1	Obstetric Brachial Plexopathy L C Bainbridge Hand Surgeon DRI
2	Obstetric Brachial Plexopathy History Smellie 1765 Erb Duchenne Klumpke Platt described OBP as “a vanishing condition”
3	Obstetric Brachial Plexopathy Outcome Uniformly good 75% full recovery (Greenwald 1984) without treatment
4	Obstetric Brachial Plexopathy PERIPHERAL NERVE INJURY UNIT - Tenfold increase in last 4 years Now greater than 100 cases per year The majority do not have full spontaneous recovery
5	Obstetric Brachial Plexopathy INCIDENCE Related to the incidence of shoulder dystocia 0.2 - 1.2% 1.7% greater than 4 kilos 10% greater than 4.5 kilos WT greater than 4.5 kilos kg and 2nd stage greater than 1 hour Shoulder dystocia 35% no figures available in this country for incidence
6	Update on BPSU Survey Initiated by Mr S Kay et al, March 1998 Incidence now shown to be 0.43/ 1000 live births Shoulder dystocia 64% vs 1% Mode of delivery 42% vs 10% Weight 54% > 90th centile
7	Obstetric Brachial Plexopathy CAUSATION Probably mainly shoulder dystocia 30% unknown cause Breech presentation Probably the majority of shoulder dystocias have some nerve injury
8	SHOULDER DYSTOCIA FETAL MACROSOMIA Maternal diabetes Beckwith Wiedman syndrome Werdnig Hoffman Increased maternal birthweight Maternal obesity Gestational age > 41/52 Previous shoulder dystocia or big baby Recognised macrosomia Small mother less 150cms tall
9	SHOULDER DYSTOCIA OBSTETRIC CRISIS Should be foreseen In extremis replace the head and do an emergency caesarian Every maternity unit should have a shoulder dystocia drill
10	SHOULDER DYSTOCIA ASSOCIATED CONDITIONS Perinatal asphyxia Hypoxic ischaemic encepalopathy Neurological conditions Phrenic nerve Cervical spine Brachial plexus # clavicle # humerus
11	Obstetric Brachial Plexopathy CLASSIFICATION Erbs palsy 53% C5,6 Mixed 45% Klumpkes 2% C8,T1
12	Obstetric Brachial Plexopathy CLASSIFICATION AFTER 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%.
13	Obstetric Brachial Plexopathy 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.
14	Obstetric Brachial Plexopathy ASSESSMENT Thorough physical exam Observe position of head, neck and arm Palpate Sternocleidomastoid Clavicle, humerus, ribs Abdomen and chest x-rays Horners Ptosis, myosis Enopthalmos Anhydrosis
15	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)
16	Obstetric Brachial Plexopathy MOTOR ASSESSMENT Difficult, non co-operative patient 1943 MRC grading M0-5 1987 Gilbert & Tassin M0-3 1993 Clark & Curtis 0-7
17	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
18	Obstetric Brachial Plexopathy
19	Obstetric Brachial Plexopathy Narakas Sensory Grading System No reaction to pain or other stimuli 0 Reaction to painful stimuli none to touch 1 Reaction to touch, not to like touch 2 Apparently normal 3
20	Obstetric Brachial Plexopathy Investigation Clinical NCS and EMG Imaging Unreliable generally.
21	Obstetric Brachial Plexopathy IMAGING CT myelogram for root avulsion positive prediction 50%, negative prediction 93% Hashimoto- conventional myelography best MRI may improve diagnosis Need very high quality machines
22	Obstetric Brachial Plexopathy
23	Obstetric Brachial Plexopathy Those patients that will not recover spontaneously Gilbert Total palsy + flail arm + Horners syndrome after one month Complete C5,6 after breach delivery, no recovery at 3 months C5,6 palsy with no biceps at 3 months
24	Obstetric Brachial Plexopathy Indications for surgery Narakas Recovery started within 3 weeks - no surgery Recovery after 3 weeks but continuing - secondary surgery No recovery after 2 months - primary surgery
25	Obstetric Brachial Plexopathy Clark & Curtis Assess Elbow flexion Extension of elbow, wrist, fingers and thumb Complicated scoring system If 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)
26	Obstetric Brachial Plexopathy Surgery GA Supine Standard plexus approach
27	Obstetric Brachial Plexopathy Upper lesion Neuroma is usually between C5,6 and upper trunk resect neuroma sural nerve graft Total lesion Above and below clavicle Results depend on number of avulsions 3 usable roots - good 2 usable roots - poor Intercostal neurotisation
28	Obstetric Brachial Plexopathy Results - Gilbert 1977 - 1994 1486 patients 436 have had operative repair
29	C5-6 at 2 years > grade IV 52% Grade III 40% Grade II 8% After 2 years 33% had secondary surgery At 4 years >grade IV 80% Grade III 20%
30	Obstetric Brachial Plexopathy C5,6,7 - 2 years > grade IV 36% Grade III 46% Grade II 18% 25% had secondary surgery At 4 years > grade IV 61% Grade III 29% Grade II 10%
31	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
32	Obstetric Brachial Plexopathy Indications and timing of referral At birth: Complete Palsies with or without Horners <1 week: All neonates without active finger extension 1 month: All children without some recovery of biceps 2 months: All children without full biceps function
33	Obstetric Brachial Plexopathy Long term problems Dislocation and subluxation of the humeral head Lack of external rotation Lack of abduction Weakness of elbow flexion Elbow flexion contracture Forearm supination contracture Forearm pronation contraction These deformities can be seen individually but are usually seen in combination of 2 or more.
34	The Shoulder in Erb’s Palsy Affected in virtually all Palsies Recovery appears to be very patchy Less predictable than biceps Is it implicated in other problems? lack of supination elbow contracture
35	Shoulder Anatomy Muscles involved in internal rotation contracture
36	Shoulder Anatomy Anterior
37	Shoulder Anatomy Posterior view
38	Shoulder Anatomy
39	Present Thoughts External rotators are weak Coracoid is overgrown Subscapularis is tight Shoulder joint is abnormally shaped Contracture of latissimus dorsi and teres major Contracture of deltoid and infraspinatus
40	Subscapularis abnormality Shortened Shortened/fibrosed Overstrong with respect to external rotators
41	Severity of internal rotation contracture Simple contracture Simple posterior subluxation Simple posterior dislocation Complex posterior dislocation
42	Bony deformities The overlong coracoid The overlong and hooked acromion
43	Present Treatments Physiotherapy Coracoidectomy Subscapularis release Muscle transfers Axillary nerve release Humeral osteotomy + Splintage
44	Success Rates Coracoidectomy + Subscapularis lengthening preop mallet score 6.5 post op mallet score 10 Quad operation early increase of 40 degrees in external rotation
45	Our series 12 patients Males:females = 1:3 Original Gilbert and Tassin grades: 7 Grade 1 5 grade 2 Average age at injection 3 yrs 6 months range 8 months to 8 yrs 10 months
46	State of shoulder All patients underwent U/S pre-op No dislocations 4 - no subluxation 8 - evidence of simple posterior subluxation
47	Aims of this study To use less invasive method of helping with internal rotation contracture
48	Our Series Previous surgeries: 3 neurolyses only upper trunk upper trunk + suprascapular nerve C5/6 1 nerve grafting only C5/6 1 neurolysis (C7) and grafting (C5/6)
49	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)
50	Botulinum injection - method Under general anaesthetic Needle inserted via vertebral border of scapula Subscapularis localised using stimulating needle Dose of 6u/kg given into belly of subscapularis
51	Method Botulinum toxin injection PLUS intensive physiotherapy NOT Injection alone
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55	Post-op regimen All patients done as day cases No post-operative splintage Local physiotherapy Assessment at 2 weeks, 6 weeks, 3 months and 6 months average follow up = 74 days range 13 days to 226 days
56	Results
57	Results Active ER pre-op average 6 degrees range -15 to 30 degrees Active ER post-op average 30 degrees range 10 - 45 degrees
58	Results 50% of patients improvement in forearm supination Parents subjective feelings 6 patients - ‘great improvement’ 4 patients - ‘moderate improvement’ 2 patients - ‘disappointing’
59	Pre-op
60	Side - effects of toxin None noted
61	Conclusions Safe procedure Makes physiotherapy easier Prevents need for subscapularis lengthening in simple posterior subluxation? Prevents need for splintage?