What is it?
Mechanism of Injury, Palsy, Horner's Syndrom
Mechanisms of Injury
A typical poor functional result after spontaneous recovery in a total palsy
When diagnosing a case, it is very difficult to determine when the nerve sheath is intact or whether or not it has been disrupted.
For years, the surgeons have been trying to predict the possible recovery of a particular child in order to decide whether or not surgical exploration should occur.
The problem is that the end result will not be precisely known for 2 or 3 years and at that point it will be too late for primary surgical repair.
By that time, the target muscles are no longer alive and cannot be properly reinnervated. This is why several systems have been evaluated in order to predict
the result and determine the necessity for surgical repair.
In 1977, with TASSIN, we followed a large number of children from birth to three years of age who did not have primary surgical repair.
We were able to correlate the end-result with the extent of the injury and age of recovery. We found that if the biceps muscle had not recovered
by 3 months of age, the quality of the end result was generally poor. If the biceps had recovered before 3 months of age, the final result of the limb was quite good.
It was then decided that:
ABSENCE OF RECOVERY OF THE BICEPS AT 3 MONTHS OF AGE IS AN INDICATION FOR PRIMARY SURGICAL REPAIR
Most teams in the world use this schema although some will wait longer or use different scales.
If the baby has a complete paralysis of the upper extremity it is a little different: in this case the most important factor is the hand recovery.
IF THERE IS NO HAND RECOVERY AT 3 MONTHS, EVEN WITH BICEPS RECOVERY, THE PLEXUS MUST BE REPAIRED.
In a large number of cases ( 70 to 80% ) the spontaneous recovery occurs and there will be no need for early surgery .
In those cases , characterized by an early recovery of the Biceps ( before 3 months) we know from experience that the end results may
not be perfect but usually as good as plexus repair .
When we decide that we do not have to do repair of the plexus , physiotherapy is continued and the evolution checked regularly .
The Biceps recovers early , as well as Abduction but External rotation recovers much later , sometimes after 18 months . The
overall result will be controlled after 2 years and the necessity of secondary procedures evaluated .
During that time , physiotherapy should concentrate on keeping passive External rotation . If External rotation becomes limited BEFORE 18 months ,
our procedure is to inject 30U. of Botox in the Subscapularis muscle .
The complete paralysis is different as Elbow function may recover quickly without any
recovery of the Hand . In this case the decision is taken ONLY on Hand recovery ,
whatever the Shoulder and Elbow recovery .