Traumatic Brachial Plexus Palsy in Children: Long-Term Outcome and Strategy of Reconstruction
Tarek A El-Gammal1, Amr El-Sayed1, Mohamed M Kotb1
1Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University Hospitals and School of Medicine, Assiut, Egypt.
Insights
Pediatric traumatic brachial plexus injuries often involve root avulsions. Surgical neurotization can restore useful function, with outcomes unaffected by delayed treatment in children.
Area of Science:
- Pediatric Traumatology
- Neurosurgery
- Orthopedic Surgery
Background:
- Traumatic brachial plexus injuries in children are distinct from adult and neonatal cases.
- Limited data exists on their specific characteristics and functional restoration priorities.
- These injuries present a unique challenge in pediatric neurosurgery.
Purpose of the Study:
- To characterize traumatic brachial plexus injuries in children (excluding Erb's palsy).
- To evaluate the outcomes of surgical interventions, focusing on functional restoration.
- To determine factors influencing recovery, including surgical timing and techniques.
Main Methods:
- Retrospective review of 52 children with surgically treated traumatic brachial plexus injuries (minimum 2-year follow-up).
- Analysis of injury patterns (supraclavicular vs. infraclavicular), root avulsions, and surgical techniques (extraplexal neurotization, neurolysis, nerve grafting).
- Assessment of functional recovery in shoulder, elbow, wrist, and hand, including sensory recovery and neuropathic pain.
Main Results:
- Shoulder abduction and external rotation improved significantly; elbow flexion/extension recovery was high (≥grade 3 in >90%).
- Useful finger and wrist function (≥grade 4) was achieved in 21-32% of cases.
- Neurotization yielded superior results compared to neurolysis/grafting; high sensory recovery (S3 in 83.3%) and no neuropathic pain were observed.
Conclusions:
- Pediatric traumatic brachial plexus injuries frequently involve multiple root avulsions and are not associated with neuropathic pain.
- Extraplexal neurotization is a key surgical technique, and outcomes are not significantly impacted by delays in surgical intervention.
- Management should prioritize innervating the medial cord, similar to obstetric palsy, to restore useful hand function.
Background:
Traumatic brachial plexus injuries in children represent a definite spectrum of injuries between adult and neonatal brachial plexus injuries. Their characteristics have been scarcely reported in the literature. The priority of functional restoration is not clear.
Methods:
In total, 52 children with surgically treated traumatic brachial plexus injuries, excluding Erb's palsy, were reviewed after a minimum follow-up of 2 years. All children except nine were males, with an average age at surgery of 8 years. Forty-five children had exclusive supraclavicular plexus injuries. Twenty-one of them (46%) had two or more root avulsions. Seven children (13.5%) had infraclavicular plexus injuries. Time from trauma to surgery varied from 1 to 15 months (mean = 4.7 months). Extraplexal neurotization was the most common surgical technique used.
Results:
Shoulder abduction and external rotation were restored to an average of 83 and 26 degrees, respectively. Elbow flexion and extension were restored to grade ≥3 in 96 and 91.5% of cases, respectively. Finger flexion and extension were restored to grade ≥4 in 29 and 32% of cases, respectively. Wrist flexion and extension were restored to grade ≥4 in 21 and 27% of cases, respectively. Results of neurotization were superior to those of neurolysis and nerve grafting. Among the 24 children with insensate hands, 20 (83.3%) recovered S3 sensation, 3 recovered S2, and 1 recovered S1. No case complained of neuropathic pain. Functional recovery correlated negatively but insignificantly with the age at surgery and time from injury to surgery.
Conclusion:
Brachial plexus injuries in children are associated with a high incidence root avulsions and no pain. Neurotization is frequently required and the outcome is not significantly affected by the delay in surgery. In total plexus injuries, some useful hand function can be restored, and management should follow that of obstetric palsy and be focused on innervating the medial cord.
