Pediatric brachial plexus reconstruction.

Obstetrical brachial plexus palsy is commonly attributed to excessive traction applied to the baby's neck during a difficult delivery. The majority of infants with brachial plexus palsy recover spontaneously within the first 3 months of life. However, in 10 to 30 percent of cases, the recovery is incomplete. Global palsy and the absence of biceps muscle function at 3 months of age have been adopted as the main indications for early brachial plexus microsurgery. In late cases or when primary reconstruction has not yielded satisfactory results, secondary reconstruction will intervene as an enhancement of a specific functional deficit or of the overall function of the upper extremity. In this article, the authors review the history of obstetrical brachial plexus palsy, the epidemiology and cause, and the indications for and the timing of surgery. The current diagnostic modalities and clinical evaluation of plexus injuries are also considered. The advances in electrophysiology, myelography, and computed tomographic scanning and magnetic resonance imaging are presented, all of which are important diagnostic modalities that facilitate a more accurate diagnosis. Obstetrical brachial plexus injuries may require multistaged reconstructive procedures, including neurolysis, resection of neuromas, identification of intraplexus and extraplexus donor nerves, selective neurotizations, selective nerve transfers, and nerve grafting. Finally, the various secondary procedures in terms of anatomical location in the upper extremity are described. Whatever the reports and results, the complex doctrine of obstetrical brachial plexus palsy continues to evolve with notable functional outcomes, but return to normal function remains a challenge for the future.