There are also young adults who had the necessary treatments but whose results are poor and unsatisfactory. Few of these patients, now grown to adulthood, have had follow-up and there have been insufficient long-term longitudinal studies.

There are several stages in the occurrence of problems after obstetrical brachial plexus palsy:

The main problem, after the age of 12-13, is the slow degradation of results: the elbow contracture aggravates and the shoulder abduction diminishes progressively. This is due primarily to disuse; school has become time-consuming, there is not enough time for physiotherapy and swimming. The uninjured arm is used extensively, neglecting the injured one. The answer is continuous exercise and especially swimming, which will prevent degradation. It is also important for parents to remember that an excellent result after surgery is not the guarantee of excellent late results.

The young adult is usually adapted physically to his/her sequellae; although the psychological difficulties may be significant. The main problem that may occur is pain. This pain is often in relation with shoulder dysplasia and is the first sign of intolerance. Sometimes, rarely, it may be nerve pain. Somebody who never experienced pain as a child may start suffering after 15 or 20 years. We do not understand this mechanism but it is a fact. It is already too late for correcting these joint anomalies. Only prevention is possible: that means not letting the posterior dislocation occur.

The mature adult feels mostly the consequences of the joint dysplasia and may be subject to early arthritis. Some adults come to see us with high expectations, asking for tendon transfers to the shoulder, treatment of fixed internal rotation, absence of elbow flexion, etc. Our surgical possibilities are very limited and in most cases not possible.

The adolescent or adult with an obstetrical brachial plexus palsy represents a complex and difficult problem. We have to be honest not to give false hope.

The best we can do for him or her is to stimulate the quality of the early treatment. It is by seeing the late outcome of untreated patients that one realizes that our responsibility is great in our first assessment of a baby and the orientation that will be given in this treatment. The balance is not easy between an absence of treatment, sometimes due to lack of knowledge, or aggressive and unnecessary operations due to economical motivations.

Since 1977, Professor Alain Gilbert has developed his experience of obstetric plexus repair at the Hospital Trousseau and the Institut de la Main, France. During this period more than 3300 patients have been seen. Over 700 had a plexus repair and several hundreds have had secondary procedures on the shoulder, elbow and hand.