Outcomes of Hand Reconstruction in Obstetric Brachial Plexus Palsy
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Abstract:
Background: In children with global obstetric brachial plexus palsy, prioritization should be first focused on hand reinnervation and then directed to shoulder and elbow function. In this study, the surgical strategy for restoration of hand function and the methods and outcomes are analyzed. Methods: Between 1979 and 2005, 59 patients (61 extremities) underwent reconstruction for hand reanimation. The mean follow-up was 7.7 years (range, 2 to 22 years). Of these, 16 cases underwent primary reconstruction alone, 35 underwent both primary and secondary procedures, and 10 late cases underwent palliative surgery. Hand function was evaluated with a modified Gilbert- Raimondi hand scale (grades 4 to 6 were considered useful outcomes). Results: Grade 4 or better functional recovery was observed in six of six cases (100 percent) that underwent primary reconstruction within the first 3 months of life. These patients did not require any secondary procedures. Multiple secondary procedures were necessitated to maximize the functional outcome in late cases or in patients with incomplete recovery following primary reconstruction. Overall, 46 of 61 cases (75.4 percent) achieved grade 4 or greater. The long-term results were better; 23 of 26 cases (88 percent) with a follow-up of more than 8 years achieved grade 4 or greater. Conclusions: When primary reconstruction was performed within 3 months, functional return to the hand was the greatest and the need for palliative surgery was dramatically reduced. For older patients (≥4 months), secondary procedures can significantly enhance hand function. The best results were seen when a combination of tendon transfers and free muscles transfers was performed.Keywords:
Reinnervation
Plexus
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Obstetric brachial plexus palsy has two distinct categories: (1) early obstetric brachial plexus palsy (or obstetric brachial plexus palsy in an infant) and (2) late obstetric brachial plexus palsy with deformity (or obstetric brachial plexus palsy in a child). Both early and late obstetric brachial plexus palsy lack a uniform evaluation system, and this makes correlation between them difficult. Clinical evaluation of obstetric brachial plexus palsy in infants is difficult, but in children it is easier. Here, we utilized a new evaluation system, called "Score of 10," to evaluate 121 late obstetric brachial plexus palsy patients based on patient's functional ability and surgeon's feasibility for reconstruction. "Score of 10" is a method combining the Erb and Klumpke scores. The Erb score gives points for upper plexus functions including shoulder abduction, shoulder external rotation, elbow flexion, elbow extension, forearm supination, forearm pronation, and trumpet sign. The Klumpke score gives points for lower plexus functions including wrist extension, wrist flexion, metacarpophalangeal joint extension, interphalangeal joint extension, finger flexion, thumb adduction, and thumb abduction. The aims of this evaluation system are to determine the relationships between early and late obstetric brachial plexus palsy, to predict the progressive changes that take place with aging, and to propose the possible operation procedures to reconstruct. However, this evaluation system may differ by time and may not be suitable for comparisons between pre- and postreconstruction.
Plexus
Brachial plexus injury
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Surgical exploration and reconstruction of the brachial plexus requires adequate exposure beyond the zone of injury. In the case of extensive lesions, some authors advocate clavicle osteotomy for an extensile approach. Such an osteotomy introduces further morbidity and may impact upon the delicate nerve reconstruction. A new simple but effective method of clavicle elevation is described that provides access to the retroclavicular brachial plexus during exploration for birth brachial plexus palsy.
Birth injury
Plexus
Brachial plexus injury
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objective: To investigate the characteritics and the value of the electroghysiological exam of the obsteric brachial plexus palsy. Methods:In 27 patients with obstetric brachial plexus palsy, NCV and EMG were measured on a regular basis. Result: with 9 cases of Erb's palsy(33.3%),l 1 eases of upper and middle trunk palsy(40.7%) and 7 cases of total plexus palsy(26%) in the 27 cases investigated. The abnormity rate of both NCV and EMG in infants under 3 morths is 100%. In the follow-up check-ups within the next 3 to 6 months, the abnormity rate of EMG is higher than that of NCV. Conclusion: Erb's palsy and upper-middle trunk palsy count for a majority of cases of obstetric brachial plexus palsy, NCV and EMG display different characteristics and have different value at different stages of obstetric brachial plexus palsy.
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The causes of brachial plexus palsy in neonates should be classified according to their most salient associated feature. The causes of brachial plexus palsy are obstetrical brachial plexus palsy, familial congenital brachial plexus palsy, maternal uterine malformation, congenital varicella syndrome, osteomyelitis involving the proximal head of the humerus or cervical vertebral bodies, exostosis of the first rib, tumors and hemangioma in the region of the brachial plexus, and intrauterine maladaptation. Kaiser Wilhelm syndrome, neonatal brachial plexus palsy due to placental insufficiency, is probably not a cause of brachial plexus palsy. Obstetrical brachial plexus palsy, the most common alleged cause of neonatal brachial plexus palsy, occurs when the forces generated during labor stretch the brachial plexus beyond its resistance. The probability of obstetrical brachial plexus palsy is directly proportional to the magnitude, acceleration, and cosine of the angle formed by the direction of the vector of the stretching force and the axis of the most vulnerable brachial plexus bundle, and inversely proportional to the resistance of the must vulnerable brachial plexus bundle and of the shoulder girdle muscles, joints, and bones. Since in most nonsurgical cases neither the contribution of each of these factors to the production of the obstetrical brachial plexus palsy nor the proportion of traction and propulsion contributing to the stretch force is known, we concur with prior reports that the term of obstetrical brachial plexus palsy should be substituted by the more inclusive term of birth-related brachial plexus palsy.
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To estimate differences between shoulder dystocia-associated transient and permanent brachial plexus palsies.We performed a retrospective case-control analysis from national birth injury and shoulder dystocia databases. Study patients had permanent brachial plexus palsy and had been entered into a national birth injury registry. Cases of Erb or Klumpke palsy with documented neonatal neuromuscular deficits persisting beyond at least 1 year of life were classified as permanent. Cases of transient brachial plexus palsy were obtained from a shoulder dystocia database. Non-shoulder dystocia-related cases of brachial plexus palsy were excluded from analysis. Cases of permanent brachial plexus palsy (n=49) were matched 1:1 with cases of transient brachial plexus palsy.Transient brachial plexus palsy cases had a higher incidence of diabetes mellitus than those with permanent brachial plexus palsy (34.7% versus 10.2%, odds ratio [OR] 4.68, 95% confidence interval [CI] 1.42, 16.32). Patients with permanent brachial plexus palsies had a higher mean birth weight (4519+/-94.3 g versus 4143.6+/-56.5 g, P<.001) and a greater frequency of birth weight greater than 4500 grams (38.8% versus 16.3%, OR, 0.31, 95% CI 0.11, 0.87). There were, however, no statistically significant differences between the two groups with respect to multiple antepartum, intrapartum, and delivery outcome measures.Transient and permanent brachial plexus palsies are not associated with significant differences for most antepartum and intrapartum characteristics.
Shoulder dystocia
Birth injury
Brachial plexus injury
Birth trauma
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Brachial plexus injury
Birth injury
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Objective: To explore value of neuroelectrophysiological methods in diagnosis of obstetric brachial plexus palsy. Methods: 28 cases of obstetric brachial plexus palsy were studied by SEP, NAP and EMG. So that judge the position and degree and prognosis of obstetric brachial plexus palsy. Results: in the 28 cases of obstetric brachial plexus palsy examined with SEP and NAP, the findings were in accord with that longer followed by and seen in the operation in 25 cases. The positive detective rate was 89.3% . Conclusion: Neuroelectrophysiological methods were more dependable to judge injury position and degree of the obstetric brachial plexus palsy, and provided valuable information for clinical diagnosis and treatment plans.
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Plexus
Birth injury
Brachial plexus injury
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