Witold Wnukiewicz 1, Piotr Mazurek 1

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1 POLSKI PRZEGLĄD CHIRURGICZNY 2010, 82, 11, /v z The results of surgical treatment of the forearm deformity in perinatal brachial plexus palsy Jerzy Gosk 1, Roman Rutowski 1,2, Maciej Urban 1, Roman Wiącek 1, Witold Wnukiewicz 1, Piotr Mazurek 1 Department of Traumatology, Clinic of Traumatology and Hand Surgery, Medical University in Wrocław 1 Kierownik: prof. dr hab. R. Rutkowski Department of Biostructure, Department of Sport Medicine and Nutrition, University of Physical Education in Wrocław 2 Kierownik: prof. dr hab. M. Mędraś The aim of the study was the estimation of the results of surgical correction in pronation or supination forearm deformity. Material and methods. Clinical material comprised 19 patients, both sexes, in age from 2 years 3 months to 14 years who were treated in years because of forearm deformation due to perinatal brachial plexus palsy. Evaluation of the results of surgical treatment has been performed in all cases with using Al-Qattan s scale. Results. As a result of performed tenomioplastic operations in all operated patients functional position of forearm has been achieved (grade 3 in Al-Qattan s scale)., and in 8 cases additionally good range of pronation and supination (grade 4 in Al-Qattan s scale). Conclusions. The necessity of forearm deformity correction in perinatal brachial plexus palsy may concern patients who have been treated microsurgically in very early childhood, and also patients who haven t been qualified to primary surgical treatment because of significant improvement of upper limb function as a result of rehabilitation. Tenomioplastic operations used in forearm position correction should be reserved for patients without fixed contracture who have possibility of forearm passive rotation moves. These procedures are burdened by low risk of complications and with proper qualification they can provide significant improvement of upper limb functional efficiency. Key words: supination forearm deformity, pronation forearm deformity, perinatal brachial plexus palsy, surgical treatment Forearm deformity (supination or pronation) in perinatal brachial plexus palsy is a result of disturbed balance between supinators (biceps innervated by musculocutaneous nerve, supinator antebrachi innervated by radial nerve) and pronators (pronator teres, and pronator quadratus innervated by median nerve) (1, 2). In cases of supination deformity which are susceptible to passive redressment, improvement can be obtained by translocation of distal insertion of biceps brachii or plastic of distal insertion of brachioradialis muscle (1, 2). In some situations it is impossible to achieve pronation moves because of conflict between bicipital tuberosity and ulna. In such cases, Eberhard recommends transposition of bicipital tuberosity (3). Pronation forearm deformity with possibility of passive redressment can be corrected by elongation or transpositon of pronator teres muscle insertion under radial bone (4, 5). Tendention to contracture consolidation without possibility of passive redressment becomes stronger with the passage of time. Such a state of affairs can be corrected only by osteotomy or osteoclasis (1, 6). Material and methods Clinical material comprised 19 patients, both sexes, with perinatal brachial plexus

The results of surgical treatment of the forearm deformity in perinatal brachial plexus palsy 611 palsy who were treated surgically because of pronation (17) and supination (2) forearm deformity from

In cases of pronation deformity transposition of distal insertion of muscle pronator teres under radial bone has been performed.

2 The results of surgical treatment of the forearm deformity in perinatal brachial plexus palsy 611 palsy who were treated surgically because of pronation (17) and supination (2) forearm deformity from January 2001 till December Patients age was between 2 years 3 months and 14 years. In cases of pronation deformity transposition of distal insertion of muscle pronator teres under radial bone has been performed. In one case of supination deformity tenomioplasty of brachioradialis muscle tendon has been performed, and in second case transposition of distal insertion of biceps brachii has been performed (fig. 1 and 2). Basic clinical data such as: clinical view of lesion, patient s age during tenomioplastic surgery, kind of microsurgical treatment (early performed in some cases) have been presented in tab. 1. For evaluation of initial character of forearm deformity and achieved results of treatment Al-Qattan s scale has been used (7). Al-Qattan s scale for evaluation of forearm rotation moves: grade 1 pronated forearm causing a functional and cosmetic disability of the limb; grade 2 supinated forearm causing a functional and cosmetic disability of the limb; grade 3 functional forearm position (mid pronation-supination or slight pronation) with no or minimal active motion; grade 4 functional forearm position with good active pronation and supination; grade 5 normal power and range of motion. Evaluation: operative correction is necessary in grade 1 and 2 (7) Results Pronation forearm deformity has been observed in 2 cases of upper lesions (C5-C6), in 10 cases of upper-middle (C5-C6-C7) lesions, and in 5 cases of total lesions (C5-Th1). 11 patients from this group have been microsurgically treated in infancy, whereas in 6 cases a significant improvement of upper limb function has been achieved by rehabilitation (tab. 1, pos ). In these children, who haven t been qualified to primary microsurgical treatment, only single deficits of function such as pronation forearm deformation, contracture of subscapular muscle (2 patients tab. 1, pos. 16, 17), and elbow contracture (1 patient tab. 1, pos. 18) have been observed in long term observation. Supination deformity has Fig. 1. Intraoperative view: status after dissection of the distal insertion of the biceps brachi Fig. 2. Intraoperative view: status after transposition of the distal insertion of the biceps brachii and fixation to the radial bone been observed only in cases of total brachial plexus lesions (tab. 1, pos. 5, 8). As a result of pronation deformity treatment in 9 patients improvement from grade 1 to 3 and in 8 patients improvement from grade 1 to 4 in Al- Qattan s scale has been achieved. The patients with pronation deformation and improvement to grade 3 obtained functional position of the forearm without active suspination movement. The deficit of active pronation movement didn t exceed 20 degree in any patient. In both cases of supination deformity improvement from grade 2 to 3 has been obtained. Discussion In literature more attention is being payed to treatment a supination forearm

3 612 J. Gosk et al. Case no Table 1. Clinical data and achieved results of surgical treatment of patients with forearm deformity due to perinatal brachial plexus palsy Clinical view of lesion Patient s age Primary character of deformity deformity in perinatal brachial plexus palsy (1, 2, 3, 8, 9). According to some authors pronation forearm deformity is not such a significant functional problem to give reasons for surgical treatment (1, 8). It is necessary to remember that each of discussed deformity significantly disadvantages function of the upper limb (4, 5). In their course with time such deformations of osteoarticu- Treatment result Microsurgical treatment 1 uppermiddle 3 years 1 4 external neurolysis 2 months 2 uppermiddle 2 years 1 3 external neurolysis 3 uppermiddle 14 year 1 4 external neurolysis 4 total 9 year 1 3 external neurolysis 5 total 8 year 2 3 external and internal neurolysis 6 uppermiddle 2 years 1 3 external neurolysis 7 uppermiddle 9 year 1 4 external and internal neurolysis 8 total 4 years 2 3 external neurolysis 9 uppermiddle 3 years 1 4 rupper trunk reconstruction by direct neurorrhaphy + middle trunk neurolysis 10 total 4 years 1 3 ventral ramus of C5, C6 reconstruction by direct neurorrhaphy and middle + lower trunk neurolysis 11 total 5 year 1 3 upper trunk reconstruction by direct neurorrhaphy+ middle and lower trunk neurolysis 12 total 2 years 3 months 1 3 upper trunk reconstruction by direct neurorrhaphy+ extraanatomical intraplexus reconstruction of spinal nerve C8with proximal part of upper trunk + extraanatomical extraplexus reconstruction of spinal nerve C7with sensory ramus of cervical plexus + Th1 neurolysis 13 total 4 years 14 upper 3 years 15 upper 5 year months 16 uppermiddle 3 years uppermiddle 10 year months 18 uppermiddle 12 year uppermiddle 13 year extraanatomical extraplexus reconstruction of spinal nerve C5, C6 with motor ramus to trapezius muscle and spinal nerve C7 with sensory ramus of cervical plexus 1 4 lar system as: palmar subluxation of distal end of ulna, anterior or posterior subluxation of radial bone head are beeing observed (1, 5, 10). In own material dominated pronation deformities. To surgical treatment a cases with extreme pronation position of the forearm without fixed contracture, and with possibility of passive rotation of the forearm have been qualified.

The results of surgical treatment of the forearm deformity in perinatal brachial plexus palsy 613 Classically pronation deformity of the forearm appear in upper injuries of the brachial plexus with

Liggio and co-workers had the similar observations; they have found total lesions of brachial plexus in 5 from 7 operated patients (5).

4 The results of surgical treatment of the forearm deformity in perinatal brachial plexus palsy 613 Classically pronation deformity of the forearm appear in upper injuries of the brachial plexus with concomitant adduction and internal rotation of shoulder (5, 11, 12). In own material pronation deformity has been observed also in total lesions (in 5 from 17 operated cases). Liggio and co-workers had the similar observations; they have found total lesions of brachial plexus in 5 from 7 operated patients (5). Muscular balance disorders that lead to forearm deformity in total palsies are the consequences of diversified return of neurologic function of each part of brachial plexus (5). As a result of performed treatment in all patients functional position of forearm has been achieved, and in 8 from 19 operated also good range of pronation and supination moves (fig. 3 and 4). Conclusions 1. The necessity of forearm deformity correction in perinatal brachial plexus palsy may concern patients who have been treated microsurgically in very early childhood, and also patients who haven t been qualified to primary surgical treatment because of significant improvement of upper limb function as a result of rehabilitation. 2. Tenomioplastic operations used in forearm position correction should be reserved for patients without fixed contracture who have possibility of forearm passive rotation moves. These procedures are burdened by low risk of complications and with proper qualification they can provide significant improvement of upper limb functional efficiency. Fig. 3. The result of the surgical treatment after transposition of the distal insertion of pronator teres muscle: active forearm supination Fig. 4. The result of the surgical treatment after transposition of the distal insertion of pronator teres muscle: active forearm pronation References 1. Bahm J, Gilbert A: Surgical correction of supination deformity in children with obstetric brachial plexus palsy. J Hand Surg 2002; 27B: Ozkan T, Aydin A, Ozer K et al.: A surgical technique for pediatric forearm pronation: brachioradialis rerouting with interosseous membrane release. J Hand Surg 2004; 29A: Eberhard D: Transposition of the bicipital tuberosity for treatment of fixed supination contracture in obstetric brachial plexus lesions. J Hand Surg 1997; 22B: Chuang DC, Ma HS, Wei FC: A new evaluation system to predict the sequelae of late obstetric brachial plexus palsy. Plast Reconstr Surg 1998, 101: Liggio FJ, Tham S, Price A et al.: Outcome of surgical treatment for forearm pronation deformities in children with obstetric brachial plexus injuries. J Hand Surg 1999; 24B:

5 614 J. Gosk et al. 6. Blount WP: Osteoclasis for supination deformities in children. J Bone Joint Surg 1940; 22: Al-Qattan MM: Assessment of the motor power in older children with obstetric brachial plexus palsy. J Hand Surg 2003; 28B: Gilbert A: Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin 1995; 11: Price A, Grossman JA: A management approach for secondary shoulder and forearm deformities following obstetrical brachial plexus injury. Hand Clin 1995; 11: Gosk J, Rutowski R, Szmida A: Okołoporodowe obrażenia splotu ramiennego. W: Czernik J (red.) Powikłania w chirurgii dziecięcej.: PZWL, Warszawa 2009; s Birch R: Obstetric brachial plexus palsy. J Hand Surg 2002; 27B: Price A, Tidwell M, Grossman JA: Improving shoulder and elbow function in children with Erb s palsy. Sem Pediatr Neurol 2000; 7: Received: r. Adress correspondence: Wrocław, ul. Borowska 213

Neurolysis of the conducting neuroma-in-continuity in perinatal brachial plexus palsy evaluation of the results of surgical treatment

Original article Neurolysis of the conducting neuroma-in-continuity in perinatal brachial plexus palsy evaluation of the results of surgical treatment Jerzy Gosk 1, Roman Rutowski 1, 2, Maciej Urban 1,