Birth-related Brachial Plexus Injury Research Articles

Educational quality of YouTube content on brachial plexus injury and treatment.

While surgical literature exists on birth-related brachial plexus injury (BPI), there are not validated sources of information on BPI for patients, which can impact patient autonomy and decision-making. With YouTube as a popular source for patients to research diagnoses, this study aims to evaluate the quality of information regarding BPI and its treatment available on the platform. BPI YouTube videos were screened independently by two reviewers. Videos were categorized by source: (1) academic, government, and non-profit organizations; (2) private practices, companies, and for-profit organizations; (3) independent users. Each video was evaluated for reliability, credibility, and quality using the modified DISCERN criteria (scale, 0-5), Journal of the American Medical Association (JAMA) criteria (scale, 0-4), and Global Quality Scale (GQS; scale, 1-5). Surgical treatment videos were analyzed by the senior author using a modified "treatment" DISCERN criteria (scale, 8-40). Non-English videos were excluded from this study. Analysis of variance tests were used to compare means. One hundred and fifteen videos were selected for final analysis. The mean modified DISCERN score was 3.26; JAMA was 2.31; GQS was 3.48. Videos were subdivided according to source. Group 1, 2, and 3 had 45, 24, and 46 videos, respectively. Modified DISCERN score was greater for Group 1 than Group 2 (3.58 vs. 3.04, p < .001) and Group 3 (3.58 vs. 3.07, p < .001). JAMA score was greater for Group 1 than Group 2 (2.63 vs 2.15, p = .041) and Group 3 (2.63 vs. 2.08, p = .002). GQS score was greater for Group 1 than Group 2 (3.93 vs. 3.31, p = .031) and Group 3 (3.93 vs. 3.13, p < .001). Of the 34 videos (44.7%) that mentioned treatment, the DISCERN score was 14.32. The videos analyzed were found to have moderate reliability, credibility, and quality. The reliability of information regarding treatments for BPI was poor. Healthcare providers should supply additional information on treatment of BPI.

Nfrared thermography as a complementary method when diagnosing birth-related brachial plexus injury

The main objective of this study was to determine whether infrared thermography could be used as anefficient technique to evaluate the impact of a birth-related brachial plexus injury on the temperature of the injured arm and whether it could be used as a complementary method when diagnosing this injury in clinical praxis. Clinically, the brachial plexus injury is a peripheral paresis, which occurs when nerves that send signals from the spinal cord to the shoulder, arm, and hand are stretched or compressed. In principle, the brachial plexus injury, as a long-lasting injury, should be causing hypothermia of the injured arm. The usage of contactless infrared thermography could offer a "new view" of the diagnostic process in this case. The present study, therefore, describes a process of clinical infrared thermography examination of three patients of different age and presents results from those examinations. From our results, it can be confirmed that the birth-related brachial plexus injury affects the temperature of the affected arm, especially in the area of the cubital fossa, to an extent that the thermal camera is capable of detecting significant temperature differences between the healthy and injured arms (Tab. 3, Fig. 7, Ref. 13). Text in PDF www.elis.sk Keywords: birth brachial plexus injury, upper type palsy, peripheral palsy, infrared thermography.

The shifting demographics of birth-related brachial plexus injury: The impact of socio-economic status and ethnic groups

Many of the risk factors for birth-related brachial plexus injury (BRBPI), such as maternal gestational diabetes and macrosomia, are known to vary between demographic groups. Socio-economic differences are known to influence access to healthcare, including elective caesarean section rates and access to consultant obstetricians, which could impact the rates of BRBPI. This study aims to explore whether BRBPI is affected by demographic factors. This retrospective study compares cohorts of BRBPI patients referred to the Royal National Orthopaedic Hospital in 2004, 2014 and 2017. N = 67 in 2004, N = 61 in 2014 and N = 71 in 2017. The risk of BRBPI for Black patients was 6 times higher than for White patients, and 2.7 times higher for Asian patients as compared to White patients (p < 0.001). There was an unequal distribution of BRBPI occurring in patients from lower socio-economic groups based on the index of multiple deprivation, with the highest level seen in those from the second lowest quintile. Neither of these risk factors have changed within the three years that they were examined. In this sample, the risk of BRBPI varies with ethnic groups; patients from non-White backgrounds are at a higher risk overall and are disproportionately represented in the BRBPI cohort as compared to White groups. Similarly, there seems to be a trend towards greater risk for those from lower socio-economic groups. These changes are consistent each year, suggesting that these inconsistencies are yet to be addressed. Further studies are warranted to explore why these demographic factors are significantly affecting health outcomes.

Fabrication of the external rotation abduction thermoplastic shoulder orthosis for infants and children with birth-related brachial plexus injuries

Fabrication of the external rotation abduction thermoplastic shoulder orthosis for infants and children with birth-related brachial plexus injuries

Intercostal Nerve Transfers to the Musculocutaneous-A Reliable Nerve Transfer for Restoration of Elbow Flexion in Birth-Related Brachial Plexus Injuries.

Introduction There is consensus on the need for early microsurgical reconstruction in birth palsies involving three or more roots, that is, extensive partial palsies and total palsies. The fundamental principles of these operations are complete exploration and judicious use of the ruptured stumps by nerve grafting to suitable distal targets. The frequent observation of root avulsions in such cases makes it imperative to look for extraplexual nerve donors for some functions. Intercostal nerves are readily available in such patients. Materials and Methods This is a study of 50 patients of extensive partial and total birth palsies operated upon by the senior author between 1995 and 2010. These included 33 patients with total palsies, 16 patients with near total palsies, and one patient with C56 deficit (operated upon more than 20 years ago). These children were all operated upon between 3 and 6 months of age, except for two patients in whom surgery was delayed till a year due to the phrenic nerve deficit noted at birth. Four intercostal nerves were transferred to the musculocutaneous nerve (MCN) by direct approximation with fibrin glue. Results No respiratory complication was noted from the intercostal harvest. The follow-up ranged from 8 to 20 years (mean 10 years). As many as 48 of the 50 patients regained fully independent elbow flexion. In two cases, the procedure failed completely and had to be salvaged with a free functioning muscle transfer and reuse of the intercostal nerves. Conclusion Intercostal nerve transfers can be relied upon for restoration of elbow flexion in birth palsies. The ruptured roots can then be utilized for augmenting shoulder function in partial palsies or for hand function in total palsies.

Surgical treatment of birth-related brachial plexus injuries: a historical review.

This historical review presents the relevant data about the evolution of the surgical treatment of neonatal brachial plexus palsy. Starting with the first clinical description by Smellie in 1754, we will present the initial enthusiasm for the surgery followed by a lack of interest that lasted many years, the resurgence of interest in operative management in the 1970s, and the consolidation in the 1980s of surgery as the standard indication in cases of neonatal brachial plexus palsy without a functional spontaneous recovery.

Coordination and balance in children with birth-related brachial plexus injury: a preliminary study.

Most children with severe birth-related brachial plexus injury (BRBPI) have some functional impairment, but information on the impact of BRBPI on coordination and balance is limited. The study's purpose was to determine whether children with BRBPI exhibit deficits in body coordination and balance. A prospective cohort study involving 39 children with BRBPI aged 5-15 years was conducted. Range of motion, strength, active movement, and balance and coordination motor skills were assessed using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2), and the Movement Assessment Battery for Children-Second Edition (MABC-2). A self-report measure of physical disability, the Activities Scale for Kids-Performance Version (ASKp), was also administered. Participants scored a mean of 44.72 on the BOT-2 Body Coordination composite subtest; scores can range from 20 to 80. Eleven participants (28.2%) scored below average on this test. Participants scored a mean of 7.3 on the Balance subtest of the MABC-2; scores can range from 1 to 19. Twenty-six participants (66.7%) scored below average on this test. Of 38 participants, 25 (65.8%) had an ASKp score indicating some level of disability (<95/100); we found a statistically significant difference in balance (p=0.007) between these 25 participants and those without disability (ASKp score 95-100). The majority of our study population scored in the categories of at risk or significant difficulty for balance on the MABC-2. Balance rehabilitation may be a valuable treatment adjunct for children with BRBPI.

Sup-ER orthosis: An innovative treatment for infants with birth related brachial plexus injury

Impairments in active and passive range of upper extremity supination and shoulder external rotation are common sequelae for children with delayed recovery from birth related brachial plexus injury. Orthotic intervention may complement traditional treatment strategies commonly employed in the newborn period. These authors describe their custom fabricated orthosis designed to balance shoulder growth and muscular function, and improve prognosis of long term functional outcomes for children with birth related brachial plexus injury. – Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor

An Early Shoulder Repositioning Program in Birth-Related Brachial Plexus Injury: A Pilot Study of the Sup-ER Protocol

Birth-related brachial plexus injury (BRBPI) occurs in 1.2/1,000 births in British Columbia. Even in children with "good" recovery, external rotation (ER) and supination (Sup) are often weaker, and permanent skeletal imbalance ensues. A preventive early infant shoulder passive repositioning program was created using primarily a novel custom splint holding the affected arm in full ER and Sup: the Sup-ER splint. The details of the splint and the shoulder repositioning program evolved with experience over several years. This study reviews the first 4years. A retrospective review of BCCH patients managed with the Sup-ER protocol from 2008 to 2011 compared their recovery scores to matched historical controls selected from our database by two independent reviewers. The protocol was initiated in 18 children during the study period. Six were excluded due to the following: insufficient data points, non-compliance, late splint initiation, and loss to follow-up. Of the 12 matches, the Sup-ER group final score at 2years was better than controls by 1.18 active movement scale (AMS) points (p = 0.036) in Sup and 0.96 AMS points in ER (but not statistically significant (p = 0.13)). Unexpectedly, but importantly, during the study period, zero subjects were assessed to have the active functional criteria to indicate brachial plexus reconstruction, where previously we operated on 13%. Early application of passive shoulder repositioning into Sup and ER may improve outcomes in function of the arm in infants with BRBPI. A North American multi-site randomized control trial has been approved and has started recruitment.

Current Concepts: Neonatal Brachial Plexus Palsy

Educational Objectives As a result of reading this article, physicians should be able to: 1. Explain how to diagnose infants with birth-related brachial plexus injuries. 2. Describe the classification system used to characterize brachial plexus injuries. 3. List the indications for microsurgical intervention for brachial plexus birth palsies.

Birth-related brachial plexus palsy

Geburtstraumatische Armplexusparesen werden oft als schicksalhaft angesehen, wodurch der richtige Zeitpunkt für eine sinnvolle primäre Operation am Plexus brachialis verpasst werden kann. Zwar liegen in den meisten Fällen leichte Dehnungsverletzungen vor, die sich unter Physiotherapie erholen können, jedoch hinterlassen schwere Ab- oder Ausrissverletzungen oft beachtliche lebenslange Einschränkungen. Die „Arbeitsgruppe geburtstraumatische Armplexusparese München“ hat sich zum Ziel gesetzt, eine kompetente Beratung und Behandlung für Patienten und ihre Eltern anzubieten. In einer monatlichen interdisziplinären Sprechstunde werden Betroffene möglichst im 3. Lebensmonat vorgestellt, klinisch und ggf. elektrophysiologisch untersucht und weitere diagnostische Maßnahmen eingeleitet. Bis spätestens zum 9. Lebensmonat wird entschieden, ob eine direkte Operation am Plexus brachialis sinnvoll ist. Mit der weiteren Entwicklung des Kindes können auch zu einem späteren Zeitpunkt sekundäre therapeutische Maßnahmen sinnvoll sein. Seit 2002 wurden durch die Arbeitsgruppe mehr als 150 Patienten interdisziplinär behandelt. Die gemeinsame Beratung und Behandlung durch Pädiatrie, Entwicklungsneurologie, Neurologie, Handchirurgie und Plastische Chirurgie werden überaus positiv aufgenommen. Die vorliegende Arbeit soll eine Übersicht und ein Behandlungsschema hinsichtlich der aktuellen Vorgehensweise bei Patienten mit geburtstraumatischer Armplexusparese geben sowie die Möglichkeiten chirurgischer Rekonstruktionsverfahren aufzeigen.

Medial pectoral nerve transfer

Dr. Wellons and his colleagues6 report convincing evidence that medial pectoral nerve (MCN) to musculocutaneous nerve (MCN) transfer can improve elbow flexion in infants with birth brachial plexus injury.6 They performed the MPN transfer procedure in a relatively large number of patients and achieved excellent surgical outcomes. Their results corroborate those previously reported by Blaauw and Sloof4 and make a strong case for MPN as a donor nerve that can be used in brachial plexus reconstruction for birth injury. The present report will serve as a valuable reference for many years. I commend the authors for their significant contribution to the treatment of birth-related brachial plexus injury. Some aspects of their report and the use of this particular MPN transfer in infants warrant discussion. As the authors indicate, infants with C8–T1 injury would not be candidates for the nerve transfer procedure because the MPN receives output from C8–T1 nerve roots. Potential candidates are infants with C5–6 or C5–7 injury. In these infants, surgical treatment should be aimed to maximize improvement of both shoulder and elbow function and should be undertaken before 12 months of age. Patients with persistent limited shoulder abduction, arm external rotation, and elbow extension/flexion suffer from life-long disabilities, and they develop fixed shoulder and elbow joint deformities that cannot be corrected. Unless infants show shoulder abduction greater than 90°, the limited shoulder abduction in infancy will lead to worsening shoulder abduction due to increased shoulder adductor contractures. These patients cannot carry out arm movements that require concomitant shoulder movement. Orthopedic procedures for the fixed deformities coupled with muscle weakness do not restore full shoulder and elbow function. For example, rotational osteotomy at a later age can reposition the arm in more external rotation but does not increase the total arc of motion of the arm. Fixed elbow flexion deformities cannot be fully corrected with surgeries. Shoulder subluxation/dislocation and resulting late shoulder deformities cannot be prevented in many patients. Thus, one should not rely on palliative orthopedic procedures later in childhood. Instead, one should employ a broad brachial plexus reconstruction before the patient reaches 12 months of age. When planning a type of brachial plexus reconstruction for C5–6 or C5–7 injury, one should remember favorable surgical outcome of resection of neuroma and nerve grafts, sometimes combined with C-4–suprascular nerve neurotization. Gilbert and colleagues5 reported shoulder abduction of more than 90° in 81% of 241 infants with C5–6 repairs and 76% of 81 infants with C5–7 repairs. Such good improvements were also observed in elbow flexion and extension. We have reported similar outcomes.1 In contrast, the MPN transfer improves only elbow flexion but does not help improve elbow extension and shoulder function. If infants older than 6 months cannot flex their elbow against gravity but can abduct their shoulder more than 90°, the MPN transfer would be a good option. However, I have not seen persistent weakness confined to the biceps in our patients, nor am I aware of reports of such cases in 345 347

Magnetic resonance neurography in children with birth-related brachial plexus injury

Magnetic resonance neurography in children with birth-related brachial plexus injury

Magnetic resonance neurography in children with birth-related brachial plexus injury

Magnetic resonance neurography (MRN) enables visualization of peripheral nerves. Clinical examination and electrodiagnostic studies have been used in the evaluation of birth-related brachial plexus injury. These are limited in their demonstration of anatomic detail and severity of injury. We investigated the utility of MRN in evaluating birth-related brachial plexus injury in pediatric patients, and assessed the degree of correlation between MRN findings and physical examination and electromyographic (EMG) findings. The MRN findings in 11 infants (age 2 months to 20 months) with birth-related brachial plexus injury were evaluated. A neuroradiologist blinded to the EMG and clinical examination findings reviewed the images. Clinical history, examination, EMG and operative findings were obtained. All infants had abnormal imaging findings on the affected side: seven pseudomeningoceles, six neuromas, seven abnormal nerve T2 signal, four nerve root enlargement, and two denervation changes. There was greater degree of correlation between MRN and physical examination findings (kappa 0.6715, coefficient of correlation 0.7110, P < 0.001) than between EMG and physical examination findings (kappa 0.5748, coefficient of correlation 0.5883, P = 0.0012). MRN in brachial plexus trauma enables localization of injured nerves and characterization of associated pathology. MRN findings demonstrated a statistically significant correlation with physical examination and EMG findings, and might be a useful adjunct in treatment planning.

Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography—A Faustian bargain?

Both our previously performed decision analysis and more recent clinical data considered in the context of our decision analytic framework support the claim that in the pregnancies of women without diabetes the level of intervention and the economic costs of prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography are predicted to be excessive. Under the most plausible assumptions, a prophylactic cesarean policy with either a 4000- or 4500-g macrosomia threshold would require more than 1000 cesarean deliveries and millions of dollars to avert a single permanent brachial plexus injury. In the pregnancies of diabetic women, although such policies would be expected to perform appreciably better, their use would nevertheless entail considerable intervention for any benefit achieved. Under most assumptions, hundreds of cesarean deliveries and hundreds of thousands of dollars would be required to avert a single permanent brachial plexus injury. In light of the available data, optimizing the management of shoulder dystocia seems at present to be the most immediate and tenable approach to the prevention of birth-related brachial plexus injury. (Am J Obstet Gynecol 1999;181:332-8.)

Outcome of surgically treated birth-related brachial plexus injuries in twenty cases.

Birth-related brachial plexus injury occurs in 0.19-2.5 per 1,000 live births, of which 70-92% improve with conservative management. With the advent of microsurgical techniques, patients who fail expectant treatment may benefit from brachial plexus exploration and reconstruction. From 1991 to 1996, 87 patients were referred to the multidisciplinary brachial plexus clinic at St. Louis Children's Hospital. Twenty patients were selected for surgical management. The average age at surgery was 10.5 months (range 3-35, median = 8), with an average follow-up of 23.9 months (range 7-45, median = 24). Two patients were lost to follow-up. Surgical procedures included neurolysis (n = 8), neurotization (n = 2), nerve grafting (n = 5), and a combination (n = 3) of the above. Two patients underwent exploration without repair. Intercostal nerves, pectoral nerves, and C4 roots were used for neurotizations, and the sural nerve was used for nerve grafting. Results from 18 patients were available for follow-up review. Fifteen patients (83% demonstrated clinical improvement postoperatively. Of the 3 patients without improvement, 2 underwent exploration without repair, and one underwent neurolysis of the axillary nerve. Of patients undergoing reconstruction, 93% had improved strength postoperatively. No subjects had worsening neurologic status, and there were no complications. These results suggest that surgery for birth-related brachial plexus injury may show favorable outcomes if patients are selected appropriately. Patients undergoing neurolysis and nerve grafting had more favorable outcomes than those undergoing neurotization.

Fast spin—echo magnetic resonance imaging for radiological assessment of neonatal brachial plexus injury

Neurosurgical management of birth-related brachial plexus palsy involves observing the patient for a period of several months. Operative intervention is usually undertaken at 3 to 6 months of age or more in infants who have shown little or no improvement in affected muscle groups. Ancillary tests such as electromyography and nerve conduction studies are occasionally useful. No radiological study has been consistently helpful in operative planning, except for contrast computerized tomography (CT) myelography, which requires general anesthesia in infants. This is because the infant's small size exceeds the functional resolution of the imaging modalities. This report describes the use of a special sequence of magnetic resonance (MR) imaging entitled "fast spin echo" (FSE-MR). Unlike CT myelography, this technique provides high-speed noninvasive imaging that allows clinicians to evaluate preganglionic nerve root injuries without the use of general anesthesia and lumbar puncture. The utility of this technique is illustrated in three cases, two involving either infraclavicular exploration or a combination of infraclavicular and supraclavicular exposure based on FSE-MR findings. The FSE-MR imaging offers an excellent alternative to contrast CT myelography in evaluation of infants with birth-related brachial plexus injuries.

Birth-related upper brachial plexus injuries in infants: operative and nonoperative approaches.

Advances in intraoperative neuroelectrodiagnostic testing and microneurosurgical techniques have made it possible to accurately explore the brachial plexus of neonates. Since 1987, we have followed 250 infants with birth-related brachial plexus injuries, and successful operations have been completed on more than 70 infants. Fifty infants who underwent surgery have been followed for more than 18 months. Based on these accumulated data and historical data, this review describes both nonoperative and operative approaches to the treatment of birth-related brachial plexus injuries.

Early Infantile Surgery for Birth-Related Brachial Plexus Injuries: Justification Requires a Prospective Controlled Study

Early Infantile Surgery for Birth-Related Brachial Plexus Injuries: Justification Requires a Prospective Controlled Study

Neurosurgical correction of upper brachial plexus birth injuries

The authors review the cases of 116 infants treated consecutively for birth-related brachial plexus injuries. Twenty-eight infants with upper brachial plexus lesions who showed no neurological improvement by 4 months of age were selected for early surgical reconstruction (at a mean age of 5 months). Neurological improvement of the affected arm was observed in more than 90% (p < 0.05) of the children examined longer than 9 months after brachial plexus reconstruction. A conservatively managed control subgroup of 44 children, first examined at less than 3 months of age, demonstrated neurological improvement by 4 months of age and continued to show improvement at 1 year of age. Early surgical reconstruction is recommended for infants with birth-related upper brachial plexus injury who show no neurological improvement by the age of 4 months.