Secondary reanimation procedures in late obstetrical brachial plexus palsy patients

Forearm and elbow secondary surgical procedures in neonatal brachial plexus palsy: a systematic scoping review

Background

Neonatal Brachial plexus palsy is an injury during delivery that can lead to loss of motor function and limited range of motion in patients due to damage of nerves in the brachial plexus. This scoping review aims to explore types of procedures performed and assess outcomes of forearm and elbow secondary surgery in pediatric patients.

Methods

Searches of PubMed, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Web of Sciences, and Scopus were completed to obtain studies describing surgical treatment of elbow and forearm in pediatric patients with neonatal Brachial plexus palsy. 865 abstracts and titles were screened by two independent reviewers resulting in 295 full text papers; after applying of inclusion and exclusion criteria 18 articles were included. The level of evidence of this study is level IV.

Results

Ten main procedures were performed to regain function of the forearm and elbow in neonatal brachial plexus birth palsy patients. Procedures had different aims, with supination contracture (6) and elbow flexion restoration (5) being the most prevalent. The variance between preoperative and postoperative soft tissue and bony procedures outcomes decreased and showed improvement with respect to the aim of each procedure category. For soft tissue procedures, a statistically significant increase was found between preoperative and postoperative values for active elbow flexion, passive supination, and active supination. For bony procedures, there was a statistically significant decrease between preoperative and postoperative values of passive and active supination.

Conclusion

Overall, all procedures completed in the assessed articles of this study were successful in their aim. Bony procedures, specifically osteotomies, were found to have a wider range of results, whereas soft tissue procedures were found to be more consistent and reproducible with respect to their outcomes. Bony and soft tissue procedures were found vary in their aims and outcomes. This study indicates the need for further research to augment knowledge about indications and long-term benefits to each procedure.

Clinical and psychosocial outcomes following correction of supination deformity in obstetrical brachial plexus palsy patients: A retrospective study

Background

Forearm supination contracture is the mostAQ common deformity of the forearm following obstetric brachial plexus palsy (OBPP). Supination deformities in OBPP may be corrected by performing forearm osteotomy; however, the high recurrence rate limits patient satisfaction. Apart from the cosmetic impairment of this deformity, there are no previous reports on the clinical and psychosocial outcomes of forearm osteotomy in patients with supination deformities secondary to OBPP. Therefore, our study aimed to assess the clinical, functional, and psychosocial outcomes following forearm pronation osteotomy in OBPP patients with supination deformity.

Methods

This retrospective study was conducted after a chart review of all OBPP sequelae with supination forearm deformity in patients who underwent forearm pronating osteotomy from 2006 to 2018. Data relating to OBPP were gathered, and functional and psychosocial outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire through interviews

Results

This study included 60 patients with a mean age of 8.7 years at the time of surgery. A total of 46 patients had lesions involving C5-T1 (76.7%). The mean preoperative supination deformity position was 68.5°, the mean amount of correction was 98.9°, and the mean forearm position was 30.5°, postoperatively. In the DASH assessment scale used postoperatively, 24 patients (42.9%) reported no restrictions on their daily activities, 25 patients (44.6%) believed that their social activities were unaffected, and 20 patients (35.7%) strongly disagreed with feeling less capable or less confident due to arm, shoulder, or hand problems. The factors significantly affecting position at the final follow-up were the amount of correction (p = 0.011), postoperative position (p = 0.005), and degree of pronation achieved (p = 0.02). The amount of correction significantly affected both self-confidence (p = 0.049) and activities of daily living (p = 0.033).

Conclusion

In conclusion, our study showed that the position at the final follow-up, the degree of pronation achieved intraoperatively, and the postoperative position significantly affected the position at follow-up and the outcome assessment. The amount of intraoperative correction was significantly associated with higher self-confidence and normal activities of daily living.

Clinical and functional outcome of modified Quad surgery in adult obstetric brachial plexus injury patients: Case reports

Untreated adult obstetric brachial plexus injury (OBPI) patients, in general, use compensatory strategies to achieve their lost upper extremity functions; they cause some adverse effects. Our present study is a case series of 3 female adult OBPI patients, aged 46, 23 and 21 years old. They all had a modified Quad surgical procedure. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized upper extremity movements using the modified Mallet scale. The average postoperative follow-up was 4.3 months (1 to 9 months). Total Mallet score significantly improved from 15 and 18 to 21 in two patients. Supination angle measured from active movement of these 3 patients improved from 40°, 0° and -60° to 80°, 40° and -40°, respectively. The modified Quad surgical procedure significantly improves active abduction and other shoulder functions not only in young pediatric and adolescent patients, as we have previously reported, but also in adult patients with muscle imbalance secondary to brachial plexus injury sustained at birth.

Arthroscopic versus open release of internal rotation contracture in the obstetrical brachial plexus paralysis (OBPP) sequela

BACKGROUND

Latissimus dorsi (LD) and teres major (TM) tendon transfers are effective surgical procedures to improve shoulder abduction and external rotation for children with obstetrical brachial plexus palsy (OBPP). Open pectoralis major (PM) tendon Z-plasty and arthroscopic subscapularis (SS) release are 2 options for the release of internal rotation contractures to enhance muscle transfers. This study compared the functional results of LD and TM tendon transfers with open PM tendon Z-plasty or arthroscopic SS release.

METHODS

The study included 24 patients who underwent LD and TM tendon transfers for OBPP (9 arthroscopic SS release, 15 open PM tendon Z-plasty) with a mean follow-up of 41.33 months (range, 36-60 months) and 47.2 months (range, 36-60 months), respectively. Functional evaluation was made according to range of motion and Mallet scoring system.

RESULTS

Shoulder abduction-external rotation degrees and scores in all sections of the Mallet scoring system significantly increased in both groups (P < .001). Postoperatively, the arthroscopic SS release group had significantly better abduction degrees (P = .003), total Mallet scores (P < .001), and superior abduction (P = .043), active external rotation (P = .043), hand-to-head (P = .043), and hand-to-mouth (P < .001) scores for the Mallet scoring system.

DISCUSSION

Transfer of LD together with TM tendons combined with one of the internal rotation contracture release procedures yielded good clinical and functional results in patients younger than age 7, regardless of the type of release method. However, arthroscopic SS release, although requiring an experienced surgeon, revealed better clinical and functional outcomes and is considered to be a less invasive and superior method.

Prevalence and etiology of elbow flexion contractures in brachial plexus birth injury: A scoping review

PURPOSE

To synthesize the evidence on the prevalence and etiology of elbow flexion contractures secondary to brachial plexus birth injury (BPBI).

METHODS

Using Arksey and O'Malley's scoping review framework, MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched, followed by a comprehensive grey literature search. Articles and abstracts of studies of all level of evidence on the prevalence, natural history, clinical presentation, etiology, and treatment of elbow flexion contractures in BPBI were included.

RESULTS

Of the 884 records found, 130 full text articles were reviewed, and 57 records were included. The median prevalence of elbow flexion contracture in BPBI was 48%. The magnitude of the contractures was between 5 and 90 degrees. Contractures > 30 degrees were found in 21% to 36% of children. With recent clinical and lab studies, there is stronger evidence that the contractures are largely due to the effects of denervation causing failure in the growth of the affected flexor muscles, while muscle imbalance, splint positioning, and postural preferences play a smaller role.

CONCLUSION

The etiology of elbow flexion contractures is multifaceted. The contribution of growth impairment in the affected muscles offers greater understanding as to why maintaining passive range of motion in these contractures can be difficult.

Correction of elbow flexion contracture by means of olecranon resection and anterior arthrolysis in obstetrical brachial plexus palsy sequelae

The authors have developed a particular surgical technique (olecranon bone resection together with anterior elbow arthrolysis) to increase the elbow's range of motion in adolescents and young adults suffering from elbow flexion contracture in obstetrical palsy sequelae. The surgical procedure was carried out in a preliminary group of 11 patients. The original procedure included a double incision: first of all by means of a posterior approach to resect the tip of the olecranon and then another incision carried out through the anteromedial aspect of the elbow, with a view to performing the anterior capsulotomy. Preoperatively, the average clinical elbow extension was 64.9°, whereas after surgery, the value increased to 43.63°. The average DASH score was 38.27 points before surgery, whereas it decreased to 29.98 points after surgery. A statistical analysis was also carried out to confirm the outcome. The procedure is reliable, is not time-consuming, and does not lead to any major complications.

Free functioning gracilis transplantation for reconstruction of elbow and hand functions in late obstetric brachial plexus palsy

BACKGROUND

In late obstetric brachial plexus palsy (OBPP), restoration of elbow and hand functions is a difficult challenge. The use of free functioning muscle transplantation in late OBPP was very scarcely reported. In this study, we present our experience on the use of free functioning gracilis transfer for restoration of elbow and hand functions in late cases of OBPP.

PATIENTS AND METHODS

Eighteen patients with late OBPP underwent free gracilis transfer for reconstruction of elbow and/or hand functions. The procedure was indicated when there was no evidence of reinnervation on EMG and in the absence of local donors. Average age at surgery was 102.5 months. Patients were evaluated using the British Medical Research Council (MRC) grading system and the Toronto Active Movement Scale. Hand function was evaluated by the Raimondi scoring system.

RESULTS

The average follow-up was 65.8 ± 41.7 months. Contraction of the transferred gracilis started at an average of 4.5 ± 1.03 months. Average range of elbow flexion significantly improved from 30 ± 55.7 to 104 ± 31.6 degrees (P <0.001). Elbow flexion power significantly increased with an average of 3.8 grades (P = 0.000147). Passive elbow range of motion significantly decreased from an average of 147 to 117 degrees (P = 0.003). Active finger flexion significantly improved from 5 ± 8.3 to 63 ± 39.9 degrees (P < 0.001). Finger flexion power significantly increased with an average 2.7 grades (P < 0.001). Only 17% achieved useful hand (grade 3) on Raimondi hand score. Triceps reconstruction resulted in an average of M4 power and 45 degrees elbow extension.

CONCLUSION

Free gracilis transfer may be a useful option for reconstruction of elbow and/or hand functions in late OBPP.

Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome

AIM: To systematically review and analyze the overall impact and effectiveness of bony surgical procedures, the triangle tilt and humeral surgery in a comparative manner in permanent obstetric brachial plexus injury (OBPI) patients.

METHODS: We conducted a literature search and identified original full research articles of OBPI patients treated with a secondary bony surgery, particularly addressing the limitation of shoulder abduction and functions. Further, we analyzed and compared the efficacy and the surgical outcomes of 9 humeral surgery papers with 179 patients, and 4 of our secondary bony procedure, the triangle tilt surgical papers with 86 patients.

RESULTS: Seven hundred and thirty-one articles were identified, using the search term “brachial plexus” and obstetric or pediatric (246 articles) or neonatal (219 articles) or congenital (188 articles) or “birth palsy” (121 articles). Further, only a few articles were identified using the bony surgery search, osteotomy “brachial plexus” obstetric (35), “humeral osteotomy” and “brachial plexus” (17), and triangle tilt “brachial plexus” (14). Of all, 12 studies reporting pre- and post- operative or improvement in total Mallet functional score were included in this study. Among these, 9 studies reported the humeral surgery and 4 were triangle tilt surgery. We used modified total Mallet functional score in this analysis. Various studies with humeral surgery showed improvement of 1.4, 2.3, 5.0 and 5.6 total Mallet score, whereas the triangle tilt surgery showed improvement of 5.0, 5.5, 6.0 and 6.2.

CONCLUSION: The triangle tilt surgery improves on what was achieved by humeral osteotomy in the management of shoulder function in OBPI patients.

Meta-analysis of function after secondary shoulder surgery in neonatal brachial plexus palsy

BACKGROUND

Shoulder internal rotation contracture, active abduction, and external rotation deficits are common secondary problems in neonatal brachial plexus palsy (NBPP). Soft tissue shoulder operations are often utilized for treatment. The objective was to conduct a meta-analysis and systematic review analyzing the clinical outcomes of NBPP treated with a secondary soft-tissue shoulder operation.

METHODS

A literature search identified studies of NBPP treated with a soft-tissue shoulder operation. A meta-analysis evaluated success rates for the aggregate Mallet score (≥ 4 point increase), global abduction score (≥ 1 point increase), and external rotation score (≥ 1 point increase) using the Mallet scale. Subgroup analysis was performed to assess these success rates when the author chose arthroscopic release technique versus open release technique with or without tendon transfer.

RESULTS

Data from 17 studies and 405 patients were pooled for meta-analysis. The success rate for the global abduction score was significantly higher for the open technique (67.4%) relative to the arthroscopic technique (27.7%, P<0.0001). The success rates for the global abduction score were significantly different among sexes (P=0.01). The success rate for external rotation was not significantly different between the open (71.4%) and arthroscopic techniques (74.1%, P=0.86). No other variable was found to have significant impact on the external rotation outcomes. The success rate for the aggregate Mallet score was 57.9% for the open technique, a nonsignificant increase relative to the arthroscopic technique (53.5%, P=0.63). Data suggest a correlation between increasing age at the time of surgery and a decreasing likelihood of success with regards to aggregate Mallet with an odds ratio of 0.98 (P=0.04).

CONCLUSIONS

Overall, the secondary soft-tissue shoulder operation is an effective treatment for improving shoulder function in NBPP in appropriately selected patients. The open technique had significantly higher success rates in improving global abduction. There were no significant differences in the success rates for improvement in the external rotation or aggregate Mallet score among these surgical techniques.

Documentation of postoperative pain in the neonatal brachial plexus palsy population

AIMS AND OBJECTIVES

To assess postoperative pain management in neonatal brachial plexus palsy children who underwent a primary nerve repair, release only and/or a release and transfer procedure.

BACKGROUND

Previous studies have noted pain management inadequacies in postoperative pain management in certain paediatric populations. However, this is the first study to focus on postoperative pain management in this particular population.

METHODS

Seventy-five patients, who underwent a primary nerve repair, release only and/or a release and transfer procedures at our institution, were reviewed. Postoperative pain management was assessed on a patient and drug administration level through appropriate pain scale use; appropriate dosage for the medication prescribed; appropriate reassessment of pain following medication administration; and complications leading to a longer hospital stay.

RESULTS

Based on our institution's guidelines following drug administration, 64 patients were not appropriately reassessed for pain. Based on the drug's duration following drug administration, 40 patients were not appropriately reassessed for pain. Twenty-eight per cent of all medication administrations were not properly reassessed for pain based on the drug's duration and 62% of the time based on our institution's guidelines. Fifty per cent of all medication administrations were not properly dosed and 51 patients were not appropriately dosed at least once during their hospital stay. Pain scales were documented incorrectly 20% of the time and administered improperly to 13 patients.

CONCLUSIONS

Opportunities for improvement in postoperative pain management in the paediatric population - particularly those with neonatal brachial plexus palsy - exist.

RELEVANCE TO CLINICAL PRACTICE

Findings from this study demonstrate that healthcare professionals may have (1) insufficient knowledge regarding pain and/or (2) inadequate direction and guidance to appropriately assess and document pain in the paediatric population. Improvements for these individual healthcare professionals and clinical settings are needed to overcome postoperative pain management issues in the future.

Bone discrepancy as a powerful indicator for early surgery in obstetric brachial plexus palsy

OBJECTIVES

One of the unfortunate sequelae in obstetric brachial plexus palsy (OBPP) is upper limb length discrepancy. However, the influence of primary nerve reconstruction remains undetermined. In this study, the resultant discrepancy in children with OBPP who underwent primary reconstruction was analyzed in relation to the severity of the lesion, the timing of surgery, and the functional outcome following surgery.

METHODS

Fifty-four patients that met the inclusion criteria were included in this study. Preoperative and postoperative bilateral scanograms were obtained to document the effect of reinnervation on bone growth. The length of the humerus, ulna, third metacarpal, third proximal phalange, and total limb length were measured and the percentage between the affected and normal side were accessed. Correlations between all the measures of limb length and measures of active motion (i.e., three different classification systems) were performed.

RESULTS

Spearman's rank correlation coefficients revealed significant correlations between limb length discrepancies and nearly all measures of active upper extremity movement. The timing of surgery and the severity of the lesion significantly influenced the resultant limb length discrepancy.

CONCLUSIONS

The prevention of a non-acceptable upper limb discrepancy is fundamental for both the patient and family. The extent of the resultant discrepancy appeared to be strongly related to the time between injury and surgery, degree of severity, and the outcome of surgery. Patients with better functional recoveries of the affected upper extremities showed smaller differences in limb length.

Outcomes of hand reconstruction in obstetric brachial plexus palsy

BACKGROUND

In children with global obstetric brachial plexus palsy, prioritization should be first focused on hand reinnervation and then directed to shoulder and elbow function. In this study, the surgical strategy for restoration of hand function and the methods and outcomes are analyzed.

METHODS

Between 1979 and 2005, 59 patients (61 extremities) underwent reconstruction for hand reanimation. The mean follow-up was 7.7 years (range, 2 to 22 years). Of these, 16 cases underwent primary reconstruction alone, 35 underwent both primary and secondary procedures, and 10 late cases underwent palliative surgery. Hand function was evaluated with a modified Gilbert- Raimondi hand scale (grades 4 to 6 were considered useful outcomes).

RESULTS

Grade 4 or better functional recovery was observed in six of six cases (100 percent) that underwent primary reconstruction within the first 3 months of life. These patients did not require any secondary procedures. Multiple secondary procedures were necessitated to maximize the functional outcome in late cases or in patients with incomplete recovery following primary reconstruction. Overall, 46 of 61 cases (75.4 percent) achieved grade 4 or greater. The long-term results were better; 23 of 26 cases (88 percent) with a follow-up of more than 8 years achieved grade 4 or greater.

CONCLUSIONS

When primary reconstruction was performed within 3 months, functional return to the hand was the greatest and the need for palliative surgery was dramatically reduced. For older patients (>or=4 months), secondary procedures can significantly enhance hand function. The best results were seen when a combination of tendon transfers and free muscles transfers was performed.

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.

Secondary procedures for elbow flexion restoration in late obstetric brachial plexus palsy

Even though total absence of elbow flexion in obstetric brachial plexus palsy (OBPP) is rare, weakness is a frequent problem. Numerous procedures for elbow flexion restoration in late obstetric brachial plexus palsy have been described. In this study, children with OBPP who underwent secondary reconstruction for elbow flexion restoration were studied. A retrospective review of 15 patients (16 elbows) who underwent 16 pedicled and eight free-muscle transfers for elbow flexion restoration was conducted. The mean follow-up period was 8.4 ± 2.9 years (range, 25 months to 12.2 years). The mean age at operation (elbow surgery) was 5.4 ± 1.9 years. The total arc of elbow motion was the result of the active elbow flexion less the flexion contracture. There was significant improvement in biceps muscle power from an average grading of 2.49 ± 0.80 preoperatively to 3.64 ± 0.46 postoperatively (p < 0.001). Thirteen of 16 elbows (81%) achieved good and excellent results (≥M3+); and three elbows (19%) fair results (M3- or M3). The average arc of motion was significantly improved from 36° ± 25° preoperatively to 94° ± 26° postoperatively (p < 0.001). The preoperative and postoperative average elbow flexion contracture was 10.9° ± 8.9° and 20° ± 12.2°, respectively. Pedicled and/or free-muscle transfers can significantly improve elbow flexion in late obstetric brachial plexus palsy. Choice of the procedure should be individualized and determined on the basis of the type of paralysis, availability of donor muscles, previous reconstruction, and experience of the surgeon.

Wrist arthrodesis for brachial plexus palsy using an external fixator and a cannulated screw (Ioannina technique)

PURPOSE

To present a new technique for wrist arthrodesis and review its treatment outcomes in 33 patients with brachial plexus palsy.

METHODS

26 men and 7 women (mean age, 26 years) with global brachial plexus palsy underwent wrist arthrodesis using an external fixator and a cannulated screw. All surgeries were performed under local anaesthesia by a single senior surgeon. An external fixator was applied to the radius and the metacarpal of the index finger. The articular surfaces of the radius, scaphoid, lunate, and capitate were debrided, and a cannulated screw inserted from the base of the radial styloid to the carpo-metacarpal joint of the ring finger. Cancellous allografts mixed with demineralised bone matrix were added to the decorticated wrist bones. The external fixator was removed at week 8 and the wrist protected with a short-arm splint until solid wrist fusion.

RESULTS

All patients achieved wrist fusion after a mean of 14 (range, 12-16) weeks. Two patients had delayed fusion and slight wrist instability, because the shorter screw was embedded in the cancellous bone and not self-tapped to the cortex. Fusion was achieved after replacement with a longer screw. No patient developed a superficial or deep wound infection; 2 developed pin track infections. All patients were satisfied with the outcome and able to perform simple daily activities after one year.

CONCLUSION

Our new technique for wrist arthrodesis is less invasive. Blood loss, the risk of postoperative infection, and adhesions at the extensors are decreased.

Elbow flexion after primary reconstruction in obstetric brachial plexus palsy

Fifty-two children (54 upper extremities) with obstetric brachial plexus palsy who underwent primary reconstruction for elbow flexion restoration were studied. The outcomes were analysed in relation to the type of brachial plexus lesion, timing of surgery, and the type of reconstruction. Overall, 42 of 54 extremities (78%) achieved good and excellent results (> or =M3+). The average postoperative muscle grading for the biceps was 3.7 (SD 0.8), and the average postoperative active elbow flexion was 108 degrees (SD 33 degrees ). The average elbow flexion contracture was 18 degrees (SD 21 degrees ). The timing of surgery and the type of the brachial plexus injury significantly influenced the final outcome. The best results were seen in early cases (< or =3 months), where the lateral cord was reconstructed from intraplexus donors. In this group, minimal flexion contracture deformity was observed. Late reconstruction (> or =7 months) of the musculocutaneous nerve resulted in inferior results.

A simple effective design for a thermoplastic shoulder spica following secondary surgery for obstetrical brachial plexus palsy

Secondary shoulder surgery is frequently needed to improve shoulder contracture and movement after obstetrical brachial plexus palsy. This surgery comprises subscapularis release coupled in half the cases with tendon transfers, and is generally performed from ages three to nine years. Postoperatively, a shoulder splint is used to immobilize the shoulder in a position that maintains the released position and prevents tension on the tendon transfer, if performed. A thermoplastic splint design that is light and effective is presented.

Obstetric brachial plexus palsy: treatment strategy, long-term results, and prognosis

BACKGROUND

Obstetric brachial plexus palsy is rare, but the limb impairments are manifold and often long-lasting. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed with success. The role of conservative and operative treatment options should be regularly reviewed.

METHODS

Selective literature review (evidence levels 3 and 4) and analysis of personal clinical operative and scientific experience over the past 15 years.

RESULTS

Children with upper and total plexus palsy displaying nerve root avulsions and/or -ruptures are treated today by early primary nerve reconstruction in the first few months of life followed by secondary corrections, with good functional results. The late complications, with muscle weakness, impaired motion patterns, and joint dysplasia, are often underrated.

CONCLUSIONS

The potential for scientific analysis is limited, due to the rarity and interindividual variability of the lesions and the varying effects on function and growth. Expectations and compliance are different in every patient. Surgical techniques are not yet standardized. Knowledge of the consequences for joint growth and congruence is inadequate. Today, functional improvement can be achieved by surgery in most clinical manifestations of obstetric brachial plexus palsy, within the framework of an interdisciplinary treatment concept.

Primary and secondary shoulder reconstruction in obstetric brachial plexus palsy

OBJECTIVES

In this retrospective review, the methods and outcomes in 96 children (98 extremities) with obstetric brachial plexus palsy who underwent primary reconstruction and/or palliative surgery for shoulder function were analysed.

METHODS

Thirty cases underwent primary reconstruction alone, 37 underwent both primary and secondary procedures, and 31 late cases underwent only palliative surgery. The mean follow-up period was 6.7 years.

RESULTS

The mean shoulder abduction increased from 48 degrees +/-32 degrees preoperatively to 123 degrees +/-35 degrees postoperatively (average gain 75 degrees ); the mean active external rotation with the arm at the side increased from -19 degrees +/-17 degrees to 62 degrees +/-21 degrees (mean gain 81 degrees ); and the mean aggregate Mallet score improved from 8.8 points to 20.9 points, respectively.

CONCLUSIONS

Reconstruction of both axillary and suprascapular nerves yielded improved outcomes of shoulder abduction and external rotation. Early plexus reconstruction (<or=3 months) offered the best functional results and reduced the need for secondary reconstructions. A marked improvement was observed after palliative surgery irrespective of prior nerve reconstruction. Rerouting of latissimus dorsi and/or teres major tendons, combined with extra-articular musculotendinous lengthening, significantly improved global shoulder function.

Management of obstetrical brachial plexus palsy with early plexus microreconstruction and late muscle transfers

Birth brachial plexus injury usually affects the upper roots. In most cases, spontaneous reinnervation occurs in a variable degree. This aberrant reinnervation leaves characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are the internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Nowadays, the strategy in the management of obstetrical brachial plexus palsy focuses in close follow-up of the baby up to 3-6 months and if there are no signs of recovery, microsurgical repair is indicated. Nonetheless, palliative surgery consisting of an ensemble of secondary procedures is used to further improve the overall function of the upper extremity in patients who present late or fail to improve after primary management. These secondary procedures include transfers of free vascularized and neurotized muscles. We present and discuss our experience in treating early and/or late obstetrical palsies utilizing the above-mentioned microsurgical strategy and review the literature on the management of brachial plexus birth palsy.