Birth Brachial Plexus Palsy: An Indian Perspective

Abstract

Birth brachial plexus palsy (BBPP) is an unfortunate outcome of a difficult labor, which can often lead to long-lasting upper limb impairments. Spontaneous recovery may or may not occur. Timely diagnosis of the condition and initiation of the appropriate treatment can be instrumental in decreasing the functional impact. The management begins right from the day the child presents first and ranges from physiotherapy to surgical intervention such as nerve repair/transfer or grafts. The sequelae of the condition are also quite common and need to be detected preemptively with initiation of appropriate treatment. However, prevention is the key to reducing the incidence of secondary deformities. In this study, the team of authors, based on their considerable experience, discuss their approach to the management of BBPP. This is done in the background of Indian cultural practices and social constraints. A detailed discussion has been done on importance of preoperative passive joint mobilization regime and role of botulinum toxin in the authors' preferred ways of surgical correction of primary as well as secondary deformities. An extensive review of peer-reviewed publications has been done in this study, including clinical papers, review articles, and systematic review of the subject. Good results are possible with early and appropriate intervention even in severe cases.

Keywords: Botox; birth brachial plexus palsy; brachial plexus secondary deformities; brachial plexus surgery; co-contractions.

Fig. 1

Surface markings for the incision for exploration of brachial plexus in pediatric patient. Key: 1, sternocleidomastoid muscle; 2, supraclavicular incision; 3, infraclavicular incision; 4, trapezius muscle.

Fig. 2

Previous incision surface markings for exposure of brachial plexus. Key: Dotted line 1, sternocleidomastoid muscle; 2, supraclavicular incision marking; 3, clavicle; 3, infraclavicular incision marking.

Fig. 3

Exposed brachial plexus, both supraclavicular and infraclavicular, via the current choice of incisions by the authors.

Fig. 4

Clinical picture showing the exposed right-side brachial plexus with rupture of C5, C6, C7 roots at the level of trunks. Key: 1, neuromas over the upper and middle trunks.

Fig. 5

Clinical picture showing the cables formed from the various nerve grafts harvested for the purpose of bridging the nerve gaps after excision of the neuromas.

Fig. 6

Clinical picture showing the nerve grafts in situ used to bridge the gap between the roots and trunks.

Fig. 7

Clinical picture showing the judicious use of Tissel fibrin glue, at the sites of coaptation sites for brachial plexus reconstruction.

Fig. 8

Clinical photographs showing restricted external rotation of the right upper limb owing to co-contraction between the muscles leading to changes in the glenoid over time if untreated.

Fig. 9

Clinical photograph showing the restricted right shoulder abduction in a BBPP kid with internal rotation attitude of the limb.

Fig. 10

A child with left-sided BBPP, showing the utility of straight elbow splint in achieving straight overhead abduction. The elbow often remains in a flexed position, in the absence of an adequate support via splint.

Fig. 11

Showing ASR exposure. 1, coracohumeral ligament; 2, pectoralis minor attachments; 3, coracobrachialis.

Fig. 12

Surface marking of the incision over the axillary region for the procedure of shoulder muscle transfer.

Fig. 13

Modified Mallet scoring system. Maximum score (sum of individual score) is 25. Scale 1 for every action is no movement possible. Fixed forearm supination is noted in the resting position as indicated by the drawings labelled 2A (first web space visible) and 4A (palm visible).