جراحة العظام / علاج العظام في الاردن / افضل دكتور عظام في الاردن / افضل اخصائي عظام في الاردن / استشاري عظام/ االمفاصل /مستشار جراحة العظام والمفاصل والكسور / مستشار جراحة عظام الأطفال. شلل الظفيرة العصبيه في الرقبه، خلع الولاده، شلل الولاده

1. OBSTETRICAL PARALYSIS

2. * Smellie 1764
* Duchenne 1872
* Erb’s 1874 (Adult)

3. Pathogenesis
* Congenital.
* Trauma (Duchenne).
* Compression over first rib (Walton).
* Secondary to lesions of the shoulder.

4. Obstetrical factors
* Cephalic : Overweight, 88%.
* Breech : Small baby.
* Pressure neuropathy in uterus.

5. Incidence
* 4 : 1000 in poor Obstetrical care.
* 0.1 - 0.3 : 1000 in good care areas.
* 1% bilateral.

6. Clinical Picture
* Pseudo paralysis.
* ? Neonatal Tetraplegia.

7. Clinical Types = A. Gilbert
* Upper roots.
* Elbow extended : C5-6.
* Elbow flexed : C5-6-7.
* Complete paralysis
* Flial arm with clinched hand.
* ? Horner’s syndrome.
* ? Medullary lesion.

8. Early management.
* Assess both U.L. + L.L.
* X-ray shoulder + clavicle.
* Chest x-ray.
* Collar & Cuff.
* See one week.

9. Spontaneous recovery.
* (80% - 90%) : (Brown 1984).
* If some contraction of biceps & deltoid at
4 weeks and normal contraction at 8
weeks (Complete recovery).
Tassin 1983.

10. If no contraction of Biceps or Deltoid
at 3m : Poor recovery & result.
---------> surgery is needed.
Tassin 1983.

11. Indications of surgery
1. No recovery of Biceps after 3 months.
2. Any total lesion even after 2 years.
3. Persistent hypotonic paralysis &
atrophy.

12. 4. Persistent Phrenic N palsy.
5. Horner’s sign : 2m.
6. Severe sensory disturbances.
7. Pathological results on MRI
or CT myelography.

13. Operative procedures
*Neurolysis.
*End to end repair.
*Sural N. cable graft.
*Neutrisation.

14. Abduction ER Splints
• Useless.
• Can cause abduction contracture.

15. Classification at 3 weeks
(NARAKAS).

16. Group 1 : (C5-6)

17. Group 1 : (C5-6)
* Functioning biceps.
* Recovery will happen before 6W.
* Normal at 4 - 6m.

18. Group 2 : (C5-6-7) = Mild

19. Group 2 : (C5-6-7) = Mild
* Weak elbow extension.
* No recovery at 6 weeks.
* Needs surgery at 6-8 m.

20. Group 3 : C5 -6 -7 (Severe).
C8 - T1 (Mild).

21. Group 3 : C5 -6 -7 (Severe).
C8 - T1 (Mild).
* Flial shoulder.
* No elbow flexion or extension.
* Tight fist.

22. Prognosis of group 3
* Hand will recover.
* Will end in very poor shoulder.
* Needs surgery at 3m.

23. Group 4 : Complete
paralysis.

24. Group 4 : Complete
paralysis.
* No movement in the limb or fingers at all.
* Needs surgery at 3m.
- MRI --- Myelomeningocele ---> Neutrisation.
- In Horner’s : Operate. at 2m.
* 50% useful hand post op.

25. Upper trunk at birth
* Review : 7 , 21 days.
* 1st M. : Physiotherapy.
* 2nd M. : If no recovery of Biceps --> EMG.
* 3rd M. : If no recovery of Biceps,
MRI then explore and repair .

26. Subscapularis Disinsertion
* At 6 - 8 M in Non Operated patient.
* At 12 - 18 M in operated patient.

27. Late deformity
* Shoulder (Soft tissue).
- Internal rotation contracture.
- Adduction contracture.

28. Treatment
* Lengthening of PM.
* Subscapularis disinsertion.
* Transfer of L.D., T.M. to I.S.

29. * Shoulder (Bony) = 67%.
* Fixed bony changes.
- Proximal humeral osteotomy.
* Dislocation
* Long coracoid.

30. Restoration of abduction
Trapezius transfer in flail shoulder.
#. Advantages:
* Simple.
* Minimal blood loss.
* Functional & pain elimination.
#. C.I. : Advanced O.A. of the shoulder.

31. Elbow surgery
* Biceps re-routing for poor pronation.
* LD for flexion.
* Forearm osteotomy for poor supination.
* Flexor plasty.
* Extension distal humeral osteotomy.

32. Wrist surgery
* FCU to restore extension of fingers.
* P. Teres to ECRB to restore wrist
extension.
* Arthrodesis in complete palsy after 12y.

33. A. Gilbert (1977 - 1994)
1486 Palsy.
( 435 needed surgical repair).
* 93.25% Cephalic.
* 6.5% Breech.
* 0.25% C.S.

34. Epidemiology
Gilbert
* R: 59% , L: 39.5% , R+L: 1.5%.
* Average wt.
Cephalic : 4306g.
Breech : 2849g.
* 51% M 49% F

35. Surgery in Obstetrical palsy
will increase the number of
good shoulders and decrease
the number of very bad ones.
Tassin

36. Clinical picture
Gilbert
* C5-6 : 48%.
* C5-6-7 : 29%.
* Complete : 23%.

37. Recovery after surgery
Gilbert
* Starts : After 6 - 8 M.
* Lasts : 2 Y upper palsy.
3 - 4 Y in complete palsy.

38. Recovery in complete lesion
Supra spinatus is the first to recover.
(1 mm/day).
3 - 4 M.
Brunelli, 1996.

39. Results
Gilbert
C5 - 6 : 209 patient.
At 2 years :
Grade IV (Good - Excellent: 52%).
“ III 40%.
“ II 8%.

40. C5-6
Gilbert
After 2 years : Tendon transfer.
13 Subscapularis release.
33 L.D. transfer.
06 Trapezius transfer.

41. C5-6
Gilbert
At 4 years (After tendon transfer).
Grade IV : 80%.
Grade III : 20%.

42. C5-6-7 = 126 patient
Gilbert
At 2 years.
Grade IV : 36%.
Grade III : 46%.
Grade II : 18%.

43. C5-6-7
Gilbert
Tendon transfer after 2 years.
- 7 Subscapularis release.
- 24 L.D. transfer.
- 1 Trapezius transfer.

44. C5-6-7
Gilbert
At 4 years
Grade IV 61%.
Grade III 29%.
Grade II 10%.

45. Complete paralysis = 100 patient
Gilbert
All treated by Neutrisation.
50% gave a useful hand at 4 years.

46. Why good results?.
1. Greater surgical experience.
2. Precise knowledge of the anatomy.
3. Sophisticated imaging.
4. Better evaluation & appreciation of
the results.

47. C8 - T1 : Klumpke
* Non existent alone.
(Narakas, Gilbert)

48. Endoscopic diagnosis of root
avulsions.

49. Conclusion
* Traumatic palsy (Duchenne 1872).
* 0.6% Congenital aplasia.
* Repair superior to spontaneous recovery
(Taylor & Clark : 1905)
* If no recovery of biceps at 3 months - surgery.