Obstetric brachial plexus Palsy

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Obstetric brachial plexus Palsy

  1. 1.  Early days – congenital deformity. Smillie [1768] – Obstetric origin Danyau [1851] – Autopsy – lesion Duchenne [1861]- traction injury, OBPI ERB [1875]- pointed lesion at upper trunk Kennedy [1903]- early surgical repair Narakas [1981]- microsurgical results.
  2. 2.  Incidence: 4/1000 in poor OBG care, 0.1-0.3% in good centers. 1% of OBPP, injury is bilateral More on one side. [exclusive in breach]
  3. 3.  Formed by anterior primary rami of C5-T1. Roots – between scalene muscles Trunks – posterior triangle Divisions- behind clavicle. Cords in axilla. Roots & trunk- supraclavicular part [OBPP] Cords & branches – infraclavicular part
  4. 4.  Stretching Overweight babies with cephalicpresentations Underweight babies with breech Forceful widening of angle between the neck& shoulder. Force is more at C5 root Always supraclavicular Not associated with vascular damage.
  5. 5.  Large birth weight Breech presentation Maternal diabetes Multiparity II stage of labour - > 60 min Assisted delivery [forceps, vacuum ext] previous child with OBPP Intrauterine torticollis Shoulder dystocia
  6. 6.  Lesions range from degree I[neuropraxia] – V[neurotmesis or root avulsions]. Upper trunk –1staffected, most vulnerablepart. Upper trunk – mostly stretched Lower trunks – mostly ruptured
  7. 7.  U.E is flail & dangling Look for other extremities U.R: arm held in IR,add, active abd notpossible, elbow extended forearm pronated,thumb flexed. Complete paralysis- vasomotor impairment,pale & marble like color Horner’s sign Associated # [clavicle,humerus,]
  8. 8.  Complete Recovery Extent of paralysis regress, total paralysis limitedto U.R No improvement.
  9. 9.  C5-6: the arm is adducted and internallyrotated at the shoulder, elbow extended,forearm pronated, wrist and (sometimes)fingers flexed. (Classic waiter tip/Erb’spalsy/upper roots). C5-7 : as above, although the elbow may beslightly flexed. Intermediate root palsy C7. C5-T1 : the arm is totally flail with a clawhand. marbled appearance, Horner’ssyndrome.
  10. 10.  Done at 2 months of age Not anatomic, Grading overall severity of lesion based onclinical course. Prognosis.
  11. 11. X - RAY epiphyseal # of humerus, # clavicle, Later changes, retardation of growth,deformity of shoulder jt & dislocation of radialhead.
  12. 12. EMG Performed at 3-4 wks- confirm neuropraxia oraxonotmesis At 2 months, signs of re-innervation.EVOKED SENSORY POTENTIAL Useful to ascertain root avulsions Can be used preop to test the availability ofproximal stumps.
  13. 13.  Fluoroscopy- phrenic nerve injury. Lumbar puncture- xanthochromic CSF- in rootavulsions. C.T myelogram Fast spin Echo MRI: preganglionic nerve rootinjuries. Large diverticulae and meningoceles areindicative of root avulsions
  14. 14.  Nature of injury [rupture better] Lower plexus paralysis, global involvement, persistence of pupillary signs of phrenic nervepalsy Ass. #.
  15. 15.  Physiotheraphy- cornerstone Rest for first 2 wks, Arm fixed across the chest by pinning ROM ex, facilitation of active movt, promotionof sensory awareness. Avoid abduction & posterior projection ofshoulder. Limb to be supported when holdingbaby Goals: minimizing bony deformities, Jtcontractues. Weight bearing activity-skeletal growth
  16. 16. Early nerve repair Indications:1. Failure of recovery of biceps or deltoid at 3months2. Group III& IV lesions3. Presence of Horners sign.
  17. 17.  Diminishing potential for axon regeneration withage Cross innervation & muscle imbalance aborted Provide better condition for tendon transfer Nerve repair is superior to spontaneous recovery.
  18. 18.  Total palsy: 3 months Upper trunk palsy: 5 monthsTYPE OF SURGERY1. neurolysis,2. resection and anastomosis in ruptures3. nerve grafting using sural nerves asinterposition grafts.
  19. 19.  Repair using the proximal roots of the plexus itselfif the injury is post ganglionic as in a rupture Extra plexal neurotisation using other donormotor nerves to selectively aim at reinnervatingthe important muscle groups.
  20. 20.  Spinal accessory (XIth) nerve. Intercostal nerves (commonly 3rd to 6th) C4 motor root Ansa hypoglossi Opposite C7.
  21. 21.  Suprascapular Musculocutaneous, Axillary Median.Order of priority of restoration of function Elbow flexion Shoulder stability (rotator cuff viasuprascapular nerve) Shoulder abduction Hand prehension
  22. 22.  To predict poor outcomes if microsurgicalrepair or grafting is not done. scale consists of grading elbow flexion,elbow extension, wrist extension, fingerextension, and thumb extension. [max -12] score of < 3.5 predicted a poor long-termoutcome without microsurgery.
  23. 23.  Fracture of clavicle or humerus shaft or physealseparation septic arthritis / osteomyelitis Congenital malformation of plexus Postinfectious [varicella] plexopathy of muscles
  24. 24.  Nerve regeneration: some muscles recoverearlier, others paretic  muscle imbalance Recovery results from misdirection of regeneratedaxons  cross innervation
  25. 25.  Co-contraction of synergestic & antagonisticmuscles Diminishing functional recovery Muscle contracture  deformity
  26. 26.  Sequelae depends on three factors whichare additive1. Paralysis of muscle groups [ext.rot, elbowflexors]2. Contracture of healthy antagonist muscles3. Impaired growth  osseous deformities Sequale – seen in spontaneous recovery ingr III & IV lesion.
  27. 27.  Between shoulder abductors [S.S, I.S ,del] &adductors [pect maj, ter.m]  limitation ofshoulder elevation Elbow flexors [biceps & brachialis] & elbowextensors [triceps] Elbow flexors & shoulder abductors  trumpetsign Shou abd, elb flex,forearm flex
  28. 28.  Putti sign; with shoulder abduction, medialedge of scapula, often seen protruding aboveshoulder jt line Reduction of shou abd – deltoid weakness orlack of ER. Trumpet sign Mild shortening & atrophy of limb Posterior sublux of shoulder – IR overpowerER. Bitting of nail & hand (47%) –total obp.
  29. 29.  UPPER ARM: mainly in shoulder & occ elbow &forearm LOWER ARM: hand more affected WHOLE ARM; flaccid paralysis
  30. 30.  Group I: joint contracture due to nerve lesions& simultaneous trauma to shoulder Jt Group II Flaccid; flaccid paralysis- upper trunkinjury. Group I: subdivided in to 4 groups
  31. 31.  I –internal rotation & adduction contracturewith preservation of Jt II – with Jt deformity – posterior subluxation &dilocation III – external rotation & abd contracture-anterior & inferior disloc IV –pure abduction contracture.
  32. 32.  Grade I ,II, mild grade III (slight posteriorsubluxation) glenohumeral deformities havean anterior musculotendinous lengthening ofthe pectoralis major and posterior latissimusdorsi and teres major transfer to the rotatorcuff Advanced grade III, IV, or V glenohumeraldeformities should have a humeral derotationosteotomy.
  33. 33.  Fairbank: release of subscapularis & capsule. L’ Episcopco procedure improves externalrotation of the shoulder by releasing theinternal rotation contracture and transferringthe latissimus dorsi and teres majorposteriorly to provide active external rotation Wickstrom recommendes external rotationosteotomy of the humerus for severe fixedrotation contracture.
  34. 34.  In flaccid paralysis of complete lesion Difficult to manage & difficult to rehabilitation If no active wrist extension & no possible transfers– W. fusion with comb inter-metacarpalarthrodesis.
  35. 35.  Elbow flexion and forearm supinationdeformities weak or absent triceps, pronator teres, andpronator quadratus muscles with an intactbiceps muscle Radial head dislocation wrist & hand usually in extreme dorsiflexion –unopposed DF biceps tendon, Z-lengthened and reroutedaround the radius to convert it from asupinator to a pronator
  36. 36.  Prevention is better than cure Effort made to improve obstetric practice Group I & II- conservative Group III & IV –early surgery Late sequale: proper evalu & manage withtendon transfer or osseous surgry Conservative Rx – fruitless.

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