title: Obstetrical brachial plexus palsy: Can excision of upper trunk neuroma and nerve grafting improve function in babies with adequate elbow flexion at nine months of age?
abstract: Accepted indications for exploration in obstetrical brachial plexus palsy (OBPP) vary by center. Most agree that full elbow flexion against gravity at nine months of age implies high chance of spontaneous recovery and thus excludes a baby from surgical intervention. However, there are certain movements of the shoulder and forearm that may not be used frequently by the infant, but are extremely important functionally as they grow. These movements are difficult to assess in a baby and may lead to some clinicians to recommend conservative treatment, when this cohort of infants may in fact benefit substantially from surgery. A retrospective review was conducted on all infants managed surgically at the Brachial Plexus Center of a major children's hospital from 2009 to 2014. Further analysis identified five patients who had near-normal AMS scores for elbow flexion but who had weakness of shoulder abduction, flexion, external rotation, and/or forearm supination. In contrast to standard conservative management, this cohort underwent exploration, C5-6 neuroma excision, and sural nerve grafting. Data analysis was performed on this group to look for overall improvement in function. During an average follow-up period of 29 months, all patients made substantial gains in motor function of the shoulder and forearm, without loss of elbow flexion or extension, or worsening of overall outcome. In select infants with brachial plexus injuries but near-normal AMS scores for elbow flexion, surgical intervention may be indicated to achieve the best functional outcome.
authors.affiliation: Department of Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, USA.
authors.forename: Anne E
authors.initials: AE
authors.lastname: Argenta
authors.affiliation: School of Clinical Medicine, University of Cambridge, UK.
authors.forename: Jack
authors.initials: J
authors.lastname: Brooker
authors.affiliation: Department of Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, USA.
authors.forename: Zoe
authors.initials: Z
authors.lastname: MacIssac
authors.affiliation: Department of Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, USA.
authors.forename: Megan
authors.initials: M
authors.lastname: Natali
authors.affiliation: Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, USA.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Greene
authors.affiliation: Department of Physical Therapy, Children's Hospital of Pittsburgh of UPMC, USA.
authors.forename: Meg
authors.initials: M
authors.lastname: Stanger
authors.affiliation: Department of Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, USA. Electronic address: lorelei.grunwaldt@chp.edu.
authors.forename: Lorelei
authors.initials: L
authors.lastname: Grunwaldt
mesh_terms: D000367:Age Factors; D001720:Birth Injuries / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D020516:Brachial Plexus Neuropathies / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D002574:Cervical Vertebrae; D004551:Elbow Joint / Q000502:physiology; D005260:Female; D006801:Humans; D007223:Infant; D009068:Movement; D009463:Neuroma / Q000601:surgery*; D010243:Paralysis / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D011247:Pregnancy; D016059:Range of Motion, Articular; D020127:Recovery of Function; D012189:Retrospective Studies; D012785:Shoulder Joint / Q000502:physiology; D013497:Sural Nerve / Q000637:transplantation*
keywords: Active movement scale; Cookie test; Neuroma excision; Obstetrical brachial plexus palsy