Please rate topic.
Average 3.9 of 44 Ratings
Which of the following is the most common long term consequence of untreated brachial plexus birth palsy?
Select Answer to see Preferred Response
Figure A shows glenoid hypoplasia and retroversion which is most commonly associated with unresolved brachial plexus birth palsy.
With or without nerve repair or transfer, internal rotation contracture of the shoulder is the most common problem requiring treatment in children with incomplete brachial plexus palsy recovery. This contracture results from an imbalance between the strength of the relatively unaffected internal rotators and the paralytic external rotators. Untreated, it usually leads to progressive glenohumeral deformity characterized by posterior displacement of the humeral head on an increasingly dysplastic and retroverted glenoid.
Waters et al. performed a study to determine the effects of correction of external rotation weakness and internal rotation contractures on glenohumeral development in patients with brachial plexus birth palsy. Twenty-five patients who underwent latissimus dorsi and teres major tendon transfers to the rotator cuff were evaluated clinically and radiographically before the operation and at a minimum 2 years postoperatively. Soft-tissue rebalancing procedures alone were found to have halted the progression of, but not to have markedly decreased, glenohumeral dysplasia at the time of a 2-5 year follow-up.
Pearl et al. completed a review article on shoulder problems related to children with brachial plexus palsy. They discuss the clinical workup, imaging studies, and surgical interventions used to treat these difficult clinical problems. They also state that evaluating the status of glenohumeral development is critical throughout the treatment of these palsies.
Figure A shows an axillary cut from a CT scan of the left shoulder. There is significant glenoid hypoplasia and retroversion secondary to unresolved brachial plexus palsy.
Answer 2: Figure B shows absent clavicles in the setting of cleidocranial dysplasia.
Answer 3: Figure C shows a lesion consistent with an underlying diagnosis of multiple hereditary exostosis.
Answer 4: Figure D shows a widened proximal humeral physis in the setting of little leaguer shoulder.
Answer 5: Figure E shows a clinical photo of scapular winging secondary to a long thoracic nerve palsy.
Waters PM, Bae DS.
J Bone Joint Surg Am. 2005 Feb;87(2):320-5. PMID: 15687154 (Link to Abstract)
Waters, JBJS 2005
J Am Acad Orthop Surg. 2009 Apr;17(4):242-54. PMID: 19307673 (Link to Abstract)
Pearl, JAAOS 2009
Please rate question.
Average 3.0 of 18 Ratings
A newborn child born via a difficult breech delivery is found to have a brachial plexus birth palsy. While initially born with a flail limb, the child regained elbow flexion at 10 weeks. At age 18 months (1.5 years old), which of the following deficits is most likely to be seen on physical exam?
Fixed adduction and internal rotation at shoulder with elbow extension
Hyperextension of the MCP joints and flexion of the IP joints of the hand
Weakness in elbow flexion
Normal physical exam without deficits
At 18 months, a majority of children who have sustained an obstetric brachial plexus birth (OBPBP) injury will have a complete recovery without weakness or noticeable asymmetry.
Neonatal obstetric birth palsy results from traction forces being applied to the arm during a difficult delivery. Brachial plexus injury is classified by the level of nerve involvement and the nature of the injury. Type I injury, or Erb’s palsy, involves C4–6 nerve roots. Type II injury, or Erb-DuChenne-Klumpke, involves the entire brachial plexus. Type III, or Klumpke palsy, involves only C8–TI. In newborns, Type 1 injuries involving the upper cord are the most common (>80%). Fortunately, most newborns with OBPBP, and almost all children that have regained elbow flexion by 3 months, will have complete recovery by 18 months of age without intervention.
Lagerkvist et al. discuss obstetric brachial plexus birth palsy (OBPBP). During a two-year period, 114 of 38,749 infants were diagnosed with a OBPBP. Only 18 children had symptoms at 18 months. Normal or near-normal muscle strength in elbow flexion, shoulder external rotation, and forearm supination at 3 months of age was almost always associated with complete recovery.
Answers 1-4: A majority of all brachial plexus birth palsies will have full recovery by 18 months of age.
Lagerkvist AL, Johansson U, Johansson A, Bager B, Uvebrant P
Dev Med Child Neurol. 2010 Jun;52(6):529-34. PMID: 20041937 (Link to Abstract)
A 3-month-old is brought to clinic for evaluation of a right upper extremity abnormaility present since birth. Which of the following physical exam findings is associated with the best functional outcome?
Loss of hand function with preserved shoulder function
Absent shoulder abduction and external rotation with intact wrist and digit flexion and extension
Rotator cuff dysfunction, elevated hemidiaphragm, and absence of rhomboid function
Loss of shoulder and wrist function
Ptosis, myosis and anhydrosis
The findings provided are all associated with neonatal brachial plexus palsy. The best prognosis is seen in patients with the classic 'Erb palsy' presentation consisting of absent shoulder abduction and external rotation. Bicep activity is associated with a more favorable prognosis.
Kirjavainen et al evaluated the hand function of patients receiving surgery for brachial birth palsies and found that almost all patients had observable deficits in both strength and sensation at final follow up. Avulsion injuries were associated with the poorest outcomes.
Waters provides an excellent overview of the management of brachial plexus palsies. He describes the classification of palsies and associated prognosis, with poorer outcomes seen in those with more distal and advanced findings.
Answer 1: Additional involvement of the wrist is associated with a worse prognosis, as is the rare 'Klumpke palsy' presenting with absent hand function seen in lower plexus lesions.
Answer 3: A flail extremity can be seen with preganglionic lesions as well and portends poor outcomes.
Answer 4: The additional involvement of the wrist motors is associated with a worse prognosis compared to those with shoulder involvement only
Answer 5: Preganglionic lesions are associated with the worse prognosis and are suggested when Horners syndrome or loss of rhomboid function is seen.
Kirjavainen M, Remes V, Peltonen J, Rautakorpi S, Helenius I, Nietosvaara Y
J Bone Joint Surg Br. 2008 Mar;90(3):349-55. PMID: 18310759 (Link to Abstract)
Kirjavainen, BJJ 2008
J Pediatr Orthop. 2005 Jan-Feb;25(1):116-26. PMID: 15614072 (Link to Abstract)
Waters, JPO 2005
Average 3.0 of 25 Ratings
An infant is born with total brachial plexus palsy and Horner’s syndrome after a difficult vaginal delivery. What is the prognosis for spontaneous recovery of motor function in the involved arm by 3 months?
Infants with total brachial plexus palsy (C5, C6, C7, C8, T1) with an associated Horner's syndrome have a very little (<10%) chance of ever recovering spontaneous motor function.
A study by Al-Qattan et al found that 0 of 22 infants with Horner's and total plexus palsy recovered spontaneously.
Another comparative review by Waters found Horner's syndrome was associated with very poor chances for spontaneous recovery of biceps function. Brachial plexus birth palsies are classified into upper (C5, C6, C7), lower (C8, T1), total (C5, C6, C7, C8, T1) and intermediate (predominantly C7) palsies. The presence of concurrent Horner's syndrome (ptosis, miosis, and anhidrosis on the ipsilateral side of the face) indicates injury to T1 root and the origin of the sympathetic branch that supplies the face.
Al-Qattan MM, Clarke HM, Curtis CG.
J Hand Surg Br. 2000 Apr;25(2):166-7. PMID: 11062575 (Link to Abstract)
Al-Qattan, JHANDS 2000
J Bone Joint Surg Am. 1999 May;81(5):649-59. PMID: 10360693 (Link to Abstract)
Waters, JBJS 1999
Average 3.0 of 24 Ratings
Which of the following muscles would be affected if a 6-month-old child sustains a birth-related brachial plexopathy affecting C5 nerve root?
Flexor digitorum profundus
The biceps and brachialis muscles are supplied by C5-6 and as such a brachial plexopathy affecting the C5 nerve root would affect the child's ability to perform elbow flexion and forearm supination. The deltoid is also supplied by C5 and palsy would lead to deficient shoulder abduction. Finally, extensor carpi radialis longus and brevis are supplied by C5-6 and palsy would result in weak wrist extension.
The trapezius is supplied by the spinal accessory nerve (cranial nerve XI) and palsy would lead to scapular winging. The interossei are supplied by T1, the triceps by C6-7, and the flexor digitorum profundus by C7-8.
Waters studied the natural history of brachial plexus palsy and the effects of treatment including microsurgical repair, tendon transfer, and derotational osteotomy.
Smith et al evaluated 170 patients to determine prognosticators for recovery of function in brachial plexopathy. They found that prolonged neurological recovery or a greater level of initial injury were each associated with worse long-term shoulder function.
Smith NC, Rowan P, Benson LJ, Ezaki M, Carter PR
J Bone Joint Surg Am. 2004 Oct;86-A(10):2163-70. PMID: 15466724 (Link to Abstract)
Smith, JBJS 2004
Average 3.0 of 20 Ratings
Dr. Susan Mackinnon performs a double fascicular transfer (DFT) includes two ner...