Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Tendon Transfers About the Shoulder and Elbow in Obstetrical Brachial Plexus Palsy*†

Abstract

Obstetrical or birth palsy of the brachial plexus occurs in as many as one in 250 births30,32. Predisposing factors include high birth weight, prolonged labor, breech presentation, and shoulder dystocia. The actual lesion is produced by traction on the neural elements—for example, stretching of the brachial plexus with forced lateral flexion of the head and neck. Most of these injuries resolve without operative intervention. For patients who are more severely affected, however, a variety of procedures are available (Table I). The treatment algorithm to maximize each child's long-term functional recovery is continuously evolving (Table II). View this table: TABLE I OPTIONS FOR TENDON RELEASE, TENDON OR MUSCLE TRANSFER, AND OSSEOUS PROCEDURES BY SITE View this table: TABLE II TIMING OF OPERATIVE PROCEDURES IN PATIENTS WHO HAVE OBSTETRICAL BRACHIAL PLEXUS PALSY In the earliest phase of treatment, exploration, neurolysis, and operative repair or reconstruction of the injured brachial plexus may be undertaken. The decision to intervene with an operation depends on the time that has elapsed since the injury, the recovery of function to that point, and the surgeon's personal philosophy regarding the likelihood of additional gains with nonoperative treatment. Most surgeons perform such procedures, when appropriate, in infants between three and nine months of age8,35. Joint mobilization and range-of-motion exercises performed by the parents and guided by a physical or occupational therapist can help to maintain a congruent glenohumeral joint and to minimize contractures. Patients with incomplete recovery who are seen more than six months after birth frequently have muscle contractures due to unopposed muscle forces and are no longer candidates for direct repair of the plexus. These children can often benefit from releases of the contractures to maintain a congruent joint and to maximize the range of motion. Releases are usually performed between the ages of …