Birth Palsy Research Articles

Suprascapular nerve neurotization in obstetrical brachial plexus palsy using the spinal accessory nerve or the C5 root

ObjectiveTo evaluate the value of distal spinal accessory nerve (SAN) or 5th cervical (C5) root neurotization to the suprascapular nerve (SSN) in infants with obstetrical brachial plexus birth palsy.BackgroundSurgical treatment of obstetrical brachial plexus birth palsy in infants includes neurolysis, nerve repair directly, or the use of interposition nerve graft and neurotization procedures. Repair of SSN is the key to restoration of shoulder joint function.Materials and methodsOver a 3-year period, 30 infants with brachial plexus injuries were subjected to SSN repair, 18 infants by neurotization to the SAN and 12 infants by interposition nerve grafting to the C5 root as part of the primary surgical reconstruction. Operative and postoperative outcomes were evaluated with a minimum follow-up of 18 months.ResultsNeurotization of the SSN was performed by intraplexal neurotization using a nerve graft to C5 in 12 patients (40%) or extraplexal neurotization using SAN directly in 18 patients (60%). Nineteen infants were subjected to surgical reconstruction at less than 6 months of age and 11 were subjected to surgical reconstruction, age range 3 to 16 months, mean 5 months. At the latest follow-up, active shoulder movements were measured confirmed by review of videos. The outcome of nerve injury was assessed using the peripheral nerve injury unit scale. The results of neurotization and the use of an interpositional nerve graft were analyzed. SSN neurotization outcome by SAN showed 94.4% good outcome and 5.6% fair outcome, which were better than outcome by C5 root neurotization (66.7% good and 33.3% fair). Five patients developed a postoperative superficial wound infection.ConclusionAlthough both SAN and C5 root neurotization to the SSN nerve are reliable options for shoulder reinnervation in infants with obstetrical brachial plexus palsy, direct neurotization without an interpositional nerve graft yields better results.

Computational Sensitivity Analysis to Identify Muscles That Can Mechanically Contribute to Shoulder Deformity Following Brachial Plexus Birth Palsy

Two mechanisms, strength imbalance or impaired longitudinal muscle growth, potentially cause osseous and postural shoulder deformity in children with brachial plexus birth palsy. Our objective was to determine which muscles, via either deformity mechanism, were mechanically capable of producing forces that could promote shoulder deformity. In an upper limb computational musculoskeletal model, we simulated strength imbalance by allowing each muscle crossing the shoulder to produce 30% of its maximum force. To simulate impaired longitudinal muscle growth, the functional length of each muscle crossing the shoulder was reduced by 30%. We performed a sensitivity analysis to identify muscles that, through either simulated deformity mechanism, increased the posteriorly directed, compressive glenohumeral joint force consistent with osseous deformity or reduced the shoulder external rotation or abduction range of motion consistent with postural deformity. Most of the increase in the posterior glenohumeral joint force by the strength imbalance mechanism was caused by the subscapularis, latissimus dorsi, and infraspinatus. Posterior glenohumeral joint force increased the most owing to impaired growth of the infraspinatus, subscapularis, and long head of biceps. Through the strength imbalance mechanism, the subscapularis, anterior deltoid, and pectoralis major muscles reduced external shoulder rotation by 28°, 17°, and 10°, respectively. Shoulder motion was reduced by 40° to 56° owing to impaired growth of the anterior deltoid, subscapularis, and long head of triceps. The infraspinatus, subscapularis, latissimus dorsi, long head of biceps, anterior deltoid, pectoralis major, and long head of triceps were identified in this computational study as being the most capable of producing shoulder forces that may contribute to shoulder deformity following brachial plexus birth palsy. The muscles mechanically capable of producing deforming shoulder forces should be the focus of experimental studies investigating the musculoskeletal consequences of brachial plexus birth palsy and are potentially critical targets for treating shoulder deformity.

Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy

The debate addressed in this article is that of surgical treatment methods for a neuroma-in-continuity. The authors of this study chose to test the hypothesis that more severe nerve injuries, as distinguished by < 50% conduction across a neuroma-in-continuity, could be treated with neuroma resection and grafting, whereas less severe nerve injuries, with > 50% conduction across the neuroma, could be treated with neurolysis alone. The goal of this study was to compare preoperative and postoperative Active Movement Scale (AMS) scores in children with upper trunk brachial plexus birth injuries treated with neurolysis alone if the neuroma's conductivity was > 50% on intraoperative nerve testing. Seventeen patients (7 male, 10 female) met the criteria for inclusion in this study. Surgery was done when the patients were an average of 10 months old (range 6-19 months). The authors analyzed AMS scores from the preoperative assessment, 1-year postoperative follow-up visit, and subsequent follow-up assessment as close to 3 years after surgery as possible (referred to in this paper as > 2-year postoperative scores). Comparison of preoperative and 1-year follow-up data showed significant improvement in shoulder abduction, flexion, external rotation, and internal rotation; elbow flexion and supination; and wrist extension. Comparison of preoperative findings and results of assessment at > 2-year follow-up showed significant improvement in shoulder abduction, flexion, external rotation; and elbow flexion and supination. At final follow-up, useful function (AMS score of 6 or 7) was achieved for elbow flexion in 14 of 16 patients, shoulder flexion in 11 of 15 patients, shoulder abduction in 11 of 16 patients, and shoulder external rotation in 5 of 15 patients. This report indicates that there is a subgroup of patients who can benefit clinically, with functional improvement of shoulder and elbow function, from treatment with neurolysis alone for upper trunk lesions demonstrating more than 50% conduction across the neuroma on intraoperative nerve testing. Patients with less than 50% conduction, indicating more severe disease, are treated with nerve resection and grafting in the authors' treatment algorithm.

Birth size and the risk of cerebral palsy in term births

This commentary is on the original article by Dahlseng et al. on pages 53–58 of this issue.

Corrigendum

Acta PaediatricaVolume 102, Issue 11 p. 1110-1110 CorrigendumFree Access Corrigendum This article corrects the following: Characteristics and outcome of brachial plexus birth palsy in neonates Pelle G Lindqvist, Kristina Erichs, Cecilia Molnar, Saemundur Gudmundsson, Lars B Dahlin, Volume 101Issue 6Acta Paediatrica pages: 579-582 First Published online: February 21, 2012 First published: 03 October 2013 https://doi.org/10.1111/apa.12369AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat In 1, under Key notes, the text is incorrect and it is stated as follows: Extent and reversibility of the palsy were not influenced by maternal and foetal characteristics, but the risk for BPBP was increased in accelerators (>35 g/day after 32 days) and in foetus with estimated weight deviation ≥ 22% at 32 weeks. The correct form of the sentence is: Extent and reversibility of the palsy were not influenced by maternal and foetal characteristics, but the risk for BPBP was increased in accelerators (>35 g/day after 32 weeks) and in foetus with estimated weight deviation ≥ 22% at 32 weeks. Reference 1Lindqvist PG, Erichs K, Molnar C, Gudmundsson S, Dahlin LB. Characteristics and outcome of brachial plexus birth palsy in neonates. Acta Paediatr 2012; 101: 579– 82. Wiley Online LibraryPubMedWeb of Science®Google Scholar Volume102, Issue11November 2013Pages 1110-1110 ReferencesRelatedInformation

Scapulothoracic and glenohumeral contributions to motion in children with brachial plexus birth palsy

Brachial plexus birth palsy occurs in 0.4 to 4.6 of every 1000 live births, with residual shoulder dysfunction in approximately one third of cases. Clinical measures, such as the Mallet classification, provide no insight into the scapulothoracic and glenohumeral contributions to tested global shoulder movements. This study describes the scapulothoracic and glenohumeral components of shoulder motion during the modified Mallet test. Twelve children with Erb's palsy (C5-6) and 8 children with extended Erb's palsy (C5-7) were recruited. The unaffected limbs of 6 subjects were also tested. Locations of markers placed on the thorax, humerus, and scapula were recorded in a neutral position and each of the modified Mallet positions. Scapulothoracic, glenohumeral, and humerothoracic helical displacements and acromion process linear displacements were compared between groups. The brachial plexus birth palsy groups exhibited significantly smaller glenohumeral displacements in all modified Mallet positions and significantly larger scapulothoracic displacements in the global external rotation and hand to mouth positions. Discriminant function analysis using only humerothoracic variables correctly classified 76.9% of subjects. Discriminant function analysis incorporating scapulothoracic, glenohumeral, and acromion process displacement variables produced accuracy of 92.6%. Children with brachial plexus birth palsy demonstrated decreased glenohumeral contributions to achieve every modified Mallet position and increased scapulothoracic contribution in two positions compared with the unaffected group. Different scapulothoracic and glenohumeral strategies were identified between groups. Finally, scapulothoracic and glenohumeral components of shoulder motion are more specific than humerothoracic measures to diagnostic classification.

Does the Trapezius Play a Role During Upper Extremity Motion in Patients With Obstetrical Brachial Plexus Birth Palsy?: Level 4 Evidence

Does the Trapezius Play a Role During Upper Extremity Motion in Patients With Obstetrical Brachial Plexus Birth Palsy?: Level 4 Evidence

Computer Adaptive Test Approach to the Assessment of Children and Youth With Brachial Plexus Birth Palsy

This study examined the psychometric properties of item pools relevant to upper-extremity function and activity performance and evaluated simulated 5-, 10-, and 15-item computer adaptive tests (CATs). In a multicenter, cross-sectional study of 200 children and youth with brachial plexus birth palsy (BPBP), parents responded to upper-extremity (n = 52) and activity (n = 34) items using a 5-point response scale. We used confirmatory and exploratory factor analysis, ordinal logistic regression, item maps, and standard errors to evaluate the psychometric properties of the item banks. Validity was evaluated using analysis of variance and Pearson correlation coefficients. Results show that the two item pools have acceptable model fit, scaled well for children and youth with BPBP, and had good validity, content range, and precision. Simulated CATs performed comparably to the full item banks, suggesting that a reduced number of items provide similar information to the entire set of items.

Dynamic Sonographic Evaluation of Posterior Shoulder Dislocation Secondary to Brachial Plexus Birth Palsy Injury

onographic evaluation of hip dysplasia has been used since the early 1980s and is now a well-established procedure for the assessment and monitoring of neonatal and infantile hip stability. This same technology can be applied to glenohumeral joint evaluation. Computed tomography (CT) was the first radiographic modality to be used to describe shoulder instability in children with Erb palsy 25 years ago, 1 followed by magnetic resonance imaging

Identification of pregnancies at increased risk of brachial plexus birth palsy – the construction of a weighted risk score

Objective: Since it is difficult to identify women at increased risk of fetal brachial plexus birth palsy (BPBP) during labor and delivery, we aimed to construct and validate a risk score.Methods: A retrospective case-control study was undertaken in 2001 and 2006 in an urban context in Malmö, Sweden. A risk score was constructed for all women who had received routine municipal maternal health care at Skåne University Hospital (n = 10 459). The model was validated among all pregnant women with BPBP and controls in Sweden between 2006 and 2007.Results: The likelihood of BPBP increased as the risk score rose: 3.1% of the women studied had a risk score ≥5, including 32.1% of the BPBP cases, where the risk showed a 38-fold increase, as compared to those with a risk score ≤1 (2/3 of the population).Conclusion: Our findings indicate that it is possible to identify women at increased risk of having a child with BPBP by using variables observable in advance of delivery.

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

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). 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. 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. 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.

Geometry of the proximal humeral articular surface in young children: a study to define normal and analyze the dysplasia due to brachial plexus birth palsy

Little is known regarding the morphology of the proximal humerus in growing children. This study reports bilateral magnetic resonance imaging measurements in children with internal rotation contractures from birth palsy, hypothesizing that dysplasia alters normal humeral sphericity and symmetry. We studied 25 children with unilateral internal rotation contractures (mean age, 3.7 years) for humeral shape by bilateral magnetic resonance imaging studies at the mid-glenoid level. Local radii of curvature were compared for symmetry and orientation. Neither side showed uniform radii (sphericity), but normal humeri showed symmetry lost in dysplasia. Internal rotation contractures were correlated with flattening of the anterior humeral head (P= .0002). All heads were flatter in the region of articular contact. The skew axis (the largest cross-sectional diameter of the proximal humerus) was collinear with the articular surface centerline in normal humeri, an alignment often lost with dysplasia, resulting in a skew axis angle. The severity of glenoid deformity correlated with progressive posterior displacement of the humeral head center (P < .0003). The normal humeral articular surface in the young child is not spherical and is flatter in the middle than at the periphery but is symmetric about its central axis. Internal rotation contractures result in loss of this symmetry with characteristic flattening of the anterior humeral head and development of a skew axis angle. Posterior displacement of the humeral head center of rotation beyond 50% of the calculated head radius warrants vigilance and possibly surgical intervention because there is a high likelihood for development of a pseudoglenoid.

Restoring function for children with brachial plexus birth palsy

Restoring function for children with brachial plexus birth palsy

Restoring function for children with brachial plexus birth palsy

Restoring function for children with brachial plexus birth palsy

Children’s orthopaedics

The February 2013 Children’s orthopaedics Roundup360 looks at: ABC treated with suction and curettage; peri-acetabular osteotomy; cast index; Perthes’ disease associated with accidental injury; brachial plexus birth palsy; MRI assessment of DDH; total meniscectomy; and paediatric septic arthritis.

Iatrogenic Burn Caused by an Operating Microscope: Case Report

We present a patient who experienced a burn from an operating microscope during surgery for a brachial plexus birth palsy, a literature review, and recommendations on how to avoid such injuries.

Finger movement at birth in brachial plexus birth palsy

To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury. 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. 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. 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.

Combined Glenoid Anteversion Osteotomy and Tendon Transfers for Brachial Plexus Birth Palsy

In the setting of severe glenohumeral dysplasia secondary to brachial plexus birth palsy, external rotation osteotomy of the humerus has traditionally been used to transpose the existing arc of shoulder motion to a more functional position. Here we introduce a surgical alternative, the aim of which is to gain stable reduction of the shoulder and restore active external rotation. All patients with brachial plexus birth palsy and Waters type-III, IV, or V glenohumeral dysplasia who underwent glenoid anteversion osteotomy combined with tendon transfers between 2006 and 2009 were identified. The Mallet score, Active Movement Scale, and active and passive ranges of motion were used to assess functional outcomes. Axial imaging was used to measure glenoid version, the degree of subluxation, and the Waters type. Thirty-two patients with a median age of 6.8 years (range, 2.1 to 16.2 years) were followed for a mean of twenty months (range, twelve to twenty-nine months). On average, passive external rotation with the shoulder in neutral increased by 43° (95% confidence interval [CI], 26° to 60°), passive internal rotation decreased by 22° (95% CI, 12° to 31°), active external rotation with the shoulder in neutral increased by 82° (95% CI, 66° to 98°), and active internal rotation decreased by 26° (95% CI, 14° to 38°). The aggregate Mallet score improved by a mean of 4.0 points (95% CI, 3.0 to 4.9). Glenoid retroversion improved by a mean of 26° (95% CI, 20° to 32°). The percentage of the humeral head anterior to the midscapular line improved by a mean of 35% (95% CI, 30% to 40%). In patients with severe glenohumeral dysplasia, glenoid realignment osteotomy in conjunction with soft-tissue rebalancing permits maintenance of joint reduction and functional improvement in the short term. In our view, external rotation osteotomy of the humerus is no longer the only surgical option for these cases.

Combined Glenoid Anteversion Osteotomy and Tendon Transfers for Brachial Plexus Birth Palsy.

Combined glenoid osteotomy with tendon transfers is a new alternative procedure for patients with severe glenohumeral dysplasia secondary to brachial plexus birth palsy. Use axial plane MRI or CT for preoperative planning. Position the patient laterally, and undertake a posterior approach, including lateral elevation of the deltoid origin. Elevate the subscapularis from the scapula, provisionally reduce the humeral head, and apply gentle external rotation. Incise the insertions of the teres major and latissimus dorsi from the proximal part of the humerus and perform a tenolysis. Open the posterior glenohumeral joint and assess overhead elevation. Improve abduction contracture if it is marked. Harvest tricortical graft from the scapular spine or posterior aspect of the acromion. Undertake a posterior opening wedge osteotomy of the scapular neck. Insert the bone graft into the osteotomy site. Close the posterior aspect of the capsule and the infraspinatus. Transfer the teres major and latissimus dorsi tendons into an osseous trough at the greater tuberosity. Repair the deltoid, close the wound in layers, and apply a shoulder spica cast. Maintain the spica cast for five to six weeks; then initiate physiotherapy. In our series of thirty-two patients with severe glenohumeral dysplasia who underwent combined glenoid osteotomy and tendon transfers, early results suggest that the outcomes of this procedure are similar to those of proximal humeral external rotation osteotomy1. IndicationsContraindicationsPitfalls & Challenges.

Commentary on Abdel-Ghani et al. Tendon transfer for treatment of internal rotation contracture of the shoulder in brachial plexus birth palsy

Commentary on Abdel-Ghani et al. Tendon transfer for treatment of internal rotation contracture of the shoulder in brachial plexus birth palsy