OBSTETRIC TRACTION INJURIES OF THE BRACHIAL PLEXUS

8/13/2019 OBSTETRIC TRACTION INJURIES OF THE BRACHIAL PLEXUS

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V O L . 7 0-B , N o . 4 , A U G U S T 198 8 71

OBSTETR IC TRACT ION IN JUR IES O F THE BRACH IAL PLEXUSN A T U R A L H IS T O R Y , IN D IC A T IO N S F O R S U R G IC A L R E P A IR A N D R E S U L T S

R . S . BOOM E , J . C . K AYE

From G roo te Schu ur H osp ita l, C a pe Tow n

O f a co nsecu tive series of 70 b ab ie s w ith ob ste fric frac tio n in ju ry to the b rach ial p lexus w e w ere ab le torev iew 40 w ho had h ad o n ly con serva tive trea tm en t. W e fou nd tha t if reco ve ry in the up pe r ro o ts h ad no ts ta rted by three m on ths of ag e th en , a t fo llow -up th ere w as a sig n ifican t res id ua l fu nc tion al de fic it.

In a fu rthe r 2 2 b ab ie s w h o show ed no recov e ry o f th e up pe r roo ts by th ree m o nth s , exp lora tio n and sura lne rve gra ftin g w ere pe rform ed ; 2 0 o f these ch ild ren w ere rev iew ed a t on e year. G oo d recov ery o f th e de lto idw as seen in 8 0% an d of the b iceps in 55 , w hile 25 % h ad go od exte rna l ro ta tion a t the sh ou lde r. W e co nc lu deth at if th ere is d isru p tio n o f the up pe r ro o ts w ith n o sig n of recov ery a t th ree m on ths , g ra ftin g of th ese ro o tspro v id es the best ch an ce of usefu l recov ery .

O bste tric pa lsy o f th e up pe r lim b is caused by a tractioninjury to the brach ia l p lex us d urin g b irth (T ay lor 19 07 ;S eve r 19 25 ). T he firs t de sc r ip tion w as by S m e llie in 17 64and D u ch en ne in 18 72 im plica ted trac tion o n th e a rm asthe cause . In 1 874 E rb desc rib ed a s im ila r pa lsy in adu ltsand su gg ested tha t traction or com press ion o f the C S andC 6 ro ots co u ld pro du ce the in ju ry (R an g 19 66 ). T h epro gn osis o f su ch in ju ries has been rev iew ed b y B enn etan d H arro ld (19 76 ) and H ardy (1 98 1), w h o repo rtedco m ple te recov ery in 94% an d 8 4% of pa tien ts re spec-tive ly . E arlie r repo rts ind ica ted co m ple te recov ery in asfew as 1 3% (W ickstrom , H aslan and H utch inso n 195 5)bu t, s in ce reco ve ry va ries w ith the seve rity o f in ju ry , th isd isc repancy m ay b e du e to recen t im p rov em ent inob stetric p ractice .

In ha lf the pa tien ts , on ly the u ppe r ro o ts o f th eb rach ial p lex us a re a ffec ted , b u t th e C 7 roo t also isinvo lv ed in a furthe r q ua rte r, w ith in ju ry to the w h olep lexu s in the rem a in ing q ua rte r. T h e K lum pk e lo w erroo t in ju ry is ve ry ra re (T ass in 1 983 ).

P erm an en t d am age to the up pe r ro o ts is un co m m on ,bu t cause s a de fo rm ity and a sev e re fun ctio na l de f icit.C lassica lly the re is a loss o f ab du ction an d ex te rna lro tation o f th e sh ou lde r, o f flex ion a t the e lbo w andsup ina tio n of the fo rea rm . H an d fun ction , w hich m ay

a lread y b e im pa ired , is fu rthe r co m prom ised b y thep ro x im a l w eakn ess .

T h e firs t a ttem p t to rep air ex tra-fo ram in al rup ture so fthe C S and C 6 ro ots w as m ad e by K en nedy in 19 03 . H erepo rted th ree case s w ith one excellen t re su lt, bu t h ad nofo llow -u p in the o th er tw o . T ay lo r (1 920 ) rep o rted 70exp lo ra tion s, and o b ta ined goo d im provem en t in m any ,e spec ially the ve ry y oun g , b u t had th ree po stop era tivedea ths. D irec t repa ir o f the u ppe r roo ts rem a inedco n trove rsial (S eve r 1 925 ; J ep son 1 930 ; W ickstro rn et a .19 55 ) and even tua lly ceased to be stan da rd p rac tice.

M o re recen tly , m od e rn m ic rosu rg ical techn iqu esand sa fe anaesth esia h av e renew ed in tere s t in th e rep airof ex tra-fo ram in al roo t in ju rie s , e spec ially o f the u ppe rroo ts . So lon en , T e la ran ta an d R yo ppy (1 98 1) reportedth ree case s in w h ich th e up pe r tru nks w ere repa ired atth ree m on th s o f ag e w ith goo d recov ery . G ilbe rt, K h ou riand C arlio z (19 80 ), in a la rge r se rie s w ith a w id er ag erang e, had th e b est resu lts in pa tien ts und e r s ix m o nth s o fage . If ch ild ren w ith ex tra-fo ram in al in ju r ies w ith littlechance o f recov e ry cou ld b e id en tified ea rly , the se w ou ldc lear ly m erit exp lo ra tion an d g ra ftin g o f the upp er roo ts .

T h is p ape r ex am in es th e na tura l h is to ry , theind icatio ns fo r, an d the re su lts fo llo w ing repa ir o f thebrach ia l p lex us in bab ies a fter trac tion in ju rie s at b irth .

P A T I E N T SR . S . B o o m e , FRC S, FC S Or tho )SA , C onsu ltan t O rthopaed ic SurgeonC ity P ark M edic al C entre, 1 81 L on gm ark et S tre et, C ape T ow n 80 01 ,So uth A fric a.J . C . K ay e, FRC S, O r thopaed ic R eg istrarPrin ce ss M arg are t R o se H ospita l, Fa irm ile hea d, E d inb urg h E H 1O7 ED , S co tla nd .C orrespond en ce sh ou ld b e sen t to M r R . S . B oom e. 198 8 B ritish E d ito ria l S ociety of B on e an d Jo in t S urgery03 01-62 0X /8 8 /41 12 $2 .00J B on e Jo in t S urg [B r] 1988;70-B:571-6.

A ll th e p atien ts had susta ined b irth in ju rie s o f thebrach ia l p lexu s. T he G ro ote S ch uu r H o sp ita l b rach ia lp lexu s clin ic is a seco nda ry re ferra l cen tre , so tha ttran sien t pa lsie s w ere no t n o rm a lly seen . B etw een 198 1an d 19 85 , 7 0 ch ild ren un de r s ix m on ths o ld w ere seenwith 7 2 brach ia l p lex us pa ls ie s. E igh t ch ild ren w ereexc lud ed as h av ing in ad eq ua te record s . T h e rem a in ing


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Sup r a scapu la r nerve

Muscu lo cu taneous nerve

Radial

M ed ian nerve

Ti

U lnar nerv e

57 2 R . S . BOOM E , J . C . KAYE

TH E JOURNAL O F BONE AND JO INT SURG ERY

6 4 pa lsies in 62 bab ie s w ere cons ide red in tw o g rou ps:N on -op era ted gro up . S p on tan eous reco ve ry w as seen o f42 pa ls ies in 40 ch ild ren . T hese w ere fo llow ed e ith er tofu ll reco ve ry o r u n til the m ax im um expec ted recov ery .A verage fo llo w -u p w as 17 .9 m o nth s (rang e, on e m on th tofiv e years). In those n ot attain in g fu ll recov ery th em in im um fo llow -up w as o ne yea r.O p era ted gro up . In a ll, 2 2 infan ts h ad an exp lora tio n o fth e b rach ia l p lex us. T his w as co nside red at th ree m o nth sif the re w as no ev idence o f recove ry in the m uscle sinne rva ted by C S or C 6 .

M E T H O D SC lin ica l asse ssm en t. A ll ch ild ren w ere ex am in ed b y on e ofth e au th ors (JC K ). T he streng th of ind iv idu al m uscles orm u sc le g ro ups w as reco rd ed a t each c lin ic v isit, andm oth ers w ere instru cted in stre tch in g exe rcise s fo r th esho ulde r, pe rform ed a t ev ery n ap py chang e, to p rev en tjo in t c on tr ac tu re s.

C S roo t w as con side red to in ne rva te th e d elto idm usc le an d the ex tern al ro ta to rs of th e sho uld er, C 6 toinn e rv a te the b icep s , C 7 th e ex tenso rs of th e w ris t andth e fing ers an d T l the in trins ic m usc le s o f the han d .M usc le s treng th w as assessed b y ob serv atio n d urin g p layand by c lin ica l exam ina tio n . M usc le po w er w as g radedacco rd in g to the M R C sca le (M ed ica l R esea rch C ou nc il19 43 ). A ccu rate grad ing is d ifficu lt in in fan ts and yo ung

ch ild ren , so th is w as sim p lif ied . M R C G rades 1 and 2w ere consid e red to ge th er, an d sco red as G rad e 1 /2 w henthe re w as de fin ite m usc le co n trac tio n b ut no use fu lm o vem en t co u ld b e m ade aga in st g rav ity . In G rade 3the re w as som e m o vem ent aga in st g rav ity bu t w ithlim ited ran ge an d no t su stain ed . G rades 4 an d S w ere alsoconsid ered to ge the r, inc lud in g those sh ow ing som ew eakn ess afte r repe titiv e m ov em en ts w ith slow ness onreflex tes tin g , and th ose w hich w ere clin ica lly n orm al.

E xte rna l ro tatio n o f th e sh oulde r is e ssen tial fo r fu llsh ou lde r ab du ction and is d ifficu lt to tes t in an infan t.W eak ness w as d iag no sed w h en p lac in g th e han d to th em ou th necessita ted sh ou lde r ab du ction to 90 #{1 76 }o com pen-sate for th e w eak ro tato rs ; p ow er G rad e 3 w as reco rded .In ab ility to p u t the hand to the m o u th d esp ite go odpo w er in d e lto id and b iceps w as reco rded as G rad e 2 orle ss fo r ex te rn al ro ta tion .

T E C H N IQ U E O F O P E R A T IO NT h e b rach ial p lex us is app roach ed abo ve the c lav ic leth rou gh a ho rizo n ta l inc is io n . If a w ide r exp osure isreq u ired , the c lav ic le is d iv ided . O n ce exp osed , d am agedroo ts are fo llo w ed pro x im ally and neuro lysis pe rform edas fa r in to th e fo ram en as p ossib le (F ig . 1 ) . T he v iab ilityo f n erv e ro o ts is a sse ssed ; tho se tha t a re th in anda ttenua ted or soft an d oedem ato us, w ith m in im al d is talneu rom a, su gg estin g em pty fa sc ic le s, are co nside red to

F ig . 1D ia gra m of th e b rac hia l p lex us. N e uro lys is (in dic ate d by bla ck ro ots )w a s u sed alone in tw o p atie nts .

in d ica te a m ore p rox im a l in ju ry an d a re no t su itab le forg raft ing . W here a neu ro m a is p resen t, it is ex cised .

T h e gap be tw een the n erv e end s is gra fted , usin g thesura l n erv e (F ig . 2 ). T h e m ean len g th o fgra ft w as 2 .5 cm ,and o n av erage fou r g rafts a re p laced on each ro o t s tum p.T h e su prascapu la r n erv e is alw ays g rafted sepa ra tely toth e C S ro ot. In tw o cases n erv e ro o ts w ere in co ntinu itybu t sev ere ly constricted b y d ura l fib ro sis a t th e foram en ;on ly neuro lysis w as p erfo rm ed . T h e low er roo ts w ereex plored w h en th is w as ind icated by the pre -op era tiv ef ind ings.

P os tope rativ ely , the ch ild is nu rsed fo r tw o w eek s ina p la ster cow l to p rev en t d is traction be tw een th e h eadan d shou lde r. T he a rm is strapped to the bo dy fo r afu rth er fou r w eek s, a fte r w h ich tim e the ch ild s m oth er isen courag ed to re sum e sh ou lde r ex erc ise s to p rev en t jo in tcontracture.

R E S U L T SN o n-o pe rated g rou p . T he age at pre sen tation o f th isgro up w as be tw een tw o w eeks and th ree m on ths (m ean ,seven w eeks). T h ere w ere 26 bo ys an d 14 g irls , w ith 24righ t, 1 4 left an d tw o b ila te ra l p alsies . T h ere w ere 21p a lsies invo lv ing C S and C 6 (50% ), 1 6 inv o lv in g C S , C 6an d C 7 (3 8% ) and five in vo lv in g all five roo ts (12 % ).

In the C S and C 6 p alsies the age at w h ich m u scleco n trac tion w as firs t seen to sta rt w as re la ted to theeven tu al recov ery (T ab le I) . If m usc le co n trac tion in th ed elto id o r b icep s had sta rted b y three m o nth s o f age , thena G rad e 4 /S reco ve ry ensued . O f six cases w ith a fou r-m on th de lay , five had resid ua l w eakn ess at th e fin alrev iew . T he oth e r in fan t h ad been ad m itted forexp lora tio n a t fou r m on ths o f ag e, bu t de lto id ac tiv ityw as noted o n ad m issio n and op era tio n w as d efe rred ;th ere w as a fu ll recov ery . E x te rna l ro tation w as w eak o rab sen t in n ine of the 2 1 ch ild ren (42 % ); th is requ ired anex te rna l ro tation transfe r to re s to re good fu nc tio n to theshou lder .


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Sup r a scapu la r

F ig . 2a T e n ca ses F ig . 2 b Fo ur c ase s

C5

:c 6C7

C8

Ti

Pa tterns o f pla cem en t o f su ral n erv e gra ftsin 20 p atien ts .

F ig . 2c Thr ee cases

C6

C7

C8

Ti

Fig . 2d - T w o case s F ig . 2 e O ne case

O B S T E T R IC T R A C T IO N IN JU R IE S O F T H E B R A C H IA L P L E X U S 57 3

VOL . 70 -B , N o . 4 , A UGU ST 1988

In tho se w ith in vo lvem en t o f the low er roo ts , a llex cep t o ne reco ve red fu ll fu nc tion . In tha t ch ild , pow erw as G rad e 3 in th e C 7 and C 8 in ne rva ted m u scle s .O pe rated gro up . T w en ty-tw o in fan ts h ad exp lora tio n ofth e b rach ia l p lexus , a ll op era tions be ing p e rfo rm ed byth e sam e surgeon (R S B ). A t f irs t p re sen ta tion the pa lsy

Table I. N on -op erated g roup th e ag e in m onths a t w hic h reco veryf irst s tarted in C S a nd C 6 in nervated m uscles related to m usc le stren gtha t f ina l re vie w

N u m b e r ofA ge a t firsts ign o f r ec ov er y

patien tsRecov ery

M usc le streng th at re vie w

mo n t h s ) Total a s sho w n E xte rn al ro ta to rs Delto id Biceps1 8 7

14/ 52/ 3

4/ 54/ 5

4/ 54/ 5

2 10 55

4/ 52/ 3

4/ 54/ 5

4/ 54/ 5

3 18 1 17

4/ 52/ 3

4/ 54/ 5

4/ 54/ 5

4 6 11I111

4/ 503203

4/ 52334/ 53

4/ 535033

w as c lin ically ev id en t o n ly in th e C S an d C 6 roo ts in tw ocases, in 1 3 C 7 w as a lso in vo lved an d seven hadinvo lvem en t o f th e w h o le p lex us. Im m ed ia tely b efo reop era tion no ne h ad clin ica l ev id en ce o f m u sc le con trac -tio n in e ith er th e d elto id o r b icep s . T he av erage ag e a texp lo ra tion w as 5 .3 m o n ths (ran ge th ree to 20 m o nths ).

T he op era tiv e fin d in gs an d p rocedures a re sh ow n inF igure s 1 an d 2 and in T ab le II . T h e on ly com plicatio nw as o ne case o f w o un d infectio n . T w o p atien ts (R C , S C )had a con strict ion w ith in the foram en fro m du ralsca rrin g ; t h ey had o nly neuro ly sis o f the roo ts . In o ne ofth ese the re w as b iceps recov ery on th e firs t day afte roperat ion .

T w o p atien ts (C Q , M N ) w ere lo st to fo llo w -up ,leav ing 2 0 pa tien ts w ith an ave rag e fo llow -u p o f 1 .8 years(ran ge , n in e m o n ths to fou r y ea rs). O f the se , ex te rna lro tatio n had recov ered to G rade 4 /S in fiv e case s (2 5% )and the rem a in de r w ere G rade 3 or le ss an d requ iredtransfe r o f la tiss im us d orsi and te re s m a jo r to a tta ingo od sho u lde r fun ctio n .

In 16 p a tien ts (80 % ) th ere w as G rade 4 /S reco ve ry inthe d elto id . In o ne pa tien t (Y E ) w ith no de lto id recov ery ,the C S ro o t had been g ra f ted to the la te ra l co rd to sup p lyb icep s. U nfo rtu na te ly , th e C S ro o t w as a ttenu ated ; th isw as th e only case w ith ou t recov ery in any g ra fted roo t.


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5 74 R . 5 . BOOM E , J . C . K AYE

T able II. O p era ted g roup details of finding s an d m usc le stre ngths at fin al re vie w in 2 2 pa tie n ts

M usc le stre ng th a t r ev ie wExtensors of

Patient Exte rna l w ris ts an d( see tex t) In ju ry C om m e nt ro tato rs D e lto id B ic eps finge rsRC C56 N euro lys is 4 /5 4 /5 4 /5 (5)5

F ibrosis on lySC C567 N eu rolysis 0 4 /5 4 /5 2

F ibrosis on lyNR C 4/5 4/5 4/5 5

EFR tR J C56 C l 3 4/5 4 /5 5

EFR N eu rolysisBLR C 56 C l 0 4/5 4 /5 5

E FR N eu rolysisSG C 4/5 4/5 4/5 5

EF RSA C 567 E FR 0 4/5 4/5 0

C 8 avu lsionIS C 56 3 4 /5 4 /5 (5 )

EF RES C 567 C 8, T l 3 4 /5 4 /5 3

EFR F ibrosisAVN C 56 C 6 root 4 /5 4 /5 3 5)

EFR a ttenu atedCC C56 C l 4 /5 4 /5 0 5

EFR Neuroly sisOF C56E FR 3 4/5 1/2 3

C T av uls ionTB C56 C 7 0 4 /5 3 (4)

EFR F ibro sisJK C 56 C l 3 4 /5 3 5 )

E FR F ib ros isLM C56 C7 0 3 4/5 3 )

E FR F ibro sisJL C567 0 3 3 3

EF RYE C 5 EFR CS roo t 0 0 0 5)

C 6 avu ls ion attenu atedCQ C S EFR W ound N o fo llow -u p

C 6 avu ls ion in fectionM N C 567 C7 root N o fo llow -u p

E FR atten uated

NM C 56EFR C8 ,T l 3 3 0 0C l avu ls ion ex ten siv ef ibros is

N T C 5 E FR C l 0 4/5 3 W 3 , F5C 6 fib ros is

VB C 5E FR 3 4/5 4 /5 5)C 6 a va sc ula r

a P aren theses ind ica te th at recovery had o ccu rred before opera tiont EFR , extra-fo ram in al ru ptu re

TH E JO URNAL O F BONE AND JO IN T SURGERY


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O B S T E T R IC T R A C T IO N IN JU R IE S O F T H E B R A C H IA L PL E X U S 57 5

V O L . 7 0-B , N o. 4 , A U G U ST 19 88

B icep s reco ve ry w as G rade 4 /S in 1 1 pa tien ts (55 % ) andG rade 1 /2 o r le ss in fo u r (20% ). In th e latte r fou r pa tien ts ,the v iab ility o f the g raf ted roo t h ad been do ub tfu l in one(Y E ); in tw o pa tien ts (N M , O F ) th e C 6 roo t w as g ra ftedto p rov id e w rist an d fin ge r ex tensio n as w e ll a s b icep s,and th e fou rth pa tien t (C C ) had a standa rd g raf t.

G ra fts o f C 7 to p rov ide w rist an d fin ge r ex tensio nw ere p laced in f ive pa tien ts , o f w ho m o nly th ree (JL , O F ,E S ) ga in ed G rade 3 p ow er a fter s lo w reco ve ry in th ew ris t and fing er ex tenso rs. In fo ur pa tien ts w h ere C 7fu nc tion w as w eak or absen t p re -ope ra tiv ely and th e roo tw as fo und to be in tac t bu t f ib ro sed , neu ro lysis w aspe rfo rm ed . In th ree o f the se pa tien ts (B L R , C C , R J )G rad e 4 /S po w er even tu ally re tu rned .

In tw o case s th e C 8 and T l roo ts w ere ex p lo red . Inon e p atien t (S A ), C 8 roo t had been avu lsed ; th e m ed ia lco rd w as g ra fted to the C 7 roo t w ith no sig n ific an trecove ry . In the o the r, the re w as in tense f ib rosis an d roo tv iab ility w as in d oub t, so n o ac tion w as taken . T h ispa tien t (N M ) h ad no recov ery o f w rist o r fin ge r flexo rfun ctio n an d w as th e o n ly p atien t to deve lop troph icu lcers o n th e kn uck le s. In 10 of th e 20 op era ted p atien tsth e re w as fu ll, o r nea r fu ll, fun ctio na l reco ve ry o f b o thth e d elto id and b iceps m usc le s (T ab le II).

D I S C U S S I O NIn the no n-o pe rated g rou p , 50 % of th e pa ls ie s w erecon fin ed to the C S and C 6 roo ts . T h ere w as a h ig h ra tio# {14 9}of C 7 in ju r ie s com pared to C 8 and T l in ju r ies , w h ich inT assin s (1 983 ) se rie s w ere eq ua lly d istr ibu ted . S pon -tan eo us recove ry o f the lo w er roo ts m ay accou n t fo r thed iffe ren ce . B y con tra st, in th e ope rated g ro up o n ly 7 % ofin ju rie s w ere co nfin ed to the C S an d C 6 roo ts ; th isre fle c ts a g rea te r seve rity o f in ju ry .

R ecen t repo rts have dem o nstrated tha t the ov e ra llp rog nosis fo r recove ry is go od , bu t ea rly iden tif ic atio n o fthe in fan t w ith a b ad p rog nos is h as no t b een d iscussed(B enn et an d H arro ld 1 97 6; H ard y 19 81 ). T assin (1 98 3)rev iew ed G ilbe rts p atien ts and sh ow ed tha t fa ilu re o frecov ery in the de lto id and b iceps w ith in tw o m onth s o fage m ean t tha t ru p tu re o f th e C S and C 6 roo ts w asp rob ab le, and n o usefu l recove ry co u ld be exp ec ted . Inou r se r ies a ll b ab ies tha t h ad sta rted to recove r so m efu nc tion in e ithe r the de lto id o r b iceps be fo re th reem o n ths o f age ga ined fu ll recov ery , excep t in the ex te rn alro ta to r m u scle s . W hen th ere w as fou r m on ths de laybe fo re reco ve ry sta rted , a ll bu t on e ch ild h ad sig n if ican tre sidu a l w eakn es s in de lto id o r b iceps. If the de lay w asg reate r , a s in som e o f those u nde rgo in g exp lo ra tion ,recove ry d id n o t sta rt. F u rthe rm ore , the su rg ica l fin d -in gs, in ou r o p in io n , w o u ld h ave prec lud ed use fu lreco ve ry . O n th is b as is , o pe ra tion shou ld b e co nsid eredfrom th ree m on th s o f age if the re is no ev idence o freco ve ry in e ith er th e de lto id o r b iceps .

O the r au tho rs h ave u sed e lectro m yog raphy (E M G )

and ce rv ical m ye log raph y to he lp de fin e w hich pa lsie sa re su rg ica lly co rrec tab le . W e hav e no t used E M Gstu d ie s ; m ye log raphy in n ine o f o u r pa tien ts co rre la tedp oorly w ith th e o pe ra tive f ind ings an d added no usefu lin fo rm a tion rega rd ing se lec tion o r o pe ra tive dec ision s.W e n o lo ng er use it.

In G ilbe rts p atien ts (T assin 19 83 ) a ll in ju rie s to theC S and C 6 roo ts w ere ex tra-fo ram ina l, b u t a func tio n lessC 7 roo t h ad alw ays been avu lsed . O u r f ind in gs w ere tha ta ltho ugh th e C S roo t w as alw ays dam ag ed ex tra -fo ram in a lly , th e C 6 ro o t h ad been av u lsed in fou r ca se sand the C 7 roo t had been rup tu red ex tra -fo ram ina lly inth ree . F urth erm ore , in som e cases w ith an ex tra -fo ra -m ina l ru p tu re the ro o t w as th in and a ttenu ated o r so ftand oedem a tou s su ggestin g tha t th ere had a lso beenprox im a l d am age . W e w ould n o t n ow g ra ft such a ro o t;w e be lieve gra ftin g to be va lue le ss .

In eve ry case in w hich the po ste rio r cord w as g raftedto pro v id e de lto id fu nc tion , po w er of G rade 3 o r b e tte rw as ach ieved ; 16 pa tien ts (80 % ) had effec tive ly norm a lde lto id streng th .

T h e sup rascap ula r n e rv e w as a lw ay s g ra fted sepa r-a tely , b u t a ltho ugh the C S roo t had b een v iab le , a s sho w nby de lto id recove ry , o n ly 2 0% had norm a l recove ry o fex te rna l ro tation . In the n on -op era ted g rou p ex te rna lro ta tion w as a lso the m o st com m on residu a l w eak ness.T h is h as b een no ted th rou gho u t th e lite ra tu re . T ay lo r(1 90 7) em ph asis ed th is an d su ggested the p resence o f ap rox im a l le sio n . A d istal le sion at the leve l o f th esup ra scapu la r n o tch is a lso po ssib le , bu t in o ne case w ehave exp lo red the su prascapu lar n e rve as fa r a s th esup ra scap u la r no tch , bu t foun d n o les ion . H ow ev e r, anex te rn al ro ta to r m usc le trans fe r, in o u r exp e rience , isve ry rew ard ing and sim p le to pe rform ; w e con side r it as aseco nd-stage p roced ure a f te r the ne rve repa ir .

B iceps d id no t reco ve r a s su ccessfu lly a s de lto id ;on ly 55 % becam e func tion ally no rm al. In th e fou rpa tien ts w ith no use fu l b iceps recove ry , the p ro x im a lro o t stum p had a lso b een used fo r g rafts fo r e ith ersho u lde r o r w rist fun ctio n ; th is m ay have a ffec ted th e re -in ne rv atio n . R ecove ry o f C 7 fun ctio n w as d isapp o in tin g ,and th is p ara llels the ex pe rience o f o the r au th o rs . Inth ree pa tien ts w ith so m e w ris t reco ve ry , tha t recove ryw as m uch s low er in re tu rn ing th an the m o re p ro x im a lm uscle s . O n ly one ch ild f ina lly show ed do m inance on th es ide o pe ra ted on , w h ich ref lects the fac t th at tru en orm a lity is un lik ely a fte r a g ra ftin g p roced ure. H ow -eve r, a t th e early age o f ou r fo llo w -up , con tinu edim provem en t in streng th and co -o rd in atio n can beexpec ted .C o nc lu sio ns . M ost b ab ie s w h o suffe r trac tion in ju rie s ofthe b rach ial p lex us a t b irth hav e an ex ce llen t p rog no sis ifrecove ry has sta rted w ith in th ree m o nth s . If reco ve ry inth e m u scle s inne rva ted b y the u ppe r roo ts is d elayedbey ond th ree m o n th s, then roo t d isrup tio n is lik ely .E xp lo ra tion an d ne rve g ra f ting then offe rs th e bestp rosp ec t o f a u se fu l arm .


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57 6 R . S . BOOM E , J . C . K AYE

T H E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

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G ilbert A , K b O U r I N, C arlioz H . E xplora tio n ch iru rgica le d u p lexusb rac hia l da ns Ia pa ralysie ob st# {2 33} tr icale : c ons tatatio ns an ato m ique schex 21 m alade s op {2 33 }r {2 33 }s.ev C hir O r tho p l980;66:33-42.

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OBSTETRIC TRACTION INJURIES OF THE BRACHIAL PLEXUS

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