Five oriented tasks in manual skills of a baby child with obstetric brachial plexus palsy / Cinco tarefas direcionadas nas habilidades manuais de uma criança com paralisia braquial obstétrica

Brachial plexus (BP) injury during labor is called obstetric brachial palsy (OBP). It is an abnormality that occurs in the upper extremity of the body due to excessive stretching of the neural roots of the BP. Every motor skill that the child with OPB acquires will be hampered by the deficiency in the movement of an upper limb (MS), impacting his motor experimentation. To modify their motor behavior, task-directed therapy can contribute to the function of the affected upper limb, because it is characterized by a protocol of functional exercises, which is still scarce in researches aimed at this morbidity. The objective of the study was to evaluate the effect of a motor intervention by means of five directed tasks on the manual skills of the upper limb of a child with OBP, as well as on his gross motor function. The child in the study was 17 months old, with left OBP, with weakness of shoulder abduction, external rotation, elbow flexion and wrist drop. He underwent 24 physiotherapy sessions with directed tasks for 45 minutes, three times a week. The Manual Ability Classification System (MACS) was used to classify the degree of severity of the MSE. The Gross Motor Function Measure (GMFM-66) quantitatively measured motor and static aspects and the Gross Motor Function Classification System (GMFCS) was used to determine which level best represented the abilities and limitations in the child's gross motor function. The targeted tasks were based on the model of the Induced Constraint Therapy (ICT) protocol, being: find the surprise; orange spoon; hair elastic fitting; fishing for bottle caps; stacking blocks. In the post-intervention assessments, the MACS showed improvement in the tasks of finding the surprise, orange spoon, and fishing for lids, but remained the same in the level of the activities of fitting the rubber bands and stacking the blocks. The GMFM-66 obtained an increase in the final score and the GMFCS remained at the level I. The GMFM-66 showed a 4.99% improvement at the end of the intervention. The activities finding the surprise, picking oranges, and fishing for bottle caps showed an improvement in the MACS level classification compared to the initial assessment. The findings show better muscle recruitment, with refinement in elbow flexion movements, forearm supination and external rotation (ER) of the shoulder (AU)

A lesão do plexo braquial (PB) durante o parto é denominada paralisia braquial obstétrica (PBO). É uma anormalidade que ocorre na extremidade superior do corpo, em consequência de um estiramento excessivo das raízes neurais do PB. Toda habilidade motora que a criança com PBO adquirir será dificultada pela deficiência na movimentação de um membro superior (MS), repercutindo em suas experimentações motoras. Para modificar seu comportamento motor, a terapia por tarefas direcionadas pode contribuir na função do MS afetado, pois a mesma caracteriza-se com um protocolo de exercícios funcionais, que ainda há escassez em pesquisas voltados a esta morbidade. O objetivo do estudo foi avaliar o efeito de uma intervenção motora através de cinco tarefas direcionadas sobre as habilidades manuais do membro superior de uma criança com PBO, bem como sua função motora grossa. A criança do estudo tinha 17 meses, com PBO à esquerda, com fraqueza de abdução de ombro, rotação externa, flexão de cotovelo e queda do punho. Realizou 24 sessões de fisioterapia com tarefas direcionadas por 45 minutos, três vezes por semana. Para classificar o grau de severidade do MSE, foi utilizado o Manual Ability Classification System (MACS). A Medida da Função Motora Grossa (GMFM-66) mediu quantitativamente aspectos motores e estáticos e o Sistema de Classificação da Função Motora Grossa (GMFCS) foi utilizado para determinar qual nível melhor representou as habilidades e limitações na função motora grossa da criança. As tarefas direcionadas foram baseadas no modelo do protocolo de terapia por contensão induzida (TCI), sendo: achar a surpresa; colher laranja; encaixar elástico de cabelo; pescaria de tampinhas; empilhar blocos. Nas avaliações pós-intervenção, o MACS demonstrou melhora no nível das tarefas de achar a surpresa, colher laranja e pescaria de tampinhas, mas manteve-se igual no nível das atividades de encaixar os elásticos e empilhar os blocos. O GMFM-66 obteve aumento do escore final e o GMFCS manteve-se no nível I. O GMFM-66 apresentou melhora de 4,99% ao final da intervenção. As atividades de achar a surpresa; colher laranjas e pescaria de tampinhas obtiveram melhora na classificação no nível do MACS quando comparadas à avaliação inicial. Os achados evidenciam melhor recrutamento muscular, com refinamento nos movimentos de flexão de cotovelo; supinação do antebraço e rotação externa (RE) de ombro (AU)

Parálisis del nervio radial neonatal: relato de un caso / Isolated radial nerve palsy in a newborn: case report

La parálisis radial neonatal aislada (PRNA) es un cuadro clínico infrecuente que debe distinguirse de otras entidades más frecuentes, como la parálisis braquial obstétrica (PBO). Debemos sospechar una PRNA en neonatos que presentan incapacidad para la extensión de muñeca y de dedos, pero mantienen intacta la función del deltoides, del bíceps, y del tríceps, así como la flexión de muñeca y de dedos. Mientras la PBO tiene una evolución clínica variable dependiendo de la extensión de la lesión neurológica, la PRNA presenta una resolución espontánea, independientemente del grado de afectación inicial. Presentamos el caso de un recién nacido con PRNA cuyo diagnóstico inicial fue de PBO.

Isolated radial nerve palsy (IRNP) in the newborn is a rare clinical condition that must be distinguished from entities that are more common, such brachial plexus birth palsy (BPBP). It should be suspected in newborns presenting with absent wrist and digital extension but intact deltoid, biceps, and triceps function, as well as wrist and digital flexor function. Whereas BPBP is highly variable depending on the extent of the neurological involvement, IRNP resolves spontaneously, regardless of the severity of the initial presentation. We herein present a case of newborn with IRNP whose initial diagnosis was of BPBP.

Cinco tarefas direcionadas nas habilidades manuais de uma criança com paralisia braquial obstétrica / Five oriented tasks in manual skills of a baby child with obstetric brachial plexus palsy

RESUMO: A lesão do plexo braquial (PB) durante o parto é denominada paralisia braquial obstétrica (PBO). É uma anormalidade que ocorre na extremidade superior do corpo, em consequência de um estiramento excessivo das raízes neurais do PB. Toda habilidade motora que a criança com PBO adquirir será dificultada pela deficiência na movimentação de um membro superior (MS), repercutindo em suas experimentações motoras. Para modificar seu comportamento motor, a terapia por tarefas direcionadas pode contribuir na função do MS afetado, pois a mesma caracteriza-se com um protocolo de exercícios funcionais, que ainda há escassez em pesquisas voltados a esta morbidade. O objetivo do estudo foi avaliar o efeito de uma intervenção motora através de cinco tarefas direcionadas sobre as habilidades manuais do membro superior de uma criança com PBO, bem como sua função motora grossa. A criança do estudo tinha 17 meses, com PBO à esquerda, com fraqueza de abdução de ombro, rotação externa, flexão de cotovelo e queda do punho. Realizou 24 sessões de fisioterapia com tarefas direcionadas por 45 minutos, três vezes por semana. Para classificar o grau de severidade do MSE, foi utilizado o Manual Ability Classification System (MACS). A Medida da Função Motora Grossa (GMFM-66) mediu quantitativamente aspectos motores e estáticos e o Sistema de Classificação da Função Motora Grossa (GMFCS) foi utilizado para determinar qual nível melhor representou as habilidades e limitações na função motora grossa da criança. As tarefas direcionadas foram baseadas no modelo do protocolo de terapia por contensão induzida (TCI), sendo: achar a surpresa; colher laranja; encaixar elástico de cabelo; pescaria de tampinhas; empilhar blocos. Nas avaliações pós-intervenção, o MACS demonstrou melhora no nível das tarefas de achar a surpresa, colher laranja e pescaria de tampinhas, mas manteve-se igual no nível das atividades de encaixar os elásticos e empilhar os blocos. O GMFM-66 obteve aumento do escore final e o GMFCS manteve-se no nível I. O GMFM-66 apresentou melhora de 4,99% ao final da intervenção. As atividades de achar a surpresa; colher laranjas e pescaria de tampinhas obtiveram melhora na classificação no nível do MACS quando comparadas à avaliação inicial. Os achados evidenciam melhor recrutamento muscular, com refinamento nos movimentos de flexão de cotovelo; supinação do antebraço e rotação externa (RE) de ombro. (AU)

ABSTRACT: Brachial plexus (BP) injury during labor is called obstetric brachial palsy (OBP). It is an abnormality that occurs in the upper extremity of the body due to excessive stretching of the neural roots of the BP. Every motor skill that the child with OPB acquires will be hampered by the deficiency in the movement of an upper limb (MS), impacting his motor experimentation. To modify their motor behavior, task-directed therapy can contribute to the function of the affected upper limb, because it is characterized by a protocol of functional exercises, which is still scarce in researches aimed at this morbidity. The objective of the study was to evaluate the effect of a motor intervention by means of five directed tasks on the manual skills of the upper limb of a child with OBP, as well as on his gross motor function. The child in the study was 17 months old, with left OBP, with weakness of shoulder abduction, external rotation, elbow flexion and wrist drop. He underwent 24 physiotherapy sessions with directed tasks for 45 minutes, three times a week. The Manual Ability Classification System (MACS) was used to classify the degree of severity of the MSE. The Gross Motor Function Measure (GMFM-66) quantitatively measured motor and static aspects and the Gross Motor Function Classification System (GMFCS) was used to determine which level best represented the abilities and limitations in the child's gross motor function. The targeted tasks were based on the model of the Induced Constraint Therapy (ICT) protocol, being: find the surprise; orange spoon; hair elastic fitting; fishing for bottle caps; stacking blocks. In the post-intervention assessments, the MACS showed improvement in the tasks of finding the surprise, orange spoon, and fishing for lids, but remained the same in the level of the activities of fitting the rubber bands and stacking the blocks. The GMFM-66 obtained an increase in the final score and the GMFCS remained at the level I. The GMFM-66 showed a 4.99% improvement at the end of the intervention. The activities finding the surprise, picking oranges, and fishing for bottle caps showed an improvement in the MACS level classification compared to the initial assessment. The findings show better muscle recruitment, with refinement in elbow flexion movements, forearm supination and external rotation (ER) of the shoulder. (AU)

Nerve Graft and Nerve Transfer for Improving Elbow Flexion in Children with Obstetric Palsy. A Systematic Review / Enxerto e transferência de nervo para melhora da flexão do cotovelo em crianças com paralisia obstétrica. Uma revisão sistemática

Abstract Obstetric brachial plexus palsy is a rather common injury in newborns, caused by traction to the brachial plexus during labor. In this context, with the present systematic review, we aimed to explore the use of nerve graft and nerve transfer as procedures to improve elbow flexion in children with obstetric palsy. For the present review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the MEDLINE, EMBASE, LILACS, The Cochrane Central Register of Controlled Trials, Web of Science, Wholis and SCOPUS databases. Predetermined criteria defined the following requirements for inclusion of a study: Clinical trials, quasi-experiments, and cohort studies that performed nerve graft and nerve transfer in children (≤ 3 years old) with diagnosis of obstetric palsy. The risk of bias in nonrandomized studies of interventions assessment tool was used for nonrandomized studies. Out of seven studies that used both procedures, three of them compared the procedures of nerve graft with nerve transfer, and the other four combined them as a reconstructive method for children with obstetric palsy. According to the Medical Research Council grading system, both methods improved equally elbow flexion in the children. Overall, our results showed that both techniques of nerve graft and nerve transfer are equally good options for nerve reconstruction in cases of obstetric palsy. More studies approaching nerve reconstruction techniques in obstetric palsy should be made, preferably randomized clinical trials, to validate the results of the present systematic review.

Resumo A paralisia obstétrica do plexo braquial é uma lesão bastante comum em neonatos, sendo causada pela tração do plexo braquial durante o trabalho de parto. A presente revisão sistemática tem como objetivo exploraro uso de enxertose transferências de nervo como procedimentos para melhora da flexão do cotovelo em crianças com paralisia obstétrica. A presente revisão sistemática seguiu as diretrizes Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, na sigla em inglês) e foi baseada em pesquisa nos bancos de dados MEDLINE, EMBASE, LILACS, The Cochrane Central Register of Controlled Trials, Web of Science, Wholis e SCOPUS. De acordo com os critérios pré-determinados, os artigos incluídos eram ensaios clínicos, quase-experimentos, e estudos de coortes sobre enxertos e transferências de nervos em crianças (de até 3 anos de idade) com diagnóstico de paralisia obstétrica. A ferramenta de avaliação Risk of Bias in Non-Randomized Studies of Interventions foi usada em estudos não randomizados. Sete estudos utilizaram os dois procedimentos; três deles compararam os procedimentos de enxerto e transferência de nervo, enquanto os outros quatro os combinaram como método reconstrutivo em crianças com paralisia obstétrica. Segundo o sistema de classificação do Medical Research Council, os dois métodos melhoraram a flexão do cotovelo das crianças de maneira similar. De modo geral, nossos resultados mostraram que o enxerto de nervo e a transferência de nervo são opções igualmente boas para a reconstrução nervosa em casos de paralisia obstétrica. Mais estudos sobre as técnicas de reconstrução nervosa na paralisia obstétrica devem ser realizados, de preferência ensaios clínicos randomizados, para validação dos resultados dessa revisão sistemática.

Cirugía de oberlin en parálisis braquial obstétrica. Nota técnica / Oberlin surgery in obstetric brachial palsy. Technical note

Introducción: La parálisis braquial obstétrica (PBO) constituye una complicación poco frecuente del parto. La mayoría de los pacientes recuperan espontáneamente, sin embargo en algunos casos debe realizarse una neurocirugía para reinervar músculos y restablecer funciones. Las ramas mayoritariamente afectadas son C5-C6. Oberlin describió por primavera vez un tipo de trasferencia nerviosa en 4 pacientes adultos, utilizando fascículos del nervio ulnar para reanimar el músculo bíceps. El objetivo de este trabajo consiste en realizar una nota técnica sobre la cirugía de Oberlin, en el contexto de una PBO. Esta nota técnica surge del análisis de 4 cirugías pediátricas y de las disecciones de 14 miembros superiores fetales. Descripción técnica: Paciente en decúbito dorsal, con el brazo afectado extendido, en supinación y abducción de 90°. Se incide piel 4cm de extensión en cara interna del brazo, hasta identificar la fascia braquial. Posteriormente se diseca la rama motora del bíceps y fascículos del ulnar. Mediante magnificación se aproximan los cabos y se realiza la neurorrafia. Discusión: Existen múltiples técnicas descriptas de transferencia nerviosa, escasa es la bibliografía en pacientes pediátricos. La cirugía de Oberlin puede ser realizada en pediatría. Conclusión: Presentamos los pasos de la cirugía de transferencia nerviosa descripta por Oberlin, la misma es reproducible en pacientes lactantes en contexto de PBO, quedando expuestos los detalles técnicos y los reparos anatómicos para su realización.

Introduction: Obstetrical brachial plexus palsy (OBPP) is a rare complication of labor. Most patients recover spontaneously, however, in some cases neurosurgery must be perform to re innervate muscles and restore functions. The most frequent affected roots are C5-C6. Oberlin first described a type of nervous transfer in 4 adult patients, using fascicles of the ulnar nerve to reanimate the biceps muscle. The objective of this paper is to make a technical note about Oberlin's surgery regarding OBPP. This technical note emerges from the analysis of 4 pediatric surgeries and 14 fetal upper limbs dissections. Technical description: Patient was place in dorsal decubitus, with the compromised upper limb extended in supination and 90 ° abduction. Skin incision of 4 cm long is made along the medial aspect of the arm, until the brachial fascia is identified. Subsequently, the motor branch of the biceps muscle and fascicles of the ulnar nerve are dissect. Under microscopic magnification, both nerves are approached and the neurorrhaphy is performed. Discussion: There are multiple nerve transfer techniques described; but bibliography in pediatric patients is limited. Oberlin surgery can be performed in pediatrics. Conclusion: The steps of the nerve transfer surgery described by Oberlin presented can be applied in the case of obstetrical brachial plexus palsy, the technical details and the anatomical repairs for its realization are outlined

Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n » 43), or a fascicle of themedian nerve (group B, n » 16) or a combination of both (group C, n » 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar þ median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

Instrumentos de avaliação utilizados por terapeutas ocupacionais na criança com paralisia braquial obstétrica / Assessment tools used by occupational therapists in children with obstetric brachial plexus palsy

Introdução: A paralisia braquial obstétrica (PBO) é resultado de lesão do plexo braquial ao nascimento, podendo ocasionar disfunções do membro superior acometido, repercutindo de forma significativa na vida da criança. Ao avaliar a criança com PBO, o terapeuta ocupacional pode fazer uso de instrumentos de avaliação, devendo ter conhecimentos para escolher e aplicar o instrumento mais apropriado. Objetivo: O objetivo desta revisão foi analisar a literatura sobre utilização de instrumentos de avaliação por terapeutas ocupacionais na criança com PBO. Método: A busca dos artigos foi realizada nas bases de dados Scirus, Cinahl, Medline, Psycinfo, Scopus e Lilacs, atendendo aos critérios de seleção: estudos realizados em crianças com PBO de 0 a 12 anos, nos idiomas inglês, português e espanhol, publicados nos últimos 10 anos, que tivessem o terapeuta ocupacional como um dos autores e/ou reportassem a aplicação do instrumento por este profissional. Resultados: Foram encontrados 15 estudos, provenientes de seis países que reportaram 17 instrumentos de avaliação, dos quais cinco desenvolvidos recentemente eram específicos para essa clientela. Não foi identificada a necessidade de modificar os instrumentos não específicos para a aplicação nas crianças com PBO, demonstrando que estes podem ser usados em seu formato original, facilitando o uso na prática clínica. A maioria dos instrumentos contemplou aspectos relacionados ao desempenho ocupacional inseridos no domínio de Atividade e Participação da Classificação Internacional de Funcionalidade, indicando a preocupação deste profissional em adequar o processo de avaliação da criança com PBO ao paradigma atual de compreensão de saúde e ao campo da Terapia Ocupacional.

Introduction: The Obstetric Brachial Plexus Palsy (OBPP) is a result of brachial plexus injury at birth and may cause dysfunction of the affected upper limb, reflecting significantly in the child's life. When evaluating a child with OBPP the occupational therapist can use evaluation tools, and has to have knowledge to choose and apply the most appropriate instrument. Objective: This review aimed to analyze the literature on the use of evaluation tools by occupational therapists in children with OBPP. Method: The search for articles was performed in the databases Scirus, Cinahl, Medline, Psycinfo, Scopus and Lilacs using the following selection criteria: studies with 0-12 years old children with OBPP in English, Portuguese and Spanish, published in the last 10 years, with the occupational therapist as one of the authors and/or reporting the application of the instrument by this professional. Results: There were 15 studies from six countries that reported 17 evaluation instruments, five of which, recently developed, were specific to this clientele. The study did not identify the need to modify the non-specific instruments to the application in children with OBPP, demonstrating that they can be used in its original format, facilitating the use in the clinical practice. Most instruments included aspects related to occupational performance inserted in the field of Activity and Participation of the International Classification of Functioning, indicating the concern of this professional in suiting the assessment process of the child with the OBPP to the current paradigm of health understanding and occupational therapy field.

Effect of Electromyographic Biofeedback Motion Sensing Game on Upper Limb Function in Children with Ob-stetric Brachial Plexus Injury / 中国康复理论与实践

Objective To investigate the effect of electromyographic biofeedback motion sensing game on upper limb function in chil-dren with obstetric brachial plexus palsy (OBPP). Methods From March, 2013 to February, 2014, 41 children with OBPP were randomly as-signed into conventional rehabilitation group (n=21) and motion sensing game group (n=20). Both groups underwent a comprehensive course of rehabilitation, and the motion sensing game group received upper limb occupational therapy in the motion sensing game, for four weeks. They were assessed with Mallet shoulder function scale and the surface electromyogram (EMG) of the deltoid muscle when abduct-ing the shoulder before and after treatment. Results Before treatment, there was no significant difference in the Mallet scores between two groups (t=0.730, P>0.05), the scores improved after treatment in both groups (t>5.085, P3.195, P4.420, P2.282, P2.155, P<0.05). Conclusion Electromyographic biofeedback motion sensing game therapy plays a role in the rehabilitation of upper limb function and muscle strength in children with OBPP.

Effects of Botulinum Toxin on Reducing the Co-contraction of Antagonists in Birth Brachial Plexus Palsy

Birth brachial plexus palsy (BBPP) is usually caused by plexus traction during difficult delivery. Although the possibility of complete recovery is relatively high, 5% to 25% of BBPP cases result in prolonged and persistent disability. In particular, muscle imbalance and co-contraction around the shoulder and elbow cause abnormal motor performance, osseous deformities, and joint contracture. Physical and occupational therapies have most commonly been used, but these conventional therapeutic strategies have often been inadequate, in managing the residual muscle imbalance and muscle co-contraction. Therefore, we attempted to improve the functional movements, by using botulinum toxin type A, to reduce the abnormal co-contraction of the antagonist muscles.

Artrodesis de hombro vs cirugía primaria de reconstrucción en pacientes con lesiones graves de plexo braquial: estudio comparativo / Shoulder arthrodesis vs. primary reconstruction surgery in patients with serious brachial pexus injuries: comparative study

Objetivo: La cirugía de reparación nerviosa es la primera elección en lesiones del plexo braquial. La artrodesis de hombro estabiliza y otorga cierta abducción por desplazamiento de la escápula. El objetivo del presente trabajo es: comparar la artrodesis de hombro versus la transferencia del nervio espinal accesorio al supraescapular. Materiales y métodos: se analizaron en forma retrospectiva 20 pacientes con parálisis completa del miembro superior y avulsión radicular de al menos 4 raíces. Diez fueron artrodesados, y en los otros 10 se realizó una única transferencia nerviosa para el hombro, antes citada. El seguimiento mínimo fue de 2 años. Se determinó la abducción en grados y se describió una escala para estudiar los resultados de ambas técnicas. Los resultados fueron comparados estadísticamente. Resultados: en los pacientes artrodesados el promedio, según la escala, fue 4,5 puntos, mientras que en los transferidos fue 4,8. La media de abducción en grados fue de 37 en artrodesados y 43,5 en transferidos. No se encontraron diferencias estadísticamente significativas entre ambos grupos. Conclusiones: los resultados de ambas técnicas son semejantes. La artrodesis escápulo-humeral es una posibilidad terapéutica aceptable del hombro paralizado en los pacientes con lesiones muy graves del plexo braquial y escasez de donantes nerviosos.

Objective: Primary nerve reconstruction surgery is the gold standard in brachial plexus injuries. Shoulder arthrodesis stabilizes and abducts the shoulder by the movement of the scapula. The goal of the present study is to compare shoulder arthrodesis versus spinal nerve transfer to supraescapular nerve. Materials y methods: 20 patients with complete brachial plexus palsy (flail arm) and at least 4 roots avulsions were analyzed retrospectively. Ten were submitted to shoulder arthrodesis, while in the other 10, only one nerve transfer was performed to reinervate the shoulder. Minimum follow-up was 2 years. The results were determined in degrees of abduction, also measured in a scale, and compared statistically. Results: the mean result in the patients with shoulder arthrodesis was 4.5, and 4.8 in the nerve transferred. Mean final abduction was 37 degrees in arthrodesis and 43.5 in nerve transfer. No statistical significant difference was found between groupsConclusions: the results of both techniques are similar. Shoulder arthrodesis is a viable option in severely injured brachial plexus patients where donor nerve are scarce.

Paralisia obstétrica de plexo braquial: revisão da literatura / Obstetrics brachial plexus palsy: literature review

Paralisia obstétrica é uma lesão do plexo braquial ao nascimento. Em nosso meio, sua prevalência não é conhecida, mas as disfunções do membro comprometido são muitas vezes frequentes e duradouras. Distócia de ombro é definida como a necessidade de manobras para o desprendimento dos ombros, ou um intervalo maior que 60 segundos entre a saída da cabeça e a dos ombros, estando relacionada a 50% doscasos de lesão do plexo braquial. A maioria dos casos ocorre na ausência de fatores de risco. As manobras de assistência ao parto com distócia de ombro devem ser treinadas e memorizadas. A abordagem da lesão braquial deve ser multidisciplinar. Fisioterapia, reconstrução microcirúrgica do plexo, correção de deformidades articulares secundárias e transposições musculares são empregadas com sucesso. O papel do tratamento conservador e operatório deve ser regularmenterevisado. O objetivo deste trabalho foi realizar uma revisão da literatura sobre a paralisia obstétrica do plexo braquial.

Obstetric palsy is a brachial plexus injury at birth. In our country, its prevalence is unknown, but the dysfunction of the affected limb are frequent and often long lasting. Shoulder dystocia is defined as the need to maneuver to the delivery of the shoulders, or a range greater than 60 seconds between deliveryng the head and shoulders. It is related to 50% of cases of brachial plexus injury. Most cases occur in the absence of risk factors. The maneuvers of assisted childbirth with shoulder dystociashould be trained and stored. The approach of the brachial injury must be multidisciplinary. Physiotherapy, microsurgical reconstruction of the plexus, secondary correction of joint deformities and muscle transpositionsare employed successfully. The role of conservative treatment and surgical procedures should be regularly reviewed. The aim of this study was performed a literature review about obstetrics brachial plexus palsy.

Study of nerve grafting to the change of GDNF and GFRα1 on neurons after brachial plexus nerve injury in young rats / 中华显微外科杂志

Objective To investigate the difference of the glial cell line-derived neurotrophic factor and its receptor content of proximal neurons after nerve grafting was used to reconstruct C5 root in young rats.Methods Model of C5 resection was set up in 12 18-day-old SD rats.Experimental animals were divided in to two groups, one group for C5 resection, another for nerve grafting to reconstruct the C5 defection.At 4 weeks postoperatively, the immunohistochemical staining was performed and the number of GDNF and GFRa1 immunohistochemical positive neurons were calculated respectively.Results The number of GDNF positive neurons in spinal cord and dorsal root ganglion of C5 repairing group was 786.3 ± 176.84 and 2997.0 ±357.99, and that of C5 resection group was 335.0 ± 49.50 and 1632.0 ± 305.55.On the other hand, the number of GFRa1 positive neurons in spinal cord and dorsal root ganglion of C5 repairing group was 787.5 ±178.55 and 3111.0 ± 445.72, that of the other group was 397.3 ± 41.78 and 1588.3 ± 229.00.The statistical analysis result showed GDNF and GFR immunohistochemical positive neurons in spinal cord and dorsal root ganglion of C5 repairing group was statistically more than that of C5 resection group(P < 0.01 ).Conclusion The neuronal protective effect of nerve grafting after reconstructing brachial plexus nerve injury in young rats may be attributed to the increase of GDNF and its receptor GFRa1 content of proximal neuron.

Effects of Neuromuscular Electrotherapy and Kinesitherapy on Brachial Plexus Palsy / 中国康复理论与实践

@#Objective To study the effects neuromuscular electrotherapy and kinesitherapy on brachial plexus palsy. Methods 20 patients with brachial plexus palsy accepted neuromuscular electrical stimulation on involved muscles, and were followed up for 18～58 months. Other 17 patients accepted neurolysis alone were as control. Results The function of shoulder and elbow in electric stimulation group was significantly superior to that of control (P<0.01). Conclusion Neuromuscular electrotherapy combined with kinestherapy is effective on the brachial plexus palsy.

Pyogenic Arthritis of the Shoulder Associated with Brachial Plexus Palsy: A Case Report / 대한정형외과학회잡지

Pyogenic arthritis of the shoulder joint is rare in adults and true paralysis associated with pyogenic arthritis is reported more rarely. We describe a case brachial plexus palsy associated with pyogenic arthritis of the glenohumeral joint. Weakness of upper extremity associated with pyogenic arthritis of shoulder is common and usually overlooked but differentiation from true paralysis of brachial plexus with electromyelogram is needed.

Bilateral Brachial Plexus Palsy after a Radical Subtotal Gastrectomy for Early Gastric Cancer: A case report

If pressure injuries to neuromuscular, vascular, and tissue structures are to be avoided, care in the positioning patients on the operating table and in preparing for anesthesia is always important. Avoiding excessive traction of upper and lower extremities adjacent to major nerves will also limit dangerous neurologic sequelae. Here, we report the case of a 44-year-old male patient who underwent a radical subtotal gastrectomy. He suffered postoperative weakness in both arms. This article presents that case of bilateral brachial plexus palsy after a radical subtotal gastrectomym as wekk as a review of the literature.

A Case of Unilateral Diaphragmatic Paralysis with Brachial Plexus Palsy in the Neonate

The diaphragm is especially important in sustaining minute ventilation in the neonate. Consequently, diaphragmatic paralysis is not tolerated well by the neonate and often results in prolonged respiratory failure. We experienced a case of unilateral diaphragmatic paralysis with the brachial plexus palsy in a male newborn infant who presented with apnea and cyanosis due to birth asphyxia. After endotracheal intubation, mechanical ventilaton was started. At two weeks after therapy, chest X-ray showed atelectasis and elevation of the right hemidiaphragm. The diagnosis of unilateral diaphragmatic paralysis was confirmed by real-time ultrasonography. At 4 weeks old, after several unsuccessful attempts at weaning from ventilatory support, right hemidiaphragm was plicated. On the second postoperative day, he could be weaned from ventiatory support without difficulty. He was doing well at follow-up 3 months later.

Brachial Plexus Palsy after Thoracoscopic Sympathectomy: A case report / 대한마취과학회지

We experienced a complication of brachial plexus palsy secondary to operative position during thoracoscopic thoracic sympathectomies. His general health was excellent and no previous histories vulnerable to peripheral nerve systems were observed. The thoracic sympathectomies were done under general anesthesia. The patient was placed left lateral position with his right arm abduced 150o on padded arm board. An operation was lasted 2 hours and 30 minutes at this position because of severe right apical lung adhesion. The controlateral side was performed same procedure and lasted 20 minutes. After the patient recovered from the anesthesia, the patient had a complete paralysis of right arm. There was also slightly diminished sensation to pinprick on the arm and hand. Neurologic examination and EMG study revealed brachial plexus palsy. Nerve blocks and physiotherapy were performed to treat brachial plexus injuries. His motor functions were improved day by day and he was discharged with a complete range of motion against gravity on 14th. postoperation day. However, there were loss of muscle powers against some resistances and tingling sensations of fingertips. Two months later, he was recovered completely and there was no residual disabilities.

Incomplete Brchial Plexus Palsy as a Neglected Caused of Painful Stiff Shoulder / 대한정형외과학회잡지

Painful stiff shoulder after trauma may be one of the difficult situation. Incomplete brachial plexus palsy may cause painful stiff shoulder. Symptoms and signs of this entity are vague. It is not rare to miss detecting subtle damage of the brachial plexus. We analysed these cases to identify specific clues on history and physical examination that help making the diagnosis of this entity. We have experienced 14 cases of incomplete brachial plexus palsy that showed painful stiff shoulder in Asan Medical Center from March 1995 to February 1996. All the charts and letters from primary care hospitals were reviewed. Initial diagnosis of the primary hospital, duration of delay of diagnosis after initial trauma, clues for the diagnosis in history and physical findings, patterns of the nerve injuries were analyzed. Average age was 48 years (from 25 to 84). Nine cases were male, and five cases were female. The most common primary diagnosis was proximal humerus fracture. Delayed diagnosis was the most remarkable feature. Average duration of delayed diagnosis was about three months (from one to thirteen months). Tentative diagnosis was made on the base of history and physical examination. The most frequent clue on the history was long standing painful stiff shoulder inappropriate to the initial diagnosis. The most common physical finding was tenderness at the brachial plexus area. Definite diagnosis was confirmed with electromyography. Careful history taking and thorough physical examination are essential for every shoulder injury. Incomplete brachial plexus palsy is one of the cause of painful stiff shoulder. It is important to keep in mind this entity to arrive correct diagnosis. Eletromyography should be done for the suspected cases.

A Case Report of Brachial Plexus Palsy after Laparascopy Assisted Vaginal Hysterectomy / 대한마취과학회지

Trendelenburg position has been used for the low abdominal and pelvic surgery or for the management of the hypotensive patients. But, various adverse effects can also occur in steep Trendelenburg position, of which brachial plexus injury has been known as the most common nerve injury during this position under the general anesthesia especiaUy when the shoulder braces are used. We experienced a case of brachial plexus palsy in a 53 year old woman who had a laparas-copy assisted vaginal hysterectomy(LAVH) under the general anesthesia for myoma uteri for four and a half hours. During the operation she was in a 30 degree-tilting Trendelenburg and combined lithotomy position with her arms tucked at her side with drawsheet and shoulder braces were placed over the acromioclavicular joints bilaterally. In the morning of the postoperative 1st day, she complained the right shouder pain and the right arm tingling sensation and weakness. After needle electromyography and nerve conduction study, it was decided that she got an intraoperative brachial plexus injury mainly involving the lateral cord of the brachial plexus, resulting from the nerve compression caused by shoulder braces in Trendelenburg position. The symptoms were improved after the physical therapy and she was recommended to take more physical therapy after discharge.