Current Concepts in the Management of Brachial Plexus Birth Palsy

doi:10.1016/j.jhsa.2009.11.026

The Journal of Hand Surgery

Volume 35, Issue 2, February 2010, Pages 322-331

https://doi.org/10.1016/j.jhsa.2009.11.026 Get rights and content

Brachial plexus birth palsy, although rare, may result in substantial and chronic impairment. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed to help the child maximize function in the affected upper extremity. Many present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery remain unresolved in infants with brachial plexus birth palsies. Recent literature has enhanced our understanding of the pathoanatomy and natural history of the injury as well as the surgical indications, expected outcomes, and complications; this literature has led to improved care of these patients. Based on the present evidence, recommendations for both microsurgery and shoulder reconstruction with tendon transfer and arthroscopic and open reductions are presented.

Section snippets

Natural History

The incidence of brachial plexus birth palsy (BPBP) is estimated to be between 0.4 and 4 per 1000 live births.1, 2, 3 The range in reported incidence is postulated to be a result of variance in clinical care and average infant birth weights across regions. Perinatal risk factors include large-for-gestational age infants (macrosomia), multiparous pregnancies, previous deliveries resulting in BPBP, prolonged labor, breech delivery, and assisted (vacuum or forceps) and difficult deliveries.2, 3

Patient Evaluation and Therapy

Serial physical examination of children with BPBP is recommended, because it is essential to predict recovery and determine the need for additional therapeutic or surgical intervention. Passive range of motion and active muscle strength should be assessed. Assessing infants often requires approximation of function by observing spontaneous activity, assessing reflexes (Moro, asymmetric tonic neck, and symmetric tonic neck), and prompting them to reach for objects with and without gravity

Microsurgical Indications

Microsurgical intervention aims to improve function, often without the expectation that the affected extremity will completely recover. General consensus is that microsurgical reconstruction should be undertaken for infants with global lesions and Horner's syndrome, by 3 months of age.3, 4, 13, 23 As noted previously, without microsurgical intervention, these patients have lifelong profound functional deficits. Early timing of surgery is important in global lesions to minimize motor endplate

Microsurgical Procedures

Many of the recent advances in the microsurgical treatment of BPBP have been in techniques for reinnervation of the musculature of the upper extremity. The spectrum of nerve surgery historically used includes neurolysis, neuroma resection, and nerve grafting. Nerve transfers³⁰ and nerve conduits have led to an expansion of procedures available for nerve reconstruction. Neurolysis alone is no longer indicated in BPBPs.³¹

The most common anatomic finding in BPBP is a neuroma-in-continuity of the

Progression of Disease at the Shoulder

Up to 35% of infants and children with BPBPs experience some degree of shoulder weakness, contracture, or joint deformity.2, 5 Only infants who recover completely within the first 2 months of life are spared from some degree of long-term sequelae.8, 26 Variable nerve recovery of upper-plexus injuries leads to soft tissue contractures resulting from relatively unaffected internal rotators and adductors versus weak external rotators and abductors.47, 48, 49 Multiple authors have postulated that

Imaging

Different imaging modalities, including radiographs, arthrograms, ultrasound, computed tomography scans, and magnetic resonance imaging have been used to assess joint and bony development in BPBP. In the first few years of life, the humeral head and glenoid are mostly nonossified cartilage, precluding visualization with plain radiographs or computed tomography. For that reason most centers use magnetic resonance imaging scans because they offer the ability to visualize the cartilaginous

Surgical Management of the Shoulder

Indications for surgical intervention involving the shoulder include infantile dislocation, persistent internal rotation contracture refractory to physiotherapy, limitation of active abduction and external rotation function with plateauing of neural recovery, and progressive glenohumeral deformity. The principles of treatment for each individual include contracture release, muscle rebalancing, and joint reduction. The age at intervention and type of procedure depend on the problem and its

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Cited by (192)

Three-Dimensional Upper Limb Movement Analysis in Children and Adolescents With Brachial Plexus Birth Injury: A Systematic Review
2024, Pediatric Neurology
To synthesize the current evidence on clinical use of three-dimensional upper limb movement analysis (3D-ULMA) in children and adolescents with brachial plexus birth injury (BPBI).
MEDLINE, Embase, and Web of Science were searched for relevant studies up to April 2022. An automatic e-mail alert was installed to ensure no eligible article was missed. Articles evaluating 3D-ULMA in children and adolescents with BPBI were included. Covidence web-based platform was used for blind screening of eligible articles. Twenty-one observational studies with a final sample size of 609, encompassing 493 BPBI cases, met the inclusion criteria. Data were extracted using a custom form to support standardized extraction conforming to the Cochrane Checklist of items. Risk of bias was assessed using the Newcastle-Ottawa Scale, the Strengthening the Reporting of Observational Studies in Epidemiology checklist, and a specifically established quality assessment form for kinematic analysis studies.
Study setups differed, including six different types of kinematic devices. Twelve studies used the (modified) Mallet positions for their 3D-ULMA. Throughout the studies, 3D-ULMA was used for various purposes. The Newcastle-Ottawa Scale scored 16 articles with five stars or more, indicating fair to moderate quality.
This systematic review summarizes the different 3D-ULMA kinematic devices, test protocols, and their clinical use for BPBI. The use of 3D-ULMA provides valuable, objective, and quantified data to clinicians with regard to movement strategies; it complements existing clinical scales and can be implemented to evaluate effectiveness of therapy interventions. Implications for future research and clinical practice are discussed.
Evaluation of Upper Extremity Reachable Workspace in Children With Brachial Plexus Birth Injury
2024, Journal of Hand Surgery
Brachial plexus birth injury (BPBI) results in upper extremity (UE) movement limitations. Current assessments of UE function used to inform clinical decision-making only evaluate a limited set of static postures and/or movements and have been criticized for being insensitive to certain meaningful differences in function. Reachable workspace provides a numeric and visual assessment of global UE movement ability by quantifying the regions in space that patients can reach with their hands, and it can be collected using real-time feedback to elicit a best-effort acquisition of function. This study evaluated the ability of a real-time feedback reachable workspace tool to assess UE movement in BPBI.
Twenty-two children with BPBI participated. Reachable workspace data were collected with three-dimensional motion capture using real-time visual feedback to measure UE reaching ability in all regions surrounding the body. All outer, far-from-body points reached by the hand were recorded and analyzed by region. A two-way, within-subjects analysis of variance was used to assess interlimb differences in percentage workspace reached and median reach distance for each of the six regions.
The affected limb had significantly less percentage workspace reached than the unaffected limb for all six regions (mean interlimb differences by region, 5.7%–38.6%). The affected limb had significantly less median reach distance than the unaffected limb for all six regions (mean interlimb differences by region, 3.1%–36.8%).
The workspace approach was capable of detecting UE movement impairments of the BPBI-affected limb. The reported deficits in workspace on the affected limb correspond to common movement impairments in BPBI, such as limitations in shoulder elevation, external rotation, extension, and elbow extension.
The real-time feedback reachable workspace tool is sufficiently robust for assessing UE movement impairments in children with BPBI.
Evaluating the feasibility of implementing the Sup-ER protocol for infants with brachial plexus birth injury
2024, Journal of Hand Therapy
The Sup-ER protocol involves a repositioning program for infants with brachial plexus birth injury to position the shoulder in external rotation (ER) to address progressive loss in passive range of motion (PROM). The British Columbia Children’s Hospital (BCCH) eligibility criteria for this protocol are infants aged 4-8 weeks with decreased shoulder ER PROM and/or Active Movement Scale (AMS) shoulder ER and/or supination scores ≤2. The resources needed to implement this protocol in large clinics have not been studied.
This study aims to evaluate the BCCH criteria that are used to identify appropriate candidates for the Sup-ER protocol.
A retrospective cohort study was conducted to identify the percentage of infants who would have been recommended the Sup-ER protocol based on their PROM and AMS scores between 4 and 8 weeks of age.
A sensitivity and specificity evaluation was used to describe the BCCH criteria's ability to identify infants in this historical cohort who went on to have incomplete shoulder function (ie, true positive) vs infants who had functional shoulder outcome at 9 months of age (ie, false positive).
At a mean of 5.8 weeks (95% confidence interval [CI] 5.3, 6.3), 46 of the 87 (53%) infants satisfied the BCCH Sup-ER protocol criteria. Forty-four (51%) were female, half (n = 45) were left side affected, and 88% had upper plexus injury. The BCCH Sup-ER protocol criteria had sensitivity of 100% and specificity of 71% to identify infants with incomplete shoulder function. Removing the AMS supination ≤2 score criterion from the criteria improves the specificity to 84%, while sensitivity remains high (97%).
Modifying the BCCH criteria to all infants aged 4-8 weeks with AMS shoulder ER ≤2 and/or decreased shoulder ER PROM improves the precision of identifying infants who would benefit from the Sup-ER protocol.
Brachial Plexus Palsy and Ptosis in a Newborn
2023, Journal of Pediatrics
Assessment of approaches to estimate scapular orientation in children with brachial plexus birth injury
2022, Gait and Posture
Citation Excerpt :
Approximately 0.9–4.6 of every 1000 infants suffer a brachial plexus birth injury (BPBI) with 6–34% of cases resulting in lifelong complications [1–4]. Muscle weakness and impaired muscle growth [5,6] associated with BPBI create an imbalance of forces across the glenohumeral joint [7,8] leading to joint deformity, dysplasia, and subluxation [9–11], as well as glenohumeral range of motion deficits [12–14]. Operative interventions primarily aim to restore glenohumeral function by either re-balancing forces across the joint, re-centering the humeral head in the glenoid, and/or aligning the humerus to a more functional position [7,15].
Challenges in measuring dynamic scapular orientation limit assessment of scapulothoracic and glenohumeral contributions to shoulder function in children with brachial plexus birth injury (BPBI). Double calibration acromion marker cluster (D-AMC) and linear model approaches have been validated to estimate scapular motion in healthy adults, but neither has been evaluated in BPBI.
Are the linear model and D-AMC approaches able to accurately estimate scapular orientation in children with BPBI at functional arm postures?
Seventeen children with BPBI positioned their affected limbs in 11 static positions while their segment orientations were measured with motion capture. Linear model and D-AMC estimates of scapular orientation were compared against palpation at six of the static positions with functional relevance to BPBI using a three-way repeat measures ANOVA and a comparison of root mean square errors (RMSE) against literature AMC values for healthy adults.
The D-AMC was similar to palpation across all positions and scapular axes while the linear model differed from palpation in a few instances. RMSEs of the D-AMC (3.7–14.8°) and particularly the linear model (4.6–24.8°) were generally at or beyond the upper range of past AMC analyses on healthy adults (1.6–14.2°), especially for more complex, multiplanar arm postures. Despite the D-AMC outperforming the linear model, this approach still produced clinically meaningful (>10°) errors for roughly (12.7–22.5%) of subjects.
Current methods for estimating dynamic scapular orientation remain less than ideal for BPBI. Use of the D-AMC may be appropriate to gain broad insights into general dynamic scapulothoracic and glenohumeral function; however, given their potential for producing clinically meaningful errors, the D-AMC and linear model are not recommended for diagnostic purposes or outcomes assessment on an individual patient basis unless their patient-specific accuracy has been evaluated and confirmed prior to use.
Brachial Plexus Birth Injuries
2022, Orthopedic Clinics of North America

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Current conceptCurrent Concepts in the Management of Brachial Plexus Birth Palsy

Section snippets

Natural History

Patient Evaluation and Therapy

Microsurgical Indications

Microsurgical Procedures

Progression of Disease at the Shoulder

Imaging

Surgical Management of the Shoulder

J Hand Surg

Pediatr Neurol

Hand Clin

J Hand Surg

J Hand Surg

J Hand Surg

Lancet

J Shoulder Elbow Surg

Arthroscopy

Hand Clin

J Shoulder Elbow Surg

J Shoulder Elbow Surg

The epidemiology of neonatal brachial plexus palsy in the United States

J Bone Joint Surg

Neurological recovery in obstetric brachial plexus injuries: an historical cohort study

Dev Med Child Neurol

Obstetric brachial plexus injuries: evaluation and management

J Am Acad Orthop Surg

Neurosurgical correction of upper brachial plexus birth injuries

J Neurosurg

Natural history of obstetric brachial plexus palsy: a systematic review

Dev Med Child Neurol

Nerves and nerve injuries

Injuries of the brachial plexus and neighboring peripheral nerves in vertebral fractures and other trauma of the cervical spine

Orthopade

Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy

J Bone Joint Surg

[Obstetrical paralysis of the brachial plexus. II. Therapeutics. Treatment of sequelae. Priority for the treatment of the shoulder. Method for the expression of results]

Rev Chir Orthop Reparatrice Appar Motil

Management of birth brachial plexus palsy

Childs Nerv Syst

Outcome following nonoperative treatment of brachial plexus birth injuries

J Child Neurol

Obstetrical brachial plexus palsy (OBPP) outcome with conservative management

Muscle Nerve

Navigating the gray zone: a guideline for surgical decision making in obstetrical brachial plexus injuries

J Neurosurg Pediatr

Functional outcome at 5 years in children with obstetrical brachial plexus palsy with and without microsurgical reconstruction

Dev Med Child Neurol

Upper extremity size differences in brachial plexus birth palsy

Hand (N Y)

Upper extremity limb-length discrepancy in brachial plexus palsy

J Pediatr Orthop

Permanent brachial plexus birth palsy does not impair the development and function of the spine and lower limbs

J Pediatr Orthop B

Sports participation in selected children with brachial plexus birth palsy

J Pediatr Orthop

Correlation of pediatric outcomes data collection instrument with measures of active movement in children with brachial plexus birth palsy

J Pediatr Orthop

Reliability of three classification systems measuring active motion in brachial plexus birth palsy

J Bone Joint Surg

Surgical repair of the brachial plexus in obstetric paralysis

Chirurgie

Management of complete obstetric brachial plexus lesions

J Pediatr Orthop

Shoulder function following primary axillary nerve reconstruction in obstetrical brachial plexus patients

Plast Reconstr Surg

The outcome of Erb's palsy when the decision to operate is made at 4 months of age

Plast Reconstr Surg

Surgical strategy for infant obstetrical brachial plexus palsy: experiences at Chang Gung Memorial Hospital

Plast Reconstr Surg

Outcomes of surgical treatment of brachial plexus injuries using nerve grafting and nerve transfers

J Reconstr Microsurg

Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity

Plast Reconstr Surg

Current concept
Current Concepts in the Management of Brachial Plexus Birth Palsy