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LA PARALISI OSTETRICA:
TIMING E CHIRURGIA
PRIMARIA DELLE POPB
Pierluigi Tos, Paolo Titolo
UOD Microchirurgia – UOC Traumatologia MuscoloscheletricaASO Città della Salute e della Scienza di Torino
CTO Trauma Center Torino – [email protected] TO
1764 Obstetrical brachial palsy described by Smellie.
1874 Wilhelm H. Erb described brachial plexus paralysis in adults which involved the upper roots and described certain types of “delivery paralysis”. He credited Duchenne for describing the brachial palsy following delivery in affected newborns 1955.
1885 Augusta Klumpke first described the clinical picture resulting from injury to lower roots.
BACKGROUND
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ETIOLOGY
Stretch, tear, compression or avulsion of the nerves usually after forceful lateral deviation of the head from the shoulders during delivery.
Recent studies suggest intrinsic forces (uterine contractions)
EPIDEMIOLOGYIncidence of brachial plexus palsy is reported to affect
0.5 to 1.9 per 1000 live births (Bar et al 2001)
90% ERB- DUCHENNE PALSY
• Most common on the right side because the most common delivery presentation is left occiput anterior vertex.
• Associated with: pre and gestational diabetesolder maternal ageincreased BW (body weith),LGA (macrosomia)
• Newborns with BP injuries have a higher incidence of low Apgar scores of less than 7 at 1 and 5 mins and of asphyxia than matched controls
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Risk factor Odds ratio 95% Confidence interval
Maternal weight > 90 kg 1.3 0.2-62.6
Postdate pregnancy 1.8 0.9-3.9
Diabetes 3.2 1.6-6.3
Fetal macrosomia• 4000–4500 • >4500 • >5000
9.617.9 45.2
6.2-14.910.3-31.315.8-128.8
Assisted delivery• Low-forceps • Mid-forceps• Vacuum extractor • Cesarean delivery
3.73.717.20.5
2.0-7.05.7-59.35.1-58.20.1-1.9
Prolonged second stage of Labor 8.3 4.0-17.3
Shoulder dystocia 340.5 46.9-897.3
Epidural anesthesia 2.0 1.2-3.5
Use of Oxytocin 3.7 1.1-2.6
Application of fundal pressure 27.5 4.0-1163.4
RISK FACTORS
ANATOMY
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UPPER PALSY
Internal rotationNo elbow flexion
Good finger flexion
CLINICAL FEATURESCOMPLETE PALSY
Flail arm Horner’s syndrome
Horner’s Syndrome
usually means avulsion of T1
Lack of movement of the affected arm usually leads to referral for orthopaedic opinion
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FRACTURE CLAVICLE FRACTURE HUMERUS
DIFFERENTIAL DIAGNOSIS
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SHOULDER DISLOCATION
UPPER HUMERAL EPIPHYSOLYSIS
DIFFERENTIAL DIAGNOSIS
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TYPE OF INJURIES
PREGANGLIO
NICROOT
AVULSION
POSTGANGLIO
NIC
SEDDON SEDDON SUNDERLANDSUNDERLAND
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TYPE OF INJURIES
PREGANGLIO
NICROOT
AVULSIONNO DIRECT REPAIR !!!!!NEROTIZATION
POORER RESULTS
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ROOT AVULSIONAlso referred to as pre-ganglionic injury
In C5-C6 post-ganglionic lesion is more frequent than avulsion because the nerve is firmly
attached to the cervical spine
At lower levels connections between the spinal nerve and the transverse process are absent and root avulsions
are more common
In subsequent order rupture generally takes place at:A. the fibrous connections (1)
between nerve and foramenB. the dura (2) C. and the rootlets(3)
DRG – dorsal root ganglionB – bony foramenSC – spinal cord
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TYPE OF INJURIES
POSTGANGLIO
NIC
SEDDON SEDDON SUNDERLANDSUNDERLAND
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CLASSIFICATION of NERVE LESIONS
(Seddon -Sunderland)
1° grado - NEUROAPRASSIA (blocco di conduzione reversibile)
2° grado - ASSONOTMESI (assoplasma interrotto - degenerazione Valleriana)
3° grado - NEUROTMESI (l’endonervio è interrotto)
4° grado - NEUROTMESI (anche il perinervio è interrotto)
5° grado - NEUROTMESI (interruzione completa del nervo) TO
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SEDDON SEDDON INJURIESINJURIES
NeuropraxiaNeuropraxia: : simple simple stretching of the nervestretching of the nerve
Mild AxonotmesisMild Axonotmesis: : rupture of a few axonsrupture of a few axons
NeurotmesisNeurotmesis: : complete complete disruption of the nerve disruption of the nerve
TYPE OF INJURIES
DEGREE SPONTANEOUSRECOVERY
COSA ACCADE A MONTE
nella sintesi di proteine utili alla RICOSTRUZIONE ASSONALE
nella sintesi di proteine della TRASMISSIONE SINAPTICA
DEGENERAZIONE ASSONALE fino al 1°/2° nodo di Ranvier
CORPOCELLULARE
MONCONEPROSSIMALE
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“NORMALE” “IN RIGENERAZIONE”
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COSA ACCADE A VALLE
DEGENERAZIONE VALLERIANA
scomparsa del cilindrasse
PROLIFERAZIONE cellule di
SCHWANN (cordoni di Büngner -
“tubi endoneurali”)
SCOMPARSA delle PLACCHE MOTRICI
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RIGENERAZIONE
FORMAZIONE delCONO di CRESCITA
COLLATERAL SPROUTING
EMANAZIONE di PSEUDOPODI e
ADESIONE alla MEMBRANA
BASALEdelle CELLULE di
SCHWANNTO
ACCRESCIMENTO
con una VELOCITÀ
di 1-2 mm/die
RIGENERAZIONE
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CRESCITA dell’ASSONEE
PASSAGGIO DELLA ZONA DI LESIONE
RIGENERAZIONE
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CRESCITA DELL’ASSONE LUNGO i“TUBI ENDONEURALI” A VALLE
RIPRISTINO DI UN CORRETTO CONTATTOCON GLI ORGANI BERSAGLIO
RIGENERAZIONE
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TIMING DELLA RICOSTRUZIONE
FATTORI LIMITANTI
ADULTO- MUSCOLO
- degenera con il tempo
- distanza- NERVO MONCONE DISTALE
- perde cellule Schwann
- Fibrosi intraneurale
BAMBINO- RIORGANIZZAZIONE
CEREBRALE- DISTURBO NELLA CRESCITA OSTEOARTICOLARE- PSICOLOGIA GENITORI
-SCARSA PLASTICITA’ CEREBRALE- NEUROMA >FIBROSI
- NEUROMA < FIBROSI
DIFFERENCES BETWEEN ADULT BRACHIAL PLEXUS
LESIONS AND OBPLTRAUMA MECHANISM less velocity (compared to a motor vehicle accident) probably longer in duration
a true rupture of the nerves (Sunderland V) is seldom seen, a neuroma-in-continuity is usually found
PERIPHERAL NERVE LESION AND REGENERATIONAxonal outgrowth was shown to be superior in young compared to adults
In neuroma-incontinuity SURPRISINGLY LARGE NUMBER OF AXONS GROW ACROSS THE LESION SITE (although infants show no clinical recovery at 6 months) probably because axons in younger have a more penetrable basal lamina tube encasing
Axonal outgrowth through the neuroma might explain the lack of sustained atrophy in OBPL, which is a typical in adult
Shorter regeneration distance between the level of injury and the target organ. CO-
CONTRACTIONS
Biceps and Triceps cocontraction
Breathing ArmTO
DIFFERENCES ON RECONSTRUCTION
STRATEGIES in total palsy
ADULTS CHILDPRIORITY
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RECONSTRUCTION STRATEGIESNarakas et al.
• Group I classic upper trunk lesion C5-6
• Group II extended upper trunk lesion C5-7
• Group III flail extremity
• Group IV flail extremity + Horner’s syndrome
46%
30%
20%
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Group I• Erb’s palsy Posture of adduction and inward rotation at the
shoulder with extension and pronation at the elbow and flexion of the fingers of the hand
• Absence of shoulder abduction and external rotation, elbow flexion, and forearm supination.
• Spontaneous recovery 90%
classic upper trunk lesion C5-6
(Klumpke= absent grasp reflex)
Group II
with the absence of wrist and digital extension added to the limitations noted in
group I
extended upper trunk lesion C5-7
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CLASSIC “WAITER'S TIP”
EXAMINATIONGENERAL EXAMINATION:Head shape and size
Eyes: conjugate movements, Horner’s
Neck: control in supported sitting and prone, range limitations actively or passively
Chest: respiratory pattern, chest movement symmetry
Legs: range of motion, tone, movement pattern
Unaffected arm: range of motion passively and actively, strength
AFFECTED ARM:Resting position
Passive range of motion
Active range of motion in supine and sitting or supported sitting
StrengthEvidence of pain
INFANT REFLEXES:Moro: symmetry
Asymmetrical tonic neck reflex (ATNR)
Palmar grasp
FEEDING:Sucking, swallowing
INTERACTION WITH ENVIRONMENT:Vision, hearing, touch
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Passive External rotation of the shoulder • In adduction• At 90° of abduction
stabilizing the scapula against the thorax to assess glenohumeral joint motion and stability.
Palpation of the humeral headwithin the posterior soft spot, may indicate posterior glenohumeral joint subluxation or
dislocation.
Assess Dynamic instability and degree of scapular winging
Muscle tightness of the pectoralis major, lattisimus dorsi, and teres major is evaluated with direct palpation. Presence of any contracture
EVALUATION OF AFFECTED ARM: KEY POINTS
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External shoulder rotation. The upper arm was held in internal rotation and adduction, with the elbow at 90° flexion; the hand lay on the child’s abdomen. External rotation was presentwhen the forearm was lifted from the abdomen without active elbow extension.
Elbow flexion. With the arm extended, flexion was present when the forearm and hand were lifted while the upper arm remained static.
Supination. With the elbow passively or actively held in 90° flexion, active rotation of the distal forearm was considered supination, regardless of flexion or extension of the wrist. When forearm rotation was effected by wrist extension and gravity, supination was considered absent.
Active elbow extension. With the upper arm in 90° anteflexion, active elbow extension was present if the flexed forearm could be extended regardless of the end point of the range of motion.
EVALUATION OF AFFECTED ARM: ACTIVE MOTION
TONIC NECK REFLEX
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MORO REFLEX
spreading out the arms (abduction)unspreading the arms (adduction)
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PALMAR GRASP
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ptosis, myosis, enophthalmos, anhidrosis
TRICKS
Flessione con supinazione Flessione senza supinazione
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Bahm, J; Ocampo-Pavez, C; Disselhorst-Klug, C; Sellhaus, B; Weis, J
Obstetric Brachial Plexus Palsy: Current Treatment Strategy, Long-Term Results, and PrognosisDtsch Arztebl Int 2009; 106(6): 83-90, DOI: 10.3238/arztebl.2009.0083
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ASSESSING SHOULDER FUNCTIONMALLET SCORE
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ASSESSING ELBOW AND HAND FUNCTION
DIAGNOSIS
Evaluation can be undertaken by multiple modes of
Imaging
EMG - 1 mth Useful for more precise diagnosis NOT FOR PROGNOSIS
MRI / TC / MIELO TCRarely necessary, useful in suspicion of upper roots
avulsion
Chest X ray / Real time Ultra Sonography TO
PROGNOSIS AND NATURAL HISTORY
it is important to determine whether the injury is preganglionic or
postganglionic
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• It has previously been reported that up to 92% of patients with BPBP have mild injury and spontaneous recovery within the first 2 months of life. Laurent JP, J Neurosurg 1993;79:197–203
• Other authors suggest a much lower recovery rate with only 66% of affected children recovering completely and 10% to 15% left with considerable permanent weakness. Hoeksma AFDev Med Child Neurol 2004;46:76–83; Pondaag W, Dev Med Child Neurol 2004;46:138 –144.
• The varying degrees of clinical presentation and recovery correlate with different injury types, subspecialty referral patterns, and subsequentcare
PROGNOSIS AND NATURAL HISTORY
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Cases in which the return of biceps function occurs
after 3 months rarely have complete recovery
Waters PM. Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg 1999;81A:649–659.
Complete recovery occurs only if motor function is present at no later than 6
months of age
Global shoulder function worsens with increasing delay in return of biceps
function
PROGNOSIS AND NATURAL HISTORY
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Other authors port that patients who regained biceps function between 4 and 6 months of age were able to achieve global shoulder function with secondary tendon transfers (comparable to the function of
those who underwent microsurgical procedures at 3 months)
routinely used return of biceps function at 9 months of age
Waters PM. / Al-Qattan MM
Clarke and Curtis
PROGNOSIS AND NATURAL HISTORY
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In a series no child with full recovery of motor function had complete palsy or
nerve root avulsion
Muscle imbalance develops rapidly, and
soft tissue contracture contributes to deformity and joint
incongruence early in the neonatal period
PROGNOSIS AND NATURAL HISTORY
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THERAPY / ( SURGERY ) SHOULD START IMMEDIATELY IN INFANCY
PREVENTION OF CONTRACTURE AND JOINT DEFORMITY ABOUT THE SHOULDER
SCAPULAR STABILIZATION AND PASSIVE GLENOHUMERAL MOBILIZATION IN ALL PLANES IS
NECESSARY ON A FREQUENT BASIS.
SUPERVISED HOME PROGRAM WITH PROFESSIONAL MONITORING.
CORTICAL RECOGNITION AND INTEGRATION OF THE AFFECTED LIMB IS PROMOTED.
PROGNOSIS AND NATURAL HISTORY
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When should the repair be done ?
FOR MOST SURGEONS : 3 MONTHS
FOR OTHERS : 6 – 9 MONTHS
FOR SOME DEPENDING ON THE VARIATIONSOF AN ASSESSMENT SCALE
INDICATION AND TIMING
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Is there a difference in results between 3 and 6 months ?
Probably notThen the problem is whether the decisionwill be more precise at 3 or 6 months andsince it has not been proven, it is better
to make the decision early
INDICATION AND TIMING
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A very serious argument is psychological:
The more signs of recovery , even non significant for the end-result , the more difficult
it is for the family to take their decision
The choice is between an early operation with the risk of an excessive indication or a late
decision which will induce some refusal from the families
INDICATION AND TIMING
AS THERE HAS BEEN NO PROOF OF A BETTER PRECISION IF THE
CHOICE IS DELAYED , AND AS WE ALL BELIEVE THAT EARLY
SURGERY ALLOWS BETTER RECOVERY , MY CHOICE HAS
BEEN A DECISION AT 3 MONTHS
INDICATION AND TIMING
• General consensus:– No surgery for upper plexus injuries who recovery
of biceps by 3 months – reconstruction at 3 months for global lesions and
Horner’s syndrome
•Some argument:– Early intervention in patients with initial fail
extremity with some recovery of biceps, but no significant hand or forearm recovery
•Most controversial element:– Timing of surgery for patients with rupture-type injuries,
in which there are varying degrees of severity of injury and recovery
INDICATION AND TIMINGMicrosurgical intervention aims to improve
function without the expectation of full recover
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GILBERT ABSOLUTE INDICATION FOR EARLY OPERATION AT 3 MONTH
COMPLETE PALSY
Horner’s syndrome
UPPER PALSY
no biceps at 3 months
INDICATION AND TIMING
poorer shoulder outcomes at 5 years and increased likelihood for secondary procedures in patients who regained biceps function after 3
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THE EXACT TIMING IS STILL UNKNOWNWHAT WE SUGGEST
We consider absent or significantly impaired hand function, in the context of a flail arm at birth, to be an
absolute indication for nerve surgery as soon as the infant reaches the age of 3 months
surgery to NBPP patients who demonstrate no spontaneous recovery of shoulder external
rotation and elbow flexion/forearm supination by 3–4 months of age
If the presence of true shoulder and elbow movements is DOUBTFUL, we proceed with
SURGICAL EXPLORATION, because the POTENTIAL BENEFITS FROM REPAIRING
NEUROTMETIC LESIONS GENERALLY OUTWEIGH THE RISKS OF NEGATIVE
EXPLORATION
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WHAT WE SUGGEST
LEIDEN THREE ITEM TEST 1
At 1 month:-Elbow extension-Elbow flexion-EMG of the biceps
Prediction of severe OBPP at 1 month of age was better than at 1 week and at 3 months.
Correct prediction whether lesions were mild or severe in 93.6% of infants
try to ASSESS SEVERITY OF THE BRACHIAL PLEXUS LESION(S) AS EARLY AS POSSIBLE for surgical and
psychosocial reasons
2011
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Prediction of severe OBPP at 1 month
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STRUTTURA DEDICATA
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RECONSTRUCTION STRATEGIES
• Group I
• Group II extended upper trunk lesion C5-7
• Group III flail extremity
• Group IV
RECONSTRUCTION STRATEGIES
Group IN C5, C6
• C5 -SSC• C5- PDUT (for
shoulder)• C6- ADUT( for biceps) Or
• 11° to SSC
C5
C6
RECONSTRUCTION STRATEGIES
Group I N C5, A C6
Neuroma C5
sovrascapular
Dorsal root ganglion C6
Anterior root filaments C6
RECONSTRUCTION STRATEGIES
Group IN C5, A C6
C5
C6
RECONSTRUCTION STRATEGIES
Group IAC5, AC6
• SAN to SCC• MPN to MCN
Oberlain technique carry potential risks for the growing hand
(Breech presentation)
RECONSTRUCTION STRATEGIES
Group III – C5 C6 C7 C8 T1
• C5 -SSC• C5- PDUT (for
shoulder)• C5- ADUT (for biceps)
• C6 C8
Median nerve
Ulnar nerve
N C5-C6, A C7-C8-T1
LATE REINNERVATION – LATE NEUROTIZATIONS
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RESULTS of LATE NEUROTIZATIONS
GILBERT – RAIMONDI 2013TO
NBPP is not a static processAs the child grows up, a variety of
secondary deformities of the extremities occur.
The extent and severity of these secondary deformities is related to– the severity of the initial plexus lesion– the age of the child at presentation,– the degree of recovery of muscle function.
SEQUELE
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SEQUELE
La spalla è l’articolazione più colpitaIl gomito, avambraccio, polso, e mano
sviluppano deformità invalidanti
Esiti più frequenti:dismetria arti (accentuata dalla deformità in flessione del gomito)
(72%) deformità di rotazione interna della spalla
(62%) deformità di flessione del gomito (69%) deformità di supinazione avambraccio (29%) deformità di pronazione avambraccio(27%) deviazione ulnare del polso vari tipi di paralisi delle dita
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da 1 anno a 2 annise eccessiva intrarotazione
non ostante esercizi favorenti la extrarotazione ed, eventualmente, per
proporre un
intervento di release del muscolo sottoscapolare
TIMING – SEQUELEinterventi palliativi
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dopo i 2 annieventuali
interventi correttivi muscolari per
migliorare la funzione di spalla
dopo i 4 anni - adolescenza valutare deformità ossee ed articolari, da ulteriori procedure chirurgiche potrebbero
rendersi convenienti – ostotomie, etc
TIMING - SEQUELE
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CONCLUSIONI
LA PARALISI SEVERA VA RIFERITA TEMPESTIVAMENTE (1 mese) e
OPERATA PRECOCEMENTE – 3 MESI
STRETTI CONTROLLO CLINICI PER VALUTARE INSORGERE DI
DEFORMITA’ / FKT – CHIRURGIA
CHIRUGHI SPECIALIZZATI CHE CONOSCANO LE CURE
SUCCESSIVE / TRASFERIMENTI TENDINEI E MUSCOLARI
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Trauma Center TORINO - ITALY
Reconstructive Microsurgery Unit
Ortopaedics DepartmentCity of Health and Science
TorinoCTO Hospital – Trauma
Center Torino Italy
Pierluigi Tos
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