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Obstetrical arm paralysis

(Congenital brachial plexus palsy)

Branches of five nerve roots coming through cervical spines form a complex network, and control all movements and sensation of upper extremity. We call this network of nerves ‘’Brachial Plexus’’.

Nerves give electrical stimulus to our muscles to provide our movements, and to feel touching sensation. When nerves are out of function and cannot transmit electrical impulses, movement in these muscles and/or  sensation is impossible.

Etiology(reason)of the arm paralysis may be due to big babies weigh more than 4000 grams, babies of diabetic mothers, forced deliveries…The patient is followed up for three months and some tests are run meanwhile. In some cases, although structural integrity of the nerve is not damaged nerve functions may lost for a certain period due to traction injuries. Recovery is observed in three months in most of these patients. Accompanying injuries such as bone fractures, vessel injuries are examined and should be treated prior to nerve surgery. Advanced radiological tests(MRI, Myelo CT...)that will help to show whether the nerve is damaged and the level of injury.  Electrophysiological studies  show the nerve conduction.

Patients can be divided into two groups; upper arm paralysis(disfunction is limited to shoulder and elbow) and total arm paralysis(whole extremity is affected partially or totally). The treatment strategy is depended on where the patient’s problem is. Patients with hand involvement(no movement, no sensation in the hand)(figure 2,3) need surgery as early as possible after three months of follow up. The follow up period is longer(6-9 months) in the other group(patients whose problems are limited to shoulder and elbow)(figure 1).

Surgery may be required in about 10% of babies who were diagnosed ‘’brachial plexus injury’’ in one year after birth. Babies who are not recovered by themselves at the time as mentioned above are operated as soon as possible before age 1. Nerve transplantations from legs and/or nerve transfers from local healthy ones are primary surgery. Nerves taken from legs are sensory nerves which are not related with movements. Scars in donor site should be ignored for sperate upper extremity functions.

We need to follow the patient for a long period to see the results of nerve surgeries especially after brachial plexus injuries. Repaired nerves regenerates 1 mm each day by budding towards the target muscle. Depending to the repair and muscle distance it will take 6 months to 2 years.

For insufficiently recovered functions of babies who are followed only with physiotherapy support(who had no surgery before)  or after surgery muscle transfers and/bone rotation surgeries may be required. Preschool ages (age 4-5) are preferred for these surgeries in order to get maximum compliance for physical therapy instructions. 

There is almost impossible to get 100% recovery for patients who need any kind of surgery. The aim for everybody(patient-doctor-physiotherapist-relatives…)should be as much as possible; at least a helper extremity to the healthy one. Unfortunatelly maximum effort is expected from everyone even for small gains.