Range of motion and strength after surgery for brachial plexus birth palsy

Background

There is little information about the range of motion (ROM) and strength of the affected upper limbs of patients with permanent brachial plexus birth palsy.

Patients and methods

107 patients who had brachial plexus surgery in Finland between 1971 and 1998 were investigated in this population-based, cross-sectional, 12-year follow-up study. During the follow-up, 59 patients underwent secondary procedures. ROM and isometric strength of the shoulders, elbows, wrists, and thumbs were measured. Ratios for ROM and strength between the affected and unaffected sides were calculated.

Results

61 patients (57%) had no active shoulder external rotation (median 0° (-75–90)). Median active abduction was 90° (1–170). Shoulder external rotation strength of the affected side was diminished (median ratio 28% (0–83)). Active elbow extension deficiency was recorded in 82 patients (median 25° (5–80)). Elbow flexion strength of the affected side was uniformly impaired (median ratio 43% (0–79)). Median active extension of the wrist was 55° (-70–90). The median ratio of grip strength for the affected side vs. the unaffected side was 68% (0–121). Patients with total injury had poorer ROM and strength than those with C5–6 injury. Incongruity of the radiohumeral joint and avulsion were associated with poor strength values.

Interpretation

ROM and strength of affected upper limbs of patients with surgically treated brachial plexus birth palsy were reduced. Patients with avulsion injuries and/or consequent joint deformities fared worst.Most brachial plexus birth palsy (BPBP) patients (66–92%) recover spontaneously (Michelow et al. 1994, Noetzel et al. 2001, Hoeksma et al. 2004, Pöyhiä et al. 2010). Indications for brachial plexus surgery vary (Kay 1998, Rust 2000, O''Brian et al. 2006). However, severe total injury or upper-middle plexus injury with no signs of spontaneous recovery within 3–6 months is widely accepted as an indication for early operative treatment (Gilbert et al. 1988, Clarke and Curtis 1995, Strömbeck et al. 2000, Smith et al. 2004).The severity of neural involvement in BPBP varies from transient neurapraxia to avulsion-type root injuries. Upper plexus (C5-6) injury affects shoulder and elbow function. Furthermore, wrist function is affected to varying degrees in more extensive injuries that involve the upper and middle plexus (C5-7). In total injuries (C5-T1), finger function is also compromised (Bager 1997, Sheburn et al. 1997).Muscle weakness and joint contractures of the affected upper limb are common in patients with permanent BPBP (Zancolli 1981, Waters et al. 1998, Hoeksma et al. 2003, Kirjavainen et al. 2007, Strömbeck et al. 2007). Muscle imbalance in BPBP patients can lead to soft tissue contractures and eventually to joint deformities (Pollock and Reed 1989, Waters et al. 1998, Nath et al. 2007). There is a negative correlation between degree of osseous deformity of the glenohumeral joint and shoulder range of motion (ROM) (Hoeksma et al. 2003, Kozin 2004).In this population-based, cross–sectional, long-term follow-up study, we assessed ROM and isometric maximal muscle strength of the upper limbs of surgically treated BPBP patients.     

Indications and results of brachial plexus surgery in obstetrical palsy

This article presents the first series with long-term results of a large number of patients. As a result, it is difficult to compare these results with anything but spontaneous recovery. In most cases, the end result after surgical treatment will be better than spontaneous recovery.     

Finger movement at birth in brachial plexus birth palsy

AIM: To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury. METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

External rotation humeral osteotomy for brachial plexus birth palsy

In patients with brachial plexus birth palsy, persistent muscular imbalance across the developing shoulder results in progressive glenohumeral dysplasia, characterized by increased glenoid retroversion, humeral head flattening, and posterior subluxation of the humeral head. Soft-tissue procedures-such as tendon transfers and musculotendinous lengthenings--will provide limited functional improvements in the setting of advanced glenohumeral deformity. For patients with internal rotation contracture and external rotation weakness associated with severe glenohumeral dysplasia, external rotation osteotomy of the humerus may be used to improve global shoulder function. The purpose of this article is to review the history, indications, and surgical technique of external rotation humeral osteotomy for patients with brachial plexus birth palsy.     

Surgical treatment of brachial plexus birth palsy.

Brachial plexus birth palsy remains a challenging condition. In the 1000 infants followed from 1977 to 1988, functional results were much improved over those obtained by observation only, if surgical exploration and repair were performed when no clinical recuperation of biceps function occurred by three months of age. Recovery is slow, and comprehensive follow-up study of reconstructed and conservatively managed children is required to prevent joint contractures. Children who will benefit from palliative procedures such as tendon transfers must also be identified.     

Shoulder external rotation tendon transfers for brachial plexus birth palsy

Children with brachial plexus birth palsy may have permanent loss of shoulder external rotation strength. This impairment may result to a difficulty in reaching the face and head with the affected hand for grooming activities, and in reaching overhead for participation in sports or work-related tasks. In addition, the contracture that results from unopposed internal rotation may further restrict range of motion and cause glenohumeral joint deformity and subluxation.A combination of muscle release and transfers reliably improves the child's ability to position the hand, and may halt the development of joint deformity. Postoperative rehabilitation is necessary to maximize the strength and range of motion obtained from this operation.     

Accessory nerve neurotization in infants with brachial plexus birth palsy

We report the surgical results of 13 accessory nerve neurotizations in brachial plexus birth palsy. The mean age at operation was 5.9 months. The accessory nerve was transferred to three C5 roots, to three C6 roots, to four posterior division of the middle trunks, to one musculocutaneous nerve, and to two suprascapular nerves. Sixty-seven percent of the cases acquired M4 or more in the deltoid muscle, 88% in the infraspinatus muscle, and 100% in the biceps brachii muscle. Twenty-five percent of the cases acquired M4 or more in the triceps brachii muscle and the wrist extensor muscles. These results were much better than formerly reported for adult cases by other authors. No functional compromise of the trapezius muscle was noted. The accessory nerve neurotization can be used safely and effectively in neurosurgical reconstruction of the brachial plexus palsy in infants. © 1994 Wiley-Liss, Inc.     

Obstetric brachial plexus palsy

This article supplies data related to 11 operated children with obstetric brachial plexus palsy. Discussion of the obstetric background, pathology, pre- and postsurgical testing and of primary and secondary surgical reconstruction also is given. The need for rehabilitation regimen is stressed.     

The evaluation and treatment of children with brachial plexus birth palsy

The Andrew J. Weiland Medal is presented by the American Society for Surgery of the Hand to a mid-career researcher dedicated to advancing patient care in the field of hand surgery. The Weiland Medal for 2010 was presented to the author at the annual meeting of the American Society for Surgery of the Hand. The purpose of this article is to present a decade of research directed at establishing and building evidence in support of effective treatment of adolescents and children impaired by nerve injury. The primary beneficiaries of this effort are children affected by brachial plexus injury. The research goals have been to better understand their underlying problems, improve their lives via advanced diagnostic and surgical techniques, and, by applying appropriate outcome measures, better appreciate the changes to their lives brought about by therapeutic interventions.     

Kinematic assessment of the upper extremity in brachial plexus birth palsy

Children with brachial plexus birth palsy (BPBP) may have shoulder external rotation and abduction weakness that can restrict activities of daily living (ADLs). Static range of motion measurements may not measure ADL restrictions. Motion analysis has been used to quantify gait limitations and measure changes associated with treatment. The purpose of this study was to determine whether upper extremity motion analysis (UEMA) can measure the differences in shoulder motion during ADLs between children with BPBP and normal children. Following a previously described UEMA protocol, 55 children with BPBP and 51 normal children (control group) were studied. Kinematic data of selected ADLs were collected before surgery. UEMA was used to measure statistically significant differences between children with BPBP and control subjects for all planes of shoulder motion in all activities tested. The authors conclude that UEMA can discriminate between children with BPBP and control subjects during selected ADLs, and suggest that UEMA can also be used to measure the effects of surgical interventions in children with BPBP.     

Efficacy of 3 therapeutic taping configurations for children with brachial plexus birth palsy

Study Design

Cross-sectional clinical measurement study.

Function of the upper limb after surgery for obstetric brachial plexus palsy

We reviewed a consecutive series of 33 infants who underwent surgery for obstetric brachial plexus palsy at a mean age of 4.7 months. Of these, 13 with an upper palsy and 20 with a total palsy were treated by nerve reconstruction. Ten were treated by muscle transfer to the shoulder or elbow, and 16 by tendon transfer to the hand. The mean postoperative follow-up was 4 years 8 months. Ten of the 13 children (70%) with an upper palsy regained useful shoulder function and 11 (75%) useful elbow function. Of the 20 children with a total palsy, four (20%) regained useful shoulder function and seven (35%) useful elbow function. Most patients with a total palsy had satisfactory sensation of the hand, but only those with some preoperative hand movement regained satisfactory grasp. The ability to incorporate the palsied arm and hand into a co-ordinated movement pattern correlated with the sensation and prehension of the hand, but not with shoulder and elbow function.     

Microsurgical repair and secondary surgery in obstetrical brachial plexus palsy

We present a personal experience with 750 children suffering from obstetrical brachial plexus palsy. The related surgery is described, including early microsurgical nerve reconstruction and secondary procedures including tendon and muscle transfers. The clinical examination, indications and timing for surgery, technical details of primary and secondary operations and the possible outcome are discussed. Both clinical and research work need an interdisciplinary team approach, and diagnostic, therapeutic and prognostic improvement is based on the refinements of microsurgical skills and the continuous exchange of information between specialized centers.     

Repair of obstetric brachial plexus palsy: results in 100 children

This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations.Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired.The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer.Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury.     

The relationship between the coracoid and glenoid after brachial plexus birth palsy

The purpose of this study was to determine the changes in glenoid and coracoid anatomy after brachial plexus birth palsy. Fifty-seven children underwent bilateral shoulder magnetic resonance imaging. The uninvolved coracoid angle averaged 32.5 +/- 6.1 degrees (range 21.3-46.0) compared with 21.7 +/- 6.9 degrees (range 6.1-41.0) on the involved shoulder. The uninvolved coracoid physeal angle averaged 42.7 +/- 7.6 degrees (range 26.0-57.0) compared with 61.7 +/- 11.6 degrees (range 38.8-89.9) on the involved shoulder. The uninvolved glenoid physeal angle averaged 78.4 +/- 5.2 degrees (range 66.9-89.9) compared with 50.4 +/- 14.7 degrees (range 17.9-76.7) on the involved shoulder. The uninvolved interphyseal angle averaged 59.6 +/- 7.2 degrees (range 42.0-76.1) compared with 65.5 +/- 11.6 degrees (range 45.0-88.0) on the involved shoulder. The uninvolved coracoid scapular distance averaged 1.6 +/- 0.28 cm (range 1.0-2.5) compared with 1.2 +/- 0.37 cm (range 0.37-1.9) on the involved shoulder. These results highlight the contiguous relationship between the coracoid and glenoid physis during development and indicate that retroversion of both the glenoid and coracoid physis occurs after brachial plexus palsy.