, relative glenoid version, and percentage of the humeral head anterior to the scapular line. RESULTS: There was a significant correlation between lack of active and passive external rotation and relative glenoid version and humeral head subluxation. There was a significant correlation between active abduction and elevation of the scapula above the clavicle. There was no significant correlation between age or Mallet score with any of the CT scan parameters. CONCLUSIONS: These results suggest that presence of active and passive external rotation beyond 10° is associated with significantly lesser shoulder deformity irrespective of the degree of shoulder abduction. Hence, a patient with more than 10° external rotation does not need a screening CT scan evaluation regardless of the degree of shoulder abduction present. Conversely, a lack of external rotation beyond 10° strongly suggests relative glenoid retroversion and posterior subluxation of the humeral head and should be considered a clinical indicator of shoulder deformation. TYPE STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Isolated lower brachial plexus (Klumpke) palsy with compound arm presentation: case report.

Klumpke palsy has yet to be clearly documented in the newborn, because previous reports lack any description of the obstetrical history, clinical progression, or outcome. Based on a high incidence of breach presentation in the few clinical series that report Klumpke palsy, hyperabduction with arm overhead during delivery has been the presumed mechanism. We report a child with isolated lower brachial plexus palsy and Horner syndrome who presented at birth with a vertex compound arm presentation. Recognition of this condition and details of the clinical progression and outcome are important, because guidelines for management are currently not available.

Intra-operative neurophysiological prediction of upper trunk recovery in obstetric brachial plexus palsy with neuroma in continuity.

We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively. In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively. Our method is effective in evaluating the prognosis of C5 lesion. Neurolysis is preferred for C6 lesions.

Parálisis braquial obstétrica de etiología prenatal / Prenatal obstetric brachial palsy etiology

La parálisis braquial obstétrica (PBO) es la parálisis de los músculos inervados por raíces nerviosas originadas en el plexo braquial. La incidencia es de 0,6 a 2,6 cada 1.000 nacidos vivos. Los factores de riesgo más importantes son distociade hombro, macrosomía y el parto instrumental. Clásicamente la PBO ha sido considerada como consecuencia de una excesiva tracción del cuello fetal en el parto. Existen casos en los que no se identifican factores de riesgo; en ellos se plantea una posible causa prenatal. La atrofia muscular del miembro superior y signos de de nervación en la electromiografía, son indicadores de que la lesión del plexo braquial ocurrió intraútero. La mayoría de los estudios reportan elementos sugestivos de una causa prenatal de PBO, sin datos concluyentes de la misma. Se describe el caso de un recién nacido con parálisis braquial en el que se demuestran claros elementos de etiología prenatal.

[Radius reed osteotomy for supination deformity in children with obstetrical brachial plexus palsy]. / Ostéotomie en roseau du radius chez l'enfant dans la paralysie de la pronation du plexus brachial obstétrical.

We report our experience and results in the use of reed pronating osteotomy in supination deformities secondary to obstetrical brachial plexus injury. This retrospective study involved 11 patients with paralytic supination of the forearm due to a brachial plexus injury. Other causes of paralytic supination were excluded. The surgical technique consisted of a proximal osteotomy of the ulna fixed by an intramedullary nail and a stable elastic reed osteotomy of the radius. The minimum postoperative follow-up was 2 years. Four boys and seven girls mean aged 8 years (5-12) were operated on between 2000 and 2010. The mean preoperative supination was measured at 63°. The final position average pronation was 37°. Loss of pronation was measured at 15°. No complication was observed. With a mean follow-up of 4 years (2-12), the reed osteotomy of radius associated with a proximal transverse osteotomy of ulna has proven itself effective for correction of paralytic supination of the forearm without complication or reoperation.

Arthroscopic release of shoulder contracture secondary to obstetric brachial plexus palsy: retrospective study of 18 children with an average follow-up of 4.5 years.

INTRODUCTION: Children affected by obstetric brachial plexus palsy have an internal rotation contracture of the shoulder and a deformed glenohumeral joint. In 2003, Pearl proposed doing an arthroscopic release of the shoulder to restore external rotation and allow the glenohumeral joint to remodel. The goal of the current study was to evaluate the active and passive shoulder external rotation range of motion and glenohumeral joint remodelling in children treated with arthroscopic-directed release. MATERIALS AND METHODS: Between 2004 and 2010, 18 children with passive external rotation under 10° were treated with shoulder arthroscopy to release the anterior capsule and ligaments and perform a subscapularis tenotomy; no tendon transfer was performed. The average age was 4 years, 2 months. Nine children had an injury at C5C6, four had an injury at C5C6C7 and five had a complete injury. The average follow-up was 4.5 years. The clinical evaluation consisted of active and passive external rotation (ER) with elbow at the side, active internal rotation, and the modified Mallet score. One child who required an external rotation osteotomy of the proximal humerus was excluded from the clinical outcomes. An MRI was performed on both shoulders to assess glenoid retroversion, glenoid type, degree of posterior subluxation (measured by the percentage of humeral head anterior to the middle glenoid fossa) and humeral head hypoplasia. RESULTS: At the latest follow-up, passive ER was 58° on average and active ER was 42°. Eleven children had regained more than 30° of active ER. The average internal rotation had decreased after the release. The MRI assessment showed that the glenohumeral joint had remodelled in 66% of cases; the glenoid type had improved, the glenoid retroversion had diminished and the humeral head was recentred. Humeral head hypoplasia was found in 28% of cases. DISCUSSION AND CONCLUSION: Arthroscopic release of the shoulder results in more external rotation and allows for glenohumeral joint remodelling. Tendon transfer is not always necessary to restore active external rotation. LEVEL OF EVIDENCE: Level IV - Retrospective study.

Centering osteotomy for treatment of posterior shoulder dislocation in obstetrical palsy.

BACKGROUND: The main objective of this study is to describe a new surgical technique that, through a gleno-humeral approach, reduces the incongruent joint while a humeral head centering osteotomy achieves shoulder stabilization. A humeral medial derotational osteotomy is performed associated with the articular reduction. PATIENTS AND METHODS: Fourteen patients with obstetrical palsy presenting a posterior humeral head dislocation were submitted to a centering osteotomy procedure. Our study included patients with: (1) more than 1.5 years postoperative follow-up, (2) presence of humeral head posterior dislocation. The exclusion criteria were the following: (1) patients with total flaccid paralysis, (2) low paralysis and (3) any kind of active infection at the time of the procedure. RESULTS: Before treatment, in all patients, the shoulder joint was posteriorly dislocated and in internal rotation. All patients went on to have successful healing at the osteotomy site. In all cases, an improvement in the functional Mallet scale was observed. In all patients, except one, the posterior dislocation was corrected. In two cases, a second surgery (external derotation osteotomy) was performed to improve the upper extremity's position. CONCLUSIONS: Articular congruency, after posterior dislocations of the humeral head, is achieved by humeral head centering osteotomy in patients with obstetrical palsy late deformities and also improves function. LEVEL OF EVIDENCE: Level IV; case series.

[Current concepts in perinatal brachial plexus palsy. Part 2: late phase. Shoulder deformities]. / Conceptos actuales en la parálisis braquial perinatal: Parte 2: etapa tardía. Deformidades en hombro.

The incidence of obstetric brachial palsy is high and their sequelaes are frequent. Physiotherapy, microsurgical nerve reconstruction and secondary corrections are used together to improve the shoulder function. The most common posture is shoulder in internal rotation and adduction, because of the antagonist weakness. The muscle forces imbalance over the osteoarticular system, will result in a progressive glenohumeral joint deformity which can be recognized with a magnetic resonance image. Tendon transfers of the internal rotators towards the external abductor/rotator muscles, has good results, but has to be combined with antero-inferior soft-tissue releases, if passive range of motion is limited.

Correction of elbow flexion contracture in late obstetric brachial plexus palsy through arthrodiatasis of the elbow (Ioannina method).

Inadequate elbow extension is a recognized sequela after obstetric brachial plexus injury because of muscle imbalance and adversely affects the ability to perform sufficiently most daily living activities. The various methods that have been used to correct this deformity do not offer a satisfactory outcome in the long term and show a tendency for gradual recurrence. We present a new technique of a closed gradual arthrodiatasis using a unilateral hinged elbow external fixator. The technique was applied in 10 patients with elbow flexion contracture as a sequela of brachial plexus birth palsy. Loss of elbow extension measured 55 degrees at average. With a mean device application of 8.8 weeks all patients gained full elbow extension. No major complications were noted. All patients were satisfied with the outcome. This novel technique (closed gradual arthrodiatasis of the elbow joint) has a definite role in the treatment of elbow flexion contracture in late cases of obstetric palsy, given the otherwise limited surgical options.

Soft tissue rebalancing procedures with and without internal rotation osteotomy for shoulder deformity in children with persistent obstetric brachial plexus palsy.

INTRODUCTION: Children with obstetric brachial plexus palsy (OBPP) frequently have problems related to their shoulder. The aim of the investigation was to determine our results in treating shoulder deformity with tendon transfers and soft tissue releases with and without internal rotational osteotomy. We also evaluated the relationships between neurological status, age and selected clinical parameters. MATERIALS AND METHODS: We reviewed data of 25 patients (12 girls) after latissimus dorsi and teres major tendon transfers to the rotator cuff. Internal rotation osteotomy was performed in ten children. The mean age of patients at the time of operation was 3.2 years (range from 10 months to 7.7 years). RESULT: Patients were followed up for a mean of 3.8 years (minimum 2 years). Mallet score improved 4.7 points at last follow-up (p = 0.00002). No patient had shoulder function deterioration. Active and passive external rotation increased significantly after operation: p < 0.00001, p < 0.00001, respectively. Statistically significant reduction in active internal rotation was noted (p = 0.04). The other movements have not statistically changed after operation. Active internal rotation difference after internal rotation osteotomy was significantly better than without osteotomy (p = 0.03). Neurological involvement and age had neither positive nor negative influence on final range of motion and outcome. CONCLUSIONS: Soft tissue rebalancing procedures significantly improve shoulder function in children with persistent OBPP. Addition of internal rotational osteotomy to muscle transfers for severe cases allows maintaining of stabile joint, prevents loosening of internal rotation and does not influence other movements of the shoulder.

[Arthroscopic anterior capsular release in medial contracture of the shoulder secondary to brachial plexus birth palsy. Preliminary results]. / Arthrolyse antérieure de l'épaule sous arthroscopie dans les séquelles de paralysie obstétricale du plexus brachial. Résultats préliminaires.

PURPOSE OF THE STUDY: Retraction of the shoulder in internal rotation is observed in 25% of children with brachial plexus birth palsy (C5, C6 +/- C7). Early bone and joint deformities affecting the glenohumeral joint are the consequences. The stiff internal rotation requires surgical release which can involve the capsule and ligaments, muscles, or both. Internal release can be combined with muscle transfer to improve active external rotation. We report the results obtained with arthroscopic anterior capsular release combined with latissimus dorsi transfer. MATERIAL AND METHODS: From 1999 through 2006, fourteen children with a stiff shoulder in internal rotation secondary to brachial plexus birth palsy were managed in our unit. All had recovered biceps function six months after surgery. The glenohumeral dysplasia was analyzed on the preoperative magnetic resonance imaging. Pre- and postoperative passive external rotation (RE) were measured with the arm along the body and at 90 degrees elbow flexion. Internal rotation was measured using the Mallet score (hand-back test). Combined active abduction antepulsion was measured when the child was playing. Mean age at surgery was three years six months. Arthroscopic internal release was performed for eight children. All had an associated latissimus dorsi transfer. RESULTS: Among the 14 children managed in the unit, arthrolysis was not be performed in six, either because of the lack of an adequate electrode (two patients) or because the child presented posterior glenohumeral dislocation making it impossible to introduce the optic channel (four patients). Arthroscopic anterior release was performed for the eight other patients. These eight patients were reviewed at a mean three-year follow-up. Passive external rotation was improved, with a mean gain of 60 degrees with no recovery of passive internal rotation. The abduction antepulsion movement was also improved, mean gain 90 degrees . DISCUSSION: A stiff shoulder in internal rotation can develop during the first two years of life. Several techniques have been proposed for internal release. The origin of the progressive limitation of passive external rotation remains a subject of debate. Is it due to retraction of the internal rotators, or to capsule-ligament retraction, or both? In 1992, Harryman et al. demonstrated the role of the capsule and the coracohumeral ligament in limiting external rotation. Consequently, we have opted for early release (less than two years of age) using an arthroscopic method limited to the capsule and ligaments. Our results for passive external rotation are comparable to those reported by others. However, this technique enables preserved mobility for internal rotation. CONCLUSION: Arthroscopic anterior release limited to the capsule and the ligaments is an effective, minimally invasive technique. Leaving the internal rotator muscles intact preserves internal rotation of the shoulder and reduces the risk of anterior instability.