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24 Palliative Surgery inObstetrical Brachial Plexus Palsy

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Wrist extension is one of the goals of functional recovery of the upper arm. Lack of extension impairs hand function. Lack of wrist extension is one of the main indications for early nerve surgery. Therefore, any considerations about the outcome should be based on the expected result of the wrist.

Different patterns of wrist extension defects can be identied. First of all, wrist extension can stem from partial involvement of extensor carpi radialis tendons because of their prevalent innervation from C6 to C7 roots.

Along with physical therapy during the rst years of life, nocturnal splints can be effective in balancing wrist muscles. In the event of a child over ve years of age with persistent extension defect, despite good exor muscles of the wrist and ngers, surgery might be appropriate. Flexor carpi ulnaris transfer onto extensor carpi radialis muscles is an effective procedure; however, loss of tension of transferred tendons or on the contrary excessive tension should be taken into account [42, 43].

When the posterior cord of the brachial plexus is severely injured with expectations of poor recovery, repair options considerably decrease.

Wrist exion can be compensated by nger exor transfers but tendon transfers are often ineffective or short lasting.

Different patterns of hand defects have been described so it is hard to standardize hand deformities. Raimondi and Gilbert’s classication of palsied hand has grouped the majority of clinical aspects [44].Different from single nerve palsy, in OBPP, frail muscles do not allow the hand to reach adequate strength. Lack of sensation in the hand should discourage any surgical procedure.

Thumb extension and opposition can be obtained using tendon transfer along with joint reinforcement or fusion. Other selected transfers are possible, but the outcome is constantly poor, particularly when transfers are performed too early in life. On the other hand, late transfers result to be constantly poor because the child neglects his affected hand.

24.3 Conclusions

To sum up, palliative surgery options allow patients to achieve satisfactory results, particularly those with a favorable prognosis of recovery but still missing functions.

The main factor determining a good outcome is the correct timing of surgery based on the age of the patients. Growth can undo even a satisfactory short term surgical result.  Shoulder and elbow involvement can signicantly improve through many surgical procedures that merge orthopedic techniques and nerve surgery. Surgical procedures for correctingdistal segments are less effective because of the poor muscle recovery, particularly when a lack of sensation impairs the hand.

References

1. Gilbert A, editor. Brachial plexus injuries. London: Martin Dunitz Ltd; 2001.

2. Nixon M, Trail J.Management of shoulder problems following obstetric brachial plexus injury. Shoulder Elbow. 2014;6:12–7.

3. 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 Am. 1999;81(5):649–59.

4. Mallet J. Paralysie obstétricale. Rev Chir Orthop Réparatrice Appar Mot. 1972;58(Suppl 1):166–8.

5. Haerle M, Gilbert A. Management of complete obstetric brachial plexus lesions. J Pediatr Orthop. 2004;24:194–200.

6. Sénès FM, Catena N, Sénès J. Nerve transfer in delayed obstetrical palsy repair. J Brachial Plex Peripher Nerve Inj. 2015;10(1):e2–e14.

7. Immermann I, Valencia H, Di Taranto P, Del Sole EM, Glait S, Price AE, Grossmann JA. Subscapular slide correction of the shoulder internal rotation contracture after brachial plexus birth injury: technique and outcomes. Tech Hand Up Extrem Surg. 2013;17(1):52–6.

8. Azburg JM, Kozin SH, Waters PM. Open glenohumeral joint reduction and latissimus dorsi and teres major tendon transfers for infants and children following brachial plexus birth palsy. Tech Hand Up Extrem Surg. 2017;21(2):30–6.

9. Breton A, Mainard L, De Gasperi M, Barbary S, Maurice E, Dautel G.Arthroscopic release of shoulder contracture secondary to obstetric brachial plexus palsy: retrospective study of children with an average

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follow up of 4.5 years. Orthop Traumatol Surg Res. 2012;98:638–44.

10. Waters PM, Bae DS. Effect of tendon transfers and extraarticular soft tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg. 2005;87A(2):320–5.

11. Birch R.Late sequelae at the shoulder in obstetrical palsy in children. In: Randelli M, Karlsson J, editors. Surgical techniques in orthopaedics and traumatology: shoulder, vol. 3. Paris: Elsevier; 2001. 55-200-E-210.

12. Waters PM, Bae DS.The early effect of tendon transfers an open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy. J Bone Joint Surg Am. 2008;90:2171–9.

13. Pagnotta A, Haerle M, Gilbert A.Long term results on abduction and external rotation after latissimus dorsi transfer for sequelae of obstetric palsy. Cain Orthop Relat Res. 2004;426:199–205.

14. Ozben H, Atalar AC, Bilsel K, Demirhan M.Transfer of latissimus dorsi and teres major tendons without subscapularis release for the treatment of obstetrical brachial plexus sequela. J Shoulder Elbow Surg. 2011;20(8):1265–74.

15. Chomiak J, Dungl P, Ostadal M, Frydychova M, Burian M. Muscle transfers in children and adults improve external rotation in cases of obstetrical brachial plexus paralysis: a comparative study. Int Orthop. 2014;38(4):803–10.

16. Abzug JM, Chafetz RS, Gaughan JP, Ashworth S, Kozin SH.Shoulder function after medial approach and derotational humeral osteotomy in patients with brachial plexus birth palsy. J Pediatr Orthop. 2010;30(5):469–74.

17. McRae MC, Borschel GH.Transfer of triceps motor branches of the radial nerve to axillary nerve with or without other nerve transfers provides antigravity shoulder abduction in pediatric brachial plexus injury. Hand (NY). 2012;7(2):186–90.

18. Aly A, Bahm J, Schuind F.Percutaneous humeral derotational osteotomy in obstetrical palsy: a new technique. J Hand Surg Eur. 2014;39(5):549–52.

19. Chen L, Gu YD, Hu SN. Applying transfer of and/ or latissimus dorsi with teres major for reconstruction of abduction and external rotation of the shoulder in obstetrical brachial plexus palsy. J Reconstr Microsurg. 2002;18(4):275–80.

20. Gilbert A, Brockman R, Carlioz H. Surgical treatment of brachial plexus birth palsy. Clin Orthop. 1991;264:39–47.

21. Terzis JK, Kokkalis ZT.Primary and secondary shoulder reconstruction in obstetric brachial plexus palsy. Injury. 2008;39S:S5–S14.

22. Frich LH, Schmidt PH, Torng T.Glenoid morphology in obstetrical brachial plexus lesion: a three dimensional computed tomography study. J Shoulder Elbow Surg. 2017;26(8):1374–82.

23. Di Mascio L, Chin FK, Fox M, Sinisi M.Glenoplasty for complex shoulder subluxation and dislocation in children with obstetric brachial plexus palsy. J Bone Joint Surg Br. 2011;93:102–7.

24. Murison J, Jehanno P, Fitoussi F. Nerve transfer to biceps to restore elbow exion and supination in children with obstetrical brachial plexus palsy. J Child Orthop. 2017;11(6):455–9.

25. Kawabata H, Shibata T, Matsui Y, Yasui N.Use of intercostals nerves for neurotization of the musculocutaneous nerve in infants with birth related brachial plexus palsy. J Neurosurg. 2001;94(3): 386–91.

26. Chwei Chin Chuang D, Hattori Y, Ma HS, Chen HC.The reconstruction strategy for improving elbow function in late obstetrical brachial plexus palsy. Plast Reconstr Surg. 2003;109(1):116–26.

27. El Gammal T, El Sayed A, Kobt MM, Saleh WR, Ragheb YF, Refai O, Morsy MM.Free functioning gracilis transplantation for reconstruction of elbow and hand function in late obstetrical brachial plexus palsy. Microsurgery. 2015;35(5):350–5.

28. Nath RK, Boutros SG, Somasundaram C. Eplasty. 2017:e34.

29. Senes FM, Catena N, Dapelo E, Senes J. Nerve transfer for elbow extension in obstetrical brachial plexus palsy. Ann Acad Med Singap. 2016;45(5) :221–4.

30. Poyhia TH, Koivikko MP, Peltonen J, Kirjavainen MO, Lamminen AE, Mietosvaara AY. Muscle changes in brachial plexus birth injury with elbow exion contracture: an MRI study. Pediatr Radiol. 2007;37:173–9.

31. Shefer L, Lattanza L, Hagar Y, Bagley A, James MA. The prevalence, rate of progression and treatment of elbow exion contracture in children with brachial plexus birth palsy. J Bone Joint Surg A. 2012;94:403–9.

32. Ho ES, Roy T, Stephens D, Clarke HM.Serial casting and splinting of elbow contracture in children with obstetrical brachial plexus palsy. J Hand Surg Am. 2010;35(1):84–91.

33. Garcia Lopez A, Sebastian P, Martinez LF.Anterior release of elbow exion contractures in children with obstetrical brachial plexus lesions. J Hand Surg Am. 2012;37(8):1660–4.

34. Vekris MD, Palas D, Lykissas MG, Soucacos PN, Beris AE.Correction of elbow exion contracture in late obstetrical brachial plexus palsy through arthrodiastasis of the elbow (Ioannina method). Tech Hand Up Extrem Surg. 2010;14(1):14–20.

35. Senes FM, Catena N, Dapelo E, Senes J.Correction of elbow exion contracture by means of olecranon resection and anterior arthrolysis in obsttetrical brachial plexus sequelae. J Pediatr Orthop B. 2017;26(1):14–20.

24 Palliative Surgery inObstetrical Brachial Plexus Palsy

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36. Amrani A, Dendane MA, El Alami ZF.Pronator teres transfer to correct pronation deformity of the forearm after an obstetrical brachial plexus injury. J Bone Joint Surg Br. 2009;91(5):616–8.

37. Ruhmann O, Hierner R.Z plasty and rerouting of the biceps tendon with interosseous membrane release to restore pronation in paralytic supination posture and contracture of the forearm. Oper Orthop Traumatol. 2009;21(2):157–69.

38. Metsaars WP, Nagels J, Pijls BG, Langenhoff JM, Nelissen RG. Treatment of supination deformity for obstetric brachial plexus injury: a systematic review and meta-analysis. J Hand Surg Am. 2014;39(10):1948–58.

39. Gladstein AZ, Sachleben B, Ho ES, Anthony A, Clarke HM, Hopyan S.Forearm pronation osteotomy for supination contracture secondary to obstetrical brachial plexus palsy: a retrospective cohort study. J Pediatr Orthop. 2017;37(6):e357–63.

40. Van Kooten EO, Ishaque MA, Winters HA, Ritt MJ, Van der Sluijs HA. Pronating radius osteotomy

for supination deformity in children with obstetric brachial plexus palsy. Tech Hand Up Extrem Surg. 2008;12(1):34–7.

41. Manfrini M, Valdiserri L.Proximal radio ulnar arthrosis in the treatment of supination deformity resulting from obstetrical paralysis. Ital J Orthop Traumatol. 1985;11(3):309–13.

42. Van Alphen NA, Van Doorn Loogman MH, Mass H, Van der Sluijs JA, Ritt MJ.Restoring wrist extension in obstetric palsy of the brachial plexus by transferring wrist exors to wrist extensors. J Pediatr Rehabil Med. 2013;6(1):53–7.

43. Al Quattan MM.Tendon transfer to reconstruct wrist extension in children with obstetric brachial plexus palsy. J Hand Surg Br. 2003;28(2):153–7.

44. Raimondo PL.Evaluation of results in obstetrical brachial plexus palsy: the hand. In: Proceedings of international meeting of brachial plexus palsy, Helen, The Netherlands; 1993.

Nerve Injuries

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FilippoM.Senes, NunzioCatena, LuigiA.Nasto, andChiaraArrigoni

Abstract

Commonly,peripheral nerve injuries (PNI) of the upper limb in children result from fractures or penetrating lesions. Patient’s age signicantly affects epidemiology and demographics ofthese lesions. In very young chidren,injuries of peripheral nerves can affect nerve maturationsandimpair distal joint motion and limb residual growth potential.

Nevertheless, child regeneration potential and neuronal plasticity allow for a better outcome than inadulthood injuries. Concerning the type and level of skeletal lesion, typical PNI patterns can be described. Cutting edges of fracture fragments can cause direct damage to nearby nerves, whereas joint dislocation often determines traction injuries. Early iden-

F. M. Senes (*) Department oh Hand Surgery and Rehabilitation, San Giuseppe MultiMedica Hospital, Milan University, Milano, Italy e-mail: lipposenes@fastwebnet.it

N. Catena UOSD Microchirurgia Ricostruttiva e Chirurgia della Mano, IRCCS Istituto Giannina Gaslini, Genova, Italy

L. A. Nasto UOC Ortopedia e Traumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy

C. Arrigoni Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Torino, Torino, Italy

tication of nerve lesion is mandatory for planning the treatment that, depending on injury type and gap, consistof wait and see, direct suture, nerve grafting, andtubulization.

Keywords

Peripheral nerve · Upper limb · Children · Fractures · Penetrating lesions · Nerve graft

25.1 Introduction

Peripheral nerve injuries (PNI) of the upper limb after fractures and cutting lesions are a common occurrence in children, whereas canalicular (compression) syndrome is rare.

Although in the past, nerve injuries of the upper limbs were often grouped regardless of patient’s age, researchers have focused on pediatric nerve injuries, particularly on nerve involvement following supracondylar humeral fractures.

Age signicantly affects the occurrence of nerve lesions. Older children report a high rate of fracture-related PNI, probably because they are more commonly involved in road and sports accidents, while the youngest are usually under parental supervision [1].

Moreover, a basic approach to a pediatric nerve lesion should take into account that differences arise from the amount of myelinization of the nerve trunks, which is age- dependent.

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The absence of myelinated coating in peripheral nerve slows down nerve conduction velocity, which is about one-half compared with the ones detected in adults. A complete myelinated sheet in peripheral nerves develops at about 3 years of age.

Continue changes in the assessment of neurotrophins, neurotransmitters, and their receptors inuence the maturation of the nervous system. In young children, any injury can affect the maturation process of the nerve, impairing motion, sensibility, and residual growth of the upper limb. Skeletalmodications of the upper limb, due to prolonged denervation, are exemplied by the shortening of the upper limb observed after a severe obstetrical brachial plexus palsy [2].

Apart from these potential issues, regeneration potential and neuronal plasticity in the child allow them to achieve a better outcome than in adulthood. Besides all, the risk of joint stiffness is very low, with exception of brachial plexus injuries.

In pediatric population,the age,growth, patterns of injuries and maturity level of peripheral nerve system will lead to peculiar tratment modalities.

25.2 Types andSites ofNerve

Lesions

In the upper limb, nerve injuries show typical features, depending on the single nerve and level of lesion. A basic distinction is the presence of a skin defect: open and closed injuries occur with different patterns at different upper arm levels.

Closed injuries are usually associated with fractures, which can trigger a direct nerve involvement by bone fragments; however, joint dislocation can cause nerve lesions by traction.

Considering nerve pathways, PNI are shown as follows:

– Axillary: shoulder dislocation and rarely

proximal humeral fractures

– Radial: shaft humeral fractures

– Median, radial, and ulnar (isolated or in com-

bination): supracondylar humeral fractures – Median, ulnar, and elbow dislocation – Posterior interosseous: acute or chronic ante-

rior Monteggia lesions – Median, ulnar; diaphyseal forearm fractures;

median, distal radius fractures

Supracondylar humeral fracture is most com-

monly affected by PNI, because of two peculiar risk factors. Firstly, the close contact between nerves and bone at the elbow level is a major predisposing factor to nerve injury. Radial and ulnar nerves are often damaged because of theirpassage through denite osteobrous tunnel and septa that prevent from their natural sliding. Secondly, the severe displacement of Gartland 3 supracondylar humeral fracture increases the chances of nerve kinking, entrapment, or laceration [3] (Fig.25.1).

The pattern of nerve involvement is closely

related to the type of fracture: the median nerve is commonly injured in the event of posterolateral Gartland 3 fractures whereas the radial nerve in posteromedial ones [4, 5].

Injuries of the ulnar nerve can be occasionally

observed in rare exion-type fractures, while sometimes iatrogenic lesions may happen after medial pinning.

Many authors have reported the radial nerve

as the most commonly injured nerve; however, the recent literature has focused on the median nerve and particularly on its anterior interosseous branch (AIB).

In medical literature, anterior interosseous

nerve involvement has been often neglected for two main reasons: on the one hand, median nerve trunk and related nerve branch injuries are usually difcult to differentiateeach other, so medical reports group together these lesions as a whole; on the other hand, a suddendetection of anterior interosseous nerve involvement is hard to identify, especially in younger children who cannot adequately complain their discomfort [6].

Even though its incidence is underestimated,

ABI palsy has to be probably considered the most

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Fig. 25.1 Joint dislocation causing nerve traction and AIB injury

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common nerve injury related to supracondylar fractures, even though its origin is far from the supracondylar region.

The peculiar anatomy of the median nerve may explain the prevalent involvement of AIB, which is due to two factors.

First of all, nerve bers devoted to AIB are located in a posterior position in the main trunk of the median nerve, so that direct trauma triggered by the free edge of the proximal fragment of fracture might damage them before AIB (branch) detachmentfrom the main nerve.

Moreover, after arising from the major trunk the AIB passes through the interosseous membrane in a deep position.

The narrow passage and angulation of the nerve trunk cause reduction of the natural sliding of the nerve and a predisposition to traction [7] (Fig.25.2).

The radial nerve is commonly injured in fractures presenting with posteromedial dislocation.Notwithstanding the constant onset of the palsy, the recovery is usually spontaneous, as observed in the humeral shaft or Holstein–Lewis fractures [8, 9]. An unexpected radial nerve palsythat appears in the rst weeks after trauma is possiblydue to the compression or wrapping of

the nerve bybone callus. As regards ulnar nerve injuries, there are minor chances ofdirectnerve injury in skeletal trauma, apart from rare fractures with exion dislocation (2% of all supracondylar fractures).

Further causes of palsy might be a direct injury in the event of medial pinning for fracture xation, which inconstantly causes nerve fascicle disruption or the arising of late palsy secondary to perineural brosis in the cubital tunnel.

Open injuries are commonly due to glass or sharp objects.

On the one hand, wounds of the upper arm are usually observed in older children because of their autonomy, which exposes them to the risk of cutting with penetrating glass fragments, metal plates, knives, or cutting blades. On the other hand, little children are easily injured by the same sharp objects but more commonly are suffering from crush injuries, without signicant impairment ofnerve trunks.

The wrist, palmar surface of the hand, and ngers are the most common sites of injury. Very often, multiple cuttings are detected, interesting both the vessels, tendons and muscles, and nerves as well.

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Fig. 25.2 Kiloh–Nevin syndrome: impossibility to distal phalanx exion of the thumb and index nger after AIB injury

Physicians must be aware of thoroughly exploring  any minimal glass wounds because askin laceration might be expressionof deep structuresdamaging.

Although a clinical examination might be difcult in the child, especially in the youngest, vessels, tendons, and nerve interruption should be detected in the rst exploration [10] (Fig.25.3).

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Fig. 25.3 Small wound in the palmar region with a lesion of the collateral radial nerve for the index nger

25.3 Diagnosis

To solve the problem, some authors have proposed to assess the sensibility of uncooperative chil-

Early identication of nerve palsy is basic either for the treatment or forensic aspect. Medical reports should clearly show if the paralysis were already present at the admission of the patient to the emergency room. Although detection of nerve palsy might be independent of the treatment, very often reports lack this information, so in case of legal disagreement, it might be hard to explain a nerve lesion that occurred at the trauma [11]. Clinical examination should be accurately carried out to give the right information and decide on strategies for treatment.

Nevertheless, the examination might be challenging, especially in the youngest child presenting with bone fractures. Usually, they are uncooperative because of their age, anxiety, pain, and swelling. For those reasons, assessment methods commonly applied to test active motion and sensibility cannot be used, because of the risk of underestimating the palsy.

dren by submergingthe hand in water, soaking or wet cloth, and then observing the capability to wrinkle [12]. Immediate sign of nerve involvement is neuropraxia; however, during the rst weeks after trauma, it does not need to carry out anyearlydiagnostic examination.Closed nerve injury of the upper limb has a high chance of spontaneous recovery. On the contrary, in the event of a palsy not showing any sign of recovery from 4–6 monthsafter the trauma, it is advisable to study the nerve through ultrasound and neurophysiological exams. Similarly, early surgery should be performed in the event of persistent palsy with a Tinel’s sign remaining at the fracture site, which might be the expression of nerve entrapment in the bone regeneration callus.

The key point is to detectwhether the nerve is in-continuity or not and about perilesional tissues [13].

Neurophysiological exams are still considered the gold standard to study nerve palsy, although

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they are not always reliable, especially in the acute phase of the palsy or in uncooperative patients [14]. Sonography, giving more information on the morphology, continuity, and motility of the nerve, can easily identify nerve damage that requires early surgical treatment.

Being not inuenced by tissue changes following the trauma or by the presence of metallic devices, this examination can be carried out during the rst weeks after the injury.

Itis usually well tolerated by the child, allowing it to be repeated to assess the recovery [15].

25.4 Treatment

The approach to PNI differs from the type of injury, namely, open or closed, and the presence of a nerve gap.

The treatment of open injuries should be theoretically carried out as soon as possible to avoid the formation of scar tissue which might hinder nerve regeneration.

However, a new opinion has arisen about delayed reconstruction within 3 weeks after the trauma, especially in the event of extended or complicated multiple tissue lesions.

Moreover, this option of delayed treatment could be useful for surgeons who do not usually deal with nerve surgery, allowing them to address the injured child at a hub center where nerve surgery is commonly carried out.

According to nerve damage, nerve reconstruction can be performed through different techniques:direct suture (Fig.25.4), nerve graft (Fig.25.5), and tubulization are the options (Fig.25.6).

Neurorrhaphyis the best procedurebecause it can provide the right orientation of the axons. However, in open injuries, a nerve gap is often shown so to impose substitution of the gap through nerve grafts or conduits.

To ll the gap, nerve grafts are the best solution. Schwann cells of interposed nerve graft contribute to nerve regeneration, both for mixed and sensitive nerves.

F. M. Senes et al.

Fig. 25.4 Ulnar nerve lesion treated with direct suture

Fig. 25.5 Sural nerve graft for nerve reconstruction

The conduits represent an alternative to bridge the gap, but some concerns still remain. Although many types of tubes have been proposed to improve nerve regeneration (i.e., bio- logical or synthetic), at the time being there are still contrasting results apart from some good outcome in sensitive nerves.

On the contrary, regarding mixed nerves its application remains controversial [16].

Notwithstanding, considering the overall good recovery of nerve injury in children, the use of nerve conduits in repairing nerve defects of the upper limb may be considered even for mixed nerves [17].

Another matter that is widely debated is the approach to a closed nerve injury, especially for those associated with supracondylar humeral fractures.

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Fig. 25.6 Median nerve reconstruction with saphenous vein tubulization

On the one hand, the majority of these lesions tend to a complete recovery: a waiting attitude should be considered, postponing any treatment before 6 months from the trauma [18, 19].

If nerve palsy does not shortlyappear after the trauma but is detectedin the following weeks, a nerve entrapment into bone callus formation

In the event of neglected nerve injuries in adults, tendon transfers are commonly performed to restore function. On the contrary, tendon transfers in children should not be considered as a rst option, because of their nerve spontaneous repair or recovery achievement through delayed nerve reconstruction.

should be suspected.

Radial and median nerves are commonly

involved, although the rst one has a major risk

25.5 Conclusion

because of its closelocation to the bone.

Inthe eventof late paralysis, sonography can show the nerve morphology and surrounding bone callus formation.

If compression is conrmed, early exploration can establish whether the nerve might be freed or repaired throughautografts.

To sum up, PNI are common occurrences in pediatric traumatology, particularly in upper limbs than in the lower ones.

Althoughopen lesions are not negligible, the majority of lesions are closed injuries. Unlike adulthood, closed injuries require a waiting atti-

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