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Management of Brachial plexus birth palsy (BPBP)

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48 diapositives · 933 Views · Sep 12, 2014

Management of Brachial plexus birth palsy (BPBP). Reza Sh. Kamrani M.D. Orthopaedic Hand Surgeon TUMS, Shariati Hospital Isfehan UMS Annual Meeting 2-4 / 12 / 1391. content. 1-3 m. 3-6 m. 6-12 m. 6-12 m. 1-3 y. 3-6 y. 6-12 y. Adoles. Neon. Physical therapy. PT/Release. TT.

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  1. Management ofBrachial plexus birth palsy (BPBP) Reza Sh. Kamrani M.D. Orthopaedic Hand Surgeon TUMS, Shariati Hospital Isfehan UMS Annual Meeting 2-4 / 12 / 1391

  2. content 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y 3-6 y 6-12 y Adoles. Neon. Physical therapy PT/Release TT Osteotomy Osteotomy

  3. PT OT Butolonium Toxin (Gleno-Humeral anatomy) CT-MR Arthroscopic release Open release Open reduction Glenoid osteotomy Conservative treatment Surgical release ??? Release TT Humeral Osteotomy +/_ 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y 3-6 y 6-12 y Adoles. Neon. Close observation PT Shoulder Hand Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Forearm (Gleno-Humeral anatomy) CT-MR Elbow Arthroscopic release Open release Open reduction Glenoid osteotomy Release TT Humeral Osteotomy Latismus Dorsi +/_ Teres maj Upper, Midd, Low Ant, Med

  4. PT OT Butolonium Toxin (Gleno-Humeral anatomy) CT-MR Arthroscopic release Open release Open reduction Glenoid osteotomy Conservative treatment Surgical release ??? Release TT Humeral Osteotomy +/_ 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y 3-6 y 6-12 y Adoles. Neon. Close observation PT Shoulder Hand Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Forearm (Gleno-Humeral anatomy) CT-MR Elbow Arthroscopic release Open release Open reduction Glenoid osteotomy Release TT Humeral Osteotomy Latismus Dorsi +/_ Teres maj Upper, Midd, Low Ant, Med

  5. PT OT Butolonium Toxin (Gleno-Humeral anatomy) CT-MR Conservative treatment Surgical release ??? TT Humeral Osteotomy +/_ 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y 3-6 y 6-12 y Adoles. Neon. Close observation PT Shoulder Hand Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Forearm (Gleno-Humeral anatomy) CT-MR Elbow Arthroscopic release Open release Open reduction Glenoid osteotomy Release TT Humeral Osteotomy Latismus Dorsi +/_ Teres maj Upper, Midd, Low Ant, Med

  6. PT OT Butolonium Toxin (Gleno-Humeral anatomy) CT-MR Conservative treatment Surgical release ??? 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y 3-6 y 6-12 y Adoles. Neon. Close observation PT Shoulder Hand Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Forearm (Gleno-Humeral anatomy) CT-MR Elbow Arthroscopic release Open release Open reduction Glenoid osteotomy Release TT Humeral Osteotomy Latismus Dorsi +/_ Teres maj Upper, Midd, Low Ant, Med

  7. PT OT Butolonium Toxin (Gleno-Humeral anatomy) CT-MR Conservative treatment Surgical release ??? 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y 3-6 y 6-12 y Adoles. Neon. Close observation PT Shoulder Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair (Gleno-Humeral anatomy) CT-MR Arthroscopic release Open release Open reduction Glenoid osteotomy Release TT Humeral Osteotomy Latismus Dorsi +/_ Teres maj Upper, Midd, Low Ant, Med

  8. PT OT Butolonium Toxin (Gleno-Humeral anatomy) CT-MR Conservative treatment Surgical release ??? 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y 3-6 y 6-12 y Adoles. Neon. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair

  9. PT OT Butolonium Toxin (Gleno-Humeral anatomy) CT-MR Conservative treatment Surgical release ??? 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y Neon. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Indication Time of surgery Kind of surgery

  10. Indication & Time Alain Gilbert Howard Clarke spectrum Biceps < 3/5 in 3m. Coockey sign in 9m.

  11. Indication & Time Alain Gilbert Howard Clarke spectrum Biceps < 3/5 in 3m. Coockey sign in 9m.

  12. Indication & Time Alain Gilbert Howard Clarke spectrum Biceps < 3/5 in 3m. Coockey sign in 9m.

  13. Indication & Time • White zone • Poor biceps + Impaired hand in 3m. • Poor biceps 6m. • Gray zone • Poor biceps 3-6m

  14. Kind of surgery • Neurolysis • Nerve repair • Nerve graft • Nerve transfer

  15. Differences between Adult BPI and Obstetric BPI

  16. Adult BP inj. Obstetric BP inj. • Adult • Infant • Shorter regeneration distance • Stronger potential for regeneration • Greater capacity for brain adaptation

  17. Adult BP inj. Obstetric BP inj. • Classic nerve transfer • .Intra plexus • Avulsion is more common • . • Classic nerve transfer • .Intra plexus • Avulsion is less common • .

  18. Adult BP inj. Obstetric BP inj. • Goal • Goal

  19. Upper BPI Adult BP inj. Obstetric BP inj. • Goal • Elbow flexion • Shoulder stability • Goal • Elbow flexion • Shoulder reanimation

  20. Whole BPI Adult BP inj. Obstetric BP inj. • Goal • Elbow flexion • Shoulder stability • Medial border sensation • Wrist and finger function • Intrinsic function • Goal • Hand function • Elbow flexion • Shoulder reanimation

  21. Classic nerve graft is currently the most common approchroach for BPBP

  22. But new nerve transfers is more and more popularised

  23. Adult BP inj. Obstetric BP inj. • New nerve transfers • Becomes standard approach • New nerve transfer • Becomes more and more popularised • Acc. To Sup. Scap may be the most common

  24. PT OT Butolonium Toxin (Gleno-Humeral anatomy) CT-MR Conservative treatment Surgical release ??? 1-3 m 3-6 m 6-12 m 6-12 m 1-3 y Neon. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Indication Time of surgery Kind of surgery

  25. Case presentation • 23 months old boy • BPBP • Under observation from 5 months old • Shoulder Passive ROM is gradually reduced in spite of physical/occupational therapy • Shoulder plain X-ray is almost normal

  26. What is the treatment?

  27. Use • Dysport • Dry vial = 500IU • Dilution with normal saline • Total dose 20-25 U/kg • 1cc/location • Price = 5,000,000R./1,200,000R.F • Painful injection • Nervelocator guided injectin

  28. good bad Under-observation good Prog. New born 3-6 m Active elbow flexion Br Plex microsurgery Sling PT/OT good bad PT/OT 3-6 m visit 1-3 y Passive should. ROM 6 w visit Aggress. PT/OT good bad 3-6 m visit Passive Should. ROM Dysport injection 6 w visit 3-6 m visit good bad Passive Should. ROM good bad Soft tissue release Should. CT/MR Humerus osteotomy? OR, Glenoid osteotomy, Arthroscopic release

  29. IOA website

  30. THANK YOU