Long-term results of obstetric brachial plexus surgery

Background: Brachial plexus birth palsy (BPBP) most often occurs as a result of foetal-maternal disproportion. The C5 and C6 nerve roots of the brachial plexus are most frequently affected. In contrast, roots from the C7 to Th1 that result in total injury together with C5 and C6 injury, are affected in fewer than half of the patients. BPBP was first described by Smellie in 1764. Erb published his classical description of the injury in 1874 and his name became linked with the paralysis that is associated with upper root injury. Since then, early results of brachial plexus surgery have been reasonably well documented. However, from a clinical point of view not all primary results are maintained and there is also a need for later follow-up results. In addition most of the studies that are published emanate from highly specialized clinics and no nation wide epidemiological reports are available. One of the plexus injuries is the avulsion type, in which the nerve root or roots are ruptured at the neural cord. It has been speculated whether this might cause injury to the whole neural system or whether shoulder asymmetry and upper limb inequality results in postural deformities of the spine. Alternatively, avulsion could manifest as other signs and symptoms of the whole musculoskeletal system. In addition, there is no available information covering activities of daily living after obstetric brachial plexus surgery. Patients and methods: This was a population-based cross-sectional study on all patients who had undergone brachial plexus surgery with at least 5 years of follow-up. An incidence of 3.05/1000 for BPBP was obtained from the registers for this study period. A total of 1706 BPBP patients needing hospital treatment out of 1 717 057 newborns were registered in Finland between 1971 and 1997 inclusive. Of these BPBP patients, 124 (7.3%) underwent brachial plexus surgery at a mean age of 2.8 months (range: 0.4―13.2 months). Surgery was most often performed by direct neuroraphy after neuroma resection (53%). Depending on the phase of the study, 105 to 112 patients (85-90%) participated in a clinical and radiological follow-up assessment. The mean follow up time exceeded 13 years (range: 5.0―31.5 years). Functional status of the upper extremity was evaluated using Mallet, Gilbert and Raimondi scales. Isometric strength of the upper limb, sensation of the hand and stereognosis were evaluated for both the affected and unaffected sides then the differences and their ratios were calculated and recorded. In addition to the upper extremity, assessment of the spine and lower extremities were performed. Activities of daily living (ADL), participation in normal physical activities, and the use of physiotherapy and occupational therapy were recorded in a questionnaire. Results: The unaffected limb functioned as the dominant hand in all, except four patients. The mean length of the affected upper limb was 6 cm (range: 1-13.5 cm) shorter in 106 (95%) patients. Shoulder function was recorded as a mean Mallet score of 3 (range: 2―4) which was moderate. Both elbow function and hand function were good. The mean Gilbert elbow scale value was 3 (range: -1―5) and the mean Raimondi hand scale was 4 (range:1―5). One-third of the patients experienced pain in the affected limb including all those patients (n=9) who had clavicular non-union resulting from surgery. A total of 61 patients (57%) had an active shoulder external rotation of less than 0° and an active elbow extension deficiency was noted in 82 patients (77%) giving a mean of 26° (range: 5°―80°). In all, expect two patients, shoulder external rotation strength at a mean ratio 35% (range: 0―83%) and in all patients elbow flexion strength at a mean ratio of 41% (range: 0―79%) were impaired compared to the unaffected side. According to radiographs, incongruence of the glenohumeral joint was noted in 15 (16%) patients, whereas incongruence of the radiohumeral joint was found in 20 (21%) patients. Fine sensation was normal for 34/49 (69%) patients with C5-6 injury, for 15/31 (48%) with C5-7 and for only 8/25 (32%) of patients with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand for 12/105 patients (11%). Normal stereognosis was recorded for 88/105 patients (84%). No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that two thirds (63%) of the patients were satisfied with the functional outcome of the affected hand although one third of all patients needed help with ADL. Only a few patients were unable to participate in physical activities such as: bicycling, cross-country skiing or swimming. However, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities. Incongruity of the radiohumeral joints, extent of the injury, avulsion type injury, age less than three months of age at the time of plexus surgery and inexperience of the surgeon was related to poor results as determined by multivariate analyses. Conclusions: Most of the patients had persistent sequelae, especially of shoulder function. Almost all measurements for the total injury group were poorer compared with those of the C5-6 type injury group. Most of the patients had asymmetry of the shoulder region and a shorter affected upper limb, which is a probable reason for having an abnormal gait. However, BPBP did not have an effect on normal growth of the lower extremities or the spine. Although, participation in physical activities was similar to that of the normal population, two-thirds of the patients reported problems. One-third of the patients needed help with ADL. During the period covered by this study, 7.3% BPBP of patients that needed hospital treatment had a brachial plexus operation, which amounts to fewer than 10 operations per year in Finland. It seems that better results of obstetric plexus surgery and more careful follow-up including opportunities for late reconstructive procedures will be expected, if the treatment is solely concentrated on by a few specialised teams.

Diplomatian historiapolitiikka: Historia-argumenttien käyttö Kosovon kysymyksessä 1998-2010

Tutkielmassa tarkastellaan yhtä kansainvälisten suhteiden ja diplomatian lähihistorian pulmallisinta haastetta, kysymystä Kosovon asemasta vuosina 1998–2010. Se oli yksi keskeisimmistä 1990-luvun Jugoslavian hajoamissotien solmukohdista ja suhtautuminen siihen jakaa edelleen kansainvälisen yhteisön rivejä maailmanlaajuisesti. Tapaus on erityisen mielenkiintoinen myös nationalismin ja historiapolitiikan kannalta, sillä Kosovo on sekä albaanien että serbien kansallisen identiteetin ydinaluetta. Varhaishistorian myytit ja etnohistorialliset kertomukset ovat olleet tärkeässä asemassa lukuisissa aluetta koetelleissa konflikteissa. Tutkimuksen lähtökohtana on historiapolitiikan lähestymistavan välttämättömyys kansainvälisesti politisoituneen ”Kosovon kysymyksen” ymmärtämisessä. Historiapolitiikan teoreettisen viitekehyksen soveltuvuuden koettelu diplomatian argumentaation ja kansainvälisten suhteiden analysoinnissa on olennainen osa tutkimuksen tehtävänasettelua, sillä varsinkaan Suomessa ei vastaavaa tutkimusta ole ennen tehty. Samalla tutkimuksen tavoitteena on luokitella, analysoida ja vertailla eri valtioiden diplomaattisten historia-argumenttien käyttöä Kosovon kysymyksen yhteydessä sekä tarkastella näiden argumenttien kautta suhtautumista kansallisiin etnohistorian tulkintoihin ja niiden käyttöön 1990-luvun retoriikassa. Tutkielman tärkeimpiä alkuperäislähteitä ovat YK:n turvallisuusneuvoston Kosovoa käsittelevien istuntojen pöytäkirjat vuosilta 1998–2010 sekä huhti- ja heinäkuussa 2009 YK:n kansainväliselle tuomioistuimelle (ICJ) toimitetut, Kosovon itsenäisyysjulistuksen lainmukaisuutta käsittelevät, kirjalliset lausunnot ja kommentit. Tutkimuskirjallisuuden osalta tutkielman tärkeimpiä lähteitä ovat muun muassa Oliver Jens Schmittin, Marc Wellerin ja Pekka Visurin teokset sekä monet albaanien ja serbien kansallisia historiakäsityksiä ilmentävät teokset. Tutkielman metodologisena apuvälineenä on sovellettu suomalaisessa tutkimuksessa aikaisemmin hyvin vähän käytettyä Karl-Georg Faberin mallia historian poliitisen käytön kategorisoimiseksi. Faberin mallia käytetään paitsi historia-argumenttien luokittelun kehikkona, myös ajattelua ohjaavana historianfilosofisena kolmitasoisena mallina. Sitä on täydennytty Chaïm Perelmanin ja Lucie Olbrechts-Tytecan retoriikan tutkimuksen teorialla. Tutkimuksen tärkeimpiä johtopäätöksiä on historiapolitiikan näkökulman ja Faberin mallin hedelmällisyyden toteaminen diplomatian argumentaation analysoinnissa. Samalla tutkimus osoittaa, että historia-argumenteilla oli (ja on edelleen) Kosovon kysymyksessä oma erityinen roolinsa, joka vaihteli ajallisesti ja teemoittain. Toisaalta kansalliset historiakäsitykset, kuten käsitys omasta kansasta uhrina, näkyivät argumenteissa selvästi, toisaalta pyrkimyksenä oli vältellä nationalistiseksi tulkittavia historia-argumentteja. Lisäksi monissa argumenteissa vaaditiin väkivaltaisen historian jättämistä taakse eurooppalaisen tulevaisuuden toivossa.