Elbow, Forearm and Wrist Issues in Brachial Plexus Birth Palsy: Current Concepts

Volume 7 | Issue 1 | January-April 2021 | Page: 55-64 | Praveen Bhardwaj, Darshan Kumar A Jain, Maulin M Shah, Rujuta Mehta, Badarinath Athani

Authors: Praveen Bhardwaj MS Ortho., DNB Ortho. FNB [1], Darshan Kumar A Jain MS Ortho., FNB [2],
Maulin M Shah MS Ortho. [3], Rujuta Mehta MS Ortho. DNB Ortho. [4], Badarinath Athani MS Ortho., DNB (PMR) [5]

[1] Consultant Hand and Reconstructive Microsurgeon, Ganga Hospital, Coimbatore, Tamil Nadu, India.
[2] Consultant Hand and Reconstructive Microsurgeon. Ramaiah Hospitals, Bangalore, Karnataka, India.
[3] Consultant Paediatric Orthopaedic Surgeon, Orthokids Clinic, Ahmedabad, Gujarat, India.
[4] HOD Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India.
[5] Principle consultant Safdarjung Hospital, Vardhaman Mahavir Medical College, New Delhi, India.

Address of Correspondence
Dr. Praveen Bhardwaj ,
Consultant Hand and Reconstructive Microsurgeon, Ganga Hospital, Coimbatore, Tamil Nadu, India.
E-mail: drpb23@gmail.com


The variable presentation of the sequelae of brachial plexus birth palsy (BPBP) at the elbow, forearm and wrist and their association with much extensive brachial plexus involvement makes reconstruction at these levels demanding . Functional limitation and cosmetic concern are common indications for surgical intervention. This article presents a synopsis of the incidence, pathogenesis, clinical presentation and parental concerns related to these deformities, decision-making considerations, management strategies and expected outcome for correction of these deformities. Deformities at the forearm and wrist can be often corrected simultaneously as they could be interrelated. The pattern of deformities, their severity and their impact on the overall function of the limb and parental concern differ. Each child needs a tailor-made management plan, weighing the expected outcome against parental expectation.
Keywords: Brachial plexus birth palsy, Forearm deformity, Supination deformity, Elbow flexion deformity, Pronation deformity, Ulnar deviation deformity.


1. Venkatramani H, Bhardwaj P, Sabapathy SR. Birth Brachial Plexus Palsy. In: Agarwal K. ed. Text book of Plastic & Reconstructive & Aesthetic Surgery. (Chapter 29) Vol 2. First edition Delhi: Thieme, 2017: p 665-695.
2. Sebastin SJ, Chung KC. Reconstructive strategy for recovery ofhand function. In: Chung KC, Yang LJS, McGillicuddy JE, eds.Practical Management of Pediatric and Adult Brachial Plexus Palsies. New York, NY: Elsevier Saunders; 2012:114–142
3. Nath RK, Somasundaram C, Melcher SE, Bala M, Wentz MJ. Arm rotated medially with supination – the ARMS variant: description of its surgical correction. BMC MusculoskeletDisord. 2009; 10:32.
4. Bhardwaj P, Venkatramani H, Sabpathy SR. Elbow flexion deformity in birth brachial plexus palsy. Presented at- Asia Pacific Hand Surgery Meet at Melbourne, March 2020. https://apfssh2020.org/downloads/APFSSH-APFSHT-Program-&-Abstract-Book.pdf
5. Nikolaou S, Hu L, Cornwall R. Afferent Innervation, Muscle Spindles, and Contractures Following Neonatal Brachial Plexus Injury in a Mouse Model. J Hand Surg Am2015; 40:2007-16.
6. Nikolaou S, Peterson E, Kim A, Wylie C, Cornwall R. Impaired growth of denervated muscle contributes to contracture formation following neonatal brachial plexus injury. J Bone Joint Surg Am. 2011;93(5):461e470.
7. van der Sluijs JA, van der Sluijs MJ, van de Bunt F, van Ouwerkerk WJR. What influences contracture formation in lower motor neuron disorders, severity of denervation or residual muscle function? An analysis of the elbow contracture in 100 children with unilateral Brachial Plexus Birth Injury. J Child Orthop. 2018;12(5):544-549.
8. Sheffler LC, Lattanza L, Hagar Y, Bagley A, James MA. The prevalence, rate of progression, and treatment of elbow flexion contracture in children with brachial plexus birth palsy. J Bone Joint Surg Am 2012;94(5):403–409.
9. Al-Qattan MM. Total obstetric brachial plexus palsy in children with internal rotation contracture of the shoulder, flexion contracture of the elbow, and poor hand function. Ann PlastSurg2010; 65:38-42.
10. Sheffler LC, Lattanza L, Sison-Williamson M, James MA. Biceps brachii long head overactivity associated with elbow flexion contracture in brachial plexus birth palsy. J Bone Joint Surg Am. 2012;94(4):289-297.
11. Ho ES, Roy T, Stephens D, Clarke HM. Serial casting and splinting of elbow contractures in children with obstetric brachial plexus palsy. J Hand Surg Am. 2010;35(1):84-91.
12. Nath RK, Somasundaram C. Biceps Tendon Lengthening Surgery for Failed Serial Casting Patients with Elbow Flexion Contractures Following Brachial Plexus Birth Injury. Eplasty. 2016;16: e24.
13. Vekris MD, Pafilas D, Lykissas MG, Soucacos PN, Beris AE. Correction of elbow flexion contracture in late obstetric brachial plexus palsy through arthrodiatasis of the elbow (Ioannina method). Tech Hand Up Extrem Surg. 2010;14(1):14-20. doi:10.1097/BTH.0b013e3181c848cb
14. Bhardwaj P, Venkatramani H, Sabpathy SR. Forearm deformities in birth brachial plexus palsy- Deformity profile and correction strategy. Presented at- Asia Pacific Hand Surgery Meet at Melbourne, March 2020. https://apfssh2020.org/downloads/APFSSH-APFSHT-Program-&-Abstract-Book.pdf| 12APFSSH/8APFSHT [Internet]. [cited 2020 Aug 18]. Available from: https://apfssh2020.org/program-wednesday.php
15. Allende CA, Gilbert A. Forearm supination deformity after obstetric paralysis. Clin OrthopRelat Res. 2004;(426):206-211.
16. Yam A, Fullilove S, Sinisi M, Fox M. The supination deformity and associated deformities of the upper limb in severe birth lesions of the brachial plexus. J Bone Joint Surg Br. 2009;91(4):511-516.
17. Zancolli EA II. Palliative surgery: pronosupination in obstetricpalsy. In: Gilbert A, ed. Brachial Plexus Injuries. London, UK:Martin Dunitz; 2001:275–29.
18. Al-Qattan MM, Al-Khawashki H. The “beggar’s” hand and the “unshakable” hand in children with total obstetric brachial plexus palsy. PlastReconstrSurg 2002;109(6):1947–1952
19. Zancolli, EA. Paralytic supination contracture of the forearm. J Bone Joint Surg Am. 1967, 49: 1275–84
20. Kozin, SH. Treatment of the supination deformity in the pediatric brachial plexus patient. Tech Hand Up Extrem Surg. 2006, 10: 87–95
21. Hankins SM, Bezwada HP, Kozin SH. Corrective osteotomies of the radius and ulna for supination contracture of the pediatric and adolescent forearm secondary to neurologic injury. J Hand Surg Am. 2006;31(1):118-124.
22. Manske, PR, McCarroll, HR, Hale, R. Biceps tendon rerouting and percutaneous osteoclasis in the treatment of supination deformity in obstetrical palsy. J Hand Surg Am. 1980, 5:153–9.
23. Lipskeir E, Weizenbluth M. Derotation osteotomy of the forearm in management of paralytic supination deformity. J Hand Surg Am. 1993;18(6):1069-1074.
24. Ozkan T, Aydin A, Ozer K, Ozturk K, Durmaz H, OzkanS. A surgical technique for pediatric forearm pronation:brachioradialis rerouting with interosseous membrane release.
J Hand Surg Am 2004;29(1):22–27.
25. Soucacos, Panayotis&Vekris, Marios& Kostas, John & Johnson, Elizabeth. Secondary Reconstructive Procedures in Obstetrical Brachial Plexus Palsy: Forearm, Wrist, and Hand Deformities. Semin Plast Surg. 2005;19(01):96–102.
26. Anderson GA, Thomas BP, Pallapati SC. Flexor carpi ulnaris tendon transfer to the split brachioradialis tendon to restore supination in paralytic forearms. J Bone Joint Surg Br. 2010;92(2):230-234.
27. Ozkan T, Tuncer S, Aydin A, Hosbay Z, Gulgonen A. Brachioradialis re-routing for the restoration of active supination and correction of forearm pronation deformity in cerebral palsy. J Hand Surg Br. 2004;29(3):265-270.
28. Amrani A, Dendane MA, El Alami ZF. Pronator teres transfer to correct pronation deformity of the forearm after an obstetrical brachial plexus injury. J Bone Joint Surg Br.2009;91(5):616-618.
29. Cheema, TA, Firoozbakhsh, K, De Carvalho, AF, Mercer, D. Biomechanic comparison of 3 tendon transfers for supination of the forearm. J Hand Surg Am. 2006, 31: 1640–4.
30. Al-Qattan MM, El-Sayed AA, Al-Zahrani AY, et al. Narakas classification of obstetric brachial plexus palsy revisited. J Hand Surg Eur Vol. 2009;34(6):788-791.
31. Chuang DC, Ma HS, Borud LJ, Chen HC. Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy. PlastReconstr Surg. 2002; 109:1934–1946.
32. Bhardwaj P, Parekh H, Venkatramani H, Raja Sabapathy S. Surgical correction of ulnar deviation deformity of the wrist in patients with birth brachial plexus palsy sequelae. Hand Surg. 2015;20(1):161-165.
33. Ozkan T, Aydin HU, BerkozO, Ozkan S, Kozanoglu E. ‘Switch’ technique to restore pronation and radial deviation in 17 patients with brachial plexus birth palsy. J Hand Surg Eur Vol. 2019;44(9):905-912.
34. Duclos L, Gilbert A. Restoration of wrist extension by tendon transfer in cases of obstetrical brachial plexus palsy. Ann Chir Main Memb Super. 1999; 18:7–12.
35. Bertelli JA. Brachialis muscle transfer to the forearm muscles in obstetric brachial plexus palsy. J Hand Surg Br 2006; 31:261–5.
36. Boulahouache A, Cambon-Binder A, Chouiha M, Lardjane ML, Belkheyar Z. Chondrodesis of the wrist in children with severe paralytic hand deformities. Hand SurgRehabil. 2020;39(4):251-255.

How to Cite this Article:  Bhardwaj P, Jain DA, Shah MM, Mehta R, Athani B | Elbow, Forearm and Wrist Issues in Brachial Plexus Birth Palsy: Current Concepts | International Journal of Paediatric
Orthopaedics | January-April 2021; 7(1): 55-64.

(Article Text HTML)      (Download PDF)