Ultrasound Screening for Posterior Shoulder Dislocation in Infants with Persistent Brachial Plexus Birth Palsy

Midterm Outcomes of Shoulder Dislocations in Brachial Plexus Birth Injuries Treated With Injection Botulinum Toxin A

BACKGROUND

Shoulder dislocation can be seen early in infancy and can be diagnosed by shoulder ultrasound. Botulinum toxin injection in the internal rotators of the shoulder can be used to as an adjunct to relieve the internal rotation contracture. The aim of this study was to evaluate the intermediate-term outcomes of shoulder dislocations treated with injection botulinum toxin and to identify the factors determining the outcomes of the procedure.

METHODS

Eighty-six children with ultrasound diagnosed shoulder dislocation underwent injection BTX-A between 2011 and 2022. Children who underwent nerve surgeries and the ones with inadequate follow-up were excluded. Sixty-two children were followed up for a mean duration of 36 months. Injection botulinum toxin A 2 U/kg body weight was injected each into the subscapularis and the pectoralis major. After manual stretching of contracted anterior soft tissue and shoulder capsule, a shoulder spica was applied for 3 weeks. Hospital for Sick Children Active Movement Scale (HSC-AMS) score and active and passive shoulder was recorded before and after the procedure and the requirement for further interventions was noted.

RESULTS

Outcomes were divided into 3 categories: group A-27 (44%) children who did not require any further surgery in our follow-up period; group B-27 (44%) needed further procedure for recurrence of IR contracture; and group C-8 (12%) developed external rotation contracture later. Children in group A had statistically significant higher preinjection HSC-AMS score for elbow flexion and shoulder abduction than the other groups. Children in group C had greater passive external rotation and weak elbow extension and wrist dorsiflexion as compared with the other 2 groups.

CONCLUSIONS

Injection botulinum toxin A is effective in treating shoulder dislocations in children with early recruitment of C5 to 6 muscles, while children with involvement of C7 muscles may develop an external rotation contracture subsequently, hence this procedure should be avoided.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Surgical Treatment of Infantile Shoulder Dislocation Following Brachial Plexus Birth Injury

BACKGROUND

Glenohumeral dysplasia following brachial plexus birth injury (BPBI) can present as dislocation of the glenohumeral joint in infancy. Multiple nonoperative treatment strategies have been reported for these early dislocations, yet none are universally successful; thus, surgical treatment may be required. However, reports of surgical treatment in infancy are scarce. The present study retrospectively reviews the outcomes of patients with BPBI treated surgically for glenohumeral dislocation under 1 year of age.

METHODS

Medical records were retrospectively reviewed for patients treated surgically for glenohumeral dislocation under 1 year of age. Dislocation was defined on magnetic resonance imaging (MRI) as a percentage of the humeral head anterior to the scapular line (PHHA) <10%, or on ultrasound, as the humeral head ossific nucleus entirely posterior to the posterior scapular line. The primary outcome was defined as the need for reoperation. Additional outcomes included Mallet scores for global shoulder function and PHHA and glenoid version measurements on follow-up MRI. Patients with <1 year follow-up were excluded.

RESULTS

Thirty-two patients underwent surgical intervention for shoulder dislocation at ages 5 months to <1 year with average follow-up of 4.6 years. Of these 32 patients, 25 underwent internal rotation contracture release and external rotation tendon transfer (ERTT), with 3 (12.0%) requiring revision surgery; 7 underwent release alone, with 6 (85.7%) requiring revision surgery. Across all groups, patients ultimately had improved passive and active external rotation (20.0 to 80.0 degrees, -90.0 to 30.0 degrees, respectively, P<0.0001) and global Mallet scores (14.5/30 to 19.5/30, P<0.001) without worsened internal rotation function. The indications for requiring further surgical intervention for the 9 patients were recurrent IR contracture, redislocation, persistent ER weakness, and weak abduction.

CONCLUSIONS

Surgical treatment of infantile shoulder dislocation following BPBI can improve glenohumeral alignment and global shoulder function. The inclusion of external rotation tendon transfers at the index procedure lowers the risk of reoperation, whereas not sacrificing internal rotation function when combined with partial subscapularis release.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Subscapularis Release and External Rotation Tendon Transfer for Brachial Plexus Birth Palsy: Surgical Technique

Patients with brachial plexus birth injuries commonly develop problems at the shoulder. These problems include posterior subluxation of the shoulder, internal rotation contractures, and weakness of external rotation. The most common technique for the treatment of these is the release of the shoulder joint, the release of the internal rotators, and the transfer of latissimus teres and teres major tendons. In this article, we present a detailed technique with an accompanying step-by-step video to demonstrate how to perform these procedures.

Outcomes of glenohumeral dysplasia after brachial plexus birth injury using the Sup-ER orthosis

We investigated the efficacy of the supination-external rotation ('Sup-ER') orthosis, designed as a non-operative treatment to maintain normal anatomical growth of the shoulder, on the progression of glenohumeral dysplasia in patients with brachial plexus birth injuries. The Sup-ER orthosis was fabricated for 20 infants diagnosed with glenohumeral dysplasia after brachial plexus birth injuries and its success in correcting glenohumeral dysplasia was confirmed by objective calculations of the alpha angle on serial ultrasound findings and improvement in Active Movement Scale scores. Of the 20 patients, 14 had successful resolution of glenohumeral dysplasia, confirmed by shoulder abduction, shoulder flexion, external rotation and supination, Active Movement Scale scores and improving alpha angle measurements. Failure to rectify glenohumeral dysplasia, evidenced by worsening ultrasound findings and Active Movement Scale scores, necessitated a change to operative management in six patients.Level of evidence: IV.

Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique

PURPOSE

Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD.

METHODS

We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients.

RESULTS

At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days-7 months) at presentation. Surgery was performed on average at 5.8 months of age (3-8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD.

CONCLUSION

In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.

Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction: early experience

BACKGROUND

Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting.

METHODS

A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting.

RESULTS

Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion.

CONCLUSION

Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.

Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury

OBJECTIVE

To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment.

STUDY DESIGN

Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data.

RESULTS

There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%.

CONCLUSIONS

In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

Promoting Recovery Following Birth Brachial Plexus Palsy

Neonatal brachial plexus palsies (NBPP) occur in 1.74 per 1000 live births with 20% to 30% having persistent deficits. Dysfunction can range from mild to severe and is correlated with the number of nerves involved and the degree of injury. In addition, there are several comorbidities and musculoskeletal sequelae that directly impact the overall functional development. This review addresses the nonsurgical and surgical management options and provides guidance for pediatricians on monitoring and when to refer for specialty care.

Management of Brachial Plexus Birth Injury: The SickKids Experience

This article describes the approach utilized by the multidisciplinary team at Sick Kids Hospital to evaluate and treat patients with brachial plexus birth injury (BPBI). This approach has been informed by more than 30 years of experience treating over 1,800 patients with BPBI and continues to evolve over time. The objective of this article is to provide readers with a practical overview of the Sick Kids approach to the management of infants with BPBI.

Permanent Brachial Plexus Birth Injury: Helsinki Shoulder Protocol

Passive shoulder exercises from birth and ultrasound screening from 3 to 12 months. Botox is given to shoulder internal rotators and a bracing commenced, if alpha-angle exceeds 30°, or passive shoulder external rotation is below 70 degrees. Plexus reconstruction is recommended to children with root avulsion(s) on magnetic resonance imaging or 3-month Toronto Test Score < 3.5. Specific neurotization is recommended to children without avulsions, but lack of progress in healing. Shoulder dysplasia was diagnosed in 49% of 270 patients with permanent brachial plexus birth injury in our catchment area from 1995 to 2021. The age at detection of shoulder dysplasia dropped from mean 5.4 years in children born before 2000 to mean 3.9 months in children born after 2009. Botox was given to 57% of the patients born after 2009. Rate of shoulder relocation decreased from 28 to 7% while mean active shoulder external rotation in adduction increased from 2 to 46°.

Management of Brachial Plexus Birth Injuries at British Columbia Children's Hospital

A multidisciplinary team at BC Children's Hospital provides brachial plexus birth injury management for our provincial catchment area. Although compared with many centers we service a relatively small clinic population, we have the benefit of universal health care, province-wide reach, and accessible research infrastructure. In 2008, we created the Sup-ER protocol, which includes an orthosis that passively positions the neonatal shoulder into more idealized glenohumeral contact during early growth. We have since shown that our Sup-ER patients have better shoulder outcomes, require less brachial plexus surgery, and need fewer shoulder tendon transfers than those patients treated in our clinic prior to 2008. We have also found that the rate and degree of elbow flexion contractures are reduced compared with results reported in the literature.

Recent Advances in the Treatment of Brachial Plexus Birth Injury

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation.

SUMMARY

Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.

Clinical Diagnosis of the Infantile Shoulder Subluxation in Residual Brachial Plexus Birth Injury and Its Correlation With Ultrasound Diagnosis

INTRODUCTION AND AIMS OF STUDY

Timely detection of shoulder subluxation in infants with brachial plexus birth injury (BPBI) is essential to prevent the progression of glenohumeral deformity. Shoulder ultrasonography (USG) is routinely used to detect an infantile subluxation/dislocation, but its use is limited because of the paucity of expert radiologists in developing countries. The aim of this study was to determine the clinical examination predictors to determine shoulder subluxation in patients with BPBI correlating with ultrasound confirmation.

METHODS

We prospectively studied children who presented to our hospital between 2017 and 2021 diagnosed as brachial plexus birth injury. In patients developing internal rotation contracture of the shoulder, we looked for 3 standard clinical signs: reduced passive external rotation <60 degrees, deep anterior crease (DAC) and relatively short arm segment. Shoulder subluxation was defined as USG measurement of alpha angle>30 degrees and ossific nuclei of the humerus lying behind the dorsal scapular line. Sensitivity and specificity were used to assess their efficacy in clinical diagnosis of shoulder subluxation in different groups. The predicted probability of shoulder subluxation from each prediction rule was compared with actual distributions based on USG confirmation.

RESULTS

Of the 58 BPBI infants who developed PER<60 degrees at the shoulder, 41 had USG confirmed shoulder subluxation. The 2 independent predictors of shoulder subluxation (PER<45 degrees and DAC) were identified in the current patient population based on data analysis. The presence of short arm segment is a very specific marker of shoulder subluxation but not sensitive. The predicted probability of shoulder subluxation from the prediction rule combining all the 3 markers were similar to the actual distributions in the current patient population.

CONCLUSIONS

PER<45 degrees and presence of deep anterior crease are clinical markers indicating shoulder dislocation in patients with BPBI developing reduced external rotation at the shoulder. On the basis of the proposed clinical diagnosis algorithm, the above markers along with the selective use of USG can help in early detection and treatment of infantile shoulder dislocation.

Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes

BACKGROUND

Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation.

METHODS

From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery.

RESULTS

The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations.

CONCLUSION

Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.

Comorbidities in Infants and Children with Neonatal Brachial Plexus Palsy: A Scoping Review to Inform Multisystem Screening

AIMS

The scoping review was undertaken to explore comorbidities in infants and children with neonatal brachial plexus palsy (NBPP). The purpose of the review was to inform physical and occupational therapy screening of multiple body systems during the examination of children with NBPP.

METHODS

EBSCO Discovery and EMBASE electronic databases were searched for reports published between January 1996 and September 2021 describing comorbidities in children with NBPP between birth and 18 years. Key data pertaining to comorbidity prevalence, risk factors, clinical features, and associated outcomes were extracted and charted by one researcher and confirmed by a second researcher.

RESULTS

Thirty-six articles were included in the scoping review. Fourteen comorbidities were identified across the musculoskeletal, neurological, cardiopulmonary, and integumentary systems and the communication domain. The most prevalent comorbidities were clavicle fractures, plagiocephaly, torticollis, high body mass index, and language delays. The least prevalent comorbidity was facial nerve palsy.

CONCLUSIONS

Physical and occupational therapists can use knowledge of comorbidities in infants and children with NBPP for multisystem screening during the examination. A thorough history can identify risk factors for comorbidities. Detection of comorbidities during screening allows for timely specialty referrals to optimize care.

A protocol-based treatment plan to improve shoulder function in children with brachial plexus birth injury: a comparative study

Children with permanent brachial plexus birth injury have a high risk of developing posterior shoulder subluxation. In 2010, we implemented a protocol to reduce the incidence of this deformity, including early passive exercises, ultrasound screening, botulinum toxin-A injections, shoulder splinting and targeted surgeries. Two-hundred and thirty-seven consecutive children treated at our institution, with a mean follow-up of 11 years (range 1 to 17) were compared in three groups: children born from 1995 to 1999 (n = 53), 2000-2009 (n = 109) and 2010-2019 (n = 75). Posterior shoulder subluxation developed in 48% of all patients but the mean age at detection of shoulder subluxation decreased from 5 years to 4.9 months. Need for shoulder relocation surgery also decreased from 28% to 7%. Mean active shoulder external rotation in adduction improved from 2° to 46°. In conclusion, our established protocol has the potential to reduce the incidence of posterior shoulder subluxation in children with brachial plexus birth injury.Level of evidence: II.

Influence of Brachial Plexus Birth Injury Location on Glenohumeral Joint Morphology

PURPOSE

Patient presentation after brachial plexus birth injury (BPBI) is influenced by nerve injury location; more contracture and bone deformity occur at the shoulder in postganglionic injuries. Although bone deformity after postganglionic injury is well-characterized, the extent of glenohumeral deformity after preganglionic BPBI is unclear.

METHODS

Twenty Sprague-Dawley rat pups received preganglionic or postganglionic neurectomy on a single forelimb at postnatal days 3 to 4. Glenohumeral joints on affected and unaffected sides were analyzed using micro-computed tomography scans after death at 8 weeks after birth. Glenoid version, glenoid inclination, glenoid and humeral head radius of curvature, and humeral head thickness and width were measured bilaterally.

RESULTS

The glenoid was significantly more declined in affected compared with unaffected shoulders after postganglionic (-17.7° ± 16.9°) but not preganglionic injury. Compared with the preganglionic group, the affected shoulder in the postganglionic group exhibited significantly greater declination and increased glenoid radius of curvature. In contrast, the humeral head was only affected after preganglionic but not postganglionic injury, with a significantly smaller humeral head radius of curvature (-0.2 ± 0.2 mm), thickness (-0.2 ± 0.3 mm), and width (-0.3 ± 0.4 mm) on the affected side compared with the unaffected side; changes in these metrics were significantly associated with each other.

CONCLUSIONS

These findings suggest that glenoid deformities occur after postganglionic BPBI but not after preganglionic BPBI, whereas the humeral head is smaller after preganglionic injury, possibly suggesting an overall decreased biological growth rate in this group.

CLINICAL RELEVANCE

This study expands understanding of the altered glenoid and humeral head morphologies after preganglionic BPBI and its comparisons with morphologies after postganglionic BPBI.

Analysis of Three-Dimensional Ultrasound in Diagnosis of Shoulder and Neck Inflammation and Surrounding Tissue Lesions

Ultrasound imaging technology can not only show neck tear the degree and extent of disease, to help make the correct diagnosis, can also be used to assess shoulder neck inflammation after surgery to repair a shoulder muscle neck tissue integrity and healing. Ultrasound imaging with high-resolution, real-time operation, low cost, etc. gradually become shoulder neck inflammatory disease preferred imaging modality. The sensitivity and specificity for three-dimensional ultrasound imaging of shoulder neck inflammation were 78% and 93% in this study. The full-thickness inflammation sensitivity and specificity were 50% and 95%. The sensitivity and specificity of inflammation were 57% and 87%, respectively. This study shows that the diagnostic accuracy of 3D ultrasound imaging in shoulder and neck inflammation and surrounding tissue lesions is close to that of MRI. Three-dimensional appearance of new technologies such as ultrasound imaging will further improve ultrasound imaging techniques in shoulder neck inflammation application in the diagnosis and treatment assessment.

Neonatal brachial plexus palsy: associated birth injury outcomes, hospital length of stay and costs

OBJECTIVE

To compare the birth injury outcomes and hospital length of stay and costs among newborns delivered at 34-42 weeks with neonatal brachial plexus palsy (NBPP) versus those without.

STUDY DESIGN

We conducted a retrospective, cross-sectional study using data from the National Inpatient Sample to identify all newborns hospitalizations that occurred in the U.S. between 2016 and 2017. We included non-anomalous single liveborn delivered in-hospital at 34-42 weeks. The newborns with NBPP were identified by International Classification of Diseases, 10th Revision, Clinical Modification codes. Birth injury outcomes, and hospital length of stay and hospital costs were examined. A multivariable Poisson regression model with robust error variance was used to examine the association between NBPP and birth injury outcomes. A multivariable generalized linear regression model was used to examine the association between NBPP and hospital length of stay and hospital costs.

RESULTS

Of 7,019,722 non-anomalous single liveborn delivered at 34-42 weeks in the U.S. from 2016 to 2017, the rate of NBPP (n = 6695) was 0.95 per 1000 newborn hospitalizations. After multivariable regression adjustment, compared to newborns without NBPP, the risk of the composite birth injury outcome was 2.91 (95% CI 2.61-3.25) times higher in those with NBPP. Similar results of an increased risk among newborns with NBPP were observed in all individual birth injury outcomes. Compared to newborns without NBPP, after adjustment, the hospital length of stay was 1.48 (95% IC 1.38-1.59) times higher and the hospital costs were 2.21 (95% CI 1.97-2.48) times higher in those with NBPP.

CONCLUSIONS

Among newborns delivered at 34-42 weeks, the risk of associated birth injuries, hospital length of stay and costs, were significantly higher in newborns with NBPP than those without.

Predictors of neonatal brachial plexus palsy subsequent to resolution of shoulder dystocia

OBJECTIVE

The objective was to ascertain factors among deliveries complicated by shoulder dystocia (SD) and neonatal brachial plexus palsy (NBPP).

METHODS

At 11 hospitals, deliveries complicated by SD were identified. The inclusion criteria were vaginal delivery of non-anomalous, singleton at 34-42 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for NBPP.

RESULTS

Of the 62,939 individuals who delivered vaginally, 1,134 (1.8%) had SD and met other inclusion criteria. Among the analytic cohort, 74 (6.5%) had NBPP. The factor known before delivery which was associated with NBPP was diabetes (aOR = 3.87; 95% CI = 2.13-7.01). After delivery, the three factors associated with NBPP were: (1) birthweight of at least 4000 g (aOR = 1.83; 95% CI = 1.05-3.20); (2) calling for help during the SD (aOR = 4.09, 95% CI = 2.29-7.30), and (3) the duration of SD ≥120 sec (aOR = 2.47, 95% CI = 1.30-4.69). The AUC under the ROC curve for these independent factors was 0.79 (95% CI = 0.77 - 0.82).

CONCLUSIONS

Few factors were identified that were associated with NBPP after SD, but they could not reliably predict which neonates will experience the complication.

Outcomes of Botulinum Toxin Injection for Shoulder Internal Rotation Contractures in Infants with Brachial Plexus Birth Injury

PURPOSE

Shoulder internal rotation contractures (IRC) are common sequela of brachial plexus birth injuries (BPBI). Botulinum toxin A (BTX-A) injection into targeted muscles has been described to facilitate functional improvement at the shoulder joint and prevent glenohumeral dysplasia. The purpose of this study was to assess the outcomes of BTX-A injections on shoulder IRC in children with BPBI.

METHODS

We conducted a retrospective analysis of 47 children with shoulder IRC due to BPBI, who were treated with BTX-A. Shoulder passive external rotation in adduction and Active Movement Scale external rotation scores were recorded before and after BTX-A injection. We also recorded the number of children who underwent secondary surgical balancing procedures to improve shoulder motion after BTX-A injection.

RESULTS

Mean age at the time of injection was 12 months (range, 5-23 months). Subjects demonstrated a significant increase in passive external rotation of 46° (range, 10° to 90) at 4 months; an average improvement of 18° (range, -30° to 80°) persisted at 11 months after injection. A total of 28 patients (60%) underwent subsequent external rotation tendon transfer. At 5-year follow-up, 7 patients (15%) had adequate functional shoulder range of motion and did not undergo external rotation tendon transfer.

CONCLUSIONS

Botulinum toxin A injections result in improvement in IRC due to BPBI, which is sustained beyond the expected half-life of 3 months. As many as 15% of patients who have this treatment avoid external rotation tendon transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Team Approach: Management of Brachial Plexus Birth Injury

Brachial plexus birth injury is an upper-extremity paralysis that occurs from a traction injury to the brachial plexus during birth. Approximately 10% to 30% of children with a brachial plexus birth injury have residual neurologic deficits with associated impact on upper-limb function. Management of brachial plexus birth injuries with a multidisciplinary team allows optimization of functional recovery while avoiding unnecessary intervention. Early occupational therapy should be initiated with a focus on range of motion and motor learning. The need for microsurgical reconstruction of the brachial plexus can be predicted based on early physical examination findings, and reconstruction is generally performed at 3 to 9 months of age. The majority of children with residual neurologic deficits develop associated glenohumeral dysplasia. These children may require secondary procedures, including botulinum toxin injection, subscapularis and pectoralis lengthening, shoulder capsular release, shoulder tendon transfer, and humeral osteotomy.

Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia

Objective  The main objective of this article is to determine if persistence of neonatal brachial plexus palsy (NBPP) following shoulder dystocia was associated with maneuvers used or duration of impacted shoulder. Study Design  Retrospective review of children with NBPP and documented shoulder dystocia. Student t -tests and chi-squared tests were used to compare outcomes when shoulder dystocia resolved with > 3 versus ≤ 3 maneuvers or duration > versus ≤ 120 seconds. Relative risk (RR) with 95% confidence intervals (CI) was calculated. Results  Among 46 children with NBPP and shoulder dystocia, incidence of persistence was significantly higher at 2 years of age when > 3 versus ≤ 3 maneuvers were used (100 vs. 62%; RR: 1.6, 95% CI: 1.2-2.2). When resolution of impacted shoulder lasted >120 versus ≤ 120 seconds, NBPP at 2 years was significantly more likely (100 vs. 63%; RR: 1.6, 95% CI: 1.1-2.2). Injury to all five nerves of the brachial plexus was more likely if standard deviation lasted > 120 versus ≤ 120 seconds (RR: 2.2; 95% CI: 1.03-4.6). Conclusion  Though the number of maneuvers used and duration of shoulder dystocia are associated with persistence of NBPP, the retrospective nature of the study of a selective cohort precludes recommendations changing the current management of shoulder dystocia.

Treating Pediatric Hand Problems in a Low-resource Environment

Although individual pediatric hand problems are rare, the combined burden of congenital anomalies, neuromuscular disease, and trauma is considerable in low-resource environments where treatment is unavailable. Surgeons from high-income countries respond to the need for care with short-term trips to low-resource environments to operate and teach local surgeons. Hand problems are amenable to this model, because they may be disabling and treatable with low-risk, low-resource surgery. Pediatric hand problems are especially compelling, because growth may adversely affect outcomes, and resulting disability is lifelong. This article addresses considerations for treating children's hands in low-resource environments, and approaches to specific conditions.