Complete obstetric brachial plexus palsy: surgical improvement to recover a functional hand.

OBJECTIVE: Complete obstetrical brachial plexus palsy remains a difficult situation for the child and his/her family. The quality of spontaneous reinnervation is rarely good and always leads to a non-sensitive and non-functional hand, even if abduction of the shoulder and elbow flexion do spontaneously recover. The aim of this study was to assess the results from nerve reconstruction in cases of complete palsy and to demonstrate the effect of a change in surgical technique on the outcome of hand function.
METHODS: Thirty pediatric patients with complete obstetric brachial plexus palsy were operated on in our department between 1987 and 2003. Twenty-five of these patients were clinically reviewed and evaluated by a physiotherapist and a surgeon (not the surgeon who performed the surgery). Functional assessment was based on the Gilbert shoulder score, the Gilbert-Raimondi score for elbow function and the Raimondi hand score. All children underwent a nerve reconstruction as graft and/or intra- or extra-plexual neurotization. Our neural surgical strategy changed between 1995 and 1996 to one that addresses the function of the hand and the wrist. A secondary surgical intervention was required in 18 cases. The most frequent procedures were a radial rotation osteotomy and a tendon transfer restoring wrist extension.
RESULTS: Mean follow-up was 7 years and 10 months. Among children operated on with the first surgical strategy-the pre-1995-1996 period-hand function was good in three cases, satisfactory in four cases and unsatisfactory in one case. Among children for whom the second surgical strategy was used-1995-1996 and later-hand function was good or very good in eight cases, satisfactory in four cases and unsatisfactory in two cases. When the 25 patients were assessed for shoulder function, the functional result was good or very good in 12 cases, satisfactory in seven cases and unsatisfactory in six cases. In terms of elbow function, the results were good or very good in 14 cases, satisfactory in eight cases and unsatisfactory in three cases. All hands recovered sensation to a certain degree.
CONCLUSION: The surgical results are encouraging in terms of shoulder and elbow function, but not as good for hand function. With the change in neural surgical strategy in 1995-1996, when more focus was placed on the hand (second surgical strategy), the results on hand function improved relative to those obtained with the first surgical strategy. It must also be noted that hand recovery requires more time, which may partially explain why functional results are not as good for the hand as for the shoulder and elbow. These results demonstrate that early surgical exploration is useful in complete obstetrical brachial plexus palsies and that there is a need for neural reconstruction of the lower trunk.