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Obstetric brachial plexus palsy: 20 years’ experience at a tertiary center in Turkey  [cached]
G?nu?l Acar,Bar?? Ekici,Feride Bilir,Mine ?al??kan
Turk Pediatri Ar?ivi , 2013,
Abstract: Aim: The aim of this study was to examine cases of obstetric brachial plexus palsy (OBPP) treated over 20 years at a single tertiary center.Material and Method: We retrospectively reviewed 777 cases of OBPP who were observed at the Pediatric Neurology Department at Istanbul Medical Faculty between March 1989 and December 2010. The patients were evaluated in terms of demographic characteristics, treatment methods, surgical approaches, complications and functional levels according to Narakas Clasification Scale. Results: Out of a total of 777 OBPP patients, 393 were female and 384 were male. The mean birth weight was 3968.9 g. Three of the patients were siblings. OBPP was bilateral in 3 patients; right sided in 463 patients and left sided in 311 patients. In terms of concomitant conditions, 82 patients had torticollis, 62 had Horner’s syndrome, 47 had broken clavicle, 3 had broken humerus, 3 had cerebral palsy and 1 had facial paralysis. According to the Narakas classification, 430 patients (55%) were evaluated as stage 1 OBPP, 219 (28.5%) were evaluated as stage 2, 66 (8.5%) were evaluated as stage 3 and 62 (8%) were evaluated as stage 4. One third of the patients (%33) underwent Vojta and neurodevelopmental therapy in addition to routine physiotherapy. Complete recovery was observed in 439 (%56) of all patients, in 66% of the patients with stage 1 OBPP, in 56% of the patients with stage 2 OBPP, in 35% of the patients with stage 3 OBPP and in 18% of the patients with stage 4 OBPP. Botulinum Toxin Type A was applied in 97 cases; 30 patients underwent primary nerve surgery and 94 underwent multiple surgical procedures (25 of them required a second surgery and 15 required a third surgery). Various joint contractures were seen in 200 patients.Conclusions: Despite physiotherapy, Botulinum Toxin Type A application and surgical intervention, one out of three patients had difficulty using their arm and developed contractures and disabilities that affected their every day life. In conclusion, OBPP continues to be a severe problem leading to functional impairment and disability. (Turk Arch Ped 2013; 48: 13-6)
Free functional gracilis muscle transfer in children with severe sequelae from obstetric brachial plexus palsy
J?rg Bahm, Claudia Ocampo-Pavez
Journal of Brachial Plexus and Peripheral Nerve Injury , 2008, DOI: 10.1186/1749-7221-3-23
Abstract: We describe our indications for this complex microsurgical procedure, the surgical technique and the outcome.Obstetric brachial plexus palsy may result in a severe impairment of upper limb function. Early microsurgical reconstruction is proposed in upper and total palsies with insufficient functional recovery [1]. Nevertheless, major motor functions may not recover, both in operated or not operated children.Free functional muscle transfer has been developed in the last 30 years to replace major muscle function, especially in the face and the upper limb [2,3]. Volkmann's ischemic contracture, tumor resection, and extensive palsy are possible indications.An isolated motor deficit in a major upper limb function in children suffering from obstetric brachial plexus palsy might be corrected by means of a free muscle transfer, using the gracilis muscle. Finger and elbow flexion are obvious primary goals. These were also the indications where we decided to apply this technique.We present our strategy, indications, operative technique and results.We also report the advantages of this microsurgical procedure, but also technical drawbacks and reasonable limits of indication.The experimental background was set in 1970 when Tamai [4] reported the first successful transplantation of a rectus femoris muscle to the forelimb of a dog, using microneurovascular techniques.The first clinical case was published 3 years later, when Chinese surgeons [5] transplanted part of a pectoralis major muscle to improve the hand function of a patient with Volkmann's ischemic contracture.Harii [6] started to use the technique for a paralyzed face, Manktelow [7] applied it to the forearm region, Zuker [8] for children.In the field of brachial plexus reconstruction, Doi [9] presented a new approach using two free gracilis muscle transfers to reconstruct major upper limb motors, and an extensive and impressive clinical series in children was recently published by Chuang [10].Our clinical series include
Comparison of visual and objective quantification of elbow and shoulder movement in children with obstetric brachial plexus palsy
Andrea E Bialocerkowski, Mary Galea
Journal of Brachial Plexus and Peripheral Nerve Injury , 2006, DOI: 10.1186/1749-7221-1-5
Abstract: 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.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.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.Obstetric brachial plexus palsy (OBPP) is a complication of childbirth, which is characterized by one or more nerve conduction blocks within the brachial plexus [1]. These blocks range in severity and location within the plexus and primarily affect the child's ability to move and effectively use their affected upper limb [2]. Thus the quantification of motor funct
Oberlin partial ulnar nerve transfer for restoration in obstetric brachial plexus palsy of a newborn: case report
Koji Shigematsu, Hiroshi Yajima, Yasunori Kobata, Kenji Kawamura, Naoki Maegawa, Yoshinori Takakura
Journal of Brachial Plexus and Peripheral Nerve Injury , 2006, DOI: 10.1186/1749-7221-1-3
Abstract: In 1994, Oberlin et al. [1] described a new technique of partial ulnar nerve transfer to the biceps muscle nerve for restoration of elbow flexion in traumatic C5-C6 avulsion of the brachial plexus in adult. We report treating an eight month old male infant without C5 to C6 function by an Oberlin's partial ulnar nerve transfer and an accessory-to-suprascapular nerve transfer.An 8 month old male infant with obstetric brachial plexus palsy associated with a breech delivery (at 40 weeks 1 day, birth weight: 3535 g), was treated by peripheral nerve transfer. He was complicated with phrenic nerve palsy, and a surgical treatment (reefing of the diaphragm) for this lesion had been undertaken at two months of age in another institute. At the first examination in our institute (at 5 months of age), active shoulder abduction and elbow flexion were absent (Fig. 1). Mental and other motor functional developments were normal. During 3 months of observation, no spontaneous recovery of elbow flexion or shoulder abduction was shown. On electrophysiological evaluations, no action potential of the neuromuscular unit was revealed in the biceps and deltoid muscles. The action potential of the neuromuscular unit of the abductor pollicis brevis muscle showed a normal wave. Physical and electrical examinations revealed an upper trunk type (C5-C6) right-side plexopathy. We considered the possibility of spontaneous recovery for several months, but functional recovery was poor. An Oberlin's nerve transfer and an accessory to suprascapular nerve transfer were selected to facilitate a rapid motor functional recovery of the biceps and deltoid muscles.Under general anesthesia, an operation was performed in the supine position. The brachial artery and the median, ulnar, and a branch of the musculocutaneous nerve supplying the biceps muscle were identified at a level approximately 7.0 cm distal from the acromion. One fascicle of the ulnar nerve was separated at the same level as the branch of the b
Monopolar teres major muscle transposition to improve shoulder abduction and flexion in children with sequelae of obstetric brachial plexus palsy
J?rg Bahm, Claudia Ocampo-Pavez
Journal of Brachial Plexus and Peripheral Nerve Injury , 2009, DOI: 10.1186/1749-7221-4-20
Abstract: In addition, we provide the clinical outcome in the first 17 operated children.Muscle weakness is a frequent sequela after obstetric brachial plexus palsy (obpp) and might be improved by muscle transpositions, especially at the shoulder level [1]. The teres major muscle (tmm) is included in the technique described by Hoffer [2] to enhance active lateral rotation of the shoulder, where this muscle should address the function of the infraspinatus muscle.We propose a single transfer of the tmm in selected conditions in children suffering obpp sequelae:1. when shoulder flexion and/or abduction are weak against gravity (active ROM less than 90° with a strength less or equal M3)2. when the tmm shows cocontractions during shoulder abduction (mixed reinnervation of the dorsal cord)3. to add muscle volume to a cranial trapezius transfer for weak shoulder abduction4. to modify a Hoffer transfer [2], using the latissimus dorsi muscle (ldm) to improve the lateral shoulder rotation with an abducted arm, and tmm to allow an active abduction up to 90° (horizontal line), which will bring the transferred ldm under good tension.Essentially, the tmm might be considered as a valuable functional muscle transfer to enhance shoulder abduction and elevation in selected children with obpp sequelae, under 10 years of age with reasonable body weight. The muscle thereby improves prime movers of the shoulder joint.The child is placed in a lateral position under general anesthesia. A double access is needed to the midaxillar line (to detach the muscle) and to the acromio-clavicular region (to transpose the muscle onto the antero-lateral deltoid muscle (dm) insertion).A strait skin incision is drawn beginning in the axilla following down the midaxillar line until the lower angle of the scapula. The subcutaneous tissue is divided, and the lateral borders of both ldm and tmm are identified and dissected free. The tmm is dissected free from the ldm progressively from its lateral border, from proxima
分娩性臂丛损伤的神经重建诊治进展
ADVANCES IN NERVE RECONSTRUCTION OF OBSTETRIC BRACHIAL PLEXUS PALSY
 [PDF]

孙嘉宇,陈亮,胡韶楠
- , 2016, DOI: 10.7507/1002-1892.20160266
Abstract: 目的综述分娩性臂丛损伤(又称产瘫)的诊治进展。 方法广泛查阅近年与产瘫有关的文献,并对其发病率、危险因素、临床分型、辅助检查以及神经重建手术的适应证、方式和疗效进行总结分析。 结果近年来产瘫发病率未见明显下降。体质量≥4 kg、产钳助产和孕妇体质量指数≥21是产瘫的主要危险因素,而剖宫产是保护因素。神经电生理检查可用于产瘫的定性诊断,但不可用作定量指标。脊髓CT及MRI造影的敏感度和特异性分别约为0.7和0.97。一般采用Narakas分型,即Ⅰ型为C 5、6损伤,Ⅱ型为C 5~7损伤,Ⅲ型为全臂丛损伤,Ⅳ型为Ⅲ型伴Horner征。通常认为3个月无屈肘动作是臂丛探查指征。10%~30%产瘫需要手术治疗,对于上干创伤性神经瘤,绝大多数作者主张行神经瘤切除神经重建。上中干手术疗效的最终评价应在术后4年、全臂丛应在术后8年;功能评价主要采用肩关节Mallet评分、肘关节Gilbert评分和手功能Raimondi分级。 结论出生后3个月无屈肘时应行手术探查;对于创伤性神经瘤(即使术中有电传导)应行切除并臂丛重建。
ObjectiveTo review the advances in the diagnosis and treatment of obstetric brachial plexus palsy (OBPP). MethodsThe incidence, risk factors, classification, and imaging tests of OBPP and indication, technique, and results of surgery were reviewed and summarized. ResultsThe incidence of OBPP is not declining in recent years. Birth weight of ≥4 kg, forceps delivery, and prepregnancy body mass index of ≥21 are considered to be major risk factors, and caesarean section delivery seems to be a protective factor. Neurophysiological investigations can be applied to qualitative diagnosis of OBPP, but can not to quantitative one. Sensitivity and specificity of both CT and MRI myelography are about 0.7 and 0.97, respectively. Narakas classification is widely used:C 5, 6 injury as type I, C 5-7 injury as type Ⅱ, C 5-T 1 injury as type Ⅲ, C 5-T 1 injury with Horner's syndrome as type IV. It is generally considered that the brachial plexus exploration should be undertaken for infants without spontaneous recovery of elbow flexion by a maximum of 3 months old; and 10% to 30% of patients may need nerve reconstruction surgery. It is advocated that traumatic neuroma of the upper trunk should be resected with nerve reconstruction. The final evaluation for surgical results should be at minimal 4 years for upper roots and 8 years for total roots. Scales of Mallet, Gilbert, and Raimondi are mostly used for assessing shoulder function, elbow function, and hand function. ConclusionBrachial plexus exploration should be undertaken for infants without flexion of elbow at the age of 3 months. Traumatic neuroma (even neuroma-in-continuity) resection followed by microsurgical reconstruction of the brachial plexus is favored.
Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: Evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture
Rahul K Nath, Sonya E Melcher, Melia Paizi
Journal of Brachial Plexus and Peripheral Nerve Injury , 2006, DOI: 10.1186/1749-7221-1-9
Abstract: Four patients with Scapular Hypoplasia, Elevation And Rotation (SHEAR) deformity who had undergone unsuccessful humeral osteotomies to treat internal rotation underwent acromion and clavicular osteotomy, ostectomy of the superomedial border of the scapula and posterior capsulorrhaphy in order to relieve the torsion developed in the acromio-clavicular triangle by persistent asymmetric muscle action and medial rotation contracture.Clinical examination shows significant improvement in the functional movement possible for these four children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy.These results reveal the importance of recognizing the presence of scapular hypoplasia, elevation and rotation deformity before deciding on a treatment plan. The Triangle Tilt procedure aims to relieve the forces acting on the shoulder joint and improve the situation of the humeral head in the glenoid. Improvement in glenohumeral positioning should allow for better functional movements of the shoulder, which was seen in all four patients. These dramatic improvements were only possible once the glenohumeral deformity was directly addressed surgically.Obstetric brachial plexus injury (OBPI) has been described as a discrete entity since 1754 [1]. The pathophysiology of the secondary deformities encountered in this population was described succinctly in 1905 by Whitman who wrote that the large majority of internal rotation and subluxation deformities of the shoulder in children with obstetric brachial plexus injuries were caused by fibrosis and contractures developed as a consequence of the neurological injury [2]. The medial rotation contracture (MRC) is the most significant secondary shoulder deformity in children with severe OBPI, requiring surgery in more than one third of patients whose injury did not resolve spontaneously [3].The current surgical approach to treating persistent MRC in OBPI patients is derotational humeral ost
Finger movement at birth in brachial plexus birth palsy  [cached]
Rahul K Nath,Mohamed Benyahia,Chandra Somasundaram
World Journal of Orthopedics , 2013, DOI: 10.5312/wjo.v4.i1.24
Abstract: AIM: To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury. METHODS: We conducted a retrospective study reviewing pre-surgical records of 87 patients with residual obstetric brachial plexus palsy in study 1. Posterior subluxation of the humeral head (PHHA), and glenoid retroversion were measured from computed tomography or Magnetic resonance imaging, and correlated with the finger movement at birth. The study 2 consisted of 141 obstetric brachial plexus injury patients, who underwent primary surgeries and/or secondary surgery at the Texas Nerve and Paralysis Institute. Information regarding finger movement was obtained from the patient’s parent or guardian during the initial evaluation. RESULTS: Among 87 patients, 9 (10.3%) patients who lacked finger movement at birth had a PHHA > 40%, and glenoid retroversion < -12°, whereas only 1 patient (1.1%) with finger movement had a PHHA > 40%, and retroversion < -8° in study 1. The improvement in glenohumeral deformity (PHHA, 31.8% ± 14.3%; and glenoid retroversion 22.0° ± 15.0°) was significantly higher in patients, who have not had any primary surgeries and had finger movement at birth (group 1), when compared to those patients, who had primary surgeries (nerve and muscle surgeries), and lacked finger movement at birth (group 2), (PHHA 10.7% ± 15.8%; Version -8.0° ± 8.4°, P = 0.005 and P = 0.030, respectively) in study 2. No finger movement at birth was observed in 55% of the patients in this study group. CONCLUSION: Posterior subluxation and glenoid retroversion measurements indicated significantly severe shoulder deformities in children with finger movement at birth, in comparison with those lacked finger movement. However, the improvement after triangle tilt surgery was higher in patients who had finger movement at birth.
Obstetrical Brachial Plexus Palsy: Electrodiagnostical Study and Functional Outcome  [PDF]
V. Toupchizadeh,Y. Abdavi,M. Barzegar,B. Eftekharsadat
Pakistan Journal of Biological Sciences , 2010,
Abstract: Obstetrical Brachial Plexus Palsy (OBPP) is a complication of difficult delivery and resulted from excessive traction on the brachial plexus during delivery. Erb palsy, klumpke paralysis and panplexus palsy reported in 46, 0.6 and 20% of patients, respectively. Unilateral injury is more common than bilateral injury. Risk factors include macrosomia, multiparity, prior delivery of a child with OBPP, breech delivery shoulder dystocia, vacium and forceps assisted delivery and excessive maternal weight gain. The recovery rate is usually reported to be between 80 and 90%. We evaluated 42 children with OBPP. Out of them, we could follow only 28 cases during two years. Poor to moderate recovery occurred in 13 cases. Good to complete (expected) recovery occurred in 15 cases. Most of the patients were females. Right side palsy was more prevalent than left side palsy. Vaginal delivery without forceps was the most mode of delivery. Vertex was the most common presentation. Most of the patients were term. The mean weight of the birth was 3.8 kg. Erb palsy and pan-plexus palsy consisted of 71.4 and 28.6% of lesions. In patients with Erb palsy, there were preganglionic palsy in 3 (15.8%) and postganglionic palsy in 16 (84.2%) cases, while all the patients with panplexus palsy had postganglionic palsy. All patients with complete recovery (9 of 15) had Erb palsy and postganglionic lesion. Erb palsy was present in 71.4% and panplexus palsy was present in 28.6% of cases. Also, 23.8% of cases had preganglionic and 76.2% of cases had postganglionic injures.
Clinical and neuropathological study about the neurotization of the suprascapular nerve in obstetric brachial plexus lesions
Dominique Schaakxs, J?rg Bahm, Bernd Sellhaus, Joachim Weis
Journal of Brachial Plexus and Peripheral Nerve Injury , 2009, DOI: 10.1186/1749-7221-4-15
Abstract: We operated on 65 patients with obstetric brachial plexus palsy (OBPP), aged 5-35 months (average: 19 months). We assessed the recovery of passive and active external rotation with the arm in abduction and in adduction. We also looked at the influence of the restoration of the muscular balance between the internal and the external rotators on the development of a gleno-humeral joint dysplasia. Intraoperatively, suprascapular nerve samples were taken from 13 patients and were analyzed histologically.Most patients (71.5%) showed good recovery of the active external rotation in abduction (60°-90°). Better results were obtained for the external rotation with the arm in abduction compared to adduction, and for patients having only undergone the neurotization procedure compared to patients having had complete plexus reconstruction. The neurotization operation has a positive influence on the glenohumeral joint: 7 patients with clinical signs of dysplasia before the reconstructive operation did not show any sign of dysplasia in the postoperative follow-up.The neurotization procedure helps to recover the active external rotation in the shoulder joint and has a good prevention influence on the dysplasia in our sample. The nerve quality measured using histopathology also seems to have a positive impact on the clinical results.Brachial plexus lesions during birth affect one in 2000 newborns [1]. Ten percent of them need early or secondary surgical reconstruction [1]. In the treatment of obstetric brachial plexus lesions, one of the main problems is the poor recovery of abduction and external rotation in the shoulder joint [2].In children with upper and total brachial plexus lesions, the suprascapular nerve, the first motor branch of the upper trunk located in the center of the obstetric brachial plexus lesion, is usually affected. The clinical manifestation is the lack of active external rotation in the glenohumeral joint. The child adopts an internal rotation position and migh
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