The role of primary surgery in delayed presenting cases of brachial plexus birth injury is still debated. The purpose of this study was to evaluate the results of brachial plexus reconstruction performed at the age of ≥12 months.
Twenty-nine cases were included. Five cases had upper (C5–6) palsy, 4 had upper/middle (C5–7), and 20 had total (C5–8 and T1) palsy.
The age at the time of primary surgery was an average of 15.6 months. The brachial plexus was formally explored and neurolysis, grafting, and neurotization were used in different combinations. Exploration revealed that 27% of the roots were avulsed and 32% were ruptured. The follow-up was an average of 7.9 years. Generally, the best functional recovery was elbow flexion followed by shoulder external rotation. Satisfactory shoulder abduction (≥6 on the Toronto Active Movement Scale [TAMS]) was achieved in 31% of cases. The abduction range was an average of 79° ± 35°; 50° in upper palsy, 103° in upper/middle palsy, and 82° in total palsy. Shoulder external rotation ≥6 on the TAMS was achieved in 62% of cases. External rotation range was an average of 58° ± 29°; 78° in upper palsy, 68° in upper/middle palsy, and 52° in total palsy. Elbow flexion and extension of ≥6 on the TAMS were achieved in 69% and 58% of cases, respectively. Wrist flexion and finger flexion of ≥6 on the TAMS were achieved in 35% and 12.5%, whereas wrist and finger extension of >6 on the TAMS were achieved in 25% and 4% of cases, respectively.
In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in good functional recovery of elbow flexion and shoulder external rotation but modest functional recovery of finger flexion and wrist extension. The rate of functional recovery of the elbow flexion was similar following nerve grafting and transfer. Nerve transfer for shoulder external rotation should be considered even in infants with available roots for grafting.
Type of study/level of evidence
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- Birth injuries resulting in neurologic insult.Newborn Infant Nurs Rev. 2016; 16: 13-16
- Assessment of current epidemiology and risk factors surrounding brachial plexus birth palsy.J Hand Surg Am. 2019; 44: 515.e1-515.e10
- Natural history of brachial plexus birth injury: a systematic review.Dev Med Child Neurol. 2004; 46: 138-144
- Prognosis and early management of birth injuries to the brachial plexus.Br Med J. 1976; 1: 1520-1521
- Long-term results of primary repair of brachial plexus lesions in children.Microsurgery. 2006; 26: 334-342
- Complete brachial plexus birth injury: surgical improvement to recover a functional hand.J Child Orthop. 2009; 3: 101-108
- The treatment of brachial plexus injuries.Int Orthop. 1985; 9: 29-36
- Obstetric brachial plexus palsy: reviewing the literature comparing the results of primary versus secondary surgery.Childs Nerv Syst. 2016; 32: 415-425
- Total brachial plexus birth injury: results and strategy of microsurgical reconstruction.Microsurgery. 2010; 30: 169-178
- Results of nerve reconstructions in treatment of obstetrical brachial plexus injuries.Acta Neurochir (Wien). 2015; 157: 673-680
- Microsurgical technique in obstetric brachial plexus repair: a personal experience in 200 cases over 10 years.J Brachial Plex Peripher Nerve Inj. 2007; 2: 1
- The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy.Plast Reconstr Surg. 2002; 109: 116-129
- Intercostal nerve transfer in infants with brachial plexus birth injury.Microsurgery. 2008; 28: 499-504
- 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?.J Plast Reconstr Aesthet Surg. 2016; 69: 629-633
- The effect of duration of muscle denervation on functional recovery in the rat model.Muscle Nerve. 1997; 20: 858-866
- Microsurgery for brachial plexus injury before versus after 6 months of age: results of the multicenter Treatment and Outcomes of Brachial Plexus Injury (TOBI) study.J Bone Joint Surg Am. 2020; 102: 194-204
- A systematic review of evaluation methods for neonatal brachial plexus palsy: a review.J Neurosurg Pediatr. 2013; 12: 395-405
- Birth palsy: natural recovery course and combined root avulsion.J Pediatr Orthop. 1984; 4: 279-284
- Surgical strategy for infant obstetrical brachial plexus palsy: experiences at Chang Gung Memorial Hospital.Plast Reconstr Surg. 2005; 116: 132-144
- Treatment and Outcomes of Brachial Plexus Birth Injury (TOBI) Study Group. Outcomes of late microsurgical nerve reconstruction for brachial plexus birth injury.J Hand Surg Am. 2020; 45: 555.e1-555.e9
- Delayed selective neurotization for restoration of elbow and hand functions in late presenting obstetrical brachial plexus palsy.J Reconstr Microsurg. 2014; 30: 271-274
- Accessory nerve to suprascapular nerve transfer to restore shoulder exorotation in otherwise spontaneously recovered obstetric brachial plexus lesions.Neurosurgery. 2006; 59: 858-869
- Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement.Childs Nerv Syst. 2017; 33: 1571-1574
- Comparing the efficacy of triple nerve transfers with nerve graft reconstruction in upper trunk obstetric brachial plexus injury.Plast Reconstr Surg. 2017; 140: 747-756
- Outcomes with suprascapular nerve reconstruction in obstetrical brachial plexus patients.Plast Reconstr Surg. 2008; 121: 1267-1278
- External rotation as a result of suprascapular nerve neurotization in obstetric brachial plexus lesions.Neurosurgery. 2005; 57: 530-537
- Suprascapular nerve reconstruction in obstetrical brachial plexus palsy: spinal accessory nerve transfer versus C5 root grafting.Plast Reconstr Surg. 2011; 127: 2391-2396
- Spinal accessory nerve transfer outperforms cervical root grafting for suprascapular nerve reconstruction in neonatal brachial plexus palsy.Plast Reconstr Surg. 2015; 135: 1431-1438
- Reconstruction of the suprascapular nerve in brachial plexus birth injury: a comparison of nerve grafting and nerve transfers.J Bone Joint Surg Am. 2020; 102: 298-308
- Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy.J Neurosurg Pediatr. 2014; 13: 229-237
- Outcomes of hand reconstruction in obstetric brachial plexus palsy.Plast Reconstr Surg. 2008; 122: 516-526
Published online: December 18, 2022
Accepted: November 9, 2022
Received in revised form: October 22, 2022
Received: April 24, 2022
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
© 2023 by the American Society for Surgery of the Hand.