Introduction Injury to the brachial plexus during birth usually a stretching injury from a difficult vaginal delivery some rare cases reported following C-sections Epidemiology incidence approximately 1 to 4 per 1,000 live births decreasing in frequency due to improved obstetric care often right sided or bilateral risk factors large for gestational age (macrosomia) multiparous pregnancy difficult presentation shoulder dystocia forceps delivery breech position prolonged labor Associated orthopedic conditions glenohumeral dysplasia increased glenoid retroversion, humeral head flattening, posterior humeral head subluxation develops in 70% of infants with obstetric brachial plexopathy caused by Internal rotation contracture (loss of external rotation) elbow flexion contracture etiology is unclear, likely due to persistent relative triceps weakness (C7) compared with biceps (C5-6) clavicle and humerus fractures torticollis Prognosis 90% of cases will resolve without intervention spontaneous recovery may occur for up to 2 years prognostic variables for spontaneous recovery favorable Erb's Palsy complete recovery possible if biceps and deltoid are anti-gravity by 2 months early twitch biceps activity suggests a favorable outcome poor lack of biceps function by 3 months preganglionic injuries (worst prognosis) avulsions from the cord, which will not spontaneously recover motor function loss of rhomboid function (dorsal scapular nerve) elevated hemidiaphragm (phrenic nerve) Horner's syndrome (ptosis, miosis, anhydrosis) less than 10% recover spontaneous motor function C7 involvement Klumpke's Palsy Anatomy Brachial plexus diagram Classification Narakas Classification Group Roots Characteristics Group I (Duchenne-Erb's Palsy) C5-C6 Paralysis of deltoid and biceps. Intact wrist and digital flexion/extension. Group II (Intermediate Paralysis) C5-C7 Paralysis of deltoid, biceps, and wrist and digital extension. Intact wrist and digital flexion. Group III (Total Brachial Plexus Palsy) C5-T1 Flail extremity without Horner's syndrome Group IV (Total Brachial Plexus Palsy with Horner's syndrome) C5-T1 Flail extremity with Horner's syndrome Presentation General Symptoms lack of active hand and arm motion Physical exam upper extremity exam arm hangs limp at side in an adducted and internally rotated position decreased shoulder external rotation affected shoulder subluxates posteriorly provocative testing stimulate neonatal reflexes including Moro, asymmetric tonic neck and Votja reflexes pain with gentle shaking of a flail arm may indicate pseudoparalysis from infection or fracture rather than nerve palsy Hospital for Sick Children Active Movement Scale (AMS) muscle strength grading system full range of motion with gravity eliminated (score of 4) must be achieved before higher scores may be assigned Imaging Radiographs may be useful for evaluation of clavicle or humerus fractures limited utility in infant given minimal ossification of humeral head and glenoid axillary view to evaluate position of humeral head if patient is older and suspicion is high for joint subluxation Myelography/CT myelography/MRI may be used to distinguish between root avulsion and extraforaminal rupture EMG/NCV poor reliability and often underestimate the severity of injury Ultrasound allows for assessment of joint subluxation or dislocation Erb's Palsy (C5,6) - Upper Lesion Most common type Mechanism results from lateral flexion of the head towards the contralateral shoulder with depression of the ipsilateral shoulder producing traction on plexus occurs during difficult delivery in infants Physical exam adducted, internally rotated shoulder; pronated forearm, extended elbow (“waiter’s tip”) C5 deficiency axilllary nerve deficiency deltoid, teres minor weakness suprascapular nerve deficiency supraspinatus, infraspinatus weakness musculocutaneous nerve deficiency biceps and brachialis weakness C6 deficiency radial nerve deficiency brachioradialis, supinator weakness Prognosis best prognosis for spontaneous recovery Klumpke's Palsy (C8,T1) - Lower lesion Mechanism rare in obstetric palsy usually arm presentation with subsequent traction/abduction from trunk Physical exam deficit of all of the small muscles of the hand (ulnar and median nerves) “claw hand” wrist in extreme extension because of the unopposed wrist extensors hyperextension of MCP due to loss of hand intrinsics flexion of IP joints due to loss of hand intrinsics Prognosis poor prognosis for spontaneous recovery frequently associated with a preganglionic injury and Horner's Syndrome Total Plexus Palsy (C5-T1) Mechanism stretch, rupture, and avulsion injury Physical exam flaccid arm both motor and sensory deficits Imaging chest radiograph to look for ipsilateral hemidiaphragm paralysis from phrenic nerve injury Prognosis worst prognosis Treatment - General Nonoperative observation & daily passive exercises by parents indications first line of treatment for all obstetric brachial plexopathies while awaiting return of function key to treatment is maintaining passive motion while waiting for nerve function to return Operative microsurgical nerve grafting indications lack of antigravity biceps function between 3-9 months of age postganglionic injury with intact nerve roots with segmental injury to nerve outcomes improved outcomes are seen with shorter grafts (<10cm) nerve transfer (neurotization) indications lack of antigravity biceps function between 3-9 months of age preganglionic injury or avulsion of nerve roots Treatment - Shoulder Dislocation & Contractures Operative soft tissue procedures latissimus dorsi and teres major transfer (Hoffer procedure) indication persistent internal rotation contracture or external rotation weakness without glenohumeral dysplasia technique pass tendons posteriorly around humerus to create external rotation forces pectoralis major and +/- subscapularis lengthening indication to lessen the internal rotation forces may be used in conjunction with tendon transfers bony procedures proximal humeral derotation osteotomy (Wickstrom) indication persistent internal rotation contracture or external rotation weakness with glenohumeral dysplasia arthrodesis indication non-functional deltoid with good function of hand and wrist Treatment - Elbow Flexion Contracture Nonoperative serial nighttime elbow extension splinting indications for elbow flexion contracture <40 degrees outcomes prevents progression, does not correct contracture serial elbow extension casting indications for elbow flexion contracture >40 degrees Operative anterior capsular release, biceps/brachialis tendon lengthening indications for severe, persistent contracture outcomes may have high recurrence rate Complications failure of nerve reconstruction important to discuss preoperatively with parents phrenic nerve palsy if persist may require diaphragm plication
QUESTIONS 1 of 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.160) Which of the following is the most common long term consequence of untreated brachial plexus birth palsy? Review Topic QID: 4520 FIGURES: A B C D E 1 Figure A 56% (1961/3485) 2 Figure B 3% (114/3485) 3 Figure C 9% (330/3485) 4 Figure D 5% (167/3485) 5 Figure E 25% (877/3485) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.218) 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? Review Topic QID: 4578 1 Claw hand 5% (123/2480) 2 Fixed adduction and internal rotation at shoulder with elbow extension 8% (207/2480) 3 Hyperextension of the MCP joints and flexion of the IP joints of the hand 5% (130/2480) 4 Weakness in elbow flexion 3% (78/2480) 5 Normal physical exam without deficits 77% (1916/2480) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ10.73) 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? Review Topic QID: 3161 1 >90% 12% (203/1711) 2 75% 7% (116/1711) 3 50% 6% (95/1711) 4 25% 11% (196/1711) 5 <10% 64% (1094/1711) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ08.232) Which of the following muscles would be affected if a 6-month-old child sustains a birth-related brachial plexopathy affecting C5 nerve root? Review Topic QID: 618 1 Trapezius 5% (52/1031) 2 Triceps 1% (9/1031) 3 Biceps 92% (952/1031) 4 Interossei 1% (8/1031) 5 Flexor digitorum profundus 0% (5/1031) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ11.232) 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? Review Topic QID: 3655 1 Loss of hand function with preserved shoulder function 21% (479/2281) 2 Absent shoulder abduction and external rotation with intact wrist and digit flexion and extension 73% (1657/2281) 3 Rotator cuff dysfunction, elevated hemidiaphragm, and absence of rhomboid function 1% (22/2281) 4 Loss of shoulder and wrist function 1% (26/2281) 5 Ptosis, myosis and anhydrosis 4% (86/2281) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Double Fascicular Transfer: Median Fascicle to Biceps Branch and Ulnar Fascicle to Brachialis Branch Nerve Transfers-Dr. Susan Mackinnon Pediatrics - Obstetric Brachial Plexopathy (Erb's, Klumpke's Palsy) - Surgical Approaches Dr. Susan Mackinnon performs a double fascicular transfer (DFT) includes two ner... 8/10/2014 838 views