Obstetric Brachial Plexus Injuries. Surgery department grand rounds Bassam MJ Addas, FRCSC Neurological Surgery, KAUH

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1 Obstetric Brachial Plexus Injuries. Surgery department grand rounds Bassam MJ Addas, FRCSC Neurological Surgery, KAUH

2 Definition Obstetric versus birth palsy Obstetric versus congenital palsy Not all birth palsies are Obstetric but the majority are..

3 Types of injuries 1. Complete brachial plexus injury 2. Duchenne-Erb palsy 3. Upper-middle trunk brachial plexus injury 4. Klumpke-Dejerine palsy

4 5. Fasicular brachial plexus palsy 6. Bilateral brachial plexus palsy

5 Complete injury 1.All the ventral rami 2.Flail arm 3.Sensation is variably involved 4.Horner syndrome may be present

6 Duchenne-Erb palsy 1.Involves C5 and C6 2.Upper trunk 3.Classical waiter s tip posture

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8 Clinical picture of Duchenne-Erb palsy Paralysis of the following muscles opposed by the following healthy muscles. 1. Suprascapular nerve Supraspinatus and infraspinatus Abduction and lateral rotation of the arm

9 Healthy counterpart 1. Lower and upper subscapular nerves Subscapularis and Teres major Adduction and medial rotation of the arm

10 2. Musculo-cutanous nerve Biceps, brachialis and coracobrachialis Flexion and supination of the forearm

11 Healthy counterpart 2. Forearm extensors and pronators

12 3.Axillary nerve Deltoid and teres minor Health counterpart Subscapularis and Teres minor

13 Incidence USA reports KSA / / 1000 Right arm is affected slightly more than the left The reported incidence of upper trunk palsy ranges from 58-72%, up to 90% in some studies

14 The whole plexus is involved in about 10% Phrenic nerve and diaphragmatic paralysis is involved in 5% of the cases. The incidence of permanent disability can be as high as 25%

15 Risk factors Cephalopelvic disproportion, shoulder dystocia, forceps delivery!!! Maternal diabetes Breech presentation, can be bilateral Previous child with plexus injury Fetal anomalies, cervical ribs, other. The practice of midwifery!!!!!!!

16 Natural history Largely unknown Retrospective studies Small number of patients, lots of loss of follow up Referral bias A surgical series will differ significantly when compared to a rehabilitation or medical series

17 Overall it is good for upper trunk, no so for total palsy External rotation of the shoulder and supination usually recovers late. Sensory recovery is better than motor recovery particularly in the hand

18 Return of motor function continue to recover up to 2½ years and the sensory function up to 3 years.

19 Clinical picture Flail arm is seen in most babies with the entire plexus involved The disease declares itself in 2-8 weeks Upper trunk palsy is the commonest and Klumpke paralysis is extremely rare in isolation.

20 Trauma to the clavicle, humerus, ribs, shoulder joint and scapula can occur in conjunction with OBPI and complicates the clinical picture further (pseudoparalysis) SCM tumor, torticollis, injury to c-spine, neonatal spinal cord tumor are all in the differential diagnosis.

21 Babies tend to look away from the affected side and contractures can result as a consequence.

22 The role of EMG Attempt to improve the accuracy of preoperative diagnosis. Absence of reinnervation in 3 months is indicative of avulsion injury Near normal EMG can be found in patients with complete OBPI

23 In patients with OBPI denervation occurs and disappears much earlier, can be found as early as 4 days and disappear by 4 months Short distance and small nerves are two possible explanations

24 The process may start as early as 1-2 days and disappears as early as days The majority of centres do not rely on EMG in making a preoperative diagnosis

25 Timing and indications for surgery Watching the trend myself during my residency, it was a year, then 6 months, at the end of my residency it was only 4 months

26 No deltoid or biceps recovery by 3 month Suboptimal recovery of muscle grade (M2) Persistent Horner beyond one month or so.

27 Does it matter 3 or 9 months? Not really, it does not seem to matter much on the long term in total palsy, but be careful in Erb s Why? Do patient recover beyond 9 month?

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46 Breech delivery May be small babies. Can be bilateral

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54 Traumatic Pediatric Brachial Palsy excluding Erb`s Palsy

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