Obstetric Brachial Plexus Injury Patients Research Articles

Clinical and functional outcome of modified Quad surgery in adult obstetric brachial plexus injury patients: Case reports.

Untreated adult obstetric brachial plexus injury (OBPI) patients, in general, use compensatory strategies to achieve their lost upper extremity functions; they cause some adverse effects. Our present study is a case series of 3 female adult OBPI patients, aged 46, 23 and 21 years old. They all had a modified Quad surgical procedure. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized upper extremity movements using the modified Mallet scale. The average postoperative follow-up was 4.3 months (1 to 9 months). Total Mallet score significantly improved from 15 and 18 to 21 in two patients. Supination angle measured from active movement of these 3 patients improved from 40°, 0° and -60° to 80°, 40° and -40°, respectively. The modified Quad surgical procedure significantly improves active abduction and other shoulder functions not only in young pediatric and adolescent patients, as we have previously reported, but also in adult patients with muscle imbalance secondary to brachial plexus injury sustained at birth.

10-year Follow-up of Mod Quad and Triangle Tilt Surgeries in Obstetric Brachial Plexus Injury.

Aim:To evaluate whether obstetric brachial plexus injury (OBPI) children who had mod Quad and triangle tilt surgeries maintained their recovered upper extremity functional movements over 10 years.Background:The short-term outcomes of surgery in OBPI patients are well documented. However, only a few publications with results over 10-year postoperative follow-up exist. We have previously reported the outcomes of these 2 surgeries in OBPI after 1, 2, and 5 years. Here, we report the successful outcomes in 17 of these patients over 10 years.Methods:Seventeen OBPI patients, who had mod Quad, a modified muscle release operation and triangle tilt, a bony surgical procedure with us between 2005 and 2008, had postoperative follow-up of 10 years and met the inclusion criteria. Patients who had multiple surgeries and did not have 10-year follow-up are excluded in this study.Results:Fifteen of 17 children maintain their recovered upper extremity functions for extended long period (mean, 10 years; range, 9–13 years). There was statistically significant improvement in total functional Mallet score after 3 years (mean, 18.8 ± 2.1; P ≤ 0.01) from the preoperative mean total Mallet score of 14.5 ± 1.2. This improvement was not only maintained for extended period but also improved (mean total Mallet score, 20.35 ± 2.3; P ≤ 0.01) in some patients.Conclusions:Overall, all upper extremity functions improved greatly after mod Quad and triangle tilt surgeries in OBPI children, and they were able to maintain their recovered functional movements over extended period of 10 years.

The triangle tilt procedure for treatment of secondary shoulder deformities in obstetric brachial plexus injury

The purpose of this study was to evaluate the shoulder functional and radiographic outcomes of the triangle tilt surgery for treatment of shoulder deformities secondary to obstetric brachial plexus injury (OBPI). Patients and Methods: A prospective study was executed at our institution, between Dec. 2013 and Jan. 2017, on the triangle tilt procedure for treatment of 22 OBPI patients (who were available for final follow-up), with persistent medial rotation contracture, SHEAR scapular deformity and glenohumeral joint instability. Their mean age at the time of the surgery was 6.1 ± 2.2 years (range: 4 – 12 years). We excluded cases having previous tendon transfers or bony operation. Results: The mean follow-up period was 17 ± 2.2 months (range: 12 - 24 months). Clinicaly, significant improvements were noted in the mean overall Mallet score (from 11.3±1.6 to 16.9±1.8 points), also, in (external rotation, hand-to-mouth, hand-to-neck, and hand-to-spine) functions and in the posture of the arm at rest, but with no considerable improvement in global abduction. Radiographically, significant improvements were demonstrated in: posterior subluxation (from a mean of 12±7.2% to 30±3.5%), glenoid version (from a mean of −30±5˚ to −17.5±6˚) and scapular elevation (from a mean of 7.1±2 % to 2.8±0.2 %). No significant postoperative complications were noted. Conclusions: The triangle tilt procedure is an effective procedure in treating OBPI patients with secondary shoulder deformities; achieving encouraging functional and anatomical results.

Significant improvement in nerve conduction, arm length, and upper extremity function after intraoperative electrical stimulation, neurolysis, and biceps tendon lengthening in obstetric brachial plexus patients.

BackgroundProgressive loss of extension and concomitant bony deformity of the elbow are results of persistent biceps contracture in obstetric brachial plexus injury (OBPI) patients, if they do not fully recover. This adversely affects the growth and development and functions of the upper extremity.Patients and methodWe have performed biceps tendon lengthening (BTL) using a Z-plasty technique on OBPI patients aged 4 years to adulthood, who had been diagnosed with biceps tendon fixed flexion contractures. Ulnar, radial, and median nerve decompression was also performed at the same sitting. Somatosensory evoked potential (SSEP) monitoring was performed by stimulating the median and ulnar nerves at the wrist and the radial nerve over the dorsum of the hand and recording the peripheral, cervical, and cortical responses.Seven children with obstetric brachial plexus palsy with an average age of 11 years (8.7–14.2 years) were included in this report. Mean follow-up time was 7.4 months (4–11 months). All the patients in this report had the elbow flexion contractures greater than 30°.ResultsMean flexion contracture was 35° (30°–45°) preoperatively, which was improved to 0°–10° postoperatively with an average follow-up of 7 (4–11) months. This surgical procedure corrected the elbow flexion contractures, about an average of 25° and an improved length almost to normal, and improved the upper extremity functions. Neurophysiological data showed significant improvement in conduction of all three nerves tested after neurolysis. Further, median and radial nerve amplitude increase was statistically significant.ConclusionStatistically significant improvement in biceps length as well as nerve conduction was observed after the surgery. None of the children in our study lost biceps function, although weakness of the biceps is both a short- and long-term risk associated with biceps lengthening.

Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome.

To systematically review and analyze the overall impact and effectiveness of bony surgical procedures, the triangle tilt and humeral surgery in a comparative manner in permanent obstetric brachial plexus injury (OBPI) patients. We conducted a literature search and identified original full research articles of OBPI patients treated with a secondary bony surgery, particularly addressing the limitation of shoulder abduction and functions. Further, we analyzed and compared the efficacy and the surgical outcomes of 9 humeral surgery papers with 179 patients, and 4 of our secondary bony procedure, the triangle tilt surgical papers with 86 patients. Seven hundred and thirty-one articles were identified, using the search term "brachial plexus" and obstetric or pediatric (246 articles) or neonatal (219 articles) or congenital (188 articles) or "birth palsy" (121 articles). Further, only a few articles were identified using the bony surgery search, osteotomy "brachial plexus" obstetric (35), "humeral osteotomy" and "brachial plexus" (17), and triangle tilt "brachial plexus" (14). Of all, 12 studies reporting pre- and post- operative or improvement in total Mallet functional score were included in this study. Among these, 9 studies reported the humeral surgery and 4 were triangle tilt surgery. We used modified total Mallet functional score in this analysis. Various studies with humeral surgery showed improvement of 1.4, 2.3, 5.0 and 5.6 total Mallet score, whereas the triangle tilt surgery showed improvement of 5.0, 5.5, 6.0 and 6.2. The triangle tilt surgery improves on what was achieved by humeral osteotomy in the management of shoulder function in OBPI patients.

Successful outcome of triangle tilt as revision surgery in a pediatric obstetric brachial plexus patient with multiple previous operations.

Introduction. Obstetric brachial plexus injury (OBPI) occurs during the process of labor and childbirth. OBPI has been reported to be associated with shoulder dystocia, macrosomia, and breech delivery. Its occurrence in uncomplicated delivery is possible as well. Case Presentation. The patient in the present report is a 6.5-year-old girl, who suffered a severe brachial plexus injury at birth and had many reconstructive surgical procedures at an outside brachial plexus center before presenting to us. Discussion. The traditional surgical treatments by other surgical groups were unsuccessful and therefore the patient came to our clinic for further treatment. She had triangle tilt surgery with us, as a salvage procedure. Conclusion. The OBPI patient in this study clearly showed noticeable clinical and functional improvements after triangle tilt surgical management. The posture of the arm at rest was greatly improved to a more normal position, and hand to mouth movement was improved as well. Triangle tilt surgery should be conducted as a first choice treatment for medial rotation contracture of the shoulder in OBPI patients.

Extended Long-Term (5 Years) Outcomes of Triangle Tilt Surgery in Obstetric Brachial Plexus Injury

Objective:We evaluated the "extended" long-term (5 years) functional outcomes in obstetric brachial plexus injury (OBPI) patients, who underwent triangle tilt surgery between February 2005 and January 2008. Methods:Twenty two children (9 girls and 13 boys, mean age at surgery was 5.8 years; ranging 2.1-11.8 years old), who initially presented with medial rotation contracture and scapula deformity secondary to obstetric brachial plexus injury were included in this study. Functional movements were evaluated pre-operatively, and 5 years following triangle tilt surgery by modified Mallet scale. Results:Here, we report long-term (5 years) follow-up of triangle tilt surgery for 22 OBPI patients. Upper extremity functional movements such as, external rotation (2.5±0.6 to 4.1±0.8, p<0.0001), hand-to-spine (2.6±0.6 to 3.4±1.1, p<0.005), hand-to-neck (2.7±0.7 to 4.3±0.7, p<0.0001), hand-to-mouth (2.3±0.9 (92º±33) to 4.2±0.5 (21º±16), p<0.0001), and supination (2.6±1.1 (-8.2º ±51) to 4.1±0.7 (61±32)) were significantly improved (p<0.0001), and maintained over the extended long-term (5 years). Total modified Mallet functional score was also shown to improve from 14.1±2.7 to 20.3±2.5. Conclusions:The triangle tilt surgery improved all shoulder functions significantly, and maintained over the extended long-term (5 years) in these patients.

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.

Risk Factors at Birth for Permanent Obstetric Brachial Plexus Injury and Associated Osseous Deformities

Purpose. To examine the most prevalent risk factors found in patients with permanent obstetric brachial plexus injury (OBPI) to identify better predictors of injury. Methods. A population-based study was performed on 241 OBPI patients who underwent surgical treatment at the Texas Nerve and Paralysis Institute. Results. Shoulder dystocia (97%) was the most prevalent risk factor. We found that 80% of the patients in this study were not macrosomic, and 43% weighed less than 4000 g at birth. The rate of instrument use was 41% , which is 4-fold higher than the 10% predicted for all vaginal deliveries in the United States. Posterior subluxation and glenoid version measurements in children with no finger movement at birth indicated a less severe shoulder deformity in comparison with those with finger movement. Conclusions. The average birth weight in this study was indistinguishable from the average birth weight reported for all brachial plexus injuries. Higher birth weight does not, therefore, affect the prognosis of brachial plexus injury. We found forceps/vacuum delivery to be an independent risk factor for OBPI, regardless of birth weight. Permanently injured patients with finger movement at birth develop more severe bony deformities of the shoulder than patients without finger movement.

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.

Coracoid Abnormalities and Their Relationship with Glenohumeral Deformities in Children with Obstetric Brachial Plexus Injury

BackgroundPatients with incomplete recovery from obstetric brachial plexus injury (OBPI) usually develop secondary muscle imbalances and bone deformities at the shoulder joint. Considerable efforts have been made to characterize and correct the glenohumeral deformities, and relatively less emphasis has been placed on the more subtle ones, such as those of the coracoid process. The purpose of this retrospective study is to determine the relationship between coracoid abnormalities and glenohumeral deformities in OBPI patients. We hypothesize that coracoscapular angles and distances, as well as coracohumeral distances, diminish with increasing glenohumeral deformity, whereas coracoid overlap will increase.Methods39 patients (age range: 2-13 years, average: 4.7 years), with deformities secondary to OBPI were included in this study. Parameters for quantifying coracoid abnormalities (coracoscapular angle, coracoid overlap, coracohumeral distance, and coracoscapular distance) and shoulder deformities (posterior subluxation and glenoid retroversion) were measured on CT images from these patients before any surgical intervention. Paired Student t-tests and Pearson correlations were used to analyze different parameters.ResultsSignificant differences between affected and contralateral shoulders were found for all coracoid and shoulder deformity parameters. Percent of humeral head anterior to scapular line (PHHA), glenoid version, coracoscapular angles, and coracoscapular and coracohumeral distances were significantly lower for affected shoulders compared to contralateral ones. Coracoid overlap was significantly higher for affected sides compared to contralateral sides. Significant and positive correlations were found between coracoscapular distances and glenohumeral parameters (PHHA and version), as well as between coracoscapular angles and glenohumeral parameters, for affected shoulders. Moderate and positive correlations existed between coracoid overlap and glenohumeral parameters for affected shoulders. On the contrary, all correlations between the coracoid and glenohumeral parameters for contralateral shoulders were only moderate or relatively low.ConclusionsThese results indicate that the spatial orientation of the coracoid process differs significantly between affected and contralateral shoulders, and it is highly correlated with the glenohumeral deformity. With the progression of glenohumeral deformity, the coracoid process protrudes more caudally and follows the subluxation of the humeral head which may interfere with the success of repositioning the posteriorly subluxed humeral head anteriorly to articulate with the glenoid properly.

Triangle tilt surgery as salvage procedure for failed shoulder surgery in obstetric brachial plexus injury

PurposeThe study was conducted to review the effects of triangle tilt surgery in children with OBPI (obstetric brachial plexus injury) who had previously undergone several operative procedures at other hospitals before presenting at our institute.MethodsThe study included a group of 48 OBPI patients who had undergone previous operative procedures at outside hospitals by other surgeons. Patients were assessed for shoulder function using their radiological reports and the modified Mallet functional scale. The same patients underwent the triangle tilt procedure at our institution and were re-evaluated for shoulder function.ResultsThe results of the study showed an increase in Mallet scores from 11.88 points to 15.17 points (p < 0.01), improvement in PHHA (percentage of humeral head anterior to the glenoid) from 14% to 25% (p < 0.05), enhancement in glenoid version from −32° to −25° (p < 0.01), and a decrease in the SHEAR (scapular hypoplasia, elevation, and rotation) deformity after surgery.ConclusionThe data obtained demonstrated that the triangle tilt procedure significantly enhanced shoulder function and glenohumeral congruity in these patients as evidenced by the improvements in Mallet scores, PHHA, glenoid version, and SHEAR deformity.

Arm rotated medially with supination – the ARMS variant: description of its surgical correction

BackgroundPatients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SHEAR deformity commonly occurs in conjunction with Medial Rotation Contracture (MRC) of the arm. OBPI also causes muscle imbalances at the level of the forearm, that lead to a fixed supination deformity (SD) in a small number of patients. Both MRC and SD will cause severe functional limitations without surgical intervention.MethodsFourteen OBPI patients were diagnosed with MRC of the shoulder and SD of the forearm along with SHEAR deformity during a 16 month study period, with eight patients available to long-term follow-up (age range 2.2 – 18 years). Surgical correction of the MRC was performed as a triangle tilt or humeral osteotomy depending on the age of the child, after which, the patients were treated with a radial osteotomy to correct the fixed supination deformity. Function was assessed using the modified Mallet scale, examination of apparent supination and appearance of the extremity at rest.ResultsSignificant functional improvements were observed in patients with surgical reconstruction. Mallet score increased by an average of 5.2 (p < 0.05). Overall forearm position was not significantly changed from an average of 5° to an average of 34° maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.ConclusionThe simultaneous presence of two opposing deformities in the same limb will visually offset each other at the level of the wrist and hand, giving the false impression of neutral positioning of the limb. In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder. Both of these deformities require surgical attention, and the presence of concurrent MRC and SD should be monitored for in OBPI patients.