Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction:
Leahthan F Domeshek1, Kevin J Zuo1, Sasha Letourneau1
1Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada.
Insights
Early shoulder surgery in infants with brachial plexus birth injury (BPBI) may prevent the need for nerve reconstruction. This study shows promising results for a selected group of infants, improving upper extremity function.
Area of Science:
- Pediatric Orthopedics
- Pediatric Neurosurgery
- Brachial Plexus Birth Injury
Background:
- Shoulder contracture and subluxation are recognized issues in infants with brachial plexus birth injury (BPBI).
- Traditionally, shoulder surgery follows nerve reconstruction, but shoulder pathology can hinder functional recovery.
- Early shoulder surgery may be a viable alternative in select BPBI cases.
Purpose of the Study:
- To investigate the efficacy of early shoulder surgery in infants with BPBI.
- To determine if pre-emptive shoulder surgery can obviate the need for nerve reconstruction.
- To assess functional outcomes in a highly selected group of infants with BPBI.
Main Methods:
- Retrospective review of BPBI patients who had shoulder surgery before one year of age (2015-2018).
- Evaluation of upper extremity motor function using Active Movement Scale and Cookie tests.
- Assessment of the requirement for subsequent neuroma resection and nerve grafting.
Main Results:
- Fifteen infants with upper trunk BPBI underwent early shoulder surgery (subscapularis slide, tendon transfers).
- Postoperatively, 13 of 15 patients achieved functional elbow flexion (passing Cookie test or AMS score 7).
- One patient required a nerve transfer for improved elbow flexion; two lacked sufficient follow-up.
Conclusions:
- Early, targeted shoulder surgery in infants with BPBI shows potential to avoid brachial plexus nerve reconstruction.
- This approach may be beneficial for a highly selected group of infants with BPBI.
- Further research is needed to define the exact role of infancy shoulder surgery in BPBI management.
Background:
Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting.
Methods:
A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting.
Results:
Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion.
Conclusion:
Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.
