Obstetric Brachial Plexopathy

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Obstetric Brachial Plexopathy

• L C Bainbridge
• Hand and Peripheral Nerve Surgeon
• Derbyshire Royal Infirmary

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Indications for referral

• At birth Complete Palsies with or without
  Horners
• lt1 week All neonates without active finger
  extension
• 1 month All children without some recovery of
  biceps
• 2 months All children without full biceps
  function

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Anatomy
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Obstetric Brachial Plexopathy

• History
• Smellie 1765
• Erb
• Duchenne
• Klumpke
• Platt described OBP as a vanishing condition

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BPSU Survey of Erbs Palsy

• Incidence now shown to be 0.43/ 1000 live births
• Shoulder dystocia 64 vs 1
• Weight 54 gt 90th centile

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GILBERT

• Group 1
• The child is born with paralysis of the shoulder
  muscles and elbow flexors. The hand is normal.
  C5,6 have been damaged. Full spontaneous
  recovery in 80.
  
• Group 2
• Paralysis of shoulder, elbow and wrist extensors.
  C5,6 and 7 have been damaged. Full spontaneous
  recovery in perhaps 60.

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CLASSIFICATION

• Erbs palsy 53 C5,6
• Mixed 45
• Klumpkes 2 C8,T1

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Obstetric Brachial Plexopathy

• CLASSIC POSITION
• Adduction and internal rotation of the shoulder
• Elbow extension
• Pronation of the forearm
• Flexion of wrist and fingers
• Deviation of head away from injured side (may
  develop into true torticollis)

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Gilbert

• Group 3
• Complete paralysis of the limb. The whole plexus
  has been damaged. Full spontaneous recovery in
  perhaps 30.
• Group 4
• Complete paralysis Horners syndrome. Full
  spontaneous recovery never occurs.

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ASSESSMENT

• Thorough physical exam
• Observe position of head, neck and arm
• Palpate Sternocleidomastoid
• Clavicle, humerus, ribs
• Abdomen and chest x-rays
• Horners Syndrome

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Obstetric Brachial Plexopathy

• Gilbert and Tassin System
• M-0 no contraction
• M-1 contraction without movement
  
• M-2 slight movement with weight eliminated
  
• M-3 complete movement against the weight of
  the arm

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Clarke and Curtis
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Obstetric Brachial Plexopathy

• Investigation
• Clinical
• NCS and EMG
• Imaging

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Obstetric Brachial Plexopathy
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Indications for surgery

• Gilbert
• C5,6 palsy with no biceps at 3 months
• Total palsy flail arm Horners syndrome after
  one month

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Clarke Curtis

• Elbow flexion
• Extension of elbow, wrist, fingers and thumb
• Score less than 3.5 (max 20) at 3 months then
  operate
  Reassess
• At 9 months if elbow flexion less than half ROM
  against gravity then explore
• Cookie test (45 degrees)

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Indications for Surgery

• Mixture
• Clarke and Curtis score
• Nerve conduction studies
• Classification

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Surgical approach

• Surgery
  
• GA
  
• Supine
  
• Standard plexus approach
  

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Scoring Results
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C5-6 Results

• At 2 years
• gt grade IV 52
• Grade III 40
• Grade II 8
• After 2 years 33 had secondary surgery
• At 4 years
• gtgrade IV 80
• Grade III 20

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Obstetric Brachial Plexopathy

• Complete at 4 years
• Grade IV 49
• Grade III 29
• Grade II 22
• In the hand 50 of neurotisation patients have a
  useful hand

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Long term problems

• Dislocation and subluxation of the humeral head
• Lack of shoulder external rotation, abduction,
  flexion
• Weakness of elbow flexion
• Elbow flexion contracture
• Forearm supination or pronation contracture
• These deformities can be seen individually but
  are usually seen in combination of 2 or more.

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The Shoulder in Erbs Palsy

• Affected in virtually all Palsies
• Recovery appears to be very patchy
• Less predictable than biceps
• Implicated in other problems
• lack of supination
• elbow contracture

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Shoulder Anatomy

• Muscles involved in internal rotation contracture

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Severity of internal rotation contracture

• Simple contracture
• Simple posterior subluxation
• Simple posterior dislocation
• Complex posterior dislocation

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Bony deformities

• The overlong coracoid
• The overlong and hooked acromion

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Present Treatments

• Physiotherapy
• Coracoidectomy
• Subscapularis release
• Muscle transfers
• Humeral osteotomy

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Transfers

• Hoffer Trapezius transfer
• Ober long head of triceps and short bices to
  acromion to replace deltoid
• Harmon added upper pectoralis transfer to
  acromion
• LEpiscpo anterior release, lat dorsi and teres
  major
• Itoh Lat dorsi to central deltoid

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Success Rates

• Coracoidectomy Subscapularis lengthening
• preop mallet score 6.5
• post op mallet score 10
• Quad operation (LEpiscopo)
• early increase of 40 degrees in external rotation

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Surgery performed

• 6 cases
• Botulinum toxin injection alone
• Pre-op passive ER average 37 degrees
• (range 10 to 80 degrees)
• 6 cases
• Botulinum toxin injection coracoid shortening
• Pre-op passive ER average -4 degrees
• (range -15 to 10 degrees)

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Results

• Active ER pre-op
• average 6 degrees
• range -15 to 30 degrees
• Active ER post-op
• average 30 degrees
• range 10 - 45 degrees

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Results

• 50 of patients improvement in forearm supination
• Parents subjective feelings
• 6 patients - great improvement
• 4 patients - moderate improvement
• 2 patients - disappointing

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Pre-op
Post-op
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Distal

• Weak elbow flexion or absent
• Pectoralis minor
• Free gracilis intercostals or Oberlins
• Elbow contracture unknown reason
• Biceps lesion
• Splinting
• Short arm

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Distal

• Supination contracture
• Interosseous release Zancolli biceps transfer