Developing a Decision Aid for Youth with Brachial Plexus Birth Injuries Facing Treatment Decisions for an Elbow Flexion Contracture

We report the results of ten consecutive patients who had correction of an elbow flexion contracture of greater than 30° in brachial plexus birth injury using a modified Outerbridge-Kashiwagi procedure. All patients had minimum 23-month follow-up. Pre- and post-operative elbow range of motion and DASH scores were recorded in all patients. The operative technique for the procedure and post-operative course is discussed. Surgery was supplemented by botulinum toxin injection into the biceps brachii muscle in most cases. The average age at surgery was 14 years 10 months. The initial plexus lesion was global in eight patients and upper in two. Pre-operative flexion contractures averaged 51° (range 35 to 60) and post-operative averaged 21° (range 15 to 30). Of these patients, one had no change in active flexion, four had loss of active flexion, and five had gain of active flexion. All ten patients were satisfied with their results and stated that they would recommend the procedure to other patients. Level of evidence: IV

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The Use of Botulinum Toxin Injection for Brachial Plexus Birth Injuries: A Systematic Review of the Literature

Hand ◽

10.1177/1558944718760038 ◽

2018 ◽

Vol 14 (2) ◽

pp. 150-154 ◽

Cited By ~ 6

Author(s):

Patrick J. Buchanan ◽

John A. I. Grossman ◽

Andrew E. Price ◽

Chandan Reddy ◽

Mustafa Chopan ◽

...

Keyword(s):

Systematic Review ◽

Botulinum Toxin ◽

Brachial Plexus ◽

Internal Rotation ◽

Botulinum Toxin A ◽

Botulinum Toxin Injection ◽

Elbow Flexion ◽

Complete Recovery ◽

Birth Injuries ◽

Flexion Extension

Background: Most brachial plexus birth injuries (BPBIs) are caused by traction on the brachial plexus during a difficult delivery. Fortunately, the possibility of complete recovery from such an incident is relatively high, with only 10% to 30% of patients having prolonged and persistent disability. These patients have muscle imbalances and co-contractions typically localized around the shoulder and elbow. These imbalances and co-contractures cause abnormal motor performances and bone/joint deformities. Typically, physical/occupational therapies are the conventional therapeutic modalities but are often times inadequate. Botulinum toxin A (BTX-A) injections into targeted muscles have been used to combat the muscular imbalances and co-contractions. Methods: With compliance to PRISMA guidelines, a systematic review was performed to identify studies published between 2000 and 2017 that used BTX-A to treat neonatal brachial plexus palsies. Results: Ten studies were included, involving 325 patients. Three groups of indications for the use of BTX-A were identified: (1) internal rotation/adduction contracture of the shoulder; (2) elbow flexion lag/elbow extension lag; and (3) forearm pronation contracture. Conclusions: The included studies show an overall beneficial effect of BTX-A in treating co-contractures seen in patients with BPBI. Specifically, BTX-A is shown to reduce internal rotation/adduction contractures of the shoulder, elbow flexion/extension contractures, and forearm pronation contractures. These beneficial effects are blunted when used in older patients. Nevertheless, BTX-A is a useful treatment for BPBIs with a relatively low-risk profile.

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Elbow Flexion Reconstruction by Steindler Flexorplasty in Obstetric Brachial Plexus Palsy

Journal of Hand Surgery (European Volume) ◽

10.1016/j.jhsb.2005.03.003 ◽

2005 ◽

Vol 30 (4) ◽

pp. 424-427 ◽

Cited By ~ 17

Author(s):

M. M. AL-QATTAN

Keyword(s):

Brachial Plexus ◽

Selection Criteria ◽

Elbow Flexion ◽

Drill Hole ◽

Flexion Contracture ◽

Brachial Plexus Palsy ◽

Older Children ◽

Obstetric Brachial Plexus Palsy ◽

Obstetric Brachial Plexus

The results of Steindler flexorplasty in nine patients with obstetric brachial plexus palsy are reported. There were 5 girls and 4 boys with a mean age of 6 (range 2–13) years. Selection criteria for the procedure included strong (at least M4) grip strength and wrist and elbow extension, as well as the presence of the “Steindler effect”. Pre-operatively, elbow flexion was rated as M0 or M1 in three patients and M2 in the remaining six patients. Intra-operatively, the detached common flexor origin was advanced 5 to 7 cm and fixation was done to the anterior humerus either with direct suture to the periosteum (in younger children) or suturing into a drill hole in the humerus (in older children). Postoperatively, the elbow was immobilized in flexion and supination for 6 weeks. At a mean follow-up of 5 years, the results in eight patients were good with mean active elbow flexion against resistance of 110° and a mean elbow flexion contracture of 35°. The result in the remaining patient was poor (unsuccessful transfer). It is concluded that the results of the Steindler flexorplasty in obstetric brachial plexus palsy patients are good and reliable, provided patient selection is careful.

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Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193418762950 ◽

2018 ◽

Vol 43 (6) ◽

pp. 596-608 ◽

Cited By ~ 1

Author(s):

Tomas Madura ◽

Kazuteru Doi ◽

Yasunori Hattori ◽

Sotetsu Sakamoto ◽

Takashi Shimoe

Keyword(s):

Brachial Plexus ◽

Elbow Flexion ◽

Limb Length Discrepancy ◽

Flexion Contracture ◽

Brachial Plexopathy ◽

Brachial Plexus Palsy ◽

Level Of Evidence ◽

Old Patients ◽

Useful Power

The purpose of this study was to evaluate long-term outcomes of the free functioning gracilis transfer in children with traumatic total brachial plexus palsy. We used the free functioning gracilis transfer to reconstruct elbow flexion and prehension in 17 children with a mean age of 13.4 years (range 3–17) who were followed-up over a mean period of 6 years (range 2–16). The transferred gracilis delivered a stable elbow flexion with a useful power, as well as reconstructed active finger motion. In 3–11-year-old patients we noted a tendency towards developing a progressive flexion contracture of the elbow. The limb length discrepancy observed in our patients was not different from the brachial plexus palsy patients treated without the free functioning gracilis transfer. In conclusion, the free functioning gracilis transfer is a reliable reconstructive technique for reanimating upper extremity in children of all ages capable of delivering stable function over a long period of time. Level of evidence: IV

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