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  • Before and After TT
  • Bony Improvement - Before and After - Mod-Quad and TT

OBPI Case Studies

Case Study, Obstetric Brachial Plexus Injury

The patient is a full-term male child with a birth weight of 8 pounds 11 ounces, born in New York state. He was diagnosed with a shoulder dystocia during the birth process, and was delivered after 12 hours of labor with the use of a vacuum extractor. The child was noted to be extensively ecchymotic in the area of the right shoulder and body and with a cephalohematoma.

In the immediate postnatal period, the baby was noted to have a flaccid right upper extremity and torticollis. The affected arm was noted to be in an internally rotated position at the shoulder with pronation at the wrist and cupping of the fingers. X- rays of both clavicles and humerus bones were obtained and found to be negative. A consult with the physical therapy department was obtained and gentle range of motion therapy instituted and taught to the parents. The remainder of the hospital course was unremarkable, and the child was discharged home in stable condition. Followup appointments were made with pediatrics, obstetrics, and the physical therapy department. Specialist consultation with a local pediatric neurologist was arranged at the age of 3 weeks.

By the age of three weeks, the child had regained flexion of the fingers and wrist, to grade 3+ out of 5 on the British Motor Grading system. The remainder of the extremity was essentially 0/5, with patchy sensibility, although better in the hand than the shoulder area. Regular visits to pediatric occupational therapy were instituted at two to three times per week. The parents performed range of motion and sensory rehabilitation training several times each day as instructed by their occupational therapist. An electromyogram (EMG) of the upper extremity at 5 weeks of age was consistent with a severe injury to the C5 and C6 nerve roots with additional injury to C7 and partial injury of the C8 and T1 roots.

At age three months, the baby was noted to have improving triceps and wrist and finger extension strength, to grade 3/ 5. The thumb remained tucked into the palm but less tightly than at birth. A repeat EMG revealed no improvement in the C5 and C6 distribution of the extremity, but increasing motor units in the triceps, forearm and hand. Because of the continuing deficits and positional abnormalities as well as the static EMG findings in C5 and C6, the patient was referred to the Brachial Plexus Clinic at Texas Children's Hospital, the largest such clinic in the world.

A videotape of the child's arm and hand movements while in the upright position was obtained and mailed to the TCH Brachial Plexus Clinic. The video was reviewed by a multidisciplinary team and based on clear lack of antigravity function in the shoulder and biceps, the child was scheduled for surgical intervention at 6 months of age.

The child and his parents traveled to Houston and were evaluated by the Brachial Plexus team the day prior to the planned surgery. The child was confirmed to have probable ruptures of the upper roots of the brachial plexus and taken to surgery the following day. A team of pediatric neurosurgeons and microsurgeons then reconstructed the injury of the brachial plexus which was found to have a complete rupture of the C5 and C6 nerve roots at the level of the upper trunk. Nerve graft was taken from the ankle area and used to reconstruct the torn nerves after removal of scar tissue within the brachial plexus. Following a 4 hour surgery, the child was recovered in the hospital for 2 nights then discharged home with appropriate instructions. A light sling was applied and range of motion therapy started the day after surgery. Formal return to occupational therapy began 3 weeks after surgery, although the parents performed gentle ROM for those 3 weeks at home.

Over the course of the succeeding 3 months, the child slowly improved in muscle tone of the arm with steadily improving triceps and hand strength. Five months after surgery, the child had for the first time exhibited antigravity biceps movements sufficient to bring the hand to the mouth, although with weak supination and a continued tendency toward internal rotation at the shoulder. Shoulder abduction was restricted to about 60 degrees with poor external rotation. A videotape was at this time was evaluated by the clinic surgical team and the movement pattern confirmed as indicating the presence of contractures in the axilla and chest. Upright xrays of the injured shoulder showed significant deformity of the glenohumeral joint, with a shallow glenoid fossa, hypoplastic humeral head, osteopenic and thin humerus, and a high- riding and dysplastic scapula. A posterior dislocation of the shoulder was diagnosed, due to bony developmental abnormalities and muscle contractures. The child was scheduled for Mod Quad surgery.

The Mod Quad surgery was performed by a microsurgeon when the child was 12 months of age. The tendon transfers, nerve decompressions and contracture releases were performed through an axillary incision and the child was placed in a statue of liberty splint for 3 weeks. Daily ROM of the shoulder, elbow and hand joints was performed each day by the parents for 30 minutes during the first 3 weeks. The splint was worn only at night for the next 3 weeks. Upon institution of formal therapy 6 weeks after surgery the patient was noted to have gained significant movement in active abduction, from 60 degrees to 150 degrees, and in active external rotation from 0 degrees to 40 degrees. Contracture tightness was resolved and virtually normal passive ROM was seen.

Although active ROM and functional movements increased 3-fold as a result of the Mod Quad surgery, an internal rotation posture of the arm remained at rest. Therapy continued 2-3 times per week, with the addition of Therapeutic Electrical Stimulation (TES) at night. By the age of 2 years, arm position was not improved and shoulder dislocation as evidenced by continued internal rotation and lack of supination continued. A biceps tendon contracture with a fixed elbow flexion posture of 30 degrees was noted. The affected arm was measured as 5 centimeters shorter than the uninjured side.

The child was scheduled for anterior shoulder capsule release and posterior capsulodesis surgery to tighten and improve shoulder position. At the same time, a lengthening of the biceps tendon to correct the elbow flexion contracture was also performed. Following this surgery, the child was in an external rotation splint for 8 weeks, at which time therapy was resumed. The arm and shoulder position were now noted to be normalized and supination improved. Elbow position was neutral at 0 degrees. Arm length was equal.

The child continued 2 to 3 times weekly supervised therapy, through age 18 years, by which time growth and development were essentially complete. Therapy was reduced to once monthly for the next 7 years although daily home stretching and strengthening exercises were taught. For the remainder of adult life, therapy was maintained at once each 3 to 4 months with daily home exercises. Yearly consultation with a rehabilitation physician and the brachial plexus clinic were maintained. At age 35 years, the patient underwent carpal tunnel and ulnar nerve decompression and transposition for documented nerve impingement. At age 45, the patient had the same surgical procedures on the uninjured side as a result of overuse syndrome. The patient had symptoms of arthritis of the shoulder joint and fingers at age 50, with chronic pain treated with nonsteroidal medications. The patient was employed as an office manager and took early disability retirement from work due to loss of work time for pain management and therapy.

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Association of BPI Therapists

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