Surgical Repair of Obstetric Brachial Plexus Injuries: A Case Series and Discussion of the Current Literature.

OBJECTIVE: To assess factors which may influence surgical success following brachial plexus reconstruction for Obstetric Brachial Plexus Injury (OBPI). METHODS: We retrospectively reviewed the charts of 27 consecutive patients who underwent brachial plexus reconstruction following OBPI by a single pediatric neurosurgeon, 22 of which had adequate follow-up be included in analysis. Data on pre-operative function, intra-operative findings, and post-operative outcomes were collected. Mallet grades for abduction, external rotation, and hand-to-mouth were used as a measure of upper trunk function. RESULTS: All patients undergoing brachial plexus reconstruction (n=27) were found to have some degree of upper-trunk injury intra-operatively. Of the 22 patients with adequate follow-up to be included in the analysis, 17 had some degree of improvement in Mallet grade post-operatively. Prior to surgery, 95% (21/22) of patients had an abduction Mallet grade of 1, compared to 23% (5/22) at the time of maximum improvement (p<0.001). These values were 100% (20/20) to 35% (5/14) (p<0.001), and 95% (21/22) to 27% (6/22) (p<0.001) for external rotation and hand-to-mouth, respectively. The average time to maximum Mallet grade was 583 days (SD 356 days). Age at time of surgery and time to maximum recovery were not found to be correlated. CONCLUSION: Brachial plexus reconstruction is an effective treatment modality for patients without spontaneous recovery of upper extremity function following OBPI, although identifying the optimal age-range for surgery remains elusive. Patients with intraoperative findings consistent with a more severe injury may be less likely to benefit from surgery.

The Role of Virtual Reality and Functional Electrical Stimulation on a Seven-Year-Old Child With Erb's Palsy: A Case Report.

Erb's palsy usually commonly arises from incidents such as falls, collisions, birth trauma, and shoulder injuries in children. It impairs upper extremity muscle function, which has an impact on the quality of life and social interaction. Physical therapy is beneficial in preserving and enhancing upper extremity function, improving the quality of life. In this case report, a seven-year-old female child with complaints of weakness in the right upper limb demonstrated a notable increase in the strength and function of the upper extremities after four weeks of structured rehabilitation using virtual reality and functional electrical stimulation.

Surgical treatment of a nonunion following clavicle osteotomy in a child with a history of Erb's palsy: A case report.

INTRODUCTION AND IMPORTANCE: Erb's palsy defined as muscle weakness and loss of motion caused by a nerve condition in the shoulder and arm. Children with Erb's palsy might underwent clavicle osteotomy as an appropriate surgical treatment method. However, few number of these patients who underwent clavicle osteotomy experienced nonunion and complained of shoulder deformity and pain. The aim of the present case report was to present new surgical treatment of a nonunion following clavicle osteotomy in a child affected by Erb's palsy. CASE PRESENTATION: A six years old boy with a history of Erb's palsy who underwent clavicle osteotomy at age of 6 months was referred to hospital. There was a nonunion following clavicle osteotomy. The patient had right shoulder deformity and complained of its-related pain. To correct a nonunion following clavicle osteotomy in this case, middle third fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was used. After five months of follow-up, a clavicle nonunion and shoulder deformity was thoroughly corrected. CLINICAL DISCUSSION: As clavicle osteotomy, the most commonly surgical method for Erb's palsy, has been demonstrated to not work effectively and cause nonunion in some cases, a new surgical method for correcting clavicle nonunion other than repeated clavicle osteotomy is needed. In the present case report, fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was applied and demonstrated remarkable improvement. CONCLUSION: Totally, use of fibula auto grafting and fixing it to the cite of clavicle nonunion by pins might be an effective surgical treatment for such cases.

Pitfalls in the diagnostics of shoulder dystocia: an analysis based on the scrutiny of 2274 deliveries.

PURPOSE: Shoulder dystocia is an obstetric emergency with severe complications. Our objective was to evaluate the major pitfalls in the diagnostics of shoulder dystocia, diagnostic descriptions documented in medical records, use of obstetric maneuvers, and their correlations to Erb's and Klumpke's palsy and the use of ICD-10 code 066.0. METHODS: A retrospective, register-based case-control study included all deliveries (n = 181 352) in Hospital District of Helsinki and Uusimaa (HUS) area in 2006-2015. Potential shoulder dystocia cases (n = 1708) were identified from the Finnish Medical Birth Register and the Hospital Discharge Register using ICD-10 codes O66.0, P13.4, P14.0, and P14.1. After thorough assessment of all medical records, 537 shoulder dystocia cases were confirmed. Control group consisted of 566 women without any of these ICD-10 codes. RESULTS: The pitfalls in the diagnostic included suboptimal following of guidelines for making the diagnosis of shoulder dystocia, subjective interpretation of diagnostic criteria, and inexact or inadequate documentation in medical records. The diagnostic descriptions in medical record were highly inconsistent. The use of obstetric maneuvers was suboptimal among shoulder dystocia cases (57.5%). Overall, the use of obstetric maneuvers increased during the study period (from 25.7 to 97.0%, p < 0.001), which was associated with decreasing rate of Erb's palsy and increasing use of ICD-10 code O66.0. CONCLUSION: There are diagnostic pitfalls, which could be addressed by education regarding shoulder dystocia guidelines, by improved use obstetric maneuvers, and more precise documentation. The increased use of obstetric maneuvers was associated with lower rates of Erb's palsy and improved coding of shoulder dystocia.

Reverse shoulder arthroplasty in obstetric brachial plexus injury: our experience with shoulder motion analysis.

BACKGROUND: Obstetric brachial plexus injury (OBPI) is a weakening or paralysis of the upper arm caused by brachial plexus injury followed by a muscle paralysis with severe repercussions on the movement of the shoulder joint following a progressive glenohumeral joint deformity. This case series analyzes the clinical and radiological outcomes of reverse total shoulder arthroplasty (RSA) in OBPI patients with a follow-up of 2 years. MATERIALS AND METHODS: OBPI patients with secondary end-stage glenohumeral arthritis were enrolled in the study and they were treated with RSA. Patient demographics and clinical outcomes [Range of Motion (ROM), Visual Analog Scale (VAS), Oxford Shoulder Score (OSS)] were evaluated. A novel Shoulder motion analysis was carried out to investigate specific movement patterns of scapulothoracic movements in these patients. This study is a prospective cohort study. RESULTS: Four Patients (M: F = 1:3) were enrolled in the study, the mean age was 49.3 years (+ 2.75), the mean OSS (Oxford Shoulder Score) decreased from 48.8 (± 2.5) preoperatively to 18.30 (± 2.78), the mean VAS (Visual Analog Scale) decreased from 7.25 (± 0.5) to 1.7 (± 0.3) in the follow up (∆% relative pain reduction:- 76.5%), Shoulder ROM obtained an improvement (p < 0.05) except for abduction and external rotation. The average follow-up time was 26.3 months (+- 4.5). Shoulder motion analysis showed a complete loss of the scapular tilting above 90 degrees of flexion compared to the typical one of standard RSA with a pattern shifted towards scapular retraction (engaging trapezius and rhomboid muscles) to compensate the loss of the posterior tilting. CONCLUSIONS: RSA in OBPI patients demonstrated a significant improvement of pain symptoms and a moderate improvement in daily activities, anyway with a more appreciable quality of life over time even if the marked hypotrophy especially of the posterior shoulder muscles showed some limits in maintaining suspension of the upper limb and a minor external rotation, with an internal rotation attitude during the movements. LEVEL OF EVIDENCE: Level IV, Case series.

Demographics and deprivation in obstetric brachial plexus palsy: a retrospective cohort study.

The present study analyses the relationships between deprivation and obstetric brachial plexus palsy (OBPP). A retrospective observational study was conducted of infants with OBPP seen between 2008 and 2020 (n = 321). The index of multiple deprivation (IMD) was used to assign an IMD rank to patients based on birth postcode and the relationship with OBPP was analysed, including deprivation, gestational diabetes, age at referral and at first assessment. Quintile-based analysis demonstrated over-representation of patients from more deprived neighbourhoods (n = 109, 39%) living in the top 20% most deprived neighbourhoods. A total of 48 (15%) mothers had diabetes and 98 (31%) infants underwent surgical brachial plexus exploration (a marker of disease severity). Neither diabetes, age at referral nor age at first assessment were associated with IMD score. This suggests that neighbourhood deprivation is associated with OBPP, though the mechanisms are unclear. Further studies in this area may enable targeted health intervention for more deprived maternal and infant groups.Level of evidence: III.

Detailed Management of Brachial Plexus Birth Injuries: The Miami Protocol at Nicklaus Children's Hospital.

The management of children with brachial plexus birth injuries is complex and requires a multidisciplinary approach. In the following article, we describe our approach to evaluation and management at Nicklaus Children's Hospital. It is our aim is to elucidate nuances in management.

The Philadelphia Shriners Hospital Approach to Brachial Plexus Birth Injury.

The care of children with brachial plexus birth injuries (BPBI) is a complex multidisciplinary endeavor. At the Shriners Hospital for Children in Philadelphia, we have sought to elevate the quality of care delivered to patients through outcomes research and collaboration with colleagues around the world. Our approach to the management of this challenging pathology has evolved time and again. Here, we describe our current approach to patient assessment and operative management in patients with BPBI and its many sequelae.

A systematic review of brachial plexus injuries after caesarean birth: challenging delivery?

BACKGROUND: Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI. METHODS: Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies. MAIN RESULTS: 39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions. CONCLUSIONS: In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors.

Brachial Plexus Birth Injury: A Single-Center Study.

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

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

AIM: To systematically review the effectiveness of physical therapy interventions in infants, children and adolescents with brachial plexus birth injury (BPBI). METHODS: Systematic review of randomized controlled trials including patients under 18 years old with BPBI was conducted on Medline, Cochrane, Embase, Amed and Pedro databases. Methodological quality was assessed by the PEDro score and quality of evidence by the GRADE system. The primary outcomes measured were range of motion, muscle strength and bone mineral density. RESULTS: Seven studies were included, two in infant and 5 in children, of 932 title and abstracts screened. The interventions, characteristics of the participants and outcomes were diverse. The largest effect was found when other intervention was combined with conventional physical therapy in the primary outcomes, with low quality of evidence. CONCLUSION: Physical therapy interventions alone or in combination with other treatment modalities are effective in improving short-term disabilities in children with BPBI.

Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes.

BACKGROUND: Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation. METHODS: From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery. RESULTS: The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations. CONCLUSION: Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.

Predictors of Co-activation in Erb's Palsy: A Retrospective Study.

Context: Three per thousand births have Erb's palsy. Spontaneous recovery is 50%. Co-activation yields poor outcomes. There are no objective indicators of its emergence. Aims: Analyze if 1 month Axon Viability Index (AVI) of the axillary nerve and which active movement score (AMS) measures can predict co-activation. Settings and Design: Tertiary level rehabilitation center, retrospective design. Methods and Material: The electronic medical record (EMR) was reviewed for patients with Erb's palsy with Narakas grade 2 lesions, as having co-activation or not. The one-month Axillary AVI was used with monthly AMS scores. The inclusion criteria were an AVI greater than ten percent. Exclusion criteria were bi-brachial palsy, congenital anomalies, concomitant or subsequent neurological injuries, and orthopedic injuries. Statistical Analysis Used: Descriptive statistics were used to calculate the median and interquartile values for AMS scores at each respective time point. Statistical significance for each time point was determined using a student's t-test. Results: Regarding the t-test on the AVI data, a significant P value of 0.001 was found favoring the co-activation group. AVI of the Axillary nerve between 0.1 and 0.5 at 1 month is a reliable indicator of future development of co-activation. The following were strong indicators of the emergence of co-activation respectively: month three Wrist Extension in sitting, Shoulder Abduction in supine, Shoulder Abduction in sitting, Elbow Flexion in sitting, month six Elbow Flexion in sitting, month seven Elbow Flexion in sitting. Conclusions: The axillary AVI at one month is a good predictor of future development of co-activation. The mentioned AMS items are the earliest indicators of co-activation.

Comparison of latissimus dorsi tendon transfer with subscapularis release versus sliding of internal rotation contracture in obstetrical brachial plexus paralysis sequela.

BACKGROUND: The purpose of this study was to compare the functional results of latissimus dorsi (LD) tendon transfer with those of subscapularis (SS) muscle release versus sliding. METHODS: Fifty-six patients with internal rotation contracture and external rotation (ER) weakness as sequelae of Erb's palsy were included in the study. Of the patients, 24 were included in group 1 (11 boys and 13 girls), with a mean age of 2 years 8 months (range 1.5-5 years) and a follow-up period of 62 months (range 38-68 months). The patients in group 1 underwent LD tendon transfer, with internal rotation contracture and SS release procedures. Thirty-two patients were included in group 2 (18 boys and 14 girls), with a mean age of 2 years 6 months (range 1.5-4.8 years) and a follow-up period of 58 months (range 38-68 months). The patients in group 2 underwent LD tendon transfer with SS sliding. RESULTS: A significant improvement in preoperative passive ER from - 3.6° to 67.3° after operation was observed in group 1. In group 2, preoperative passive ER in adduction improved from 0° to 72.3°. We found no significant difference (P = 0.1) in postoperative improvement in active ER in both groups (group 1 vs. group 2: 75° vs. 77.3°). Similarly, no significant difference (P = 0.7) in postoperative improvement in passive ER was found between the groups (group 1 vs. group 2: 71° vs. 72.3°). CONCLUSIONS: LD tendon transfer with SS release or sliding is an effective procedure to improve shoulder ER in patients with OBPP, with no inferiority of SS muscle release or sliding for internal rotation contractures and increased passive range of shoulder motion. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Comparison; Treatment Study.

Single Versus Double Tendon Transfer to Improve Shoulder External Rotation During the Treatment of Brachial Plexus Birth Palsy.

Background: Tendon transfers are commonly performed in patients with brachial plexus birth palsy (BPBP) to improve function. Transferring 2 tendons in patients with C5-7 injury has the potential complication of loss of midline function. The purpose of this study was to investigate whether a single tendon transfer (1TT) as opposed to the traditional double tendon transfer (2TT) resulted in any differences in functional outcomes in patients with C5-7 BPBP. Methods: A retrospective review of all patients with C5-7 BPBP who underwent tendon transfers to improve shoulder external rotation over a 5-year period was performed at 2 institutions. Outcomes were assessed using the modified Mallet (MM) classification scores. Results: Twenty-two C5-7 patients had complete records of preoperative and postoperative MM scores, including 11 sex-matched patients in both the 1TT and 2TT groups. When comparing preoperative and postoperative MM categories, there were significant improvements in both the 1TT and 2TT groups for global abduction (P < .05 and P < .01, respectively) and external rotation (P < .00001 for both). Modified Mallet (MM) hand to neck scores were significantly improved in the 2TT group (P < .05) but not in the 1TT group (P = .053). Internal rotation scores significantly decreased in both groups (P < .001). Both groups demonstrated significant increases in total scores from the preoperative MM scores (P < .01). Conclusion: The 1TT and 2TT procedures result in substantial gains in upper extremity functions for patients with C5-7 BPBP as measured by the MM score, specifically within the global abduction and external rotation subcategories. However, a significant loss occurs in internal rotation for both groups.

Clavicular Fractures in Newborns: What Happens to One of the Commonly Injured Bones at Birth?

Introduction The clavicle is one of the most commonly injured bones during the birth process. The objective of this study was to determine the frequency and outcome of fractured clavicle amongst neonates born in a five-year period at a Secondary Hospital setting and to determine the Maternal and Neonatal Characteristics involved in such cases and compare them with a control group and determine the significance of any factors. Methods All cases of fractured clavicle were retrospectively reviewed in a Secondary care hospital setting during a five-year period from July 2015 to June 2020. Maternal and neonatal factors were determined and then compared to a control group. Results Out of 21,435 live births at our center during the study period, 92 infants were diagnosed to have clavicle fractures, giving an incidence of 4.29 per 1,000 live births (0.43%). 89% cases (n=82) were detected before discharge and 11 % cases (n=10) on routine follow-up visit after discharge. Physical examination identified 77% cases (n=71) whereas 23% cases (n=21) were recognized incidentally on X-ray. All babies with fracture including 3 with Erb's palsy recovered completely without any complications. On logistic regression analysis, spontaneous vaginal delivery, prolonged second stage, vertex presentation, vitamin D deficiency in mothers, birthweight, macrosomia, all were significant risk factors. Conclusion Neonatal clavicular fracture appears to be a transient yet unpredictable and unavoidable event with an overall good prognosis. Only the birth weight was identified as the common risk factor affecting clavicular fracture. Parental concerns and anxiety can be decreased with proper counselling and reassurance.

Effect of Glenohumeral Reduction Type Combined With Tendon Transfer for Brachial Plexus Injury on Objective, Functional, and Patient-Reported Outcomes.

PURPOSE: Glenohumeral (GH) joint reductions are frequently performed during tendon transfer surgery for brachial plexus birth injuries (BPBI); however, the effect of reduction method (none required, closed, surgical) has not been assessed. This study compared objective, functional, and patient-reported outcomes between children who underwent a tendon transfer and (1) did not require GH reduction, (2) required concomitant closed GH reduction, or (3) required concomitant surgical GH reduction. METHODS: Fifty-four children with BPBI who previously underwent teres major and/or latissimus dorsi transfer with or without concomitant GH reduction participated. Joint reduction method was classified as none required (n = 21), closed (n = 9), or surgical (n = 24). Motion capture was collected in a neutral position, abduction, external rotation, and internal rotation. Glenohumeral joint angles and displacements were calculated. Joint angular displacements represented the differences between the joint angles in each terminal position and the joint angles of the arm at rest in the neutral position. A hand surgeon determined modified Mallet scores. Participants' parents completed the Brachial Plexus Profile Activity Short Form (BP-PRO-SF) to assess physical activity performance. RESULTS: The no-reduction group had significantly less GH elevation than the surgical-reduction group for all positions and significantly less GH elevation than the closed-reduction group for the neutral, external rotation, and internal rotation positions. There were no differences in GH rotation angles. Glenohumeral joint displacements from neutral and modified Mallet scores were similar. The no-reduction group demonstrated significantly greater BP-PRO-SF scores than the surgical-reduction group. CONCLUSIONS: Patients who underwent a closed or surgical GH joint reduction consistently displayed more GH elevation. Clinically, this corresponds to an abduction contracture. Whereas increased abduction contracture provided a benefit of greater overhead motion, modified Mallet scores were similar between groups. The surgical-reduction group demonstrated lower BP-PRO-SF outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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.

Teres major transfer to restore external rotation of shoulder in Erb palsy patients.

BACKGROUND: The lack of external rotation and shoulder abduction as sequelae of obstetric brachial plexus palsy requires a release of the subscapularis muscle associated with tendon transfer of the internal rotator of the shoulder. The aim of this study was to present the results of a teres major transfer to the infraspinatus tendon. METHODS: This study included 20 patients (9 boys and 11 girls) with a mean age of 3 years 8 months (range, 1.5-14 years). The average follow-up time was 42 months (range, 12-48 months) to determine whether external rotation weakness and internal rotation contracture sequelae were managed by anterior release of the subscapularis and teres major tendon transfer to the infraspinatus tendon. RESULTS: We found marked improvement in shoulder abduction from 67° before surgery to 158° after surgery. We also found marked improvements in active external rotation from 8° before surgery to 85° after surgery and in passive external rotation from 0° preoperatively to 72° postoperatively. Two cases showed a loss of the last degrees of internal rotation, but this improved after physiotherapy. CONCLUSIONS: Anterior release of the subscapularis tendon with a teres major transfer to the infraspinatus tendon significantly improves shoulder function in Erb palsy patients with internal rotation contracture.