Secondary procedures for restoration of upper limb function in late cases of neonatal brachial plexus palsy

  • Marios D. VekrisEmail author
  • Dimitrios V. Papadopoulos
  • Ioannis D. Gelalis
  • Vasilios Kontogeorgakos
  • Andreas G. Tsantes
  • Ioannis Gkiatas
  • Ioannis Kostas-Agnantis
  • Dimitrios Kosmas


Neonatal brachial plexus palsy is a devastating complication after a difficult delivery. The incidence of this injury has not significantly decreased over the past decades, despite all the advances in perinatal care. Although primary repair of the nerves with microsurgical techniques is the common treatment strategy nowadays, there are late cases in which secondary procedures in tendons or bones are necessary. Moreover, secondary procedures may be needed to improve the results of primary repair. A careful preoperative assessment of all the residual defects and deformities in upper limbs of these patients is essential. The aim of these procedures is usually to restore the deficient shoulder abduction and external rotation, release of any elbow flexion contracture or to correct a weak elbow flexion. More distally a supination or pronation deformity is usually apparent, and available options include tendon transfers or radial osteotomy. The wrist of these patients may be ulnarly deviated or may has absent extension, so tendon transfers or free muscle transfers can also be used for correction of these deformities. In severe cases, wrist fusion is an alternative option. The clinical presentation of the hand is highly variable due to complex deformities including thumb adduction deformity, metacarpophalangeal joints drop, and weak finger flexion or extension depending on the level of the injury. Each of these deformities can be restored with a combination of soft tissue procedures like local or free muscle transfer and bony procedures like arthrodesis.


Brachial plexus paralysis Neonatal Obstetric Secondary procedures Late cases 


Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Abid A (2016) Brachial plexus birth palsy: management during the first year of life. Orthop Traumatol Surg Res 102(1):S125–S132CrossRefGoogle Scholar
  2. 2.
    Heise CO, Martins R, Siqueira M (2015) Neonatal brachial plexus palsy: a permanent challenge. Arr Neuropsiquiatr 73(9):803–808CrossRefGoogle Scholar
  3. 3.
    Hale HB, Bae DS, Waters PM (2010) Current concepts in the management of brachial plexus birth palsy. J Hand Surg Am 35A(2):322–331CrossRefGoogle Scholar
  4. 4.
    Coroneos CJ, Voineskos SH, Christakis MK, Thoma A, Bain JR, Brouwers MC (2017) Obstetrical brachial plexus injury (OBPI): Canada’s national clinical practice guideline. BMJ Open 7(1):e014141CrossRefGoogle Scholar
  5. 5.
    Vekris MD, Lykissas MG, Beris AE, Manoudis G, Vekris AD, Soucacos PN (2008) Management of obstetrical brachial plexus palsy with early plexus microreconstruction and late muscle transfers. Microsurgery 28(4):252–261CrossRefGoogle Scholar
  6. 6.
    Gkiatas I, Papadopoulos D, Korompilias A, Vekris M, Beris A, Kostas-Agnantis I (2018) Traumatic upper plexus palsy: Is the exploration of brachial plexus necessary? Eur J Orthop Surg Traumatol. Google Scholar
  7. 7.
    Zyaei A, Saied A (2010) Functional outcome of ulnar nerve fascicle transfer for restoration of elbow flexion in upper brachial plexus injury. Eur J Orthop Surg Traumatol 20(4):293–297CrossRefGoogle Scholar
  8. 8.
    Thatte MR, Babhulkar S, Hiremath A (2013) Brachial plexus injury in adults: diagnosis and surgical treatment strategies. Ann Indian Acad Neurol 16(1):26–33CrossRefGoogle Scholar
  9. 9.
    Howell SM, Imobersteg AM, Seger DH, Marone PJ (1986) Clarification of the role of the supraspinatus muscle in shoulder function. J Bone Joint Surg [Am] 68:398–404CrossRefGoogle Scholar
  10. 10.
    Saha AK (1967) Surgery of the paralyzed and flail shoulder. Acta Orthop Scand Suppl 97:5–90Google Scholar
  11. 11.
    Ozben H, Atalar AC, Bilsel K, Demirhan M (2011) Tranfer of latissums dorsi and teres major tendons without subscapularis release for treatment of obstetrical brachial plexus palsy sequela. J Shoulder Elbow Surg 20(8):1265–1274CrossRefGoogle Scholar
  12. 12.
    Elhassan B, Bishop A, Shin A, Spinner R (2010) Shoulder tendon transfer options for adult patients with brachial plexus injury. J Hand Surg Am 35(7):1211–1219CrossRefGoogle Scholar
  13. 13.
    Pearl ML (2009) Shoulder problems in children with brachial plexus birth palsy: evaluation and management. J Am Acad Orthop Surg 17(4):242–254CrossRefGoogle Scholar
  14. 14.
    Andres-Cano P, Toledo MA, Farrington DM, Gil JJ (2015) Arthroscopic treatment for internal contracture of the shoulder secondary to brachial plexus birth palsy: report of a case series and review of the literature. Eur J Orthop Surg Traumatol 25(7):1121–1129CrossRefGoogle Scholar
  15. 15.
    Gilbert A (1995) Long term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin 11(4):583–593Google Scholar
  16. 16.
    Narakas AO (1993) Muscle transpositions in the shoulder and upper arm for sequelae of brachial plexus palsy. Clin Neurol Neurosurg 95(suppl):S89–S91CrossRefGoogle Scholar
  17. 17.
    L’Episcopo JB (1939) Restoration of muscle balance in the treatment of obstetrical paralysis. N Y State J Med 39:336–357Google Scholar
  18. 18.
    Al Qattan MM (2003) Latissimus dorsi transfer for external rotation weakness of the shoulder in obstetric brachial plexus palsy. J Hand Surg Br 28(5):487–490Google Scholar
  19. 19.
    Freund RK, Terzis JK, Jordan L, Taylor G (1986) Modified latissimus dorsi and terres major transfer for external rotation deficit of the shoulder. Orthopedics 9:505–506Google Scholar
  20. 20.
    Cohen G, Rampal V, Aubart-Cohen F, Seringe R, Wicart P (2010) Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer. Orthop Traumatol Surg Res 96(4):334–339CrossRefGoogle Scholar
  21. 21.
    Terzis JK, Vekris MD, Okajima S, Soucacos PN (2003) Shoulder deformities in obstetric brachial plexus paralysis: a computed tomography study. J Pediatr Orthop 23(2):254–260Google Scholar
  22. 22.
    Terzis JK, Kostopoulos E (2010) Our experience with secondary reconstruction of external rotation in obstetricalbrachial plexus palsy. Plast Reconstr Surg 126(3):951–963CrossRefGoogle Scholar
  23. 23.
    Waters PM, Bae DS (2006) The effect of derotational humeral osteotomy on global shoulder function in brachial plexus birth palsy. J Bone Joint Surg Am 88(5):1035–1042CrossRefGoogle Scholar
  24. 24.
    Cambon-Binder A, Walch A, Marcheix PS, Belkheyar Z (2018) Bipolar transfer of the pectoralis major muscle for restoration of elbow flexion in 29 cases. J Shoulder Elbow Surg 27(11):e330–e336CrossRefGoogle Scholar
  25. 25.
    Azab AA, Alsabbahi MS (2017) Bipolar transfer of latissimus dorsi myocutaneous flap for restoration of elbow flexion in late traumatic brachial plexus injury: evaluation of 13 cases. Ann Plast Surg 78(2):198–201CrossRefGoogle Scholar
  26. 26.
    Monreal R (2007) Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type. J Brachial Plex Peripher Nerve Inj 2:15Google Scholar
  27. 27.
    Chen WS (2000) Restoration of elbow flexion by modified Steindler flexorplasty. Int Orthop 24(1):43–46CrossRefGoogle Scholar
  28. 28.
    Brunelli GA, Vigasio A, Brunelli GR (1995) Modified Steindler procedure for elbow flexion restoration. J Hand Surg [Am] 20:743–746CrossRefGoogle Scholar
  29. 29.
    Price AE, Grossman JA (1995) A management approach for secondary shoulder and forearm deformities following obstetrical brachial plexus injury. Hand Clin 11(4):607–617Google Scholar
  30. 30.
    Chuang DC, Hattori Y, Ma And HS, Chen HC (2002) The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy. Plast Reconstr Surg 109(1):116–126CrossRefGoogle Scholar
  31. 31.
    Zancolli EA, Zancolli ER (1988) Palliative surgical procedures in sequelae of obstetrical palsy. Hand Clin 4:643–669Google Scholar
  32. 32.
    Gilbert A, Tassin JL (1987) Obstetrical palsy: a clinical, pathologic and surgical review. In: Terzis JK (ed) Microreconstruction of Nerve Injuries. WB Saunders, Philadelphia, pp 529–553Google Scholar
  33. 33.
    Owings R, Wickstrom J, Perry J, Nickel V (1971) Biceps brachii rerouting in treatment of paralytic supination contracture of the forearm. J Bone Joint Surg [Am] 53:137–142CrossRefGoogle Scholar
  34. 34.
    Gladstein AZ, Sachleben B, Ho ES, Anthony A, Clarke HM, Hopyan S (2017) Forearm pronation osteotomy for supination contracture secondary to obstetrical brachial plexus palsy: a retrospective cohort study. J Pediatr Orthop 37(6):e357–e363CrossRefGoogle Scholar
  35. 35.
    Van Kooten EO, Ishaque MA, Winters HA, Ritt MJ, Van der Sluijs HA (2008) Pronating radius osteotomy for supination deformity in children with obstetric brachial plexus palsy. Tech Hand Up Extrem Surg 12(1):34–37CrossRefGoogle Scholar
  36. 36.
    Zancolli E, Zancolli E (2000) Reconstructive surgery in brachial plexus sequelae. In: Gupta A, Kay SPJ, Scheker LR (eds) The growing hand: diagnosis and management of the upper extremity in children. Mosby, St. Louis, pp 805–823Google Scholar
  37. 37.
    Green DP (1993) Radial nerve palsy. In: Green D (ed) Operative Hand Surgery, 3rd edn. Churchill-Livingstone, New York, pp 1401–1417Google Scholar
  38. 38.
    Wheeler DR (1996) Reconstruction for radial nerve palsy. In: Peimer A (ed) Surgery of the Hand and Upper Extremity. McGraw-Hill, New York, pp 1363–1379Google Scholar
  39. 39.
    Chuang DCC (2001) Palliative surgery: forearm and hand deformities. In: Gilbert A (ed) Brachial Plexus Injuries. Martin Dunitz, Paris, pp 294–302Google Scholar
  40. 40.
    Terzis JK, Kokkalis ZT (2008) Outcomes of hand reconstruction in obstetric brachial plexus palsy. Plast Reconstr Surg 122(2):516–526CrossRefGoogle Scholar
  41. 41.
    Gousheh J, Arab H, Gilbert A (2000) The extended latisimus dorsi muscle island flap for flexion or extension of the fingers. J Hand Surg [Br] 25:160–165CrossRefGoogle Scholar
  42. 42.
    Murison J, Jehanno P, Fitoussi F (2017) Nerve transfer to biceps to restore elbow flexion and supination in children with obstetrical brachial plexus palsy. J Child Orthop 11(6):455–459CrossRefGoogle Scholar
  43. 43.
    Waters PM (2005) Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B 14(4):233–244CrossRefGoogle Scholar
  44. 44.
    Xu J, Cheng X, Gu Y (2000) Different methods and results in the treatment of obstetrical brachial plexus palsy. J Reconstr Microsurg 16(6):417–420CrossRefGoogle Scholar
  45. 45.
    Egloff DV, Raffoul W, Bonnard C, Stalder J (1995) Palliative surgical procedures to restore shoulder function in obstetric brachial palsy. Critical analysis of Narakas’ series. Hand Clin 11:597–605Google Scholar
  46. 46.
    van der Lingen M, de Joode S, Schotanus M, Grimm B, van Nie F, Speth L, Samijo S (2018) Satisfied patients after shoulder arthrodesis for brachial plexus lesions even after 20 years of follow-up. Eur J Orthop Surg Traumatol 28(6):1089–1094CrossRefGoogle Scholar
  47. 47.
    Vekris MD, Pafilas D, Lykissas MG, Soucacos PN, Beris AE (2010) Correction of elbow flexion contracture in late obstetric brachial plexus palsythrough arthrodiatasis of the elbow (Ioannina method). Tech Hand Up Extrem Surg 14(1):14–20CrossRefGoogle Scholar
  48. 48.
    Vekris MD, Beris AE, Lykissas MG, Korompilias AV, Vekris AD, Soucacos PN (2008) Restoration of elbow function in severe brachial plexus paralysis via muscle transfers. Injury 39(Suppl 3):S15–S22CrossRefGoogle Scholar
  49. 49.
    Soucacos PN, Vekris MD, Zoubos AB, Johnson EO (2006) Secondary reanimation procedures in late obstetrical brachial plexus palsypatients. Microsurgery 26(4):343–351CrossRefGoogle Scholar
  50. 50.
    Vekris MD, Pakos EE, Soucacos PN, Gavriilidis I, Beris AE (2010) Wrist arthrodesis for brachial plexus palsy using an external fixator and a cannulated screw (Ioannina technique). J Orthop Surg (Hong Kong) 18(1):87–91CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  • Marios D. Vekris
    • 1
    Email author
  • Dimitrios V. Papadopoulos
    • 1
  • Ioannis D. Gelalis
    • 1
  • Vasilios Kontogeorgakos
    • 2
  • Andreas G. Tsantes
    • 1
  • Ioannis Gkiatas
    • 1
  • Ioannis Kostas-Agnantis
    • 1
  • Dimitrios Kosmas
    • 1
  1. 1.Department of ΟrthopedicsUniversity Hospital of IoanninaIoanninaGreece
  2. 2.1st Orthopaedic Department of “Attikon” University HospitalAthensGreece

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