Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3–6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.

/pdf/the-natural-history-and-management-of-brachial-plexus-birth-2e3jz2n9qz.pdf

The natural history and management of brachial plexus birth palsy.

This integrative literature review has been carried out with the aim of analyzing the scientific literature aimed at identifying and describing existing rehabilitation treatments/therapies for neonatal brachial plexus palsy (NBPP). NBPP is a frequent consequence of difficult birthing, and it impairs the function of the brachial plexus in newborns. This is why knowledge on rehabilitation strategies deserves special attention. The data collection was carried out in January 2019, in the EBSCOhost and BVS (Biblioteca Virtual em Saude) platforms, in the CINAHL Complete, MEDLINE Complete, LILACS and PubMed databases. Thirteen articles were included in this integrative literature review, based on a literature search spanning title, abstract and full text, and considering the inclusion criteria. Two main treatments/therapies for NBPP rehabilitation were identified: conservative treatment and surgical treatment. Conservative treatment includes teamwork done by physiatrists, physiotherapists and occupational therapists. These professionals use rehabilitation techniques and resources in a complementary way, such as electrostimulation, botulinum toxin injection, immobilizing splints, and constraint induced movement therapy of the non-injured limb. Professionals and family members work jointly. Surgical treatment includes primary surgeries, indicated for children who do not present any type of spontaneous rehabilitation in the first three months of life; and secondary surgeries, recommended in children who after primary surgery have some limitation of injured limb function, or in children who have had some spontaneous recovery, yet still have significant functional deficits. Treatment options for NBPP are defined by clinical evaluation/type of injury, but regardless of the type of injury, it is unanimous that conservative treatment is always started as early as possible. It should be noted that there was no evidence in the literature of other types of rehabilitation and techniques used in clinical practice, such as preventive positioning of contractures and deformities, hydrotherapy/aquatic therapy, among others, so we consider there is a need for further studies at this level in this area.

https://www.mdpi.com/2077-0383/8/7/980/pdf

Rehabilitation of Neonatal Brachial Plexus Palsy: Integrative Literature Review.

Strong scientific validation for nerve reconstructive surgery in infants with Obstetric Brachial Plexus Palsy is lacking, as no randomized trial comparing surgical reconstruction versus conservative treatment has been performed. A systematic review of the literature was performed to identify studies that compare nerve reconstruction to conservative treatment, including neurolysis. Nine papers were identified that directly compared the two treatment modalities. Eight of these were classified as level 4 evidence and one as level 5 evidence. All nine papers were evaluated in detail to describe strong and weak points in the methodology, and the outcomes from all studies were presented. Pooling of data was not possible due to differences in patient selection for surgery and outcome measures. The general consensus is that nerve reconstruction is indicated when the result of nerve surgery is assumedly better than the expected natural recovery, when spontaneous recovery is absent or severely delayed. The papers differed in methodology on how the cut-off point to select infants for nerve reconstructive surgical therapy should be determined. The justification for nerve reconstruction is further discussed.

/pdf/the-evidence-for-nerve-repair-in-obstetric-brachial-plexus-2f7ka0vzxd.pdf

The Evidence for Nerve Repair in Obstetric Brachial Plexus Palsy Revisited

https://digitalcommons.chapman.edu/cgi/viewcontent.cgi?article=1096&context=pt_articles

Clinical assessment of the infant and child following perinatal brachial plexus injury.

The majority of children with obstetric brachial plexus injury show some degree of spontaneous recovery This review explores the available evidence for the use surgical brachial plexus repair to improve outcome So far, no randomized trial has been performed to evaluate the usefulness of nerve repair The evidence level of studies comparing surgical treatment with non-surgical treatment is Level IV at best The studies on natural history that are used for comparison with surgical series are also, unfortunately, of too low quality Among experts, however, the general agreement is that nerve reconstruction is indicated when spontaneous recovery is absent or severely delayed at specific time points A major obstacle in comparing or pooling obstetric brachial plexus injury patient series, either surgical or non-surgical, is the use of many different outcome measures A requirement for multicentre studies is consensus on how to assess and report outcome, both concerning motor performance and functional evaluation

https://journals.sagepub.com/doi/pdf/10.1177/1753193420934676

Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury

We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The
findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to
follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively. In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of
the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively. Our method is effective in evaluating the prognosis of C5 lesion.Neurolysis is preferred for C6 lesions.

Children orthopaedics: Intra-operative neurophysiological prediction of upper trunk recovery in obstetric brachial plexus palsy with neuroma in continuity

CHILDREN'S ORTHOPAEDICS Intra-operative neurophysiological prediction of upper trunk recovery in obstetric brachial plexus palsy with neuroma in continuity

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Children orthopaedics: Intra-operative neurophysiological prediction of upper trunk recovery in obstetric brachial plexus palsy with neuroma in continuity

CHILDREN'S ORTHOPAEDICS Intra-operative neurophysiological prediction of upper trunk recovery in obstetric brachial plexus palsy with neuroma in continuity