Long Term Outcome

Brachial plexus injuries cause severe functional deficits in the affected extremity. The full extent of the arm and hand deficits may not be known for several years. Additionally, upper body posture may be altered as a result of compensatory maneuvers used to deal with poor positioning of the shoulder and arm.

"Many parents have been told that "95% of these injuries get better without treatment" . Dr. Nath's 8 years of experience, over 5,500 evaluations and over 4,000 surgeries on children and adults with obstetric brachial plexus injuries has led us to believe that this estimate is overly optimistic.

A recent landmark report from the Children’s Hospital at the very well respected Karolinska Institute in Stockholm, Sweden evaluated 105 children for functional outcome at 5 years of age following obstetric brachial plexus injury (Sundholm LK, Eliasson A-C, and Forssberg H. Obstetric brachial plexus injuries: assessment protocol and functional outcome at age 5 years.

The Swedish study evaluated motor and sensory functions as well as the overall use of the affected limb. The results indicated that "the eventual outcome from in upper-plexus lesions is more complex than is commonly believed". Occupational Therapists and a physician specializing in movement problems of children determined these outcomes.

The findings are quite compelling and very much in agreement
with what we see in our clinic:

• Children with no apparent deficits in shoulder, biceps or hand function by 3 months of age: 70% full recovery by age 5 years.
• Children with remaining deficits in shoulder, biceps or hand function by 3 months of age: 5% full recovery by age 5 years.

It is important to understand the meaning of these results: even in the best case scenario, where no obvious deficits remain by the age of 3 months, fully 3 out of 10 children will have significant functional deficits by the age of 5 years if untreated. In children with remaining problems after the age of 3 months, over 9 out of 10 children will have residual deficits by 5 years. Overall, 66% of children, or 2 out of 3, had severe problems by the age of 5 years.

This information is critical in understanding the progression of the muscle imbalances that occur following brachial plexus injury. The 105 children in this study all received physical therapy and primary surgery where appropriate at the age of 3 to 6 months. None of the children underwent secondary or muscle transfer surgery by the age of 5 years.

It is these residual muscle imbalances that secondary surgery (including the quad procedure) attempts to correct. The surgery moves around muscles which cause the deformity to place them in a better position for overall function.

Dr. Nath has performed the Mod Quad surgery on over 2800 children and adults with excellent improvement in function in virtually all. Our overall improvement in arm abduction and flexion (lifting the arm over the head) has been 60-70 degrees, and in external rotation (placing the hand behind the head; throwing a ball) has been 40-50 degrees. We have not seen any other reports with results even close to these and certainly have not seen a series of patients this large reported elsewhere.

In summary, the arm function of children with brachial plexus injury is actually more affected than commonly thought. Even in the best group of children, those with no visible deficit by age 3 months, 30% will have residual, noticeable deficits by age 5 years. Those with visible deficits by the age of 3 months will have a 95% incidence of residual problems by age 5 years. This important study supports the idea that aggressive, including surgical, management of brachial plexus injuries may lead to better outcomes.