Paediatric Upper Limb Problems- Brachial Plexus

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  Team Member Role(s) Profile
SattAR Sattar Alshriyda Section Editor
ND Matthew Nixon Segment Author

Narakas Classification

Type 1 (Upper Erbs)

  • Commonest, best prognosis
  • C5,6
  • Adducted, internally rotated shoulder
  • Extended elbow
  • Good hand function
  • C5,6,7
  • As above, but slightly flexed elbow and wrist drop
  • C5-T1 - total plexus
  • Flail arm and hand
  • May have Horner’s sign
  • Worst prognosis
  • Total plexus with Horner’s syndrome

Type 2 (Extended Erbs)

  • C5,6,7
  • As above, but slightly flexed elbow and wrist drop

5.1.1.jpg

Typical presentation of an Erb’s OBPI. [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012].

Type 3 (Total)

  • C5-T1 - total plexus
  • flail arm and hand
  • may have Horner’s sign
  • worst prognosis

Type 4 (Total + Horner’s)

  • Total plexus with Horner’s syndrome

Klumpke

  • C8, T1
  • Lower plexus
  • Wrist flexors, intrinsics and Horners
  • Not normally seen in isolation in OBPI

5.1.2.png

Motor branches of the brachial plexus [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012].

Features

  • 1 in 1000 live births
  • 90% resolve spontaneously

Risk factors

  • High birth weight (>4kg)
  • Prolonged labour
  • Shoulder dystocia
  • Breech
  • Forceps

Dorsal Root Ganglion

  • Sensory root
  • Contains cell bodies
  • Within vertebral foramen
  • Maintains axon vitality
  • Predictor of outcome

5.1.3.jpg

Dorsal root ganglion [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012]

Injury patterns

Upper roots C5/C6/C7

  • Always involved
  • Strong connective tissue around roots
  • Rupture > avulsion
  • =post ganglionic
  • Rupture > avulsion (post ganglionic)
  • Can often use as site for grafting
  • Cannot use as site for grafting

Lower roots C8/T1

  • Never injured in isolation
  • i.e. indicates more severe injury
  • Less connective tissue
  • Avulsion > rupture
  • = pre-ganglionic

5.1.4.png

Root avulsion and rupture [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012].

5.1.5.png

Injury patterns to upper and lower roots [Image copywrite Matthew Nixon Lulu publishing 2012].

1-Avulsion - 32%

  • Pre-ganglionic injury
  • Horner’s syndrome (sympathetics)
  • Raised hemi diaphragm(phrenic nerve)
  • Winged scapula (Long thoracic nerve)
  • No stump
  • worse prognosis

2-Rupture- 33%

  • Post ganglionic injury
  • Stump present
  • Better surgical options
  • Better prognosis

3-Neuroma - 25%

  • Post ganglionic injury
  • may only be neuropraxia
  • benefit of on table EMG to distinguish
5.1.6.jpg
 
Neuroma in situ [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012].

Horners syndrome

  • 4% OBPI
  • Anhidrosis (Decrease sweating)
  • Miosis
  • Ptosis
  • Enopthalmos

Consequences

  • Phrenic nerve often involved
  • Higher anaesthetic risk
  • Cannot use intercostals as donors
  • Signifies severe injury
  • Rule out other causes of flail limb
  • Clavicle / humeral fracture
  • Septic arthritis

5.1.7.png

Neonatal scapula Osteomyelitis [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012]

5.1.8.png

Neonatal clavicle fracture [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012].

Planning

  • Supra- vs infra-spinatous
  • Pre- vs post-ganglionic
  • Potential donors

Investigations

  • Dynamic chest fluoroscopy ?phrenic nerve palsy
  • EMG - poor predictor of prognosis
  • CT myelogram / MRI- ? pseudo-meningocoele
  • Surgical exploration

Poor Prognostic Signs

  • Total plexus involvement
  • Hornets syndrome
  • Failure to improve by 6 months

The Toronto score assesses neonatal:

  • Shoulder abduction
  • Elbow flexion
  • Wrist extension
  • Fingers extension
  • Thumb extension

 With normal function scoring 2, reduced function 1 and no function 0.

In older children( above 2 years), the Mallet score is a more comprehensive assessment of shoulder function ( abduction, external rotation, hand to head, hand to back and Hand to mouth) with normal function scoring V and no function I.

  • <3.5 @ 3 months,? <4.5 if no proximal function
  • No return of biceps at 3 months
  • Not putting hand to mouth at 9 months
  • Neurolysis
  • Direct neurotisation (repair to original nerve)
  • Indirect neurotisation (repair to alt nerve)
  • Nerve to muscle neurotisation
  • + - nerve grafts
  • Sural / saphenous
  • vascularised ulnar graft
  • Artificial graft
  • Early microsurgery
  • Evidence suggests do better if operated on <3-6 months
  • Neurolysis / nerve repair +- nerve grafts

Intra-plexus donors

  • Better - more fibres
  • Often use with interposition graft
  • Use root rupture stumps, not avulsions
  • eg C5/6 root to trunks/ C7 splint into anterior and posterior divisions

Extra-plexus donors

  • Intercostal nerves - not if phrenic nerve involvement
  • Spinal accessory n- often to restore supra-scapular nerve
  • Contralateral C7- controversial
  • Upper roots post ganglionic root rupture => usuable
  • Lower roots- intact
  • Spinal accessory nerve to supra scapula nerve =>- restore cuff function
  • C5 root  to upper trunk =>  restore MCN and elbow flexion
  • C6/7 root to post trunk => restore Axillary nerve and deltoid

5.1.9.png

Primary neurotisation for upper root OBPI

[Image © Matthew Nixon 2014]

  • Upper roots - post ganglionic root rupture => usuable
  • Lower root - pre ganglionic root avulsion => not usable
  • Spinal accessory nerve to supra scapula nerve =>  restore cuff function
  • C5 to upper trunk
  • C6 to post trunk
  • C7 / intercost to lower trunk

5.1.10.png

Primary neurotisation for total plexus palsy in OBPI

[Image © Matthew Nixon 2014]

Proximal (shoulder)

  • Better overall recovery
  • Not much diff in outcome as long as done < 1 year

Distal (hand)

  • Worse prognosis - further regeneration required
  • Do better if operated on < 3 months

Free muscle transfer

(Gracilis most common)

  • Elbow flexion and/or finger flexion or extension
  • Mmay have 2 transfers and combine functions
  • e.g.
  1. Restore elbow flexion and wrist/finger extension
  2. Restore finger flexion
  • Innervations: intercostals, contralateral C7
  • Humerus flattened, loss of IR
  • Glenoid biconcave, posterior dislocation

5.1.11.png

Glenohumeral dysplasia [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012]

  • First described by Sever, 1918
  • can be done arthroscopically
  • may need posterior capsulorrhaphy
  • Subscapularis tendon released arthroscopically
  • +- pec major release / lengthening=> restoration of external rotation

5.1.12.png

Pectoralis major lengthening (top) and Posterior subscapularis release [Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012].

  • Latismus dorsi +- teres major transfer
  • Superior =>depresses humeral head, improves abduction
  • Posterior => restores external rotation, resoration of abduction
  • Trapezius transfer to deltoid + acromial advancement
  • Bipolar lat dorsi transfer
    1. one end to acromion
    2. other to deltoid insertion
    5.1.13.jpg

Latismus dorsi transfer

[Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012]

Bony procedures

  • Glenoplasty
  • Humeral derotation osteotomy
  • GHJ arthrodesis

5.1.14.png

Bony reconstructive procedures in OBPI

[Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012]

Scenario 1 - residual Erbs palsy => loss of elbow flexion (C5)

  • LHB to pectoralis major transfer
  • Common flexor origin proximal transfer
  • Triceps anterior transfer
  • Free gracilis transfer

Scenario 2 - global palsy with C5/6 recovery => flexion pronation contracture

  • biceps lengthening and re-routing
  • convert into a pronator
  • +- radius derotation osteotomy

5.1.15.jpg

Restoration elbow function OBPI

[Image is courtesy of Paediatric Orthopaedic by Matthew Nixon Lulu publishing 2012]

  • Often problems too severe for transfers
  • Main reason for plexus reconstruction
  • Can restore mass action using gracilis transfer
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References

  • 1. Berndt AL and Harty M. Transchondral fractures (osteochondritis diecans) if the talus. J Bone Joint Surg Am. 1959;41:988-1020
  • 2. Kumai T, Takakura Y, Higashiyama I, et al. Arthroscopic drilling for the treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 1999 Sep;81(9):1229-35.
  • 3. Kumai T, Takakura Y, Kitada C et al. Fixation of osteochondral lesions of the talus using cortical pegs. J Bone Joint Surg Br 2002;84:369-374
  • 4. Lahm A, Erggelet C, Steinwachs M, Reichelt A. Arthroscopic management of osteochondral lesions of the talus: results of drilling and usefulness of magnetic resonance imaging before and after treatment. Arthroscopy. 2000 Apr;16(3):299-304.
  • 5. Hepple , Winson IG, Glew D. Osteochndral lesions of the talus: A revised classification. Foot Ankle Int. 1999;20:789-793
  • 6. Zengerink M, Struijs PAA, Tol JL, van Dijk CN. Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc 2010;18:238-246
  • 7. Shearer C, Loomer R, Clement D. Non operatively managed stage 5 osteochondral talar lesions. Foot Ankle Int 2002;23:651-54
  • 8. Ferkel RD, Sgaglione NA, DelPizzo W et al. Arthroscopic treatment of osteochondral lesions of the talus: long term results. Orthop Trans. 1990;14:172-173