Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy

Neonatal brachial plexus palsy is a devastating complication after a difficult delivery. The incidence of this injury has not significantly decreased over the past decades, despite all the advances in perinatal care. Although primary repair of the nerves with microsurgical techniques is the common treatment strategy nowadays, there are late cases in which secondary procedures in tendons or bones are necessary. Moreover, secondary procedures may be needed to improve the results of primary repair. A careful preoperative assessment of all the residual defects and deformities in upper limbs of these patients is essential. The aim of these procedures is usually to restore the deficient shoulder abduction and external rotation, release of any elbow flexion contracture or to correct a weak elbow flexion. More distally a supination or pronation deformity is usually apparent, and available options include tendon transfers or radial osteotomy. The wrist of these patients may be ulnarly deviated or may has absent extension, so tendon transfers or free muscle transfers can also be used for correction of these deformities. In severe cases, wrist fusion is an alternative option. The clinical presentation of the hand is highly variable due to complex deformities including thumb adduction deformity, metacarpophalangeal joints drop, and weak finger flexion or extension depending on the level of the injury. Each of these deformities can be restored with a combination of soft tissue procedures like local or free muscle transfer and bony procedures like arthrodesis.