Case Report: Bionic Reconstruction in an Adult With Obstetric Brachial Plexus Injury

Introduction: Many adults who had a severe Narakas IV obstetric brachial plexus injury (OBPI) suffer from extensive impairments in daily living due to limited hand-arm function. The dramatic loss of axonal support at this very early age of development often render the entire extremity a biologic wasteland and reconstructive methods and therapies often fail to recover any functional hand use. In this scenario bionic reconstruction, including an elective amputation and a subsequent prosthetic fitting, may enable functional improvement in adults suffering from the consequences of such severe brachial plexus injuries. We here describe our experience in treating such patients and lay out the surgical rational and rehabilitation protocol exemplified in one patient.Case Presentation/Methods: A 27-year-old adult with a unilateral OBPI contacted our center. He presented with globally diminished function of the affected upper extremity with minimal hand activity, resulting in an inability to perform various tasks of daily living. No biological reconstructive efforts were available to restore meaningful hand function. An interdisciplinary evaluation, including a psychosocial assessment, was used to assess eligibility for bionic reconstruction. Before the amputation and after the prosthetic fitting functional assessments and self-reported questionnaires were performed.Results: One month after the amputation and de-rotation osteotomy of the humerus the patient was fitted with a myoelectric prosthesis. At the 1.5 year-follow-up assessment, the patient presented with a distinct improvement of function: the ARAT improved from 12 to 20 points, SHAP score improved from 8 to 29, and the DASH value improved from 50 to 11.7. The average wearing times of the prosthesis were 5 to 6 h per day (on 4–5 days a week).Discussion: The options for adults suffering from the consequences of severe OBPIs to improve function are limited. In selected patients in whom the neurological deficit is so severe that biologic hand function is unsatisfactory, an elective amputation and subsequent restoration of the hand with mechatronic means may be an option. The follow-up results indicate that this concept can indeed lead to solid hand function and independence in daily activities after amputation, subsequent prosthetic fitting, and rehabilitation.

Derotational Osteotomies for The Late Treatment of Brachial Plexus Injury

Obstetric brachial plexus palsy [OBBP] can affect the function of the upper extremity. Most of the injuries are limited to the upper spinal nerves and heals spontaneously. However, some of them will have incomplete recovery after OBBP often results in weakness of the external rotators [teres minor and infraspinatus] muscles compared to the internal rotators [teres major, pectoralis major, latissimus dorsi] muscles. The predominance of the internal rotators and adductor muscles over external rotators leads to an internal rotation contracture. The development of internal rotational deformity may progress to increased glenoid retroversion and posterior humeral head subluxation. If the surgeon does not repair internal rotation deformity, the humeral head is forced into a posterior position causing a complete posterior dislocation. Many procedures are performed to treat these deformities: In the young child, improving the remodeling of the glenohumeral joint, capsulectomy, and subscapular release are introduced. Tendon transfers of the shoulder have good results for motion but fail to restore the glenohumeral joint. The failure of improving joint alignment may represent the loss in clinical improvement over time. In older children, a humeral osteotomy can be an alternative to realign the limb into external rotation, improve appearance, and enhance eating, washing hair, and scratching the back of the neck. We will discuss all the techniques along with their advantages and disadvantages.

Factors of Cortical Plasticity in Brachial Plexus Injury

Cortical plasticity is the brain’s capability of decoding new information through growth and reorganization over our whole life spam. It is the basis for good outcomes after reinnervation and for rehabilitation of adult and obstetric brachial plexus injury. Knowledge about cortical reorganization is crucial to reconstructive surgeons and physiotherapists that aim to give their patients a reasonable prognosis. This chapter intends to present and summarize the current literature on how to detect and quantify cortical plasticity and how research on factors that influence cortical plasticity, mainly in relation to peripheral nerve and more precise brachial plexus injury progresses. Peculiarities of adult and obstetric brachial plexus injuries and their treatment are given. We present techniques that visualize and quantify cortical plasticity with focus on functional imaging like fMRI and nTMS as well as molecular aspects. Future research is needed to understand mechanisms of how molecular changes on a synaptic level of a neuron influence the macroscopic plasticity, to improve rehabilitative resources, to understand the exact prognostic value of nTMS in brachial plexus injury and to investigate the therapeutic capability of rTMS.

Outcome Measures in OBPP

Traditional outcome measurement scales, such as the Medical Research Council (MRC) score, the Active Movement Scale (AMS), and Mallet score, are used by surgeons to assess outcomes in patients with obstetric brachial plexus palsy (OBPP). The measurement scales used to evaluate patients fall under the International Classification of Functioning (ICF) domains of Body Function, Body Structure, Activity, Participation, and Environment and are used to assess function and disability of patients. Currently used outcome measures scales for OBPP are also contrasted with those used for another perinatal condition affecting the upper limb, cerebral palsy (CP).