Relationship of age and type of obstetric brachial plexus paralysis in forearm pronosupination.

OBJECTIVE: To evaluate the arc of forearm pronosupination of patients with sequelae of birth paralysis and correlate with these variables. METHODS: 32 children aged between 4 and 14 years with total or partial lesions of the brachial plexus were evaluated; measurements of pronation and supination, active and passive, were made, both on the injured side and the unaffected side. RESULTS: A statistically significant difference was observed between the injured side and the normal side, but there was no difference between the groups regarding age or type of injury. CONCLUSION: The age and type of injury did not impact on the limitation of the forearm pronosupination in children with sequelae of birth paralysis.

OBJETIVO: Avaliar o arco de pronossupinação do antebraço dos pacientes com sequela de paralisia obstétrica do plexo braquial e correlacionar com essas variáveis. MÉTODOS: Foram avaliadas 32 crianças entre 4 e 14 anos, com lesões totais ou parciais do plexo braquial, foram tiradas as medidas de pronação e supinação, ativa e passiva, tanto do lado lesionado quanto do lado não afetado. RESULTADOS: Observou-se diferença estatisticamente significativa entre o lado lesionado e o lado normal, porém não houve diferença entre os grupos por faixas etárias, nem quanto ao tipo de lesão. CONCLUSÃO: Os fatores idade e tipo de lesão não tiveram efeito sobre a pronossupinação nas crianças portadoras de sequela de paralisia obstétrica do plexo braquial.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement.

PURPOSE: Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. METHODS: We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. RESULTS: The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. CONCLUSION: Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.

Relationship of age and type of obstetric brachial plexus paralysis in forearm pronosupination / Relação entre a idade e o tipo de paralisia obstétrica do plexo braquial com o movimento de pronossupinação do antebraço

ABSTRACT Objective: To evaluate the arc of forearm pronosupination of patients with sequelae of birth paralysis and correlate with these variables. Methods: 32 children aged between 4 and 14 years with total or partial lesions of the , brachial plexus were evaluated; measurements of pronation and supination, active and passive, were made, both on the injured side and the unaffected side. Results: A statistically significant difference was observed between the injured side and the normal side, but there was no difference between the groups regarding age or type of injury. Conclusion: The age and type of injury did not impact on the limitation of the forearm pronosupination in children with sequelae of birth paralysis.

RESUMO Objetivo: Avaliar o arco de pronossupinação do antebraço dos pacientes com sequela de paralisia obstétrica do plexo braquial e correlacionar com essas variáveis. Métodos: Foram avaliadas 32 crianças entre 4 e 14 anos, com lesões totais ou parciais do plexo braquial, foram tiradas as medidas de pronação e supinação, ativa e passiva, tanto do lado lesionado quanto do lado não afetado. Resultados: Observou-se diferença estatisticamente significativa entre o lado lesionado e o lado normal, porém não houve diferença entre os grupos por faixas etárias, nem quanto ao tipo de lesão. Conclusão: Os fatores idade e tipo de lesão não tiveram efeito sobre a pronossupinação nas crianças portadoras de sequela de paralisia obstétrica do plexo braquial.

Utilidad de la ecografía en la evaluación del hombro en la parálisis obstétrica del plexo braquial / Utilité de l'échographie pour l'évaluation de l'épaule dans une paralysie obstétricale du plexus brachial / Usefulness of Ultrasound in Assessing Shoulder in Obstetric Brachial Plexus Paralysis

Introducción: en la parálisis obstétrica del plexo braquial se encuentra frecuentemente el hombro en aducción, rotación interna y pérdida de rotación externa, con desequilibrio muscular entre los rotadores internos y externos. Esto conduce a alteración de la articulación glenohumeral. El objetivo del presente reporte es mostrar la utilidad de la ecografía en el diagnóstico y seguimiento de las alteraciones de esta articulación. Método: se estudió una serie de casos de niños con parálisis obstétrica del plexo braquial, todos con actitud en rotación interna y aducción del hombro. Se realizó ecografía de hombro para determinar alteraciones de la articulación glenohumeral. Se determinó la posición del núcleo de osificación de la cabeza humeral con respecto a la línea escapular; se midió el ángulo alfa y se comprobó el grado de subluxación de la cabeza humeral. Resultados: se valoraron 10 pacientes con promedio de edad de 15 meses. Se apreció subluxación posterior en 5 casos con núcleo posterior respecto a la línea escapular y ángulo alfa mayor a 30°. En 4 casos con ángulo normal, había asimetría de por lo menos 10° respecto al hombro contralateral. Conclusiones: la ecografía de hombro constituye la modalidad de imagen de elección para la valoración inicial y el seguimiento del hombro en la parálisis obstétrica del plexo braquial. Es un recurso económico que permite diagnosticar la presencia y grado de subluxación posterior y no requiere sedación ni uso de radiación ionizante(AU)

Introduction: Shoulder adduction is frequently in obstetric brachial plexus paralysis, as well as internal rotation and external rotation loss with muscle imbalance between internal and external rotators. This leads to alteration of the glenohumeral joint. The aim of this report is to show the usefulness of ultrasonography in the diagnosis and monitoring of alterations in this joint. Method: A number of cases was studied for children with obstetric brachial plexus paralysis, all with internal rotation attitude and adduction of the shoulder. Shoulder ultrasound is performed to determine changes in the glenohumeral joint. The position of the humeral head ossification with respect to the shoulder line is determined; the alpha angle was measured and the degree of subluxation of the humeral head was checked. Results: Ten patients were evaluated with an average age of 15 months. Posterior subluxation was seen in five cases with posterior core relative to the shoulder line and alpha angle greater than 30°. In four cases with normal angle, asymmetry of at least 10 degrees from the contralateral shoulder was seen. Conclusions: Shoulder ultrasound is the imaging modality of choice for initial assessment and monitoring of shoulder in obstetric brachial plexus paralysis. It is an economic resource that can diagnose the presence and degree of posterior subluxation and does not require sedation or use of ionizing radiation(AU)

Introduction: Dans la paralysie obstétricale du plexus brachial, on trouve fréquemment une épaule en abduction, une rotation interne et une perte de la rotation externe, avec un déséquilibre musculaire entre les rotateurs internes et externes. Tout cela conduit à une altération de l'articulation gléno-humérale. L'objectif de ce présent rapport est de montrer l'utilité de l'échographie pour le diagnostic et le suivi des altérations de cette articulation. Méthode: Une série de cas d'enfants atteints de paralysie obstétricale du plexus brachial, tous avec une attitude vicieuse (rotation interne et adduction) de l'épaule, a été étudiée. Une échographie de l'épaule a été réalisée pour déterminer les altérations de l'articulation gléno-humérale. On a défini la localisation du noyau d'ossification de la tête de l'humérus par rapport à la ligne scapulaire; l'angle alpha a été calculé, et on a constaté le degré de subluxation de la tête de l'humérus. Résultats: Dix patients âgés de 15 mois en moyenne ont été évalués. On a constaté une subluxation postérieure dans 5 cas, avec un noyau postérieur par rapport à la ligne scapulaire et un angle alpha supérieur à 30º. Dans 4 cas avec un angle alpha normal, il y a eu une asymétrie d'au moins 10º par rapport à l'épaule controlatérale. Conclusions: L'échographie constitue la technique de choix pour l'évaluation initiale et le suivi de l'épaule dans la paralysie obstétricale du plexus brachial. C'est une ressource économique permettant de diagnostiquer la présence et le degré de subluxation postérieure, et ne requérant pas de sédation ni de radiation ionisante(AU)

Outcome measures used in clinical studies on neonatal brachial plexus palsy: A systematic literature review using the International Classification of Functioning, Disability and Health.

BACKGROUND: Symptoms of a neonatal brachial plexus palsy (NBPP) can vary widely among individuals and numerous clinical studies have been performed to identify the natural history and to improve treatment. The aim of this study was to identify and describe all outcome measures used in clinical studies on patients with an NBPP and categorize these outcome measures according to the International Classification of Functioning, Disability and Health (ICF). METHOD: Electronic searches of different databases were carried out. All clinical studies describing one or more outcomes of NBPP were selected. Data on outcome measures was systematically extracted and the contents were analyzed and linked to the ICF. RESULTS: A total of 217 full texts were selected and 59 different outcome measures were identified. The 5 most frequently used outcome measures included range of motion of the shoulder (n= 166 studies, 76%), range of motion of the elbow (n= 87 studies, 40%), the Mallet scale (n= 66 studies, 30%), Magnetic Resonance Imaging (n= 37 studies, 17%) and the Medical Research Council motor grading scale (n= 31 studies, 14%). Assessments related to Body functions and Structures were most frequent, whereas assessments associated with Activities and Participation and Environmental Factors were relatively uncommon. CONCLUSION: There was a high variability among the outcome measures used, with measures within the ICF component Body Functions being most common. These results underscore the need for the development and usage of outcome measures representing all domains of health status in patients with NBPP.

Neonatal brachial plexus palsy: a permanent challenge / Paralisia do plexo braquial neonatal: um desafio permanente

Neonatal brachial plexus palsy (NBPP) has an incidence of 1.5 cases per 1000 live births and it has not declined despite recent advances in obstetrics. Most patients will recover spontaneously, but some will remain severely handicapped. Rehabilitation is important in most cases and brachial plexus surgery can improve the functional outcome of selected patients. This review highlights the current management of infants with NBPP, including conservative and operative approaches.

A paralisia neonatal do plexo braquial (PNPB) tem uma incidência de 1,5 casos por 1000 nascidos vivos e não tem diminuído a despeito dos recentes avanços em obstetrícia. A maioria dos pacientes recupera-se espontaneamente, mas alguns permanecerão com sequelas graves. A reabilitação é importante na maioria dos casos e a cirurgia do plexo braquial pode melhorar o resultado funcional em pacientes selecionados. Esta revisão destaca o manejo atual de lactentes com PNPB, incluindo as terapêuticas conservadora e cirúrgica.

The prognostic value of concurrent Horner syndrome in extended Erb obstetric brachial plexus palsy.

Horner syndrome may be seen in infants with extended Erb obstetric brachial plexus palsy. However, its prognostic value in these infants has not been previously investigated. A total of 220 infants with extended Erb palsy were included and divided into 2 groups: group I (n = 209) were infants with extended Erb palsy without Horner syndrome, and group II (n = 11) were infants with extended Erb palsy and concurrent Horner syndrome. The rate of good spontaneous recovery of elbow flexion was 59% in group I and 27% in group II, and the difference was significant (P = .038). The rate of good spontaneous recovery of wrist extension was 61% in group I and 0% in group II, and the difference as highly significant (P < .0001). Concurrent Horner syndrome in infants with extended Erb palsy may be considered as a poor prognostic sign for recovery of the sixth and seventh cervical roots.

Atuação fisioterapêutica na paralisia braquial obstétrica / Physiotherapy approach in obstetric brachial plexus palsy

A paralisia braquial obstétrica é o resultado de uma lesão das fibras nervosas do plexo braquial durante as manobras obstétricas do parto. A lesão gera grande repercussão na funcionalidade do membro superior lesado do recém-nascido. Os sinais e sintomas variam consideravelmente, dependendo da localização da lesão. A afecção obstétrica do plexo braquial é classificada, de acordo com o nível das raízes lesadas, em três categorias: paralisia alta ou de Erb-Duchenne (forma mais comum), paralisia baixa ou de Klumpke e paralisia total. A intervenção precoce do fisioterapeuta, no processo de reabilitação, é fundamental para prevenir complicações e melhorar a função motora.

Transposición de los músculos dorsal ancho y redondo mayor para el tratamiento de la parálisis braquial obstétrica / Transposition of mayor round wide dorsal muscles for treatment of obstetric brachial paralysis

INTRODUCCIÓN. La parálisis braquial obstétrica produce un desequilibrio muscular en el hombro que limita la abducción y rotación externa, y crea una incapacidad funcional considerable. El objetivo general de este trabajo fue evaluar los resultados obtenidos con la transposición de los músculos dorsal ancho y redondo mayor al manguito rotador, en pacientes con esta afección. MÉTODOS. Se realizó un estudio retrospectivo descriptivo de 26 pacientes con parálisis braquial obstétrica, tratados mediante dicha transposición en el Servicio General del Complejo Científico Ortopédico Internacional Frank País, entre enero del 2001 y enero del 2009. RESULTADOS. La edad promedio en el momento de la transposición fue de 5,8 años (5-8 años). Se empleó el abordaje axilar en 11 casos y el braquial posterior, en 15. En 11 pacientes fue necesaria una cirugía de liberación previa o simultánea. La movilidad activa promedio en abducción era de 77º (30º - 105º) en el preoperatorio y aumentó a 132º (95º - 180º) después de la cirugía. La movilidad activa en rotación externa era de 7º (0º - 20º) y aumentó a 61º (35º - 90º). La movilidad activa en rotación interna era de 83º (75º - 90º) y disminuyó a 57º (25º - 70º). La evaluación funcional según la puntuación de Mallet modificada era como promedio de 13 puntos (8-17) y mejoró a 20 puntos (16-23). No hubo complicaciones con el tratamiento aplicado. CONCLUSIONES. La transposición del dorsal ancho y el redondo mayor proporcionan un aumento de la movilidad activa de abducción y rotación externa del hombro. Aproximadamente en la mitad de los pacientes se requiere una intervención previa o simultánea para liberar las contracturas musculares. El tratamiento consiguió una mejoría de la función global del miembro en todos los pacientes

INTRODUCTION: The obstetric brachial paralysis causes a muscular lack of balance limiting the abduction and the external rotation as well as a significant functional ability. The main objective of present paper was to assess the results obtained with the above mentioned transposition to rotator cuff in patients presenting this affection. METHODS: A descriptive retrospective study was conducted in 26 patients with obstetric brachial paralysis, treated with such transposition in the General Service of Fran País International Orthopedic Scientific Complex from January, 2002 to January, 2009. RESULTS: Mean age at transposition was of 5,8 years (5-8 years). Axillary approach in 11 cases and posterior brachial in 15 were used. In 11 patients it was necessary a previous or simultaneous release surgery. Mean active mobility in abduction was of 77º (30º - 105º) during postoperative period and increased to 132º (95 -180º) after surgery. Active mobility in preoperative period and increased to 132º (95º - 180º) after surgery. Active mobility in external rotation was of 7º (0º - 20º) and increased to 61º (35º -90º). Active mobility in internal mobility was of 83º (75º - 90º) and decreased to 57º (25º - 70º). Functional assessment according to the modified Mallet's score on average was of 13 points (8-17) and improved to 20 points (16-23). There were not complications with applied treatment. CONCLUSIONS: Above mentioned transposition leads to an increase in active mobility of abduction and external rotation of shoulder. Approximately in the half of patients it is required a previous and simultaneous intervention to release the muscular contractures. Treatment achieved an improvement of general member function in all patients

INTRODUCTION. La paralysie obstétricale du plexus brachial conduit à un déséquilibre musculaire au niveau de l'épaule, limitant l'abduction et la rotation externe, et crée un handicap fonctionnel considérable. Le but de ce travail est d'évaluer les résultats obtenus avec la transposition des muscles grand dorsal et grand-rond à la coiffe des rotateurs chez les patients atteins.MÉTHODES. Une étude rétrospective et descriptive de 26 patients atteints d'une paralysie obstétricale du plexus brachial et traités par cette technique au Service général du Complexe scientifique orthopédique international Frank Pais, entre janvier 2001 et janvier 2009, a été réalisée.RÉSULTATS. L'âge moyen au moment de la transposition a été 5.8 ans (5-8 ans). Les voies d'abord utilisées ont été la voie axillaire (11 cas) et la voie brachiale postérieure (15 cas). Une chirurgie de libération préalable ou simultanée a été nécessaire chez 11 patients. La mobilité active moyenne en abduction a été 77º (30º 105º) dans le préopératoire, et a augmenté à 132º (95º 180º) après la chirurgie. La mobilité active en rotation externe a été 7º (0º 20º), et a augmenté à 61º (35º 90º). La mobilité active en rotation interne a été 83º (75º 90º), et a diminué à 57º (25º 70º). L'évaluation fonctionnelle d'après le score de Mallet modifié a été 13 points (8 17) en moyenne, et a amélioré 20 points (16 23). Il n'y a eu aucune complication importante.CONCLUSIONS. La transposition des muscles grand dorsal et grand-rond contribue à l'augmentation de la mobilité active d'abduction et de rotation externe de l'épaule. À peu près la moitie des patients ont eu besoin d'une chirurgie préalable ou simultanée pour le soulagement des contractures. Dans tous les cas, on a réussi à récupérer la fonction générale de l'extrémité avec ce traitement