Obstetric brachial plexus palsy

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.

Discussions About Obstetric Brachial Plexus Injuries

Although patients with obstetric brachial plexus injuries (OBPI) have been recognized and treated for greater than 100 years there is much that is not understood or is mis-understood. I address 6 areas for discussion: the cause of OBPI and whether it matters to nerve surgeons; the value of the Narakas grading; whether surgeons should perform primary nerve surgery, especially in patients with incomplete OBPI; the cause and treatment of shoulder tightness; the cause and treatment of elbow contracture; and whether patients with OBPI need surgery in adulthood.

Treatment of obstetrical brachial plexus palsy sequelae: Preliminary results about 18 cases

Background

Severe obstetrical injuries of the brachial plexus lead to a complete or incomplete paralysis resulting in a significant functional handicap of the limb.

This study aimed to assess the preliminary results of our management.

Materials and methods

This prospective study involved 18 patients, with an average age of 7.7 years. The choice of the surgical technique depended on the type of palsy. We evaluated our patients using the Mallet, Gilbert-Raimondi, Brachial plexus World Group Heerlen, and Raimondi scores.

Results

Patients in groups I and II of Narakas had an anterior shoulder release (n = 2) and transfer of the latissimus dorsi (n = 8). For those in group III, we performed 5 biceps rerouting and 2 radius derotation osteotomies, one of which was associated with a Zancolli I and an arthrodesis of the thumb MCP joint. In the wrist and hand, we performed two tendon transfers from the flexor carpi ulnaris to the extensor tendons of the fingers.

After a mean follow-up of 30.52 months, in the first 9 patients, active external rotation of the shoulder increased from a mean value of −22.5°–38.8° and mean active abduction from 78.3° to 141.1°. In Group III, the mean spontaneous supination position of 75.5° was improved to 45° pronation. Regarding the two patients with tendon transfers, active wrist extension increased from 0° to 45° and from −60° to 0°, respectively.

Conclusion

Palliative surgery in the treatment obstetrical brachial plexus palsy sequelae retains an important place in the restoration of upper limb function.

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Obstetrical brachial plexus palsy lead to a complete or incomplete paralysis.

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Several techniques are proposed to improve the upper limb functions.

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Functional results depend on the severity of the injury and the age of the patient.

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Palliative surgery redistributes remaining muscular forces.

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Treatment requires a collaboration between doctor, physiotherapist and parents.

Experimental nerve transfer model in the neonatal rat

Clinically, peripheral nerve reconstructions in neonates are most frequently applied in brachial plexus birth injuries. Most surgical concepts, however, have investigated nerve reconstructions in adult animal models. The immature neuromuscular system reacts differently to the effects of nerve lesion and surgery and is poorly investigated due to the lack of reliable experimental models. Here, we describe an experimental forelimb model in the neonatal rat, to study these effects on both the peripheral and central nervous systems. Within 24 hours after birth, three groups were prepared: In the nerve transfer group, a lesion of the musculocutaneous nerve was reconstructed by selectively transferring the ulnar nerve. In the negative control group, the musculocutaneous nerve was divided and not reconstructed and in the positive control group, a sham surgery was performed. The animal´s ability to adapt to nerve lesions and progressive improvement over time were depict by the Bertelli test, which observes the development of grooming. Twelve weeks postoperatively, animals were fully matured and the nerve transfer successfully reinnervated their target muscles, which was indicated by muscle force, muscle weight, and cross sectional area evaluation. On the contrary, no spontaneous regeneration was found in the negative control group. In the positive control group, reference values were established. Retrograde labeling indicated that the motoneuron pool of the ulnar nerve was reduced following nerve transfer. Due to this post-axotomy motoneuron death, a diminished amount of motoneurons reinnervated the biceps muscle in the nerve transfer group, when compared to the native motoneuron pool of the musculocutaneous nerve. These findings indicate that the immature neuromuscular system behaves profoundly different than similar lesions in adult rats and explains reduced muscle force. Ultimately, pathophysiologic adaptations are inevitable. The maturing neuromuscular system, however, utilizes neonatal capacity of regeneration and seizes a variety of compensation mechanism to restore a functional extremity. The above described neonatal rat model demonstrates a constant anatomy, suitable for nerve transfers and allows all standard neuromuscular analyses. Hence, detailed investigations on the pathophysiological changes and subsequent effects of trauma on the various levels within the neuromuscular system as well as neural reorganization of the neonatal rat may be elucidated. This study was approved by the Ethics Committee of the Medical University of Vienna and the Austrian Ministry for Research and Science (BMWF-66.009/0187-WF/V/3b/2015) on March 20, 2015.

Preoperative multislice computed tomography evaluation of shoulder deformities in brachial plexus birth palsy patients undergoing tendon transfer

BACKGROUND

Brachial plexus birth palsy (BPBP) refers to a birth related paralysis of the upper extremity. The current study was designed to evaluate the efficacy of computed tomography (CT) in the assessment of humeral head posterior subluxation and glenoid retroversion preoperatively and to evaluate whether or not bony deformity correlates with functional improvement (based on Modified Mallet Score) following tendon transfer in brachial plexus birth palsy patients.

PATIENTS AND METHODS

This prospective study included 30 patients, 15 below 4 years and 15 above 4 years old, with a mean age 3.65 ± 1.39 (range 2-8) years old. Thirteen patients were males (43.3%) and 17 were females (56.6%). The left side was affected in 13 patients (43.3%), while the right in 17 (56.7%). The Modified Mallet Score was used for clinical assessment of the shoulder function. A multislice CT scan with 3D reconstruction was used as a preoperative radiological assessment of the shoulder. An electromyography (EMG) of the muscles around the shoulder was performed. All patients were operated upon by anterior release of the internal rotators to improve the external rotation range of motion and by transfer of teres major and latissimus dorsi to improve the abduction motion through one anterior deltopectoral incision and a small posterosuperior incision. Postoperatively, the range of shoulder abduction and external rotation had been assessed after shoulder spica removal and till the end of follow up.

RESULTS

Fourteen patients (46.7%) had a normal glenoid version angle (normal range from -12° to 2°) and normal range of articulation with the glenoid (42.3%-71.4%) and 16 patients (53.3%) had an abnormal glenoid version angle and abnormal range of articulation with the glenoid. According to the Modified Mallet Score, there was a statistically significant difference in the mean value of global abduction (P = 0.04), external rotation (P = 0.03), hand to mouth (P = 0.02), hand to neck (P = 0.03) and hand to spine (P = 0.02) between the pre- and post-operative assessment of all patients. There was a statistically significant difference in the mean value of postoperative Modified Mallet Score between the patients under the age of 4 years and those above the age of 4 years. There was no statistically significant difference between the patients with normal CT angles and those with abnormal CT angles. There was no statistically significant difference in the mean value of glenoid version angle and percentage of humeral head articulation between the patients below the age of 4 years and those above 4 years (P = 0.845).

CONCLUSION

The study concluded that the glenoid version angle and humeral head articulation percentage do not negatively affect results of the tendon transfer around the shoulder in patients of upper brachial plexus birth palsy.

LEVEL OF EVIDENCE

IV.

Humeral retroversion and shoulder muscle changes in infants with internal rotation contractures following brachial plexus birth palsy

AIM

To examine humeral retroversion in infants who sustained brachial plexus birth palsy (BPBI) and suffered from an internal rotation contracture. Additionally, the role of the infraspinatus (IS) and subscapularis (SSc) muscles in the genesis of this bony deformation is explored.

METHODS

Bilateral magnetic resonance imaging (MRI) scans of 35 infants (age range: 2-7 mo old) with BPBI were retrospectively analyzed. Retroversion was measured according to two proximal axes and one distal axis (transepicondylar axis). The proximal axes were: (1) the perpendicular line to the borders of the articular surface (humeral centerline); and (2) the longest diameter through the humeral head. Muscle cross-sectional areas of the IS and SSc muscles were measured on the MRI-slides representing the largest muscle belly. The difference in retroversion was correlated with the ratio of muscle-sizes and passive external rotation measurements.

RESULTS

Retroversion on the involved side was significantly decreased, 1.0° vs 27.6° (1) and 8.5° vs 27.2° (2), (P < 0.01), as compared to the uninvolved side. The size of the SSc and IS muscles on the involved side was significantly decreased, 2.26 cm² vs 2.79 cm² and 1.53 cm² vs 2.19 cm², respectively (P < 0.05). Furthermore, the muscle ratio (SSc/IS) at the involved side was significantly smaller compared to the uninvolved side (P = 0.007).

CONCLUSION

Even in our youngest patient population, humeral retroversion has a high likelihood of being decreased. Altered humeral retroversion warrants attention as a structural change in any child being evaluated for the treatment of an internal rotation contracture.

The prognostic value of concurrent Horner syndrome in surgical decision making at 3 months in total-type neonatal brachial plexus palsy

We investigated the prognostic value of concurrent Horner syndrome for predicting spontaneous motor recovery in surgical decision making at 3 months with neonatal brachial plexus palsy. Medical records of 129 neonates with total-type brachial plexus palsy were reviewed, and clinical and follow-up data of patients with or without Horner syndrome were compared. Twenty-seven of 129 newborn babies with total-type palsy (21%) had concurrent Horner syndrome. Poor spontaneous motor recovery was observed in 21 (78%) neonates with concurrent Horner syndrome and in 84 (82%) without concurrent Horner syndrome. Concurrent Horner syndrome in neonates with brachial plexus palsy has no prognostic value in predicting poor spontaneous motor recovery of the brachial plexus in patients with total-type palsy.

LEVEL OF EVIDENCE

III.

Relationship between glenoid deformity and gait characteristics in a rat model of neonatal brachial plexus injury

Neonatal brachial plexus injury (NBPI) results in substantial postural and functional impairments associated with underlying muscular and osseous deformities. We examined the relationship between glenoid deformity severity and gait in a rat model of NBPI, an established model for studying the in vivo pathomechanics of NBPI. At 8 weeks post-operatively, we monitored the gait of 24 rat pups who exhibited varying degrees of glenoid deformity following unilateral brachial plexus neurectomy and chemodenervation interventions administered 5 days postnatal. Five basic stride and stance metrics were calculated for the impaired forelimbs over four consecutive gait cycles. Bilateral differences in glenoid version (ΔGA_v ) and inclination (ΔGA_i ) angles were computed from data for the same rats as reported in a previous study. A linear regression model was generated for each deformity-gait pair to identify significant relationships between the two. ΔGA_v was not significantly correlated with any gait measurements, while ΔGA_i significantly correlated with all five gait measurements. Specifically, ΔGA_i was significantly positively correlated with stride length (R²  = 0.38, p = 0.001) and stance factor (R²  = 0.45, p < 0.001), and significantly negatively correlated with stance width (R²  = 0.24, p = 0.016), swing/stance ratio (R²  = 0.17, p = 0.046), and stride frequency (R²  = 0.33, p = 0.003). Rats with declined glenoids exhibited the most altered gait.

CLINICAL SIGNIFICANCE

Our findings link musculoskeletal changes and functional outcomes in an NBPI rat model. Thus, gait analysis is a potentially useful, non-invasive, quantitative way to investigate the effects of injury and deformity on limb function in the NBPI rat model. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1991-1997, 2018.

Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy

OBJECTIVE The use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting. METHODS This retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year. RESULTS No significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups. CONCLUSIONS The preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.

Evaluation of functional outcomes and preliminary results in a case series of 15 children treated with arthroscopic release for internal rotation contracture of the shoulder joint after Erb's palsy

INTRODUCTION

The purpose of this study was to evaluate shoulder function following minimally invasive subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release in children with Erb's palsy.

METHODS

A prospective study was conducted on 15 consecutive children who underwent subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release to treat internal rotation contracture of the shoulder joint after Erb's palsy. Age at surgery ranged from 24 to 38 months (average 28.3) (2.4 years). All of the patients were assessed clinically and radiologically preoperatively and postoperatively at regular intervals. The Mallet scoring system was used to analyze the results.

RESULTS

The mean external rotation improved from -24° to +46° (p = 0.001) at the last follow-up. Active internal rotation was preserved in all cases. At the final follow-up, there had been no loss of the external rotation gained and no recurrence of internal rotation contracture of the shoulder, and the mean Mallet score (total) had improved from 11 to 17 points (p = 0.001).

CONCLUSIONS

In children aged from 1 to 3 years, an arthroscopic release procedure alone may successfully restore function and yield a centered glenohumeral joint, which has a beneficial effect on glenoid remodeling.

LEVEL OF EVIDENCE

Level IV.

Shoulder Function Following Late Neurolysis and Bypass Grafting for Upper Brachial Plexus Birth Injuries

Eleven children ranging in age from 9 to 21 months underwent late nerve reconstruction for persistent shoulder paralysis following an upper brachial plexus birth injury. Only neurolysis was performed in three patients. Neurolysis and nerve grafting bypassing the neuroma with proximal and distal end-to-side repairs was performed in the other eight. All patients were followed for 2 or more years. Two patients underwent a secondary procedure before their final follow-up evaluation. All infants demonstrated significant improvement when assessed by a modified Gilbert shoulder motion scale.

Nerve Transfers in Birth Related Brachial Plexus Injuries: Where Do We Stand?

This article reviews the assessment and management of obstetrical brachial plexus palsy. The potential role of distal nerve transfers in the treatment of infants with Erb's palsy is discussed. Current evidence for motor outcomes after traditional reconstruction via interpositional nerve grafting and extraplexal nerve transfers is reviewed and compared with the recent literature on intraplexal distal nerve transfers in obstetrical brachial plexus injury.

Differentiation of endogenous neural stem cells in adult versus neonatal rats after brachial plexus root avulsion injury

An experimental model of brachial plexus root avulsion injury of cervical dorsal C_5-6 was established in adult and neonatal rats. Real-time PCR showed that the levels of brain-derived neurotrophic factor, nerve growth factor and neurotrophin-3 in adult rats increased rapidly 1 day after brachial plexus root avulsion injury, and then gradually decreased to normal levels by 21 days. In neonatal rats, levels of the three neurotrophic factors were decreased on the first day after injury, and then gradually increased from the seventh day and remained at high levels for an extended period of time. We observed that greater neural plasticity contributed to better functional recovery in neonatal rats after brachial plexus root avulsion injury compared with adult rats. Moreover, immunohistochemical staining showed that the number of bromodeoxyuridine/nestin-positive cells increased significantly in the spinal cords of the adult rats compared with neonatal rats after brachial plexus root avulsion injury. In addition, the number of bromodeoxyuridine/glial fibrillary acidic protein-positive cells in adult rats was significantly higher than in neonatal rats 14 and 35 days after brachial plexus injury. Bromodeoxyuridine/β-tubulin-positive cells were not found in either adult or neonatal rats. These results indicate that neural stem cells differentiate mainly into astrocytes after brachial plexus root avulsion injury. Furthermore, the degree of neural stem cell differentiation in neonatal rats was lower than in adult rats.

The effect of perinatal brachial plexus lesion on upper limb development

BACKGROUND

Deficiency in upper limb development is a sequel of the perinatal brachial plexus palsy. The purpose of this study was to evaluate the effect of brachial plexus birth lesion on upper limb development.

METHODS

Forty-four patients with unilateral obstetric brachial plexus palsy underwent measurements of both upper extremities. The average age at the time of evaluation was 6.8 years. Active motion was assessed using Gilbert-Raimondi, the modified MRC, and Al-Qattan scales. Paired t test was used for statistical analysis. Correlation between limb length / circumference discrepancy and age / time of surgery was assessed using Pearson correlation coefficient.

RESULTS

A decrease in the circumference and length was observed in all limbs with brachial plexus lesion. We found a statistically significant difference between degree of hand length and width decrease and its useful and useless function. We observed a statistically significant difference in measurement: forearm length, hand length and width dependent on the type of surgical procedure (neurolysis, reconstruction). We observed no correlation between age and limb length / circumference discrepancy. We also observed no correlation between time of surgery and limb length / circumference discrepancy.

CONCLUSIONS

The decrease in dimensions of the affected limbs occurred predominantly during the period of early childhood. Disparities in dimensions are observed in both cases of deficiency of useful function of upper limb and cases in which functional efficiency appears.

Psychometric properties of outcome measures for children and adolescents with brachial plexus birth palsy: a systematic review

AIM

The aim of this review was to evaluate the psychometric properties of outcome measures used to quantify upper limb function in children and adolescents with brachial plexus birth palsy (BPBP).

METHOD

Eleven electronic databases were searched to identify studies on the effects of conservative management to improve upper limb function in young people with BPBP. Outcome measures used in these studies were extracted and used in a subsequent search to identify studies that evaluated the psychometric properties of these measures. The methodological quality of these studies was rated using a standardized critical appraisal tool.

RESULTS

Thirty-three outcome measures and 12 psychometric studies were identified. Nine outcome measures had some psychometric evidence, which was variable in quality. The outcome measures which seem to have the most robust psychometric properties include the Active Movement Scale, Assisting Hand Assessment, Pediatric Evaluation of Disability Index, and the Pediatric Outcomes Data Collection Instrument.

INTERPRETATION

Further research is required to determine the psychometric properties of outcome measures used for children and adolescents with BPBP. Caution is required when interpreting the results of commonly used outcome measures in this population owing to their relatively unknown psychometric properties.

Perinatal brachial plexus palsy

BACKGROUND

Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births.

OBJECTIVES

To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions.

METHODS

A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included 'brachial plexus', 'brachial plexus neuropathy', 'brachial plexus injury', 'birth injury' and 'paralysis, obstetric'.

RESULTS

There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm function in children with serious impairments.

CONCLUSIONS

It is not possible to predict which infants are at risk for PBPP, and therefore amenable to preventive measures. Twenty-five per cent of affected infants will experience permanent impairment and injury. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary. Further research into prediction, prevention and best mode of treatment needs to be done.

Triangle tilt and steel osteotomy: similar approaches to common problems

BACKGROUND

Each year, thousands of children worldwide suffer obstetric brachial plexus nerve injuries resulting not only in primary nerve injury, but also in development of secondary muscle and bone deformities of the shoulder. The triangle tilt surgery has been developed and shown to effectively address these deformities. The triangle tilt procedure was initially designed by the lead author (RKN) to follow the concepts of joint normalization featured in the Steel pelvic osteotomy used to correct developmental dysplasia of the hip joint, and indeed ultimately bears a striking resemblance to the Steel osteotomy. Prior to performing these bony surgical procedures, soft tissue procedures are performed to release the muscle contractures of the shoulder and hip. The purpose of this article is to compare and analyze the similarities between the indications, surgical techniques, involved anatomy, and outcomes of these operative procedures.

METHODS

A literature review was conducted using PubMed to identify articles pertaining to triangle tilt surgery and the Steel pelvic osteotomy. Functional parameters and surgical strategies were compared. Pre- and post-operative CTs were analyzed to compare anatomical results of the procedures.

RESULTS

Similarities were found between both procedures in terms of indications, involved anatomy, surgical techniques, and outcomes. The triangle tilt surgery is indicated to correct the developmental dysplasia of the glenohumeral joint in obstetric brachial plexus injury patients. Steel pelvic osteotomy is performed to correct the subluxation and dislocation of the hip innominate bone in patients with congenital dysplasia, cerebral palsy myelodysplasia, and poliomyelitis. The involved anatomy of both procedures is similar in that both involve limb girdles and ball-and-socket joints, namely the shoulder and hip. Both procedures are also triple osteotomies, the triangle tilt involving the acromion, clavicle and scapula while the Steel osteotomy involves the iliac spine, ischial and pubic ramus of the innominate bone. Surgical techniques also bear likenesses in that both can theoretically be done percutaneously. Post-operative CT outcomes of both surgeries showed improved anatomical positioning of the ball-and-socket joint congruency, and therefore better functional outcomes.

DISCUSSION

The similarities between the triangle tilt surgery and Steel pelvic osteotomy could potentially be useful as a model system in developing other procedures that involve the shoulder and hip. Future clinical applications include the development and implementation of new surgical procedures based on comparisons and adaptations from the hip to the shoulder and vice versa.

Our experience with secondary reconstruction of external rotation in obstetrical brachial plexus palsy

BACKGROUND

Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy.

METHODS

From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed.

RESULTS

There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees).

CONCLUSION

Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

Obstetric brachial plexus palsy in newborn babies of diabetic and non-diabetic mothers

Compared to non-diabetic mothers, diabetic mothers are known to deliver larger babies who are at higher risk for shoulder dystocia and obstetric brachial plexus palsy. The intrapartum forces applied during delivery of larger babies are expected to be higher. Hence, the chances of these babies for good spontaneous recovery are expected to be lower; and this is a generally believed hypothesis. The objective of this retrospective study was to compare obstetric brachial plexus palsy in newborn babies of diabetic and non-diabetic mothers. There were a total of 655 cases of obstetric palsy: 253 cases with diabetic mothers and 402 with non-diabetic mothers. The former were more likely to develop total palsy while the latter were more likely to develop extended Erb's palsy. Newborn babies of diabetic mothers had significantly larger birth weights than those of non-diabetic mothers regardless of the type of palsy. The rate of good spontaneous recovery of the motor power of the limb in the two groups was not significantly different except in total palsy cases for shoulder external rotation and elbow flexion where the recovery was significantly better in the diabetic group. It was concluded that the generally believed hypothesis is not correct if one compares the outcome in the diabetic and non-diabetic groups for each type of palsy.

Structural changes in muscle and glenohumeral joint deformity in neonatal brachial plexus palsy

BACKGROUND

Internal rotation contracture of the shoulder is common in children with neonatal brachial plexus palsy. A long-standing contracture may cause osseous deformities in the developing shoulder. The purpose of the study was to evaluate the relationship between osseous deformities of the glenohumeral joint and structural differences due to muscle denervation in the rotator cuff muscles.

METHODS

One hundred and two children with residual neonatal brachial plexus palsy underwent magnetic resonance imaging of both shoulders. The glenoid version and posterior, medial, and superior subluxation of the humeral head were measured. The shapes of the glenoid and the humeral head were categorized, and the infraspinatus, supraspinatus, subscapularis, and deltoid muscles were scored as being normal, atrophic, or atrophic with fatty degeneration.

RESULTS

Muscle degeneration was most prominent in the subscapularis muscle. Glenoid version correlated with the structural differences in the subscapularis muscle. Posterior subluxation of the humeral head and the shape of the glenoid correlated with all abnormal rotator cuff muscles. Superior humeral subluxation correlated only with changes in the supraspinatus muscle. Medialization and the shape of the humeral head were not associated with atrophic changes of the rotator cuff. Regeneration of the rotator cuff muscles was not significantly different in patients with a C5-C6 (C7) or a complete brachial plexus lesion. However, the changes in glenoid version, the degree of posterior humeral subluxation, and the degree of medial humeral subluxation were significantly more severe in patients with a C5-C6 (C7) lesion compared with those in patients with a complete lesion of the brachial plexus.

CONCLUSIONS

Structural differences in the rotator cuff muscles alter the direction of the humeral head forces on the developing glenoid fossa and can lead to osseous deformities. Glenohumeral deformities are significantly greater with a C5-C6 (C7) lesion than with a complete brachial plexus lesion in which the large internal rotators are also affected. Reducing the muscular imbalance that occurs with a C5-C6 (C7) lesion could diminish glenohumeral joint incongruency and may improve the outcome of subsequent soft-tissue release or tendon transfer surgery.

Narakas classification of obstetric brachial plexus palsy revisited

Narakas classified babies with obstetric palsy into four groups: upper Erb's, extended Erb's, total palsy, and total palsy with a Horner. Over the last 15 years, it was noted at our obstetric palsy clinic that good spontaneous recovery in newborns with extended Erb's palsy (C5, C6, C7 injury) was more likely if they recovered active wrist extension against gravity before 2 months of age. A hypothesis was made that newborns with extended Erb's palsy (Narakas Group II) may be subclassified into two groups according to this 'early recovery of wrist extension.' In a retrospective study of 581 cases with strict inclusion criteria, the hypothesis was found to be true: patients with extended Erb's and 'early recovery of wrist extension' have significantly higher percentages of good spontaneous recovery of limb function than those with extended Erb's and 'no early recovery of wrist extension' (P<0.0001 by chi-squared test).

Lack of effectiveness of primary conservative management for infants with brachial plexus birth palsy

PURPOSE

Brachial plexus birth palsy (BPBP) is the most common peripheral nerve injury in children (prevalence <5.1 per 1000 live births) and conservative management is routinely used to manage them. We have previously systematically reviewed studies investigating primary conservative management, published between 1992 and 2002, and found these to be inconclusive. The aim of this review was to update our previous systematic review to include studies published between 2002 and 2008, synthesise the data thus obtained with that of our previous review and create an up-to-date body of evidence for conservative management of infants with BPBP.

PROCEDURES

Fifteen databases were searched systematically for quantitative studies (randomised controlled trials, comparative studies, case series), published in English between January 2002 and June 2008 inclusive. Studies were excluded if they investigated infants who, in their first two years of life, underwent microsurgical repair of the brachial plexus, surgical management of secondary deformities or received other treatments traditionally delivered by surgeons, such as Botulinum toxin injections. The eligibility of each study identified from the database searches was evaluated against the inclusion criteria by two independent reviewers. These studies were then critically appraised for level of evidence using the National Health and Medical Research Council of Australia Hierarchy of Evidence and methodological quality using the Critical Review Form - Quantitative Studies. Data pertaining to the demographic characteristics of study participants, treatments received, main results and outcome measures used were also extracted. Where any disagreement between reviewers occurred, consensus was reached by discussion. Data from the recently published studies were narratively synthesised and then combined with the data gained from our previous systematic review to create a body of evidence on primary conservative management for BPBP infants.

RESULTS

Four publications, representing three studies (one comparative study, two case series), were sourced. Methodological quality scores of these studies ranged from 6 to 12 (maximum =16). The current body of evidence (publications from 1992 to 2008) therefore comprises 11 studies, four using a comparative design and seven using a case series design. Six of the 11 studies were classified as being of "poor" methodological quality (score <8). Conservative management mainly consisted of exercise therapy, although splinting, massage and dynamic traction were also used. All studies lacked a clear definition of conservative management sufficient to allow replication of the treatment in a clinical setting. A variety of outcome measures were used, limiting comparability of the studies. Data from the three case studies suggests that conservative management may be more effective in infants with upper and middle plexus injuries compared with total plexus palsy. However, the different outcome measures used and lack of comparison groups limit the strength of this finding.

CONCLUSIONS

The body of evidence investigating the use of primary conservative management of infants with BPBP remains inconclusive. The studies published to date are limited in number, level of evidence and methodological quality. Further, a variety of outcome instruments, with limited psychometric properties, have been used to investigate management techniques which do not mirror those of contemporary clinical practice.

Outcomes with suprascapular nerve reconstruction in obstetrical brachial plexus patients

BACKGROUND

Restoration of shoulder abduction is very important following obstetrical brachial plexus paralysis. The purpose of this report is to present the authors' experience of suprascapular nerve reconstruction in 53 cases of obstetrical brachial plexus palsy.

METHODS

From 1978 to 2002, 170 children with obstetrical brachial plexus palsy were seen at the authors' institution. One hundred nine children underwent surgical treatment, and 53 of them had suprascapular nerve reconstruction.

RESULTS

The overall results were good or excellent in 96 percent of patients for the supraspinatus muscle and 75 percent for the infraspinatus muscle. The overall mean postoperative muscle grading was 3.71 +/- 0.7 for the supraspinatus muscle and 2.94 +/- 0.8 for the infraspinatus muscle (p < 0.05). By using the Mallet score, 23 patients (46 percent) achieved Mallet grade III and 24 patients (48 percent) achieved Mallet grade IV shoulder abduction function. Evaluating external rotation function, 21 patients (42 percent) achieved Mallet grade III and 20 patients (40 percent) achieved Mallet grade IV. Early surgery (<6 months) yielded significantly better results than late surgery (>6 months).

CONCLUSIONS

Suprascapular nerve neurotization is a worthwhile procedure and is a high priority in upper limb reanimation for restoration of glenohumeral joint stability, shoulder abduction, and external rotation. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction function. The best results are seen in patients with high severity scores, when only the upper two roots are involved, and when direct neurotization of the suprascapular nerve is performed within 6 months after the injury.

Obstetrical brachial plexus palsy

Obstetrical brachial plexus palsy, one of the most complex peripheral nerve injuries, presents as an injury during the neonatal period. The majority of the children recover with either no deficit or a minor functional deficit, but it is almost certain that some will not regain adequate limb function. These few cases must be managed in an optimal way. Considerable medical and legal debate has surrounded the etiologic factors of this traumatic lesion, and obstetricians are often considered responsible for the injury. According to recent studies, spontaneous endogenous forces may contribute substantially to this type of neonatal trauma. All obstetric circumstances that predispose to brachial plexus damage and that could be anticipated should be assessed. Correct diagnosis is necessary for the accurate estimation of prognosis and treatment. The most important aspect of therapy is timely recognition and referral, to prevent the various possible sequelae affecting the shoulder, elbow, or forearm. Since the early 1990s, research has increased the understanding of obstetrical brachial plexus palsy. Further research is needed, focused on developing strategies to predict brachial injury. This review focuses on emerging data relating to obstetrical brachial plexus palsy and discusses the present controversies regarding natural history, prognosis, and treatment in infants with brachial plexus birth palsies.

Improvement in abduction of the shoulder after reconstructive soft-tissue procedures in obstetric brachial plexus palsy

Residual muscle weakness in obstetric brachial plexus palsy results in soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. We describe the results of surgical treatment in 98 patients (mean age 2.5 years, 0.5 to 9.0) for the correction of active abduction of the shoulder. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). The transferred muscles were sutured to the teres minor muscle, not to a point of bony insertion. The mean pre-operative active abduction was 45 degrees (20 degrees to 90 degrees ). At a mean follow-up of 4.8 years (2.0 to 8.7), the mean active abduction was 162 degrees (100 degrees to 180 degrees ) while 77 (78.6%) of the patients had active abduction of 160 degrees or more. No decline in abduction was noted among the 29 patients (29.6%) followed up for six years or more. This procedure involving release of the contracted internal rotators of the shoulder combined with decompression and neurolysis of the axillary nerve greatly improves active abduction in young patients with muscle imbalance secondary to obstetric brachial plexus palsy.

Decreased muscle loading delays maturation of the tendon enthesis during postnatal development

Physical environment influences the development and maintenance of musculoskeletal tissues. The current study uses an animal model to explore the role of the physical environment on the postnatal development of the supraspinatus tendon enthesis. A supraspinatus intramuscular injection of botulinum toxin A was used to paralyze the left shoulders of mice at birth. The supraspinatus muscles of right shoulders were injected with saline to serve as contralateral controls. The supraspinatus enthesis was examined after 14, 21, 28, and 56 days of postnatal development. Histologic assays were used to examine fibrocartilage morphology and percentage osteoclast surface. Micro-computed tomography was used to examine muscle geometry and bone architecture. At 14 days there were no differences between groups in fibrocartilage formation, muscle geometry, bone architecture, or osteoclast surface. When comparing groups at 21, 28, and 56 days, muscle volume was decreased, fibrocartilage development was delayed, mineralized bone was decreased, and osteoclast surface was higher at each timepoint in the botulinum group compared to the contralateral saline control group. Our results indicate that the development of the tendon enthesis is sensitive to its mechanical environment. A reduction in muscle loading delayed the development of the tendon-to-bone insertion site by impeding the accumulation of mineralized bone. Physical factors did not play a significant role in enthesis maturation in the first 14 days postnatally, implying that biologic factors may drive early postnatal development.

Long-term follow-up of children with obstetric brachial plexus palsy I: functional aspects

The aims of this study were to describe the development of sequelae in obstetric brachial plexus palsy (OBPP) and to identify possible differences in functional outcome from 5 years of age to follow-up, 2 to 15 years later. A cohort of 70 participants (35 males, 35 females; age range 7-20y, mean 13y 6mo [SD 4y 3mo], median 13y) with OBPP of varying degrees of severity were monitored. Differences in status between 5 years of age and follow-up were studied. Active joint motion in the shoulder and hand function, especially grip strength, generally remained unchanged or improved, whereas a slight but significant deterioration occurred in elbow function. Shoulder surgery resulted in considerable improvement of shoulder function. Participants with nerve reconstruction had a similar profile of change as the non-operated group. It was concluded that ongoing follow-up of children with OBPP, beyond the preschool years, is required due to decreases in elbow function, a commonly occurring restriction in external rotation of the shoulder, together with individual variations in long-term outcomes. In a related article (part II: neurophysiological aspects) long-term neurophysiological and sensory aspects of OBPP are reported.

Comparison of visual and objective quantification of elbow and shoulder movement in children with obstetric brachial plexus palsy

BACKGROUND

The Active Movement Scale is a frequently used outcome measure for children with obstetric brachial plexus palsy (OBPP). Clinicians observe upper limb movements while the child is playing and quantify them on an 8 point scale. This scale has acceptable reliability however it is not known whether it accurately depicts the movements observed. In this study, therapist-rated Active Movement Scale grades were compared with objectively-quantified range of elbow flexion and extension and shoulder abduction and flexion in children with OBPP. These movements were chosen as they primarily assess the C5, C6 and C7 nerve roots, the most frequently involved in OBPP. Objective quantification of elbow and shoulder movements was undertaken by two-dimensional motion analysis, using the v-scope.

METHODS

Young children diagnosed with OBPP were recruited from the Royal Children's Hospital (Melbourne, Australia) Brachial Plexus registry. They participated in one measurement session where an experienced paediatric physiotherapist facilitated maximal elbow flexion and extension, shoulder abduction and extension through play, and quantified them on the Active Movement Scale. Two-dimensional motion analysis captured the same movements in degrees, which were then converted into Active Movement Score grades using normative reference data. The agreement between the objectively-quantified and therapist-rated grades was determined using percentage agreement and Kappa statistics.

RESULTS

Thirty children with OBPP participated in the study. All were able to perform elbow and shoulder movements against gravity. Active Movement Score grades ranged from 5 to 7. Two-dimensional motion analysis revealed that full range of movement at the elbow and shoulder was rarely achieved. There was moderate percentage agreement between the objectively-quantified and therapist-rated methods of movement assessment however the therapist frequently over-estimated the range of movement, particularly at the elbow. When adjusted for chance, agreement was equal to chance.

CONCLUSION

Visual estimates of elbow and shoulder movement in children with OBPP may not provide true estimates of motion. Future work is required to develop accurate, clinically-acceptable methods of quantifying upper limb active movements. Since few children attained full range of motion, elbow and shoulder movement should be monitored and maintained over time to reduce disability later in life.

Role of intraoperative neurophysiology in primary surgery for obstetrical brachial plexus palsy (OBPP)

OBJECTIVE

Management of conducting neuroma-in-continuity in primary surgery for obstetrical brachial plexus palsy (OBPP) is still discussed controversially. We present our experience with intraoperative neurophysiological recordings in the management of lesions in continuity in OBPP.

METHODS

A series of ten children with lesions in continuity of the upper brachial plexus is presented. Due to recordable compound nerve action potentials (CNAPs) and muscle response to motor stimulation across the neuroma, five children underwent external neurolysis of neuroma only (neurolysis group). Due to lack of recordable CNAPs or muscle response, resection of neuroma and interpositional nerve grafting were performed in another five children (resection and grafting group). Functional recovery after at least 30 months of follow-up was assessed.

RESULTS

There was a marked difference in functional recovery between the neurolysis and the resection and grafting group. Especially, recovery of shoulder function was disappointing after external neurolysis of conducting neuroma-in-continuity. At the end of follow-up, results of shoulder and elbow function after resection of neuroma followed by interpositional nerve grafting were better without exception.

CONCLUSION

Intraoperative neurophysiological recordings face certain difficulties when used in small children with OBPP. Due to overoptimistic assessment of prognosis after intraoperative CNAP recordings and motor stimulation, the functional results after neurolysis of conducting neuroma-in-continuity are disappointing. Resection of neuroma-in-continuity, conducting or not, offers the best opportunity for maximal functional recovery of the compromised upper limb in OBPP. The role of intraoperative neurophysiological techniques should be confined to the diagnosis of root avulsions.

Management of birth brachial plexus palsy

INTRODUCTION

The indications for surgical repair of congenital brachial plexus palsy are controversial. Our objective was to determine the results of early brachial plexus surgery following obstetric-induced brachial plexus palsy.

METHODS

We performed a retrospective analysis of the outcome of 58 cases of brachial plexus surgery. The indication for operation consisted of the presence of less than antigravity strength in the biceps, triceps, and deltoid muscle groups at 6 months of age. Data gathered prospectively, previously, showed the likelihood of improvement with less than antigravity strength in these cases to be poor.

RESULTS

Follow-up data were obtained on 52 of the 58 cases. Overall mean follow-up was 2 years. Twelve patients had more than 3 years follow-up (mean 5.5 years, range 3-11.5 years). Significant improvement was seen in all injury patterns i.e., C5-C6, C5-C7, and C5-C8, T1. Greater than antigravity strength in the biceps, triceps, and deltoid muscle groups was seen in the majority of cases at follow-up.

CONCLUSIONS

Repair of obstetrical brachial plexus palsy in children at 6 months of age that is based on less than antigravity strength in the biceps, triceps, and deltoid muscle groups produces improvement in functional capabilities. Children with obstetrical brachial plexus palsy should be referred soon after birth to a center that specializes in the treatment of this type of palsy.

Lack of evidence of the effectiveness of primary brachial plexus surgery for infants (under the age of two years) diagnosed with obstetric brachial plexus palsy

BACKGROUND

Obstetric brachial plexus palsy, which occurs in 1-3 per 1000 live births, results from traction and/or compression of the brachial plexus in utero, during descent through the birth canal or during delivery. This results in a spectrum of injuries that range in extent of damage and severity and can lead to a lifelong impairment and functional difficulties associated with the use of the affected upper limb. Most infants diagnosed with obstetric brachial plexus palsy receive treatment, such as surgery to the brachial plexus, physiotherapy or occupational therapy, within the first months of life. However, there is controversy regarding the most effective form of management. This review follows on from our previous systematic review which investigated the effectiveness of primary conservative management in infants with obstetric brachial plexus palsy. This systematic review focuses on the effects of primary surgery.

OBJECTIVES

The objective of this review was to systematically assess and collate all available evidence on effectiveness of primary brachial plexus surgery for infants with obstetric brachial plexus palsy.

SEARCH STRATEGY

A systematic literature search was performed using 13 databases: TRIP, MEDLINE, CINAHL, Web of Science, Proquest 5000, Evidence Based Medicine Reviews, Expanded Academic ASAP, Meditext, Science Direct, the Physiotherapy Evidence Database, Proquest Digital Dissertations, Open Archives Initiative Search Engine, the Australian Digital Thesis program. Those studies that were reported in English and published between July 1992 to June 2004 were included in this review.

SELECTION CRITERIA

Quantitative studies that investigated the effectiveness of primary brachial plexus surgery for infants with obstetric brachial plexus palsy were eligible for inclusion into this review. This excluded studies where infants were solely managed conservatively or with pharmacological agents, or underwent surgery for the management of secondary deformities.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion. Studies were also assessed for clinical homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format.

RESULTS

Twenty-one studies were included in the review. Most were ranked low on the hierarchy of evidence (no randomised controlled trials were found), and most had only fair methodological quality. Surgical intervention was variable, as were the eligibility criteria for surgery, the timing of surgery and the outcome instruments used to evaluate the effect of surgery. Therefore, it is difficult to draw conclusions regarding the effectiveness of primary brachial plexus surgery for infants with obstetric brachial plexus palsy.

CONCLUSIONS

Although there is a wealth of information regarding the outcome following primary brachial plexus surgery it was not possible to determine whether this treatment is effective in increasing functional recovery in infants with obstetric brachial plexus palsy. Further research is required to develop standardised surgical criteria, and standardised outcome measures should be used at specific points in time during the recovery process to facilitate comparison between studies. Moreover, comparison groups are required to determine the relative effectiveness of surgery compared with other forms of management.

The role of electromyography in the management of the brachial plexus palsy of the newborn

Despite being the foremost examination in the management of traumatic nerve damage electromyography (EMG) has an uncertain and ill-defined role in the investigation of brachial plexus palsy of the newborn (BPPN). This may be because EMG, which is used most commonly several months after birth, fails to answer adequately two of the most important questions posed by this condition: its aetiology and the likely prognosis. In this review, we contend that EMG has important contributions to the solution of both of these questions but only if the timing of the investigation is altered. Used early on in the first few days after birth, EMG can separate the rare palsies that occurred during the intrauterine period from those caused by events at the time of birth, and thus have an important role in directing the investigations of the aetiology more appropriately. EMG alone would still not be able to determine which of the perinatal events were responsible. If the EMG is then repeated before reinnervation complicates interpretation, it seems probable that it would identify accurately those cases, where neurotmesis and avulsion have occurred, much earlier than 3 months of age, the crucial age in the clinical assessment of BPPN for consideration for surgery. This might have very important implications for the future directions of treatment.

Effectiveness of primary conservative management for infants with obstetric brachial plexus palsy

BACKGROUND

Obstetric brachial plexus palsy, a complication of childbirth, occurs in 1-3 per 1000 live births internationally. Traction and/or compression of the brachial plexus is thought to be the primary mechanism of injury and this may occur in utero, during the descent through the birth canal or during delivery. This results in a spectrum of injuries that vary in severity, extent of damage and functional use of the affected upper limb. Most infants receive treatment, such as conservative management (physiotherapy, occupational therapy) or surgery; however, there is controversy regarding the most appropriate form of management. To date, no synthesised evidence is available regarding the effectiveness of primary conservative management for obstetric brachial plexus palsy.

OBJECTIVES

The objective of this review was to systematically assess the literature and present the best available evidence that investigated the effectiveness of primary conservative management for infants with obstetric brachial plexus palsy.

SEARCH STRATEGY

A systematic literature search was performed using 14 databases: TRIP, MEDLINE, CINAHL, AMED, Web of Science, Proquest 5000, Evidence Based Medicine Reviews, Expanded Academic ASAP, Meditext, Science Direct, Physiotherapy Evidence Database, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Those studies that were reported in English and published over the last decade (July 1992 to June 2003) were included in this review.

SELECTION CRITERIA

Quantitative studies that investigated the effectiveness of primary conservative management for infants with obstetric brachial plexus palsy were eligible for inclusion in this review. This excluded studies that solely investigated the effect of primary surgery for these infants, management of secondary deformities and the investigation of the effects of pharmacological agents, such as botulinum toxin.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion. Studies were assessed for clinical homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format.

RESULTS

Eight studies were included in the review. Most were ranked low on the Hierarchy of Evidence (no randomised controlled trials were found), and had only fair methodological quality. Conservative management was variable and could consist of active or passive exercise, splints or traction. All studies lacked a clear description of what constituted conservative management, which would not allow the treatment to be replicated in the clinical setting. A variety of outcome instruments were used, none of which had evidence of validity, reliability or sensitivity to detect change. Furthermore, less severely affected infants were selected to receive conservative management. Therefore, it is difficult to draw conclusions regarding the effectiveness of conservative management for infants with obstetric brachial plexus palsy.

CONCLUSIONS

There is scant, inconclusive evidence regarding the effectiveness of primary conservative intervention for infants with obstetric brachial plexus palsy. Further research should be directed to develop outcome instruments with sound psychometric properties for infants with obstetric brachial plexus palsy and their families. These outcome instruments should then be used in well-designed comparative studies.

Brachial plexus surgery (honorary lecture)

Brachial plexus injuries (B.p.i.) are lesions occurring more and more frequently due to high velocity road and sport traumas. They are severe lesions with disabling sequelae. Surgical procedures and results could greatly be improved in the last 2 decades. Although the anatomy of brachial plexus is well known, less known are the functional maps of the various brachial plexus elements. In this paper treatment modalities for obstetrical, traumatic (adult) and actinic B.p.i. are being described too.