Oberlin partial ulnar nerve transfer for restoration in obstetric brachial plexus palsy of a newborn: case report
© Shigematsu et al. 2006
Received: 09 March 2006
Accepted: 29 September 2006
Published: 29 September 2006
An 8 month old male infant with Erb's birth palsy was treated with two peripheral nerve transfers. Except for rapid motor reinnervations, elbow flexion was obtained by an Oberlin's partial ulnar nerve transfer, while shoulder abduction was restored by an accessory-to-suprascapular nerve transfer. The initial contraction of the biceps muscle occurred two months after surgery. Forty months after surgery, elbow flexion reached M5 without functional loss of the ulnar nerve. This case demonstrates an excellent result of an Oberlin's nerve transfer for restoration of flexion of the elbow joint in Erb's birth palsy. However, at this time partial ulnar nerve transfer for Erb's birth palsy is an optional procedure; a larger number of cases will need to be studied for it to be widely accepted as a standard procedure for Erb's palsy at birth.
In 1994, Oberlin et al.  described a new technique of partial ulnar nerve transfer to the biceps muscle nerve for restoration of elbow flexion in traumatic C5-C6 avulsion of the brachial plexus in adult. We report treating an eight month old male infant without C5 to C6 function by an Oberlin's partial ulnar nerve transfer and an accessory-to-suprascapular nerve transfer.
A primary contraction of the biceps muscle appeared two months after nerve transfer (British Medical Research Council grading (MRC): M1). Full ranged elbow flexion (MRC: M4), and 90 degree shoulder abduction (MRC: M3), were obtained five months after surgery. Forty months after surgery, the ranges of both elbow flexion, M5, and shoulder abduction, M4, were full.. However, these muscles were somewhat weak compared with the contralateral site. Sensation in the ulnar nerve distribution in the hand was obscure, though the patient did not complain of any discomfort in the hand.
In 2002, the first two cases using Oberlin's nerve transfer (at 16 and 18 months after birth) for Erb's birth palsy of the C5-C6 type were reported by Al Quattan . In 2004, Noaman et al.  followed this treatment method for 7 obstetric brachial plexus palsies with no elbow flexion (at 11 to 24 months after birth). This report supplements those reports and details a case younger (8 months after birth) than previous cases. Spontaneous recovery of obstetric brachial plexus palsy occasionally occurs; reported rates vary widely, ranging from 7 per cent to 96 per cent. Complete recovery can be expected only if the muscles start contracting by the first month . Tassin  treated forty-four brachial plexus palsy cases due to obstetric lesion without surgical treatment; suggesting that primary surgical repair of the brachial plexus was warranted if recovery of the biceps had not began at three to four months of age, because in such cases functional prognosis was considered poor. Based on these reports, we performed peripheral nerve transfers at 8 months of age.
In our case, primary contraction of the biceps muscle appeared at 8 weeks after nerve transfer. In previous cases, initial biceps motor return was noted at 12 and 14 weeks, respectively, after surgery . Motor reinnervation of the biceps muscle occurs within two to three months after partial ulnar nerve transfer, and thus elbow flexion is restored before permanent atrophy of the muscle occurs. In adult, Leechavengvongs et al.  performed partial ulnar nerve transfer for thirty-two patients with brachial plexus palsy. They reported that initial recovery was noted at 2 to 5 months after surgery (mean 3), and also described a functional recovery rate of 93% (patients achieving M4 or better), which compares favorably with other reported methods of brachial plexus neurotization . Moreover, partial ulnar nerve transfer was possible to undertake with just one incision at the middle upper arm; whereas other procedures require many large incisions. A lower level of invasiveness is one of the advantages of this method, as well as motor reinnervation of the muscle being faster than other procedures.
This case demonstrates an excellent result of an Oberlin's nerve transfer for restoration of flexion of the elbow joint in Erb's birth palsy. However, at this time partial ulnar nerve transfer for Erb's birth palsy is an optional procedure; a larger number of cases will need to be studied for it to be widely accepted as a standard procedure for Erb's palsy at birth.
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