Secondary Neonatal Brachial Plexus Palsy Reconstruction

Secondary Neonatal Brachial Plexus Palsy Reconstruction

Joshua M. Adkinson


  • Most commonly, the C5C6 roots are involved (Erb palsy), leading to deficits of shoulder abduction and external rotation (supraspinatus, infraspinatus, and deltoid), elbow flexion (biceps brachii, brachialis), and forearm supination (supinator).

  • C7 involvement causes paralysis of the subscapularis, teres major (TM), clavicular head of the pectoralis major (PM), brachioradialis (BR), extensor carpi radialis longus (ECRL) and brevis (ECRB), and possibly extensor carpi ulnaris and extensor digitorum communis (EDC). This leads to the classic “waiter tip” posture,3 with deficits of wrist and finger extension.

  • Rarely, the C8T1 roots alone are affected (Klumpke palsy), leading to weakness/paralysis in the wrist/finger flexors and hand intrinsic muscles.

  • Complete plexus involvement (C5-T1) leads to a flail extremity.


  • Between 50% and 92% of patients with NBPP experience complete recovery of function without primary nerve reconstruction.1,4,5,6,7,8 In those with persistent deficits, the clinical findings will vary over time.

  • Secondary deformities are impacted by the severity of the initial nerve injury, extent of muscle recovery, patient age at presentation, and previous treatments.

  • In addition to paresis/paralysis of affected muscles, co-contracture of antagonistic muscles can occur in patients with partial recovery.9 This may lead to contracture and/or joint deformity.

  • The most common posture in children with NBPP is internal rotation of the shoulder, flexion of the elbow, supination of the forearm, and ulnar deviation of the wrist, with variable involvement of the fingers.10 Many children also develop a limb-length discrepancy.


  • The preoperative evaluation of children with secondary NBPP deformities includes a detailed history, an assessment of functional limitations, and measurements of active and passive range of motion.

  • Grading function

    • No grading systems are universally recommended for assessment of elbow, forearm, wrist, and hand function in patients with NBPP.

  • Physical Examination

    • Function is observed, active and passive ranges of motion are documented, and muscle strength is assessed with and without gravity.

  • Elbow

    • Co-contracture of the elbow flexors and extensors are assessed. Dislocation of the radial head and proximal ulna are noted.

  • Forearm

    • Long-standing supination or pronation deformities may lead to fixed contracture of the interosseous membrane (IOM). Continued growth can then lead to bowing of the radius and ulna, dorsal dislocation of the distal ulna, and/or posterior dislocation of the radial head.

  • Wrist

    • Ulnar deviation is common because of paralysis of the ECRL and ECRB.

  • Hand

    • Limited metacarpophalangeal (MCP) joint extension is common, as is thumb instability.11


  • Anteroposterior and lateral radiographs of the elbow or wrist may be obtained to evaluate for joint subluxation/dislocation or articular deformities (FIG 1).


  • All patients should undergo physical therapy, with the goal of muscle strengthening and full passive range of motion of the elbow, forearm, wrist, and fingers.

  • Orthoses are used to maintain anatomic joint alignment and to prevent contracture.

  • Botox injection into spastic musculature is effective for temporary (3-6 months) muscle weakening.


  • Surgical options include tendon transfers, arthrodeses, osteotomies, muscle/tendon releases, and functioning muscle transfers.

  • Secondary reconstruction of the elbow, forearm, wrist, and hand is considered in children older than 4 years with
    incomplete recovery of upper extremity function after primary reconstruction or in those who present after the optimal window for nerve reconstruction.10,12,13,14,15

    FIG 1 • Right radial head dislocation (arrow) in long-standing brachial plexus palsy.

  • Restoration of elbow flexion is the priority, followed by wrist extension, thumb/finger flexion, wrist flexion, thumb/finger extension, and intrinsic hand reconstruction.

  • Elbow flexion contractures greater than 40 degrees are an indication for surgical release. Less significant contractures can be released, but this may cause clinically significant elbow flexion weakness.

  • Weak elbow flexion (less than MRC grade 3) may be addressed via Steindler flexorplasty or transfer of the latissimus dorsi (LD), PM, or triceps.

  • The surgical approach to the forearm depends upon the underlying deformity. Supination contractures are best treated by a biceps rerouting. If there is minimal passive range of motion, IOM release or pronation osteotomy of the radius is recommended.

  • Pronation deformities are treated by pronator teres (PT) release or rerouting. One must ensure good passive supination prior to PT rerouting.

  • Weak wrist extension can be managed by transfer of the flexor carpi ulnaris (FCU) to the ECRB or ECRL (to counterbalance an ulnar deviation force). Weak finger extension can be managed with a combination of palmaris longus/flexor digitorum superficialis (FDS)middle or FDSmiddleFDSring transfer to the extensor pollicis longus (EPL) and EDC tendons, respectively.

  • In patients with a total (pan-plexus) palsy, free functioning muscle transfers (eg, contralateral LD, gracilis, rectus femoris) are the procedure of choice.

Preoperative Planning

  • Radiographs of the affected extremity should be reviewed, if relevant.


  • The patient is positioned supine on the operating room table with the affected extremity on a hand table. A well-padded tourniquet is placed high on the arm for procedures distal to and including the elbow.

  • For pedicled LD muscle transfer, the patient is placed in the lateral decubitus position.

  • The gracilis muscle harvest requires a frog leg position.


  • Elbow approach: The muscles causing an elbow flexion contracture (brachialis, biceps brachii, and BR) are approached via an antecubital incision.

  • Procedures to restore elbow flexion require a techniquespecific approach.

  • Forearm approach: The biceps tendon is approached through an antecubital fossa incision. The entire length of the tendon and portion of the radius under which the tendon is rerouted must be visualized.

  • Wrist/fingers approach: Procedures to restore wrist and finger function require a technique-specific approach. The FCU tendon may be approached through a single longitudinal incision or several stepcut incisions.

    • Free functioning muscle transfers to restore finger flexion require an extensile approach from the anterior upper arm across the acromion and lateral clavicle. This provides full visualization of the proposed site of origin of the transferred muscle as well the adjacent neurovascular structures to be protected and/or used for vascular anastomoses and nerve coaptation.

Feb 27, 2020 | Posted by in Pediatric plastic surgery | Comments Off on Secondary Neonatal Brachial Plexus Palsy Reconstruction
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