Obstetric brachial plexus palsy: treatment strategy, long-term results, and prognosis

Abstract

Background: Obstetric brachial plexus palsy is rare, but the limb impairments are manifold and often long-lasting. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed with success. The role of conservative and operative treatment options should be regularly reviewed.

Methods: Selective literature review (evidence levels 3 and 4) and analysis of personal clinical operative and scientific experience over the past 15 years.

Results: Children with upper and total plexus palsy displaying nerve root avulsions and/or -ruptures are treated today by early primary nerve reconstruction in the first few months of life followed by secondary corrections, with good functional results. The late complications, with muscle weakness, impaired motion patterns, and joint dysplasia, are often underrated.

Conclusions: The potential for scientific analysis is limited, due to the rarity and interindividual variability of the lesions and the varying effects on function and growth. Expectations and compliance are different in every patient. Surgical techniques are not yet standardized. Knowledge of the consequences for joint growth and congruence is inadequate. Today, functional improvement can be achieved by surgery in most clinical manifestations of obstetric brachial plexus palsy, within the framework of an interdisciplinary treatment concept.

Keywords: microsurgery; nerve lesion; neurosurgery; obstetrics; trauma.

Figure 1

The typical clinical appearance of a complete lesion, with a flaccid left arm and Horner’s sign on the left side.

Figure 2

(a) Intraoperative photograph of an upper lesion with a conglomerate neuroma of the upper and middle trunks of the brachial plexus. (b) Drawing of the operative findings.

Figure 3

Result after primary reconstruction in a case of C5 and C6 nerve root avulsion during a breech delivery; (a) shoulder abduction/flexion; (b) elbow flexion (hand to mouth).

Figure 4

The Mallet scheme for shoulder movements.

Figure 5

Preventable late sequela: abnormal adaptive posture