Obstetric Brachial Plexus Injury Research Articles

Caring for a Child With an Obstetric Brachial Plexus Injury: A Metaphor Analysis

PurposeThe purpose of this study was to examine the metaphors used by mothers to describe their experiences caring for their children with obstetric brachial plexus injuries. Design and MethodsA secondary qualitative data analysis was conducted from the primary data set of a phenomenological study of mothers' experiences caring for their children with obstetric brachial plexus injuries. The type of secondary qualitative data analysis approach used was analytic expansion. Metaphor Identification Procedure was used to analyze the corpus of 132 pages of typed transcription. ResultsThis metaphorical analysis yielded seven metaphors mothers used to describe their experiences caring for their children with obstetric brachial plexus injuries. These metaphors portrayed mothers' lives as involving a heavy weight, a maze, a juggling act, a simmering pot, a dagger to the heart, a rollercoaster, and a constant battle. ConclusionThe seven metaphors helped women express what they could not completely capture using only medical jargon and provide valuable insight for clinicians. Using secondary qualitative data analysis to mine for any metaphors in a primary data set gives researchers another valuable and creative opportunity to discover new knowledge from the data they had previously collected. Practice ImplicationsSpecific interventions can be developed to target each of these seven metaphors to help mothers in their daily care for their children with obstetric brachial plexus injuries.

N-Acetylcysteine Prevents Retrograde Motor Neuron Death after Neonatal Peripheral Nerve Injury.

Neuronal death may be an overlooked and unaddressed component of disability following neonatal nerve injuries, such as obstetric brachial plexus injury. N-acetylcysteine and acetyl-L-carnitine improve survival of neurons after adult nerve injury, but it is unknown whether they improve survival after neonatal injury, when neurons are most susceptible to retrograde neuronal death. The authors' objective was to examine whether N-acetylcysteine or acetyl-L-carnitine treatment improves survival of neonatal motor or sensory neurons in a rat model of neonatal nerve injury. Rat pups received either a sciatic nerve crush or transection injury at postnatal day 3 and were then randomized to receive either intraperitoneal vehicle (5% dextrose), N-acetylcysteine (750 mg/kg), or acetyl-L-carnitine (300 mg/kg) once or twice daily. Four weeks after injury, surviving neurons were retrograde-labeled with 4% Fluoro-Gold. The lumbar spinal cord and L4/L5 dorsal root ganglia were then harvested and sectioned to count surviving motor and sensory neurons. Transection and crush injuries resulted in significant motor and sensory neuron loss, with transection injury resulting in significantly less neuron survival. High-dose N-acetylcysteine (750 mg/kg twice daily) significantly increased motor neuron survival after neonatal sciatic nerve crush and transection injury. Neither N-acetylcysteine nor acetyl-L-carnitine treatment improved sensory neuron survival. Proximal neonatal nerve injuries, such as obstetric brachial plexus injury, produce significant retrograde neuronal death after injury. High-dose N-acetylcysteine significantly increases motor neuron survival, which may improve functional outcomes after obstetrical brachial plexus injury.

Effects of Exercise Training With Proprioceptive Equipment on Proprioceptive and Functional Status of Children with Obstetrical Brachial Plexus Injury

Objectives: Decreased proprioception in Obstetric Brachial Plexus Injury (OBPI) reduces the quality of functional movement. Hence, the aim of our study was to evaluate the effects of exercise training with additional proprioceptive equipments on the functional status and proprioceptive sense in children with OBPI. Materials and Methods: Forty children with OBPI were randomly divided into two groups. Passive, active and active-assisted range of motion and stretching exercises were included in home-based program (HP) group while additional exercises with proprioceptive equipments were also added in the proprioceptive training (PT) group. After 6 weeks, proprioceptive perception and functional level were compared to pre-treatment results. Results: Proprioceptive perception at the beginning and at the end of the movement increased in both groups (p<0,05). The Active Movement Scale (AMS) scores increased significantly only in some movements in both groups (p<0,05). AMS scores of shoulder abduction and external rotation in PT group were better than HP group (p<0,05). Conclusions: Home exercise program and proprioceptive exercise training both improve proprioceptive sense and functional status in children with OBPI. The proprioceptive exercise training seems to be more beneficial in improving functional movements of shoulder.

Biceps Rerouting after Forearm Osteotomy: An Effective Treatment Strategy for Severe Supination Deformity in Obstetric Plexus Palsy

Study Design Retrospective cohort study. Objective Supination deformity in obstetric brachial plexus injury can have debilitating consequences for the functionality of the hand. Surgical treatment by a forearm osteotomy has a recurrence rate of 20 to 42%. As a complement to forearm osteotomy, a biceps rerouting may improve outcome. Methods Children with residual brachial plexus injury, who had a forearm osteotomy for a supination contracture and had a postoperative decrease of pronation to 50 degrees or less, were indicated for a biceps rerouting. Shoulder, elbow and hand function, biceps strength, Mallet score, and Raimondi score were assessed with a minimum follow-up of 2 years. Results Five patients (median age: 8 years; range: 4-10) underwent biceps rerouting between 2008 and 2012. Median follow-up time was 6.8 years (range: 3.2-7.0 years). Passive pronation increased in all cases (median 0 degree at baseline to 80 degrees at final follow-up). Active pronation also increased. Active median wrist extension was -30 degrees at baseline and 45 degrees at follow-up. Biceps strength and grip strength improved in two cases. No recurrences were present. Conclusion The sequentially planned surgical treatment of forearm osteotomy and biceps rerouting should be considered in the treatment of severe supination deformity, as it is effective in improving pronation of the forearm and hand function, without recurrence at follow-up. Level of Evidence/Type of Study Level III, case series, therapeutic study.

Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline

ObjectiveThe objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing...

Neonatal brachial plexus injury with diaphragmatic eventration

Our case report describes obstetric right brachial plexus injury leading to Erb's palsy and Klumpke's palsy with ipsilateral paralysis of diaphragm in a 9-month-old baby without Horner's syndrome. The baby required initial right brachial plexus root exploration and nerve grafts, later requiring surgical plication of diaphragm. Now, the baby is free of bronchopneumonia and is in recovering phase of upper limb motor and sensory function.

Postoperative physical therapy program for latissimus dorsi and teres major tendons transfer to rotator cuff in children with obstetrical brachial plexus injury.

The transfer of latissimus dorsi and teres major tendons to rotator cuff have been developed to rebalance the muscular dysfunction and improve shoulder range of motion in children with obstetrical brachial plexus palsy (OBPP). No previous study reported the ideal postoperative physical therapy program for these cases. The aim of the present study was to design appropriate postoperative physical therapy (PT) program after latissimus dorsi and teres major tendons transfer to rotator cuff in OBPP to improve upper limb function. Time series design. The patients were recruited from outpatient clinic of Kasr EL Aini Hospital, Cairo, Egypt. Forty seven OBPP infants (4.64±1.21 years with a range of 2.5 to 7 years, 21male and26 female) were allocated to one group. All patients had functional limitation in the involved arm due to muscle paralysis and contracture. Twenty-five patients had C5-C6 nerve root lesions while 22 had C5-C6-C7 nerve root lesions. The children underwent the surgical procedures of the transfer of latissimus dorsi and teres major tendons to rotator cuff. After the surgery the children participated in a designed physical therapy program for 6 months. Active shoulder abduction, flexion and external rotation range of motion (ROM) were assessed by electrogoniometer, and functional assessments were measured using the modified Mallet scale. All measurements were taken preoperative, 6 weeks, 3 months, and 6 months postoperatively after the application of the designed PT program. Repeated measure analysis of variance (ANOVA) followed by Bonferroni post-hoc test were used to show the improvement in all measured variables. Analysis revealed that shoulder abduction, flexion and external rotation ROM and shoulder function measured by modified Mallet scale were significantly improved (P<0.0001) after the designed postoperative PT program. It can be concluded that the combination treatment of surgical procedure and the postoperative physical therapy program seem to be effective in improving shoulder and arm functions in children with OBPP. This study describes a detailed physical therapy program after latissimus dorsi and teres major tendons transfer to rotator cuff in OBPP.

Distal transfers as a primary treatment in obstetric brachial plexus palsy: a series of 20 cases.

The purpose of this study was to examine the results of spinal accessory nerve to suprascapular nerve (with or without axillary nerve neurotization) and an Oberlin transfer as primary treatment in children with Narakas type I obstetric brachial plexus injuries, when parents refused to consent to conventional nerve trunk-/root-level reconstruction. A total of 20 children with poor shoulder abduction and no biceps antigravity function but with good hand function were treated with spinal accessory nerve to suprascapular nerve and an Oberlin transfer at a mean age of 5.8 months (SD 3.27; range 3-12.) All the patients were evaluated at a mean of 2.8 years (SD 0.8; range 1.5 to 3.8) post-operatively. Three patients were lost to follow-up. Of the remainder, 11 had grade 4+ power of elbow flexion and six patients had grade 4 power at 1 year follow-up; all had 4+ power of elbow flexion at final follow-up. At final follow-up the Mallet score was a mean of 15; (SD 4.22, range 9 to 20). Primary distal nerve transfers can give good outcomes in patients with obstetric brachial plexus injuries and may be an alternative to surgery on the nerve trunks IV.

Shoulder Function and Bone Mineralization in Children with Obstetric Brachial Plexus Injury After Neuromuscular Electrical Stimulation During Weight-Bearing Exercises.

The purpose of this study was to evaluate the effects of neuromuscular electrical stimulation during weight-bearing exercises on shoulder function and bone mineral density (BMD) in children with obstetric brachial plexus injury (OBPI). This study was a randomized controlled trial. Forty-two children with OBPI were recruited. Their ages ranged from 3 to 5 years. They were randomly assigned either to control group (received a selected program) or study group (received the same program as the control group and neuromuscular electrical stimulation during weight bearing). Mallet grading system and dual-energy x-ray absorptiometry were used to evaluate shoulder function and BMD respectively at entry and after intervention (3 months later). No significant differences of the outcome measures were detected at entry. Significant differences were observed within both groups when the pre and post treatment scores within each group were compared. Finally, significant differences favoring the study group were recorded when their post treatment scores were compared. Neuromuscular electrical stimulation during weight bearing exercises is an effective and simple method to improve shoulder function and BMD in children with OBPI.

Recovery of upper extremity function following endoscopically assisted contralateral C7 transfer for obstetrical brachial plexus injury.

Transfer of the contralateral C7 nerve for reconstruction of the brachial plexus in infants with obstetrical brachial plexus injury has rarely been reported. We developed a new endoscopy-assisted technique via the prevertebral (retroesophageal) route for the transfer of the contralateral C7 nerve in reconstruction of the brachial plexus. The reconstruction was performed in 20 infants (14 boys and six girls). Motor recovery was assessed using the Gilbert and Raimondi scales. The Narakas Sensory Grading System was used to evaluate hand sensation. The mean follow-up period was 45 months (SD 18.2). Of the 20 children, nine had contralateral C7 transfer to lower nerve roots, two had transfer to upper nerve roots and nine had transfer to both upper and lower roots. The postoperative shoulder and elbow functions were good or satisfactory according to the Gilbert classification in all children whose preoperative scores were poor. All patients with lower roots reconstruction (9) had satisfactory hand function. A total of 15 children had a Narakas score of S3. Our technique enables safe contralateral C7 transfer to the avulsed roots in severe obstetrical brachial plexus injury infants with a satisfactory functional recovery. Level IV.

Assessment of obstetric brachial plexus injury with preoperative ultrasound

Tools used in the assessment of obstetric brachial plexus injuries (OBPIs) have traditionally included electrodiagnostic studies, computerized tomography with myelography, and MRI. However, the utility of ultrasound (US) in infants for such assessment has not been extensively examined. This retrospective case series reports the preoperative brachial plexus US findings in 8 patients with OBPI and compares US with intraoperative findings. When available, the preoperative US was compared with the preoperative MRI. US revealed abnormalities in all 8 patients. Although MRI detected abnormalities in the majority of patients, US provided accurate information regarding severity and anatomic location of injury in some patients. US is a relatively inexpensive, noninvasive, painless diagnostic modality that can be used to assess OBPI. This case series suggests that US is a valuable adjunct to current diagnostic modalities. Muscle Nerve 53: 946-950, 2016.

Effectiveness of Kinesio Tape on Wrist Extensor Muscles in Children with Obstetric Brachial Plexus Injuries

Effectiveness of Kinesio Tape on Wrist Extensor Muscles in Children with Obstetric Brachial Plexus Injuries

Obstetric brachial plexus injuries and treatment between 0-2 years of age and #8232;

Obstetrical brachial plexus injury treatment was debatable before 1980. In the last three decades, however, treatment options and techniques are progressed. With successful results increasing the overall success rate, today, treatment of these patients is routinely performed in many countries, including Turkey, since 1993. Surgical treatment of brachial plexus injuries is still progressing in correlation with nerve injury treatments, but there are still obstacles related to treatment of multiple root avulsions and restoring hand function. In general, when treating an injury is difficult, it is always better to take care to prevent it. This may be possible with education of the population, patients, doctors and the government. In this article, differential diagnosis, radiological examination and conservative and surgical treatment of obstetrical brachial plexus injuries in the first two years of the age are discussed.

Global Arm Profile score assessment in children with obstetric brachial plexus injury

Global Arm Profile score assessment in children with obstetric brachial plexus injury

Obstetric brachial plexus palsy: reviewing the literature comparing the results of primary versus secondary surgery.

Obstetric brachial plexus injuries (OBPP) are a relatively common stretch injury of the brachial plexus that occurs during delivery. Roughly 30% of patients will not recover completely and will need a surgical repair. Two main treatment strategies have been used: primary surgery, consisting in exploring and reconstructing the affected portions of the brachial plexus within the first few months of the patient's life, and secondary procedures that include tendon or muscle transfers, osteotomies, and other orthopedic techniques. Secondary procedures can be done as the only surgical treatment of OBPP or after primary surgery, in order to minimize any residual deficits. Two things are crucial to achieving a good outcome: (1) the appropriate selection of patients, to separate those who will spontaneously recover from those who will recover only partially or not at all; and (2) a good surgical technique. The objective of the present review is to assess the published literature concerning certain controversial issues in OBPP, especially in terms of the true current state of primary and secondary procedures, their results, and the respective roles each plays in modern-day treatment of this complex pathology. Considerable published evidence compiled over decades of surgical experience favors primary nerve surgery as the initial therapeutic step in patients who do not recover spontaneously, followed by secondary surgeries for further functional improvement. As described in this review, the results of such treatment can greatly ameliorate function in affected limbs. For best results, multi-disciplinary teams should treat these patients.

Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system.

OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada's 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group's guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, "good" if assessed by the time the patient was 1 month of age, "satisfactory" if by 3 months of age, and "poor" if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%-60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was "good" in 28%, "satisfactory" in 66%, and "poor" in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.

Primary Nerve Repair for Obstetrical Brachial Plexus Injury: A Meta-Analysis.

Nerve repair may be effective in improving function following obstetrical brachial plexus injury. No previous review has directly compared nerve repair to nonoperative management for similar patients, and no previous analysis has been adequately powered to determine whether nerve repair reduces impairment. Electronic databases were searched (MEDLINE, Embase, CINAHL, and Cochrane Central). Eligible studies were randomized controlled trials, observational studies, and case series (n > 9); included patients younger than 2 years undergoing nerve repair or nonoperative management of obstetrical brachial plexus injury; and reported functional impairment. Two reviewers independently screened articles using objective a priori criteria. Bias was assessed for each study. Overall quality of evidence was evaluated for each outcome. Among nine cohort studies including 222 patients, nerve repair significantly reduced functional impairment compared with nonoperative management (relative risk, 0.58; 95 percent CI, 0.43 to 0.79; p < 0.001; I = 0 percent; absolute risk reduction, 19 percent; number needed to treat, six). Findings are consistent with comparison of similar patients from case series. With operative management, no deaths were reported; major adverse events were reported in 1.5 percent, and minor adverse events were reported in 5.0 percent of cases. Among demographic (all severities) samples managed nonoperatively, residual impairment remains in 27 percent (19 to 36 percent). Nerve repair reduces functional impairment in obstetrical brachial plexus injury. Nonoperative management in patients with a deficit at 3 months of age leads to a high proportion of functional impairment. Mortality is not a common risk of modern pediatric microsurgical nerve repair. Residual impairment with nonoperative management is underestimated in the reported literature. Therapeutic, IV.

Quantification of dystonia in a group of children with bilateral CP using 3D upper limb motion analysis parameters

the development of affected children into adulthood and include outcome parameter at activity and participation levels.

Isolated C5–C6 avulsion in obstetric brachial plexus palsy treated by ipsilateral C7 neurotization to the upper trunk: outcomes at a mean follow-up of 9 years

Cervical root avulsions are the worst pattern of injury in obstetrical brachial plexus injury (OBPI). The prognosis is poor and the treatment is mainly surgical with extraplexual neurotizations or muscle transfers. We present the outcomes of a technique performed in our institution to treat C5-C6 avulsion in obstetrical brachial plexus injury. This technique consists of a total ipsilateral C7 neurotization to the upper trunk. Ten babies with isolated C5-C6 root avulsion were operated on; we were able to review nine of them at over 12 months follow-up. The shoulder and the elbow function were assessed, as well as the Mallet Score. The mean follow-up was 9.2 years (SD 5.7). After a follow-up of 6 years, elbow flexion was restored with a range of motion ⩾130° and a motor function ⩾M3 in all patients. The average Mallet score was 18.1 (SD 1.2). This approach appears to be a viable alternative to extraplexual neurotizations for the treatment of C5-C6 nerve root avulsion.

“Popeye muscle” morphology in OBPI elbow flexion contracture

Background: The pathophysiology of elbow flexion contracture (EFC) in obstetrical brachial plexus injury (OBPI) is not established. In basic science models, neonatal denervation leads to impaired muscle growth. In clinical studies, diminished growth is correlated with extent of denervation, and improved with surgical repair. In EFC, the biceps are clinically short and round vs the contralateral size, termed the “Popeye muscle”. The objective of this study was to determine if the biceps morphology (muscle belly and tendon length) in arms with EFC secondary to OBPI is different vs the contralateral. Methods: This is a retrospective matched-cohort study. Patients with unilateral EFC (>20°) secondary to OBPI were identified (median = 6.6 years, range = 4.7–16.8). A blinded radiologist used computed tomography to measure length of the biceps short head muscle belly, and tendon bilaterally using standardised anatomical landmarks. Results: Twelve patients were analyzed. The biceps muscle belly in the injured arm was shorter in all patients vs contralateral, mean difference = 3.6 cm (80%), p < 0.001. The biceps tendon in the injured arm was longer in all patients vs contralateral, mean difference = 1.13 cm (127%), p < 0.001. The total biceps length in the injured arm was shorter in all patients vs contralateral, mean difference = 2.5 cm (89%), p < 0.001. Conclusions: This is the first human study confirming growth discrepancy of an elbow flexor in EFC. Distinct biceps morphology is demonstrated, with a significantly shorter muscle belly and overall length, but longer tendon vs normal. This is termed the “Popeye muscle” for its irregular morphology. Findings are consistent with impaired limb growth in denervation.