We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively.

In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively.

Our method is effective in evaluating the prognosis of C5 lesion. Neurolysis is preferred for C6 lesions.

Cite this article: Bone Joint J 2013;95-B:699–705.

We reviewed 1060 cases of OBPP prospectively at the Peripheral Nerve Injury Unit over 20 years. Data was collected for birth weight, maternal age, maternal height, maternal weight, duration of labour and associated difficulties, presentation, mode of delivery, neonatal problems, birth rank, race and social class. The mean birth weight was 4.23 kg (Range 0.63–9.49 SD 0.72) compared to 3.47 Kg nationally [p < 0.05]. There was an association between severity of lesion and increase in birth weight. Maternal age was 29.0 years in OBPP group [Range 14–43 SD 5.4] compared to 26.8 nationally [p < 0.05]. In 46.7% of the brachial plexus group, the mothers were > 30 years old. This was compared to 29.7% nationally. The difference in maternal Body Mass Index (BMI) between patient group [27 with Range 14–44 SD 3.5] and national average of 25 was significant [p< 0.05]. Hypertension [11.8%] and diabetes [11.2%] were significantly [p< 0.05] higher than the national rate [6.4% and 1% respectively]. Shoulder dystocia occurred in 56% of the cases and was strongly associated with OBPP [p< 0.05]. Mean duration of labour nationally was 5.4 hours; in the patient group 10.8 hours [p< 0.05]. Breech presentation was more than three times the national average [p< 0.05]. Caesarean sections [2%] were less than national average [18%]. Instrumental deliveries [40.3%] were four times more than national rate. [P < 0.05]. The incidence of Neonatal asphyxia [22%] and Special Care Baby Unit [15.3%] was significantly [p< 0.05] higher than the national average [2% and 8% respectively]. Other factors did not prove to be statistically significant. These included; Social class, birth rank and ethnic origin. We found that Birth weight, shoulder dystocia and body mass index are the most significant risk factors for obstetric brachial plexus plasy

Purpose of study: Glenoid dysplasia occurs early in the shoulders of some children affected by obstetric brachial plexus palsy (OBPP). Prompt treatment can reverse the deformity. A program has been devised to examine these children’s shoulders by ultrasound and the early results are described. Method: Since March 2006, all neonates born in New-castle upon Tyne with a diagnosis of OBPP have been referred to the hip ultrasound clinic. The shoulders were examined clinically for range of movement and signs of instability. A static and dynamic ultrasound examination was then performed. Treatment of subluxed shoulders involved splinting the shoulder in adduction and external rotation for six weeks after injection of the internal rotator muscles with botulinum toxin, as recommended by Ezaki and co-workers. Results: To date, six infants have been screened. Two had significant instability with ultrasonographic evidence of early glenoid dysplasia and have been treated. One had mild glenoid dysplasia with restricted external rotation which improved with physiotherapy alone. Three were clinically and ultrasonographically normal. Conclusions: The early experience of this program confirms the high incidence of shoulder dysplasia in the neonatal period in these children, as reported by others. The examination is safe and relatively easy. In the early stages of the condition the treatment to date has been simple and effective. We plan to continue with ultrasound screening for shoulder dysplasia in neonates with OBPP

In children with obstetric brachial plexus palsy (OBPP) who develop an internal rotation deformity of the shoulder, release of subscapularis improves the range of external rotation of the shoulder and the strength of supination of the forearm. We studied the strength of supination in 35 healthy adult volunteers at 45° of both internal and external rotation. The mean and maximum torques were greater in external than internal rotation by 8.7% and 7.5%, respectively. This was highly significant (p < 0.0001). The increased strength of supination in external rotation is probably because the maximum power of biceps, particularly the long head, may be exerted in this position. In children the difference may be even greater due to anatomical differences causing the dramatic increases in the strength of supination after surgery for OBPP. In adults our findings suggest that the supination exercises which are undertaken after injury or surgery to the forearm or wrist should be performed in external rotation

Introduction: Shoulder relocation is commonly performed for the subluxating or dislocated shoulder secondary to Obstetric Brachial Plexus Palsy (OBPP). We have observed that even when relocation is performed at a young age, remodelling of the immature, dysplastic glenoid is often unreliable, resulting in recurrent incongruity and requiring treatment of the glenoid dysplasia. Methods and results: In a series of 19 patients, we used a posterior bone block to buttress the deficient glenoid at the time of shoulder relocation. At a mean follow up of 28 months (6–73 months), we describe failure in at least 50% with erosion of the bone block, progressive subluxation and resultant pain. A different technique of glenoplasty is now used. An osteotomy of the glenoid is performed postero-inferiorly, elevating the glenoid forward to decrease its volume. Bone graft, often taken from an enlarged and resected coracoid is then packed into the osteotomy and the whole assembly is held with a plate. In a series of 11 patients with a mean age of 6.7 years (1–18 years) we describe good results at short term followup, suggesting that this is a technique warranting further investigation. Conclusion: We believe that where a deficient glenoid is found at surgery for relocation of the shoulder in OBPP, a glenoplasty should be performed at the same time whatever the age of the patient, as glenoid remodelling will not reliably occur. We no longer advocate posterior bone block in these cases as it has a significant failure rate

Introduction: Upper root injuries (C5–C6±C7) account for 75 % of all obstetric brachial plexus palsies (OBPP). Among them, about thirty percent develop a medial contracture of the shoulder due to an imbalance between strong internal rotators and weak external rotators. This causes glenohumeral deformities. To decrease the internal contracture it had been proposed either to release the subscapularis (Sever procedure) or to perform a capsular release (Fairbank procedure). Arthroscopic capsular release was proposed in young patient to reduce the medial contracture. Material & methods: Six children with an average age of 23 months and 1 case aged 12 years old, had a medial contracture of the shoulder secondary to a C5–C6 ( 3 cases) or C5–C7 (4 cases) obstetrical palsy. An arthroscopic evaluation of the deformities was performed in 3 cases. Next a surgical subscapularis release was applied in association with a latissimus dorsi transfer. An arthroscopic evaluation of the joint associated with an arthroscopic capsular release (release of the coracohumeral ligament) was performed in 4 cases. In addition, the latissimus dorsi was transfered. Pre and Post operative passive external rotation were measured in degrees in R1 position. Pre and post operative medial rotation were evaluated according to the Mallet classification. A comparative evaluation of the glenohumeral deformities were performed between pre-operative MRI and arthroscopic results. Results: An arthroscopic evaluation of the glenohumeral joint was performed in 6 cases. In one case the arthroscopic evaluation could not be performed. In the 6 cases, arthroscopy confirmed the MRI lesion : 3 posterior subluxations, 1 posterior luxation and 2 normal joints. The subscapularis release allowed an increase in the passive lateral rotation of an average of 50°. However, a decrease of 1 point in the medial rotation was noted according to Mallet evaluation. The coracohumeral ligament arthroscopic release allowed an increase in the passive lateral rotation of an average of 60° without decreasing the passive medial rotation. Whatever the method used, a reduction of the subluxation of the glenohumeral joint was obtained. Discussion & Conclusion: Medial contracture of the shoulder may begin in the first two years of life and an early reduction with muscular release and transfers was proposed. However, the precise nature of the progressive limitation of the external passive rotation remains unclear. Is the limitation due to a contracture of the medial rotators or a capsular retraction or a combination of both? Harryman demonstrated the role of the rotator interval capsule and coracohumeral ligament in limiting the external rotation. Our hypothesis was that capsular retraction occurred before the muscular contracture. As a result we decided to perform a capsular release in patients under 24 months. The results on the passive external rotation were similar with both methods. Although, the technique of an arthroscopic release was difficult and demanding, it appears that this technique is beneficial as it allows an evaluation of the joint deformity and treatment of the contracture in the same time. Arthroscopic release is a safe but demanding technique which allows an increase in the external passive rotation in OBPP. It should be noted that this technique requires a significant practice

A total of 35 children with Erb’s palsy and shoulder abduction of < 90° underwent transfer of teres major. In 18 cases (group 1) a trapezius transfer was added (combined procedure). In 17 cases (group 2) teres major transfer was carried out in isolation (single procedure). The mean gain in abduction was 67.2° (60° to 80°) in group 1 and 37.6° (20° to 70°) in group 2, which reached statistical significance (p < 0.001).

Group 2 was further divided into those who had deltoid power of < M3 (group 2a) and those with deltoid power ≥ M3 (group 2b). The difference in improvement of abduction between groups 2a and group 2b was statistically significant (p < 0.001) but the difference between group 2b and group 1 was not (p = 0.07).

We recommend the following protocol of management: in children with abduction ≥ 90° a single procedure is indicated. In children with abduction < 90°: a combined procedure is indicated if deltoid power is < M3 and a single procedure is indicated if deltoid power is ≥ M3. If no satisfactory improvement is achieved, the trapezius can be transferred at a later stage.

We describe the early results of glenoplasty as part of the technique of operative reduction of posterior dislocation of the shoulder in 29 children with obstetric brachial plexus palsy. The mean age at operation was five years (1 to 18) and they were followed up for a mean of 34 months (12 to 67).

The mean Mallet score increased from 8 (5 to 13) to 12 (8 to 15) at final follow-up (p < 0.001). The mean passive forward flexion was increased by 18° (p = 0.017) and the mean passive abduction by 24° (p = 0.001). The mean passive lateral rotation also increased by 54° (p < 0.001), but passive medial rotation was reduced by a mean of only 7°. One patient required two further operations. Glenohumeral stability was achieved in all cases.

We evaluated results at one year after surgical correction of internal rotation deformities in the shoulders of 270 patients with obstetric brachial plexus palsy. The mean age at surgery was 6.2 years (0.6 to 35). Two techniques were used: open subscapularis elongation and latissimus dorsi to infraspinatus transfer. In addition, open relocation was performed or attempted in all patients with subluxed or dislocated joints. A mixed effects model approach was used to evaluate the effects of surgery on internal and external rotation, abduction, flexion and Mallet score. Independent factors included operative status (pre- or post-operative), gender, age, the condition of the joint, and whether or not transfer was performed. The overall mean improvement in external rotation following surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was a mean decrease in internal rotation of between 27.6° and 34.4° in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the normal joint group. Abduction and flexion were unchanged following surgery. Adding a latissimus dorsi transfer did not result in greater improvement in the mean external rotation compared with elongation of the subscapularis alone.

Cite this article: Bone Joint J 2013;95-B:1432–8.

Inability to actively supinate the forearm makes common activities of daily living and certain vocational activities awkward or impossible to perform. A total of 11 patients with deficient supination of the arm underwent transfer of the tendon of flexor carpi ulnaris to the split tendon of brachioradialis with its bony insertion into the radial styloid left intact. Active supination beyond neutral rotation was a mean of 37.2° (25° to 49.5°) at a minimum follow-up of three years, representing a significant improvement (95% confidence interval 25 to 50, p < 0.001). Functional evaluation of the hand after this transfer showed excellent and good results in ten patients and fair in one.

The split tendon of brachioradialis as an insertion for transfer of the flexor carpi ulnaris appears to provide adequate supination of the forearm without altering the available pronation and avoids the domination of wrist extension sometimes associated with transfers of the flexor carpi ulnaris to the radial extensors of the wrist.