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Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey.

ABSTRACT: There is no consensus regarding strategies to optimally treat children with a brachial plexus birth injury (BPBI). Comparison of outcome data presented by different centers is impossible due to the use of (1) many different outcome measures to evaluate results; (2) different follow-up periods after interventions; and (3) different patient ages at the time of assessment. The goal of iPluto (international PLexus oUtcome sTudy grOup) was to define a standardized dataset which should be minimally collected to evaluate upper limb function in children with BPBI. This dataset must enable comparison of the treatment results of different centers if prospectively used. Three rounds of internet surveys were used to reach consensus on the dataset. A Delphi-derived technique was applied using a nine point Likert scale. Consensus was defined as having attained a rating of 7/8/9 by >?=?75% of the participants. A total of 59 participants from five continents participated in the Second and Third Rounds of the survey. Consensus was reached regarding four elements: (1) evaluation should take place at the age of 1/3/5/7 years; range of motion in degrees should be measured for (2) passive joint movement; (3) active range of motion; and (4) the Mallet score should be determined. Consensus on how to asses and report outcome for BPBI was only reached on motor items from the "Body Function and Structure" domain. Consensus regarding additional ICF domains to obtain a more elaborate set of outcome items, should be addressed in future research. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:2533-2541, 2018.

SUBMITTER: Pondaag W

PROVIDER: S-EPMC6175006 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey.

Pondaag Willem W Malessy Martijn J A MJA

Journal of orthopaedic research : official publication of the Orthopaedic Research Society 20180424 9

There is no consensus regarding strategies to optimally treat children with a brachial plexus birth injury (BPBI). Comparison of outcome data presented by different centers is impossible due to the use of (1) many different outcome measures to evaluate results; (2) different follow-up periods after interventions; and (3) different patient ages at the time of assessment. The goal of iPluto (international PLexus oUtcome sTudy grOup) was to define a standardized dataset which should be minimally co ...[more]

PMID: 29566312

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Project description:Background and purposeBrachial plexus birth injury is caused by traction on the neck during delivery and results in flaccid palsy of an upper extremity commonly involving C5-C6 nerve roots. MR imaging and MR myelography help to assess the anatomic location, extent, and severity of brachial plexus injuries which influence the long-term prognosis along with the surgical decision making. Recently, sonography has been increasingly used as the imaging modality of choice for brachial plexus injuries. The aim of this study was to assess the degree of correlation among brachial plexus sonography, MR imaging, and surgical findings in children with brachial plexus birth injury.Materials and methodsThis prospective study included 55 consecutive patients (girls/boys = 32:23; mean age, 2.1 ± 0.8 months) with brachial plexus birth injury between May 2014 and April 2017. The patients were classified according to the Narakas classification and were followed up at 4- to 6-week intervals for recovery by the Modified Mallet system and sonography without specific preparation for evaluation. All patients had MR imaging under general anesthesia. Nerve root avulsion-retraction, pseudomeningocele, and periscalene soft tissue were accepted brachial plexus injury findings on imaging. Interobserver agreement for MR imaging and the agreement between imaging and surgical findings were estimated using the κ statistic. The diagnostic accuracy of sonography and MR imaging was calculated on the basis of the standard reference, which was the surgical findings.ResultsForty-three patients had pre- and postganglionic injury, 12 had only postganglionic injury findings, and 47% of patients underwent an operation. On sonography, no patients had preganglionic injury, but all patients had postganglionic injury findings. For postganglionic injury, the concordance rates between imaging and the surgical findings ranged from 84% to 100%, and the diagnostic accuracy of sonography and MR imaging was 89% and 100%, respectively. For preganglionic injury, the diagnostic accuracy of MR imaging was 92%. Interobserver agreement and the agreement between imaging and the surgical findings were almost perfect for postganglionic injury (κ = 0.81-1, P < .001).ConclusionsHigh-resolution sonography can identify and locate the postganglionic injury associated with the upper and middle trunks. The ability of sonography to evaluate pre- and the postganglionic injury associated with the lower trunk was quite limited. Sonography can be used as a complement to MR imaging; thus, the duration of the MR imaging examination and the need for sedation can be reduced by sonography.

Project description:BackgroundShoulder involvement in brachial plexus birth palsy is common, and the adduction, internal rotation contracture deformity often requires some form of surgical treatment. There are very few long-term reports on release of contracted muscles and tendon transfers, especially in older children. We are reporting the single-center results of such a surgery with detailed outcome analysis.MethodsThe prospectively collected data from brachial plexus birth palsy cases who had undergone contracture release and tendon transfer were retrospectively studied and examined. The new Mallet and functional scores were compared with the original data forms and then analyzed. The radiographic evidence of glenoid dysplasia and its correlation with age and functional outcome was assessed.ResultsA total of 82 cases with surgery at mean age of 9.5 ± 5.09 years and a follow-up of 8 ± 3.8 (3-20) years entered the study. Of these, 56% of cases had 7 to 20 years of age at surgery. Fifty-four (66%) patients had only shoulder surgery, and 28 (34%) required additional reconstructive surgeries for hand and wrist. Moderate to severe glenohumeral dysplasia was present in 38%. The preoperative Mallet score of 10.6 ± 2.97 improved to 19.3 ± 3.39 (P < .001). Eighty-one percent of patients showed improvement in "reaching face" functions, 71% in "above head" functions, and 74% in "midline functions." The cases with lack of improvement in midline function mostly belonged to pan-plexus injuries. Noticeable subjective and objective improvement was also observed in cases with glenohumeral dysplasia in their Mallet and functional scores (P < .001). The improvement in function and subjective satisfaction of 92% was observed irrespective of age at surgery.ConclusionSoft-tissue release and tendon transfer for brachial plexus birth palsy shoulder can improve function and limb appearance even in older children and young adults and even in the presence of glenohumeral dysplasia.

Project description:OBJECTIVE: High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis. CLINICAL PRESENTATION: A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department. INTERVENTION: Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion. CONCLUSION: Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.

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Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey.

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Outcome assessment for Brachial Plexus birth injury. Results from the iPluto world-wide consensus survey.

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