Evaluation of Long-Term Results of Oberlin Surgery in Obstetric Brachial Paralysis / Avaliação dos resultados a longo prazo da cirurgia de Oberlin na paralisia braquial obstétrica

Abstract Objective To evaluate elbow flexion in children with obstetric brachial plexus paralysis submitted to Oberlin transfer. Methods Retrospective study with 11 patients affected by paralysis due to labor who did not present spontaneous recovery from elbow flexion until 12 months of life, operated between 2010 and 2018. Results The children were operated between 5 and 12 months of life, with a mean of 7.9 months, and the mean follow-up time was 133.2 months, ranging from 37 to 238 months. Six patients (54.5%) presented a degree of muscle strength ≥ 3, measured by the strength scale of the Medical Research Council (MRC) and, according to the active movement scale (AMS), 5 patients obtained a score of ≥ 5. A negative correlation was identified between the AMS and the Narakas classification (r = -0.509), as well as between the strength scale (MRC) and the Narakas classification (r = -0.495). A strong positive correlation was observed (r = 0.935) between the AMS and the MRC demonstrating that the higher the score on the movement scale, the higher the score on the muscle strength scale. Conclusion The Oberlin surgery is a possible option for recovery of elbow flexion in children with neonatal plexopathy, demonstrating, however, very heterogeneous results, even in the long-term follow-up.

Resumo Objetivo Avaliar a flexão do cotovelo em crianças portadoras de paralisia obstétrica do plexo braquial submetidas à transferência de Oberlin. Métodos Estudo retrospectivo com 11 pacientes acometidos por paralisia decorrente do trabalho de parto e que não apresentaram recuperação espontânea da flexão do cotovelo até os 12 meses de vida, operados entre 2010 e 2018. Resultados As crianças foram operadas entre os 5 e 12 meses de vida, com média de 7,9 meses e o tempo médio de seguimento foi de 133,2 meses, variando de 37 a 238 meses. Seis pacientes (54,5%) apresentaram grau de força muscular ≥ 3, medido pela escala de força do Medical Research Council (MRC), e, pela escala de movimentação ativa (Active Momement Scale [AMS]), 5 pacientes obtiveram pontuação ≥ 5. Foi identificada correlação negativa entre a AMS e a classificação de Narakas (r = -0,509), bem como entre a MRC e a classificação de Narakas (r = -0,495). Já entre a AMS e a MRC, foi observada forte correlação positiva (r = 0,935), demonstrando que quanto maior a pontuação na escala de movimento, maior será a pontuação na escala de força muscular. Conclusão A cirurgia de Oberlin apresenta-se como uma opção possível para a recuperação da flexão do cotovelo em crianças com plexopatia neonatal; no entanto, demonstra resultados bastante heterogêneos, mesmo no seguimento a longo prazo.

Obstetric Paralysis: Evaluation of the Sever-L'Episcopo Technique Modified by Hoffer / Paralisia obstétrica: Avaliação da técnica Sever-L'Episcopo modificada por Hoffer

Abstract Evaluate the results of a series of 28 cases of high obstetric paralysis treated with the Sever-L'Episcopo technique modified by Hoffer, between 2003 and 2016. Children (mean age, four years and seven months) with adduction contracture and internal rotation of the shoulder without secondary bone deformities (Mallet class II) underwent lengthening of the pectoralis major muscle and tenotomy of the subscapularis muscle associated with transfer of the latissimus dorsi and teres major muscle to the infraspinatus muscle, moving to the function of external rotators and elevators. The mean follow-up was three years and 10 months. At the end of the study, 24 patients achieved excellent functional assessment scores, mainly of the abduction and external rotation, passing from Mallet class II to class IV. Four patients still demonstrated some degree of global movement limitation, passing from class II to class III. Regardless of the final functional gain, all patients were able to perform tasks that were previously difficult. The data from this study suggest that Hoffer's surgery is an effective method in the treatment of the sequelae of high obstetric paralysis without secondary bone deformities.

Resumo Avaliar os resultados de uma série de 28 casos de paralisia obstétrica alta tratadas com a técnica Sever-L'Episcopo modificada por Hoffer, entre 2003 e 2016. As crianças (idade média, quatro anos e sete meses) com contratura em adução e rotação interna do ombro sem deformidades ósseas secundárias (Mallet classe II) foram submetidas ao alongamento do músculo peitoral e tenotomia do músculo subescapular associada à transferência do latissimus dorsi e músculo redondo maior para o músculo infraespinhal, movendo-se para a função de rotadores externos e elevadores. O seguimento médio foi de 3 anos e 10 meses. Ao final do estudo, 24 pacientes obtiveram excelentes escores de avaliação funcional, principalmente de abdução e rotação externa, passando de Mallet classe II para classe IV. Quatro pacientes ainda demonstraram algum grau de limitação de movimento global, passando da classe II para a classe III. Independentemente do ganho funcional final, todos os pacientes foram capazes de realizar tarefas que antes eram difíceis. Os dados deste estudo sugerem que a cirurgia de Hoffer é um método eficaz no tratamento das sequelas de paralisia obstétrica alta sem deformidades ósseas secundárias.

Obstetric Paralysis: Who is to blame? A systematic literature review / Paralisia obstétrica: De quem é a culpa? Uma revisão sistemática de literatura

Abstract Obstetric palsy is classically defined as the brachial plexus injury due to shoulder dystocia or to maneuvers performed on difficult childbirths. In the last 2 decades, several studies have shown that half of the cases of Obstetric palsy are not associated with shoulder dystocia and have raised other possible etiologies for Obstetric palsy. The purpose of the present study is to collect data from literature reviews, classic articles, sentries, and evidence-based medicine to better understand the events involved in the occurrence of Obstetric palsy. A literature review was conducted in the search engine PubMed (MeSH - Medical Subject Headings) with the following keywords: shoulder dystocia and obstetric palsy, completely open, boundless regarding language or date. Later, the inclusion criterion was defined as revisions. A total of 21 review articles associated with the themes described were found until March 8, 2018. Faced with the best available evidence to date, it is well-demonstrated that Obstetric palsy occurs in uncomplicated deliveries and in cesarean deliveries, and there are multiple factors that can cause it, relativizing the responsibility of obstetricians, nurses, and midwives. The present study aims to break the paradigms that associate Obstetric palsy compulsorily with shoulder dystocia, and that its occurrence necessarily implies negligence, malpractice or recklessness of the team involved.

Resumo A paralisia obstétrica é classicamente definida como a lesão do plexo braquial decorrente da distócia de ombros ou das manobras executadas no parto difícil. Nas 2 últimas décadas, vários estudos comprovaram que metade dos casos de paralisia obstétrica não estão associados à distócia de ombros e levantaram outras possíveis etiologias para a paralisia obstétrica. O objetivo do presente trabalho é colher dados da literatura de revisão, artigos clássicos, sentinelas e da medicina baseada em evidências para compreender melhor os eventos envolvidos na ocorrência de paralisia obstétrica. Foi realizada uma revisão da literatura no motor de busca da PubMed (MeSH - Medical Subject Headings) com as seguintes palavras-chave: shoulder dystocia and obstetric palsy, completamente aberto, sem limites de língua ou data. Posteriormente, definimos como critério de inclusão artigos de revisão. Encontramos 21 artigos de revisão com associação dos temas descritos até 8 de março de 2018. Frente às melhores evidências existentes até o momento, está bem demonstrado que a paralisia obstétrica ocorre em partos não complicados e em partos cesáreos, e são múltiplos os fatores que podem causá-la, relativizando a responsabilidade de médicos obstetras, enfermeiras e parteiras. Procuramos, com o presente estudo, quebrar os paradigmas de que paralisia obstétrica se associa obrigatoriamente à distócia de ombros e que a sua ocorrência necessariamente implica em negligência, imperícia ou imprudência da equipe envolvida.

Obstetric paralysis: anterior arthroscopic release of the shoulder and transfer of the latissimus dorsi using a homologous graft / Paralisia obstétrica: liberação artroscópica anterior do ombro e transferência do grande dorsal com enxerto homólogo

OBJECTIVE: Description of a new surgical technique for treating the shoulders of patients with sequelae of obstetric paralysis. Preliminary analysis on the results obtained from this technique. METHODS: Five consecutive patients underwent the proposed surgical procedure, consisting of arthroscopic anterior joint release followed by transfer of the latissimus dorsi tendon (elongated and reinforced with a homologous tendon graft) to the posterosuperior portion of the greater tubercle, using a single deltopectoral approach. All the patients were reevaluated after a minimum postoperative period of twelve months. The functional assessment was based on the range of motion and the modified Mallet classification system. Statistical analyses were not possible because of the small sample. RESULTS: Overall, passive and active lateral rotations increased, while medial rotation decreased. The other movements (elevation, capacity to place a hand in the mouth and capacity to place a hand behind the neck) had less consistent evolution. The mean modified Mallet score improved by 4.2 points (from 11.4 to 15.6). CONCLUSION: The latissimus dorsi tendon can be transferred to the posterosuperior portion of the greater tubercle through a single deltopectoral approach when elongated and reinforced with a homologous tendinous graft.

OBJETIVOS: Descrição de uma nova técnica cirúrgica para o tratamento de ombro de pacientes com sequela de paralisia obstétrica. Análise preliminar dos resultados obtidos com essa técnica. MÉTODOS: Cinco pacientes consecutivos foram submetidos ao tratamento cirúrgico proposto, que envolve a liberação articular anterior por via artroscópica, seguida da transferência do tendão do músculo grande dorsal (alongado e reforçado com enxerto tendíneo homólogo) para a porção póstero-superior do tubérculo maior, com o uso de uma única via delto-peitoral. Todos foram reavaliados após um período pós-operatório mínimo de 12 meses. A avaliação da função baseou-se na amplitude de movimento e na classificação modificada de Mallet. A pequena casuística não permitiu análises estatísticas. RESULTADOS: De forma geral, as rotações laterais passiva e ativa melhoraram, enquanto a rotação medial piorou. Os outros movimentos (elevação, capacidade de colocação da mão na boca e capacidade de colocação da mão na nuca) tiveram evolução menos consistente. A média do escore de Mallet modificado melhorou 4,2 pontos (de 11,4 para 15,6). CONCLUSÃO: O tendão do músculo grande dorsal pode ser transferido para a porção póstero-superior do tubérculo maior por meio de uma única via delto-peitoral, quando alongado e reforçado com enxerto tendíneo homólogo.

Parálisis braquial obstétrica en el contexto de la rehabilitación física temprana / Obstetric Brachial Plexus Palsy in the Context of Early Physical Rehabilitation

En la actualidad el sistema de salud cubano promueve el estudio prenatal y el seguimiento del embarazo; a pesar de esto la parálisis braquial obstétrica continúa siendo una consecuencia desafortunada tras un parto difícil y constituye uno de los traumatismos obstétricos más frecuentes. Su tratamiento ha sido tradicionalmente conservador, basado en el seguimiento multidisciplinario y consultas a los distintos especialistas para tratar las secuelas. Luego de realizar una amplia revisión bibliográfica, en este artículo se exponen la etiología, anatomía, fisiopatología, tipos de lesiones, pronóstico y evolución, secuelas, instrumentos de evaluación, tratamientos existentes y ejercicios para la parálisis braquial obstétrica.

Cuban health system currently promotes prenatal testing and monitoring of pregnancy; nevertheless obstetric brachial plexus palsy remains an unfortunate consequence of a difficult delivery and is one of the most common birth trauma. Traditionally, its treatment has been conservative, based on multidisciplinary monitoring and consultations with various specialists to deal with the consequences. After conducting an extensive literature review, we discussed in this paper the etiology, anatomy, pathophysiology, types of injuries, prognosis and outcome, consequences, assessment tools, existing treatments and series of exercises for obstetric brachial plexus palsy.

Una mirada a la parálisis braquial obstétrica / A glance to obstetric brachial paralysis

Se realizó una revisión bibliográfica sobre diversos aspectos de las parálisis braquiales obstétricas. Se expresan criterios de diagnóstico y se exponen opciones de tratamiento rehabilitador y quirúrgico.

We carried out a bibliographic review on the different aspects of the obstetric brachial paralysis. We express diagnostic criteria and expose options of surgical and rehabilitating treatments.

Application of electromyogram in the evaluation of subjects to N-hexane / 中国基层医药

Objective To explore the values of electromyography to examine birth injuries.Methods 34 cases of birth injuries were studied,the electromyography and motor nerve conduction of brachial plexcy were recorded.Then,the location and severity of birth injuries were determined.Results Among 34 cases,according to the location of injuries,there were 10 cases of upper trunk injuries,7 cases of upper and middle trunk injuries,5 cases of middle and lower trunk injuries,5 cases of lower trunk injuries,and 7 cases of whole brachialplexus injuries.On the other hand,according to the severity of injuries,there were one case of complete injuries and 33 cases of incomplete injuries which included 2 cases of severe injuries and 31 cases of slight injuries.Conclusion Electromyography is the reliable method to identify the location and severity of brachial plexus injuries,and this examination is necessary to diagnose birth injuries with great clinical values.

Application of nerve grafting and nerve transfer for treatment of early obstetrical brachial plexus palsy / 中华骨科杂志

Objective To evaluate the efficacy of the nerve grafting and nerve transfer (neurotization) in the treatment of early obstetrical brachial plexus palsy(OBPP). Methods 48 cases with TassinⅡ-Ⅳ lesion who had no any recovery of elbow flexion, the brachial plexus were explored from 3 to 14 months after birth. The method of nerve repair depended on findings during operation. For the traumatic neuroma, it should be resected and the defect be repaired by nerve grafting with neurotization; the root avulsion was repaired by neurotization; neurolysis was only performed to those plexus that looked nearly normal and had a positive reaction of neurophysiology as tested intra-operatively. The reconstructive procedures included: C5→upper trunk, accessory →supraspinal nerve (2 cases); C5,6→the posterior and the anterior division of the upper trunk respectively, accessory →supraspinal nerve (25 cases); C5,6→the posterior and anterior divisions of the upper trunk respectively, C7→middle trunk, accessory →supraspinal nerve (4 cases); C5→posterior cord, C6→lateral cord, accessory →supraspinal nerve (5 cases); C5→anterior division of the upper trunk, C6→C8, accessory →supraspinal nerve (1 case); C5-7→the posterior, lateral and medial cords respectively, accessory →supraspinal nerve (4 cases); C5→upper trunk, C6→lower trunk (or medial cord), accessory →supraspinal nerve (2 cases); C5,6→the lateral and medial cords respectively, accessory →supraspinal nerve (3 cases); neurolysis (2 cases). Results All the patients were available at follow-up at least for 36 months, who were studied according to both of the Gilberts shoulder and elbow rating system and the Raimondis hand scale system. The score of shoulder, elbow, and hand in 13 cases with Tassin Ⅱ lesion improved from preoperative 0.54, 1.92 and 3.23 to postoperative 3.77, 4.92 and 4.31 respectively; 11 cases with Tassin Ⅲ rose from 0.46, 1.82 and 1.91 to 3.27, 4.18 and 3.64, and 24 cases with Tassin Ⅳ had an elevation from 0.25, 1.25 and 0.33 to 2.92, 3.46 and 2.83. The medial rotation contracture of the shoulder without subluxation and dislocation was found in 7 cases(14.6%) in the process of recovery. Conclusion The resection of the traumatic neuroma combined with nerve grafting and neurotization is really effective in the treatment of early OBPP.

Diagnóstico y tratamiento de la parálisis braquial obstétrica / Diagnosis and treatment of obstetric brachial paralysis / Diagnostic et traitement de la paralysie brachiale obstétricale

Se realizó una revisión bibliográfica sobre diversos aspectos de las parálisis braquiales obstétricas. Se expresan criterios de diagnóstico y se exponen opciones de tratamiento.

A bibliographic review on the different aspects of obstetric brachial paralysis is made. Diagnostic criteria and treatment options are also approached.

Une mise en revue bibliographique sur des aspects divers des paralysies brachiales obstétricales a été effectuées. Des critères de diagnostic sont exprimés et des options de traitement sont exposées.

The Waters classification of glenohumeral joint deformity secondary to shoulder internal rotational contracture of brachial plexux birth palsy / 中华骨科杂志

Objective To evaluate the correlation between the Waters classification based on shoulder CT or MRI scan and passive shoulder external rotational angle before operation in the glenohumeral joint deformity caused by shoulder internal rotational contracture secondary brachial plexus birth palsy.Methods 33 patients suffered the shoulder internal rotational contracture secondary brachial plexus birth palsy (Tassin classification Ⅱ 19, Ⅲ 13, Ⅳ 1) including 12 girls and 21 boys, ranging from 10 months to 16 years old with an average of 4.5 years old, underwent either CT or MR examination in shoulder joint. The retroversion of the glenoid (glenoscapular angle) and the ratio of humeral head posterior subluxation were measured on the CT or MRI images according to the method described by Friedman. The deformity of glenohumeral joint was classificated according to the Waters criteria, while the passive shoulder external rotational angle was measured at neutral position in involved shoulder joint. The correlation between the external rotation and the deformity was analysed. Results 33 cases with shoulder internal rotational contracture secondary brachial plexus birth palsy were evaluated according to the Waters criteria. 4 cases were classified as typeⅠdeformity, 4 cases as typeⅡ, 7 cases as type Ⅲ, 6 cases as type Ⅳ; 5 cases as typeⅤ; 7 case as type Ⅵ. The type of glenohumeral deformity was significantly associated with the limited range of passive external rotation of the shoulder joint. Conclusion The Waters classification of the glenohumeral deformity according to the Waters criteria can accurately demonstrated the deformity of the glenohumeral joint caused by shoulder internal rotational contracture secondary to brachial plexus birth palsy.