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Natural Course of Brachial Plexus Injuries and Alteration of this Course Through Tendon Transfers
Eric Wagner, MD, Mayo Clinic, Rochester, MN, Bassem T. Elhassan, MD
Orthopaedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN

Purpose: Through these projects, we attempt to addresses two questions regarding brachial plexus injuries; elicit the likelihood of spontaneous resolution of obstetric brachial plexus injuries (OBPI) within the first year of life and then elicit how tendon transfers have been able to alter the progression of the brachial plexus injuries.

Methods: The first phase included a review of patientís treated at our institution for OBPI, examining the patientís upper extremity function throughout the early parts of their lives, as well as their birth history, pregnancy, and early life. Then, the outcomes after tendon transfers for brachial plexus injuries were elicited. The transfers included modified Eden-Lange transfer for trapezius paralysis, pectoralis major transfer for scapular winging, contralateral trapezius transfer for paralyzed shoulder external rotation and ipislateral trapezius and tendon transfers with glenoid reconstruction for OBPI.

Results: Of the 101 patients with OBPI, 23% of the patients experienced spontaneous resolution without therapeutic intervention. The factors associated with no spontaneous resolution involved only maternal or infant conditions, including maternal diabetes mellitus, maternal hypertension, and a birth weight above 10 pounds (p-values <0.04). No obstetric complications or injuries decreased the risk for spontaneous resolution. 49% patients that did not recover underwent surgery, with factors that increased their risk including clavicle fracture, shoulder dystocia, and maternal diabetes mellitus (p-values <0.05).

All of tendon transfers lead to statistically significant improvements in their DASH scores, shoulder Constant scores, shoulder subjective values, range of motion, and pain levels (p <0.05). Over Over 90% of patients reported their shoulder as significantly better than preoperatively and very satisfied with the outcomes. CT scans after the modified Eden-Lange demonstrated early healing, while dynamic ultrasound of the pectoralis major transfers showed normal muscle contraction during shoulder flexion in 11 of 15 patients. At 6 weeks after glenoid reconstruction in 29 patients, 14 patients demonstrated partial healing and 7 patients demonstrated complete healing. All patients after the contralateral trapezius reported successful retraining of the transferred muscles within the first year.

Conclusions: Complete resolution of OBPI is associated with maternal risk factors, however, is not significantly influenced by obstetric complications. In adults, tendon transfers often remain the only option to regain partial shoulder function for patients with severe brachial plexus injuries. These transfers, augmented with bony insertions or glenoid reconstruction, lead to significant improvements in stabilizing the patientís shoulders, while significantly improving their pain, function, and return to daily activities.

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