(Congenital brachial plexus injuries)
The five big nerves which are extension of the spine, combines with each other with different ways after exits from neck vertebras on side of the neck and under the scapula and forms a nerve web called brachial plexus. Nerve branches which exits from the brachial plexus are responsible either movements of a part of back and chest, arm, forearm and hand or sense of these body parts.
Congenital arm paralysis are those arisen in the brachial plexus due to various reasons before or after the birth. It is mostly unilateral. Symptoms may change according to the severity of the nerve damage. If the baby moves one arm less than the other or if the baby can not move one arm, if the effected hand can’t be made fist, the difference between arms, if one arm is softer than the other, if objects are always clutched by one arm in bigger babies, if the baby can’t take his hand to his mouth; these findings point out brachial plexus damage.
Surgery may be required in about 10% of babies who were effected by brachial plexus injury and the above mentioned problems. But babies born with arm paralysis should be under the control of a team including surgical and physiotherapy of brachial plexus injuries whether surgical treatment is required. First, it should be set forth that if the current paralysis sourced from central nervous system or a problem in the brachial plexus.
In problems that upper nerve roots are involved, shoulder and elbow movements are absent or insufficient. Usually hand movements are complete. If the baby can not take his hand to his mouth in the sitting position in 6-9. months; surgery is considered. (Figure 1)
In another frequent form of the injury, hand sense and movement is insufficient. The child doesn’t respond to stimulus that will give pain to his hand. Shoulder and elbow movements are absent or insufficient. A slight ptosis on the eyelid in the same side of the problem may be observed and the pupil may be smaller according to the other side. Surgery may be thought for patients whom this table doesn’t progress positively from the 3rd month. (Figure 1, 2)
The important is which of these five nerve roots were damaged with which levels in operations performed in this period. A nerve transplant from less used nerves in the daily life may be required for spine level damaged nerve roots. For lower level injuries, nerves taken from legs are used by making a bridge between deficit area. If necessity is thought for nerve operations, it should be applied before one year. Nerves which are taken from the leg are sensory nerves that is not related with movement. Scars in the area that nerves are taken should be ignored for arm functions that will be gained.
One of the most important points that should be remembered related with either brachial plexus surgery or other nerve operations is that operation results will be taken after a long while. The nerve progresses about 1 mm for every day to the finger tip starting from the repaired point by budding. Therefore, a long time between 6 months and 2 years until nerve buds reach to muscles. The patients should be followed with physiotherapy for a long period before and after the surgery.
After it is convinced that nerve recovery is completed, other operating muscles may be transferred instead of non operating muscles in the arm and bone correction operations may be performed if necessary. If these operations are needed, the preferred period is 3. and 5. ages and preschool period. Compatibility of the child for braces that will be used after the operation and physiotherapy process that will be performed increases the success positively.
The thing that is aimed to be obtained after a difficult treatment protocol is to form a helper extremity to the other firm extremity by providing the maximum function that will be able to be provided (a recovery with 100% and complete function should not be waited). But even this may be possible with operations that will be performed within appropriate periods, a compatible follow-up between the patient-family-doctor and physiotherapy process and a big patience.