BioMed Central Page 1 of 5 (page number not for citation purposes) Journal of Brachial Plexus and Peripheral Nerve Injury Open Access Case report Oberlin partial ulnar nerve transfer for restoration in obstetric brachial plexus palsy of a newborn: case report Koji Shigematsu*, Hiroshi Yajima, Yasunori Kobata, Kenji Kawamura, Naoki Maegawa and Yoshinori Takakura Address: Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan Email: Koji Shigematsu* - shigema2@naramed-u.ac.jp; Hiroshi Yajima - hyajima@naramed-u.ac.jp; Yasunori Kobata - ykobata@naramed- u.ac.jp; Kenji Kawamura - kkenji@naramed-u.ac.jp; Naoki Maegawa - nmaegawa@naramed-u.ac.jp; Yoshinori Takakura - ytakakaura@naramed- u.ac.jp * Corresponding author Abstract An 8 month old male infant with Erb's birth palsy was treated with two peripheral nerve transfers. Except for rapid motor reinnervations, elbow flexion was obtained by an Oberlin's partial ulnar nerve transfer, while shoulder abduction was restored by an accessory-to-suprascapular nerve transfer. The initial contraction of the biceps muscle occurred two months after surgery. Forty months after surgery, elbow flexion reached M5 without functional loss of the ulnar nerve. This case demonstrates an excellent result of an Oberlin's nerve transfer for restoration of flexion of the elbow joint in Erb's birth palsy. However, at this time partial ulnar nerve transfer for Erb's birth palsy is an optional procedure; a larger number of cases will need to be studied for it to be widely accepted as a standard procedure for Erb's palsy at birth. Background In 1994, Oberlin et al. [1] described a new technique of partial ulnar nerve transfer to the biceps muscle nerve for restoration of elbow flexion in traumatic C5-C6 avulsion of the brachial plexus in adult. We report treating an eight month old male infant without C5 to C6 function by an Oberlin's partial ulnar nerve transfer and an accessory-to- suprascapular nerve transfer. Case presentation An 8 month old male infant with obstetric brachial plexus palsy associated with a breech delivery (at 40 weeks 1 day, birth weight: 3535 g), was treated by peripheral nerve transfer. He was complicated with phrenic nerve palsy, and a surgical treatment (reefing of the diaphragm) for this lesion had been undertaken at two months of age in another institute. At the first examination in our institute (at 5 months of age), active shoulder abduction and elbow flexion were absent (Fig. 1). Mental and other motor functional developments were normal. During 3 months of observation, no spontaneous recovery of elbow flexion or shoulder abduction was shown. On elec- trophysiological evaluations, no action potential of the neuromuscular unit was revealed in the biceps and del- toid muscles. The action potential of the neuromuscular unit of the abductor pollicis brevis muscle showed a nor- mal wave. Physical and electrical examinations revealed an upper trunk type (C5-C6) right-side plexopathy. We considered the possibility of spontaneous recovery for several months, but functional recovery was poor. An Published: 29 September 2006 Journal of Brachial Plexus and Peripheral Nerve Injury 2006, 1:3 doi:10.1186/1749-7221-1- 3 Received: 09 March 2006 Accepted: 29 September 2006 This article is available from: http://www.JBPPNI.com/content/1/1/3 © 2006 Shigematsu et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Brachial Plexus and Peripheral Nerve Injury 2006, 1:3 http://www.JBPPNI.com/content/1/1/3 Page 2 of 5 (page number not for citation purposes) Oberlin's nerve transfer and an accessory to suprascapular nerve transfer were selected to facilitate a rapid motor OBSTETRICAL BRACHIAL PLEXUS PALSY KHOA BỎNG – CHẤN THƯƠNG CHỈNH HÌNH OBSTETRICAL BRACHIAL PLEXUS PALSY • Abstract • The authors review the cases of 116 infants treated consecutively for birth-related brachial plexus injuries Twenty-eight infants with upper brachial plexus lesions who showed no neurological improvement by months of age were selected for early surgical reconstruction (at a mean age of months) Neurological improvement of the affected arm was observed in more than 90% (p < 0.05) of the children examined longer than months after brachial plexus reconstruction A conservatively managed control subgroup of 44 children, first examined at less than months of age, demonstrated neurological improvement by months of age and continued to show improvement at year of age Early surgical reconstruction is recommended for infants with birth-related upper brachial plexus injury who show no neurological improvement by the age of months • August 1993 / Vol 79 / No / Pages 197-203 Evaluation and diagnosis • DUCHENNE-ERB: C5 - C6 good hand, bad shoulder • KLUMPKE-DEJERINE: C8 - D1 bad hand ,some shoulder • REMAK: C7 • Total : C5-C6-C7-C8-D1 THAÙM SAÙT THAÀN KINH GEÙP THAÀN KINH BioMed Central Page 1 of 6 (page number not for citation purposes) Journal of Brachial Plexus and Peripheral Nerve Injury Open Access Research article Comparison of visual and objective quantification of elbow and shoulder movement in children with obstetric brachial plexus palsy Andrea E Bialocerkowski* and Mary Galea Address: Rehabilitation Sciences Research Centre, School of Physiotherapy, The University of Melbourne, VIC, 3010, Australia Email: Andrea E Bialocerkowski* - aebial@unimelb.edu.au; Mary Galea - m.galea@unimelb.edu.au * Corresponding author Abstract Background: The Active Movement Scale is a frequently used outcome measure for children with obstetric brachial plexus palsy (OBPP). Clinicians observe upper limb movements while the child is playing and quantify them on an 8 point scale. This scale has acceptable reliability however it is not known whether it accurately depicts the movements observed. In this study, therapist-rated Active Movement Scale grades were compared with objectively-quantified range of elbow flexion and extension and shoulder abduction and flexion in children with OBPP. These movements were chosen as they primarily assess the C5, C6 and C7 nerve roots, the most frequently involved in OBPP. Objective quantification of elbow and shoulder movements was undertaken by two- dimensional motion analysis, using the v-scope. Methods: Young children diagnosed with OBPP were recruited from the Royal Children's Hospital (Melbourne, Australia) Brachial Plexus registry. They participated in one measurement session where an experienced paediatric physiotherapist facilitated maximal elbow flexion and extension, shoulder abduction and extension through play, and quantified them on the Active Movement Scale. Two-dimensional motion analysis captured the same movements in degrees, which were then converted into Active Movement Score grades using normative reference data. The agreement between the objectively-quantified and therapist-rated grades was determined using percentage agreement and Kappa statistics. Results: Thirty children with OBPP participated in the study. All were able to perform elbow and shoulder movements against gravity. Active Movement Score grades ranged from 5 to 7. Two- dimensional motion analysis revealed that full range of movement at the elbow and shoulder was rarely achieved. There was moderate percentage agreement between the objectively-quantified and therapist-rated methods of movement assessment however the therapist frequently over- estimated the range of movement, particularly at the elbow. When adjusted for chance, agreement was equal to chance. Conclusion: Visual estimates of elbow and shoulder movement in children with OBPP may not provide true estimates of motion. Future work is required to develop accurate, clinically-acceptable methods of quantifying upper limb active movements. Since few children attained full range of motion, elbow and shoulder movement should be monitored and maintained over time to reduce disability later in life. Published: 01 December 2006 Journal of Brachial Plexus and Peripheral Nerve Injury 2006, 1:5 doi:10.1186/1749-7221-1- 5 Received: 23 June 2006 Accepted: 01 December 2006 This article is available from: http://www.JBPPNI.com/content/1/1/5 © 2006 Bialocerkowski and Galea; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Brachial Plexus and Peripheral Nerve Injury 2006, 1:5 http://www.JBPPNI.com/content/1/1/5 Page 2 of 6 (page number not for citation purposes) Background Obstetric brachial plexus palsy (OBPP) is a complication of childbirth, which is characterized by one or more nerve conduction blocks within the brachial plexus [1]. These blocks range in severity and location BioMed Central Page 1 of 7 (page number not for citation purposes) Journal of Brachial Plexus and Peripheral Nerve Injury Open Access Research article Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: Evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture Rahul K Nath*, Sonya E Melcher and Melia Paizi Address: Texas Nerve and Paralysis Institute, 2201 W. Holcombe Blvd., Houston, TX, USA Email: Rahul K Nath* - drnath@drnathmedical.com; Sonya E Melcher - sonya@drnathmedical.com; Melia Paizi - melia@drnathmedical.com * Corresponding author Abstract Background: The current method of treatment for persistent internal rotation due to the medial rotation contracture in patients with obstetric brachial plexus injury is humeral derotational osteotomy. While this procedure places the arm in a more functional position, it does not attend to the abnormal glenohumeral joint. Poor positioning of the humeral head secondary to elevation and rotation of the scapula and elongated acromion impingement causes functional limitations which are not addressed by derotation of the humerus. Progressive dislocation, caused by the abnormal positioning and shape of the scapula and clavicle, needs to be treated more directly. Methods: Four patients with Scapular Hypoplasia, Elevation And Rotation (SHEAR) deformity who had undergone unsuccessful humeral osteotomies to treat internal rotation underwent acromion and clavicular osteotomy, ostectomy of the superomedial border of the scapula and posterior capsulorrhaphy in order to relieve the torsion developed in the acromio-clavicular triangle by persistent asymmetric muscle action and medial rotation contracture. Results: Clinical examination shows significant improvement in the functional movement possible for these four children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy. Conclusion: These results reveal the importance of recognizing the presence of scapular hypoplasia, elevation and rotation deformity before deciding on a treatment plan. The Triangle Tilt procedure aims to relieve the forces acting on the shoulder joint and improve the situation of the humeral head in the glenoid. Improvement in glenohumeral positioning should allow for better functional movements of the shoulder, which was seen in all four patients. These dramatic improvements were only possible once the glenohumeral deformity was directly addressed surgically. Published: 27 December 2006 Journal of Brachial Plexus and Peripheral Nerve Injury 2006, 1:9 doi:10.1186/1749-7221-1- 9 Received: 06 November 2006 Accepted: 27 December 2006 This article is available from: http://www.JBPPNI.com/content/1/1/9 © 2006 Nath et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Brachial Plexus and Peripheral Nerve Injury 2006, 1:9 http://www.JBPPNI.com/content/1/1/9 Page 2 of 7 (page number not for citation purposes) Background Obstetric brachial plexus injury (OBPI) has been described as a discrete entity since 1754 [1]. The patho- physiology of the secondary deformities encountered in this population was described succinctly in 1905 by Whit- man who wrote that the large majority of internal rotation and subluxation deformities of the shoulder in children with obstetric brachial plexus injuries were caused by fibrosis and contractures developed as a consequence of the neurological injury [2]. The medial rotation contrac- ture (MRC) is the most significant secondary shoulder deformity in children with severe OBPI, requiring surgery in more than one third of patients whose injury did not resolve spontaneously [3]. The BioMed Central Page 1 of 4 (page number not for citation purposes) Journal of Brachial Plexus and Peripheral Nerve Injury Open Access Research article Trapezius transfer to treat flail shoulder after brachial plexus palsy Ricardo Monreal*, Luis Paredes, Humberto Diaz and Pastor Leon Address: Manuel Fajardo Teaching Hospital. Orthopedics and Traumatology Department, Zapata y calle D, Vedado, CP:10400, Havana, Cuba Email: Ricardo Monreal* - rjmg@infomed.sld.cu; Luis Paredes - luisfe@infomed.sld.cu; Humberto Diaz - hedr@infomed.sld.cu; Pastor Leon - pastorls@infomed.sld.cu * Corresponding author Abstract Background: After severe brachial palsy involving the shoulder, many different muscle transfers have been advocated to restore movement and stability of the shoulder. Paralysis of the deltoid and supraspinatus muscles can be treated by transfer of the trapezius. Methods: We treated 10 patients, 8 males and 2 females, by transfer of the trapezius to the proximal humerus. In 6 patients the C5 and C6 roots had been injuried; in one C5, C6 and C7 roots; and 3 there were complete brachial plexus injuries. Eight of the 10 had had neurosurgical repairs before muscle transfer. Their average age was 28.3 years (range 17 to 41), the mean delay between injury and transfer was 3.1 years (range 14 months to 6.3 years) and the average follow- up was 17.5 months (range 6 to 52), reporting the clinical and radiological results. Evaluation included physical and radiographic examinations. A modification of Mayer's transfer of the trapezius muscle was performed. The principal goal of this work was to evaluate the results of the trapezius transfer for flail shoulder after brachial plexus injury. Results: All 10 patients had improved function with a decrease in instability of the shoulder. The average gain in shoulder abduction was 46.2°; the gain in shoulder flexion average 37.4°. All patients had stable shoulder (no subluxation of the humeral head on radiographs). Conclusion: Trapezius transfer for a flail shoulder after brachial plexus palsy can provide satisfactory function and stability. Background After severe brachial palsy involving the shoulder, second- ary operations are sometimes required to restore function. These include shoulder artrhodesis, rotational osteotomy, muscle transfer or a combination of these techniques. For paralysis of the deltoid and supraspinatus muscle many different muscle transfers have been advocated to restore movement and stability of the shoulder. These include transfer of the trapezius, pectoralis major and teres major, latissimus dorsi, and combined biceps and triceps. In a classic monograph; Saha [1] gave details of his expe- rience with transfer of the trapezius, using a modification of the technique originally described by Bateman [2]. However, the absence of clear indications for the opera- tion and expecting too much for this transfer alone has led to its infrequent use. Published: 12 January 2007 Journal of Brachial Plexus and Peripheral Nerve Injury 2007, 2:2 doi:10.1186/1749-7221-2- 2 Received: 27 August 2006 Accepted: 12 January 2007 This article is available from: http://www.JBPPNI.com/content/2/1/2 © 2007 Monreal et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Brachial Plexus and Peripheral Nerve Injury 2007, 2:2 http://www.JBPPNI.com/content/2/1/2 Page 2 of 4 (page number not for citation purposes) We have evaluated the results of the trapezius transfer for flail shoulder after brachial plexus injury. Methods We treated 10 patients, 8 males and 2 females, by transfer of the trapezius to the proximal humerus. In 6 patients the C5 and C6 roots had been injured; in one C5, C6 and C7 roots; and in 3 there were complete BioMed Central Page 1 of 5 (page number not for citation purposes) Journal of Brachial Plexus and Peripheral Nerve Injury Open Access Research article Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type Ricardo Monreal* Address: "Manuel Fajardo" Teaching Hospital. Orthopedics and Traumatology Department. Zapata y calle D, Vedado, CP: 10400, Havana, Cuba Email: Ricardo Monreal* - rjmg@infomed.sld.cu * Corresponding author Abstract Background: Loss of elbow flexion due to traumatic palsy of the brachial plexus represents a major functional handicap. Then, the first goal in the treatment of the flail arm is to restore the elbow flexion by primary direct nerve surgery or secondary reconstructive surgery. There are various methods to restore elbow flexion which are well documented in the medical literature but the most known and used is Steindler flexorplasty. This review is intended to detail the author's experience with Steindler flexorplasty to restore elbow flexion in patients with brachial plexus palsy C5-C6-C7 where wrist extensors are paralyzed or weakened. Methods: We conducted a retrospective follow-up study of 12 patients with absent or extremely weak elbow flexion (motor grade 2 or less), wrist/finger extensor and triceps palsy associated; who had undergone surgical reconstruction of the flail upper limb by tendon transfer (Steindler flexorplasty) and wrist arthrodesis to restore elbow flexion. The aetiology of elbow weakness was in all patients brachial plexus palsy (C5-C6-C7 deficit). Data were collected from medical records and from the information obtained during follow-up visits. Age, sex, preoperative strength (rated on a 0 to 5 scale for the flexors of the elbow, wrist flexors, pronator and triceps), previous surgery, length of follow-up, other associated operative procedures, results and complications were recorded. Results: The results are the follows: Eleven patients were found to have very good or good function of the transferred muscles. One patient had mild active flexion of the elbow despite the reconstructive procedure. There were no major intraoperative complications. Two patients experienced transient, intermittent nocturnal ulnar paresthesias postoperatively. In both patients these symptoms subsided without further surgery. Conclusion: Our study suggests that in patients with C5-C6-C7 palsy where the wrist and finger extensors are paralyzed or weaked, the flexor-pronators muscles of the forearm are strong but the triceps is not available for transfer; Steindler flexorplasty to restore elbow flexion should be complemented with wrist arthrodesis. Published: 11 July 2007 Journal of Brachial Plexus and Peripheral Nerve Injury 2007, 2:15 doi:10.1186/1749-7221-2- 15 Received: 25 April 2007 Accepted: 11 July 2007 This article is available from: http://www.JBPPNI.com/content/2/1/15 © 2007 Monreal; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal of Brachial Plexus and Peripheral Nerve Injury 2007, 2:15 http://www.JBPPNI.com/content/2/1/15 Page 2 of 5 (page number not for citation purposes) Background Traction injury of the brachial plexus results in partial or total paralysis of the upper limb, especially when there is paralysis of elbow flexion. Good hand function is wasted if the hand cannot be maintained in a useful position. Loss of elbow flexion due to traumatic palsy of the bra- chial plexus represents a major functional handicap. Then, the first goal in the treatment of the flail arm is to restore elbow flexion by primary direct nerve surgery or secondary reconstructive surgery. There are various methods to restore elbow flexion which are well documented in the medical literature. One of the .. .OBSTETRICAL BRACHIAL PLEXUS PALSY • Abstract • The authors review the cases of 116 infants treated consecutively for birth-related brachial plexus injuries Twenty-eight infants with upper brachial. .. was observed in more than 90% (p < 0.05) of the children examined longer than months after brachial plexus reconstruction A conservatively managed control subgroup of 44 children, first examined... year of age Early surgical reconstruction is recommended for infants with birth-related upper brachial plexus injury who show no neurological improvement by the age of months • August 1993 / Vol