BASSAM MJ ADDAS, FRCSC.

KING ABDULAZIZ UNIVERSITY, KING FAHAD GENERAL HOSPITAL.

JEDDAH, KSA

Obstetric brachial plexus palsy

Pediatric brachial plexus palsy

Adults brachial plexus palsy

Obstetric versus birth palsy

Obstetric versus congenital palsy

Not all birth palsies are Obstetric but the majority are……..

1. Complete brachial plexus injury

2. Duchenne-Erb palsy

3. Upper-middle trunk brachial plexus injury

4. Klumpke-Dejerine palsy

5. Bilateral brachial plexus palsy

Cephalopelvic disproportion, shoulder dystocia, forceps delivery !!!

Maternal diabetes

Breech presentation, can be bilateral

Previous child with plexus injury

Fetal anomalies, cervical ribs, other…….

The practice of midwifery !!!!!!!

Largely unknown

Retrospective studies

Small number of patients, lots of loss of follow up

Referral bias

A surgical series will differ significantly when compared to a rehabilitation or medical series

Overall it is good for upper trunk, no so for total palsy

External rotation of the shoulder and supination usually recovers late.

Sensory recovery is better than motor recovery particularly in the hand

Return of motor function continue to recover up to 2½ years and the sensory function up to 3 years.

Not right that all recovers

Not right that nothing can be done

Clinical diagnosis

Role of EMG

Role of MRI

Avulsion in adults

Avulsion and sometimes rupture in children

Can improve dramatically and even disappear, so ask about even if you do not see it

No complaints usually

Attempt to improve the accuracy of preoperative diagnosis. Absence of re-innervation in 3 months is indicative of avulsion injury

Near normal EMG can be found in patients with complete OBPI

In patients with OBPI denervation occurs and disappears much earlier, can be found as early as 4 days and disappear by 4 months

Short distance and small nerves are two possible explanations

The process may start as early as 1-2 days and disappears as early as 10-60 days

The majority of centres do not rely on EMG in making a preoperative diagnosis

* clinical exam

* preoperative imaging

- myelogram +CT scan

- MRI

CT myelogramis more sensitive

Wait for a month before getting MRI

Our main objective in OPBI is the hand.

Proximal muscles have a better chance most of the time.

The hand reconstructive procedures are not as satisfactory as the shoulder and elbow

Upper trunk

Grade IV and V 52% (80%)

Grade III 40% (60%)

Grade I and II 8%

Upper and middle trunk

Grade IV and V 36% (61%)

Grade III 46%

Grade I and II 18%

Total OBPI

Secondary reconstructive procedures are always needed.

Elbow flexion can be achieved in 60% of patients