OBSTETRICAL PARALYSIS

* Smellie 1764 * Duchenne 1872 * Erb’s 1874 (Adult)

Pathogenesis

* Congenital.

* Trauma (Duchenne).

* Compression over first rib (Walton).

* Secondary to lesions of the shoulder.

Obstetrical factors

* Cephalic : Overweight, 88%.* Breech : Small baby.

* Pressure neuropathy in uterus.

Incidence

* 4 : 1000 in poor Obstetrical care.* 0.1 - 0.3 : 1000 in good care areas.

* 1% bilateral.

Clinical Picture

* Pseudo paralysis.

* ? Neonatal Tetraplegia.

Clinical Types = A. Gilbert

* Upper roots.

* Elbow extended : C5-6.

* Elbow flexed : C5-6-7.

* Complete paralysis

* Flial arm with clinched hand.

* ? Horner’s syndrome.

* ? Medullary lesion.

Early management.

* Assess both U.L. + L.L.

* X-ray shoulder + clavicle.

* Chest x-ray.

* Collar & Cuff.

* See one week.

Spontaneous recovery.

* (80% - 90%) : (Brown 1984).

* If some contraction of biceps & deltoid at 4 weeks and normal contraction at 8 weeks (Complete recovery).

Tassin 1983.

If no contraction of Biceps or Deltoid at 3m : Poor recovery & result.---------> surgery is needed.

Tassin 1983.

Indications of surgery

1. No recovery of Biceps after 3 months.

2. Any total lesion even after 2 years.

3. Persistent hypotonic paralysis &

atrophy.

4. Persistent Phrenic N palsy.

5. Horner’s sign : 2m.

6. Severe sensory disturbances.

7. Pathological results on MRI or CT myelography.

Operative procedures

*Neurolysis.

*End to end repair.

*Sural N. cable graft.

*Neutrisation.

Abduction ER Splints

• Useless.

• Can cause abduction contracture.

Classification at 3 weeks (NARAKAS).

Group 1 : (C5-6)

Group 1 : (C5-6)

* Functioning biceps.

* Recovery will happen before 6W.

* Normal at 4 - 6m.

Group 2 : (C5-6-7) = Mild

Group 2 : (C5-6-7) = Mild

* Weak elbow extension.

* No recovery at 6 weeks.

* Needs surgery at 6-8 m.

Group 3 : C5 -6 -7 (Severe). C8 - T1 (Mild).

Group 3 : C5 -6 -7 (Severe). C8 - T1 (Mild).

* Flial shoulder.

* No elbow flexion or extension.

* Tight fist.

Prognosis of group 3

* Hand will recover.

* Will end in very poor shoulder.

* Needs surgery at 3m.

Group 4 : Complete paralysis.

Group 4 : Complete paralysis.

* No movement in the limb or fingers at all.

* Needs surgery at 3m.

- MRI --- Myelomeningocele ---> Neutrisation.

- In Horner’s : Operate. at 2m.

* 50% useful hand post op.

Upper trunk at birth

* Review : 7 , 21 days.

* 1st M. : Physiotherapy.

* 2nd M. : If no recovery of Biceps --> EMG.

* 3rd M. : If no recovery of Biceps,

MRI then explore and repair .

Subscapularis Disinsertion

* At 6 - 8 M in Non Operated patient.* At 12 - 18 M in operated patient.

Late deformity

* Shoulder (Soft tissue). - Internal rotation contracture.

- Adduction contracture.

Treatment

* Lengthening of PM.* Subscapularis disinsertion.

* Transfer of L.D., T.M. to I.S.

* Shoulder (Bony) = 67%.

* Fixed bony changes.

- Proximal humeral osteotomy.

* Dislocation * Long coracoid.

Restoration of abduction

Trapezius transfer in flail shoulder. #. Advantages:

* Simple.

* Minimal blood loss.

* Functional & pain elimination.

#. C.I. : Advanced O.A. of the shoulder.

Elbow surgery

* Biceps re-routing for poor pronation.

* LD for flexion.

* Forearm osteotomy for poor supination.

* Flexor plasty.

* Extension distal humeral osteotomy.

Wrist surgery

* FCU to restore extension of fingers.

* P. Teres to ECRB to restore wrist extension.

* Arthrodesis in complete palsy after 12y.

A. Gilbert (1977 - 1994)

1486 Palsy.

( 435 needed surgical repair).

* 93.25% Cephalic.

* 6.5% Breech.

* 0.25% C.S.

Epidemiology Gilbert

* R: 59% , L: 39.5% , R+L: 1.5%.

* Average wt.

Cephalic : 4306g.

Breech : 2849g.

* 51% M 49% F

Surgery in Obstetrical palsy will increase the number of good shoulders and decrease the number of very bad ones.

Tassin

Clinical picture Gilbert

* C5-6 : 48%.

* C5-6-7 : 29%.

* Complete : 23%.

Recovery after surgery Gilbert

* Starts : After 6 - 8 M.

* Lasts : 2 Y upper palsy.

3 - 4 Y in complete palsy.

Recovery in complete lesion

Supra spinatus is the first to recover. (1 mm/day).

3 - 4 M.

Brunelli, 1996.

Results Gilbert

C5 - 6 : 209 patient.

At 2 years :

Grade IV (Good - Excellent: 52%).

“ III 40%.

“ II 8%.

C5-6 Gilbert

After 2 years : Tendon transfer. 13 Subscapularis release.

33 L.D. transfer.

06 Trapezius transfer.

C5-6 Gilbert

At 4 years (After tendon transfer).

Grade IV : 80%.

Grade III : 20%.

C5-6-7 = 126 patient Gilbert

At 2 years.

Grade IV : 36%.

Grade III : 46%.

Grade II : 18%.

C5-6-7 Gilbert

Tendon transfer after 2 years. - 7 Subscapularis release.

- 24 L.D. transfer.

- 1 Trapezius transfer.

C5-6-7 Gilbert

At 4 years Grade IV 61%.

Grade III 29%.

Grade II 10%.

Complete paralysis = 100 patient Gilbert

All treated by Neutrisation.

50% gave a useful hand at 4 years.

Why good results?.

1. Greater surgical experience.

2. Precise knowledge of the anatomy.

3. Sophisticated imaging.

4. Better evaluation & appreciation of

the results.

C8 - T1 : Klumpke

* Non existent alone.

(Narakas, Gilbert)

Endoscopic diagnosis of root avulsions.

Conclusion

* Traumatic palsy (Duchenne 1872).

* 0.6% Congenital aplasia.

* Repair superior to spontaneous recovery (Taylor & Clark : 1905)

* If no recovery of biceps at 3 months - surgery.