The Journal of Bone and Joint Surgery (American) 86:2163-2170 (2004)
© 2004 The Journal of Bone and Joint Surgery, Inc.
Neonatal Brachial Plexus Palsy
Outcome of Absent Biceps Function at Three Months of Age
Nicholas C. Smith, MB1,
Peter Rowan, MB2,
Laurel J. Benson, MD3,
Marybeth Ezaki, MD4 and
Peter R. Carter, MD4
1 Department of Orthopaedics, Children's Hospital at Westmead, Locked Bag 4001,
Westmead, NSW 2145, Sydney, Australia
2 Brisbane Orthopaedic and Sports Medicine Centre, Level 5/259 Wickham Terrace,
Brisbane, QLD 4000, Australia
3 Department of Orthopaedics, Denver Children's Hospital, 1056 East 19th Avenue,
Denver, CO 80218
4 Department of Hand and Upper Limb Surgery, Texas Scottish Rite Hospital, 2222
Welborn Street, Dallas, TX 75219. E-mail address for M. Ezaki:
marybeth.ezaki{at}tsrh.org
Investigation performed at Texas Scottish Rite Hospital, Dallas,
Texas
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They did not receive payments or
other benefits or a commitment or agreement to provide such benefits from a
commercial entity. No commercial entity paid or directed, or agreed to pay or
direct, any benefits to any research fund, foundation, educational
institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
Background: An important prognostic factor in neonatal brachial
plexus palsy is the time interval to biceps muscle recovery. Although the
natural history is not clear, biceps muscle recovery after more than three
months of age has been used to predict poor long-term shoulder function. The
absence of biceps muscle function at three months of age has been adopted as
an indication for early brachial plexus microsurgery, in an attempt to improve
recovery. To provide a benchmark for outcome comparison, the long-term outcome
of patients with absent biceps muscle function at three months of age was
studied.
Methods: Between 1980 and 1992, 170 patients with neonatal brachial
plexus palsy were entered into a prospective study in which details of the
birth and serial clinical examinations were recorded. Patients were grouped
according to the level of injury and the time interval to biceps muscle
recovery. Twenty-nine patients were observed to have absent biceps muscle
function at three months of age. Twenty-eight of those patients were available
for long-term followup at a mean age of eleven years and one month. At the
time of follow-up, patients answered a questionnaire and underwent manual
muscle strength testing, sensory evaluation, and grading of their shoulder
function according to Gilbert's modification of the Mallet score, in which the
function was graded as II, III, or IV with class I (no function) and V
(normal) eliminated. The level of injury and the time that biceps muscle
function returned were compared with the final outcomes.
Results: The level of injury was C5-C6 in thirteen (46%) of our
twenty-eight patients with absent biceps muscle function at three months of
age, C5-C7 in five (18%), and pan-plexus (C5-T1) in ten (36%). Biceps
contraction was observed by six months of age in twenty patients (71%),
including all thirteen patients with a C5-C6 level of injury. Twenty-two
patients did not have surgery on the brachial plexus, but nine of those
patients had subsequent orthopaedic procedures. At the time of follow-up,
twenty-seven of the twenty-eight patients had at least antigravity biceps
muscle function. Patients who regained biceps muscle function between three
and six months of age had better scores for abduction (p = 0.04) and for
hand-to-neck (p = 0.05) and hand-to-back (p < 0.001) function than did
patients who regained biceps muscle function after six months of age. Patients
with a C5-C6 lesion had better scores for external rotation (p = 0.04) and for
hand-to-neck (p = 0.05), hand-to-mouth (p < 0.01), and hand-to-back (p <
0.001) function than did patients with a pan-plexus lesion. Twelve (55%) of
the twenty-two patients who did not have brachial plexus surgery had a
class-IV shoulder (good function) according to the modified Mallet score. Of
the twelve patients with a C5-C6 level of injury who did not have brachial
plexus surgery, eight had a class-IV shoulder.
Conclusions: This study indicated associations between prolonged
neurological recovery and a more extensive level of injury and worse long-term
shoulder function. Patients with a C5-C6 injury and absent biceps muscle
function at three months of age often have good long-term shoulder function
without brachial plexus surgery.
Level of Evidence: Prognostic study, Level IV (case
series). See Instructions to Authors for a complete description of levels of
evidence.
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