Brachial Plexus Birth Palsy Research Articles

Does the Functional Status of the Upper Limb Influence Limb Length Discrepancy in a Child with Birth Brachial Plexus Palsy?

Background: Limb length discrepancy (LLD) is a frequent observation in children with birth brachial plexus palsy (BBPP) and a common concern among parents. A common assumption is that the LLD decreases if the child is using the involved limb more. However, there is no literature evidence for this assumption. The present study was conducted to assess the correlation between the functional status of the involved limb and the LLD in children with BBPP. Methods: One hundred consecutive patients (age > 5 years) with unilateral BBPP seen at our institute underwent measurements of limb lengths to assess the LLD. The arm, forearm and hand segments were measured separately. The functional status of the involved limb was assessed using modified House's Scoring system (Scores 0-10). The correlation between limb length and functional status was assessed using the one-way Analysis of Variance (ANOVA) test. Post-hoc analyses were performed as required. Results: A length difference was observed in 98% of the limbs with brachial plexus lesions. The average absolute LLD was 4.6 cm with a standard deviation of 2.5 cm. We found a statistically significant difference in LLD among the patients with a House score of <7 ('Poor function') and 7 and above ('Good function'; p < 0.001) with later indicative of independent use of the involved limb. We found no correlation between age and LLD. More extensive plexus involvement resulted in higher LLD. The maximal relative discrepancy was found in the hand segment of the upper extremity. Conclusions: LLD was seen in most of the patients with BBPP. The functional status of the involved upper limb in BBPP was found to be significantly associated with LLD. Though causation cannot be assumed. We found that children using the involved limb independently tend to have the least LLD. Level of Evidence: Level IV (Therapeutic).

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

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. 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. 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. 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.

The effect of botulinum toxin application on latissimus dorsi and teres major muscles in patients with brachial plexus birth palsy: An electron microscopic and clinical study.

In brachial plexus birth palsy (BPBP), botulinum toxin may be utilized to prevent glenohumeral dysplasia and to maintain the stable growth of the glenohumeral joint. Repeated injections may cause muscular atrophy and their functional effects are uncertain. The aim of this study was to compare the microstructure and the function of the muscles that received two injections before transfer with the muscles that were not injected. BPBP patients that were operated between January 2013 and December 2015 were included in the study. Latissimus dorsi and teres major muscles were transferred to humerus in standard fashion. Patients were divided in two groups according to bo-tulinum toxin status. Group 1 was toxin negative whereas Group 2 was toxin positive. For each patient, mean latissimus dorsi myocyte thickness (LDMT) was measured with electron microscopy and pre-operative and post-operative active shoulder abduction, flexion, external and internal rotation, and Mallet scores were evaluated with goniometry. Fourteen patients (seven patients per group) were evaluated. Five patients were female whereas nine were male. Mean LDMT was not affected significantly (p>0.05). The operation improved shoulder abduction, flexion, and external rotation significantly (p<0.05), independent of the toxin status. The internal rotation decreased significantly only in Group 2 (p<0.05). The Mallet score increased in both groups, but it was not significant (p>0.05), independent of the toxin status. Botulinum toxin that was applied twice prevented glenohumeral dysplasia and it did not cause permanent latissimus dorsi muscle atropy and function loss in late period. It augmented upper extremity functions by alleviating internal rotation contracture.

Understanding the management of brachial plexus birth palsy and the roles of nerve transfers

Early recognition and management of neonatal brachial plexus injury (NBPP) is key to optimizing outcomes and surgical options. Because up to a third of patients with birth palsy may require surgical intervention, the multidisciplinary team must follow up on the function and recovery of the entire upper extremity, from shoulder to fingertips, within the first few months of life. Options include neuroma resection and primary nerve grafting and/or nerve transfers, which can be intra- or extra-plexal, as adjunctive or standalone procedures. When limited proximal nerve roots are available for nerve grafting, or when too many nerve roots are involved, exceeding the supply of nerve graft, extra-plexal nerve transfers are then indicated. While early intervention is preferred (between 3 and 6 months for most authors), older children presenting late (&gt; 1 year since birth) with partial nerve recovery may still potentially benefit from nerve transfers, which can be offered to late-presenting infants. Here we discuss the anatomy, indications, work-up, options, complications, and outcomes for such nerve transfers for upper, lower, and global plexus palsy in neonates. Nerve transfers are a common procedure done for the treatment of various types of birth plexus palsies. Currently, while there is an abundance of clinical reports and evidence, there is still a lack of clarity regarding best practices or in terms of the type of procedure and technique for the treatment of birth plexus palsy. Our hope is that this chapter provides a concise source after an extensive cumulative review of the evidence of best practices for nerve transfers in the case of birth plexus palsy.

Restoration of shoulder function after miccrosurgical reconstruction in cases of brachial plexus birth palsy

Restoration of shoulder function after miccrosurgical reconstruction in cases of brachial plexus birth palsy

Non-union of the Clavicle Osteotomy Site in an Infant with Birth Brachial Plexus Palsy.

Non-union of the clavicle in the paediatric population is extremely rare. Some anecdotal case reports show non-union following clavicle fracture. However, we could not find any report of non-union following osteotomy for brachial plexus surgery. We report non-union of clavicle following its osteotomy for brachial plexus exploration surgery in a 6-month child. We present successful management of the clavicle non-union in this patient and propose preventive steps. Level of Evidence: Level V (Therapeutic).

THE RESULTS OF ARTHROSCOPIC RELEASE WITH TENDON TRANSFERS IN CASES OF B.P.B.P WITH GLENOHUMERAL DYSPLASIA

Background: Internal rotation deformity due to brachial plexus birth palsy frequently lead to glenohumeral deformity . Our surgical approach to treat these contractures relies on arthroscopic release and tendon transfer of latissimus dorsi muscle for young children . We report the results for twenty children followed for a minimum of two years after such treatment Patients and methods: This study was done in the Orthopedic department, Sohag University Hospitals including all patients with brachial plexus birth palsy with internal rotation contracure of the shoulder. Twenty children with a mean age of 4 years (between 2 and 6 years old) underwent arthroscopic contracture release and tendon transfer of latissimus dorsi muscle as a primary procedure.Passive and active external rotation, internal rotation, and elevation were measured for all patients pre and postoperatively. Modified mallet score and active movement score was measured pre and postoperatively. Magnetic resonance imaging was performed preoperatively and postoperatively to evaluate glenoid version and head sublaxation. Results: At the time of follow-up, the mean passive external rotation was increased by 67° (p &lt; 0.005) in the children with a successful arthroscopic release and tendon transfer. The mean active elevation increased by 12°. Internal rotation was not measured consistently preoperatively, but when it had been it was found to have decreased substantially postoperatively. Mean glenoid version improved from -33° to -7° following soft-tissue releases and The percentage of the humeral head anterior to the middle of the glenoid improved from 8% to 43%. While the average duration of clinical and radiographic follow-up was twenty-four months, improvements in both shoulder motion and glenohumeral joint morphology were seen early and were maintained during the follow up period. Conclusion: In children with internal rotation contracture, arthroscopic release and tendon transfer effectively restores nearly normal passive external rotation and a centered glenohumeral joint at the time of surgery. In most of these children, external rotation strength is sufficient to maintain this range of motion and to improve glenoid development when preoperative deformity was present. Improvement in active elevation was minimal. All children have a loss of internal rotation, which is moderate in most of them.

Obstetric fractures in caesarean delivery and risk factors as evaluated by paediatric surgeons

IntroductionObstetric fractures usually occur after complicated births and are sent to paediatric orthopaedics for treatment and follow-up. Clavicle fractures represent the most common orthopaedic birth injury, involving approximately 0.2 to 3.5% of births.HypothesesCaesarean delivery, elective or necessary, along with the type of presentation, may play a determinant role in the aetiology of obstetric fractures.Materials and methodsWe chose to do a retrospective study to determine possible risk factors for this type of injury that may manifest in either delivery. Our aim was to deepen our knowledge in order to have a better prediction and a better management of this condition. Data gathered included parity, gestity, type of delivery, presentation, shoulder dystocia, type of fracture, birth weight, and APGAR score.ResultsWe followed 136 patients that were diagnosed with Allman type I clavicle fracture, 32 of them also having brachial plexus birth palsy (BPBP) type 1 (Duchenne-Erb). Natural birth with a pelvic presentation imposes a relative risk of 6.2 of associated pathology compared to cranial presentation. Caesarean delivery and cranial presentation increase the risk of related pathology by 5.04 compared to natural birth. Statistically, pelvic presentation is 5.54 times more likely to develop related pathology than cranial presentation. Type of delivery and presentation correlate with associated pathology of clavicle fractures.Discussion and conclusionCaesarean delivery brings risks for the newborn and should be practiced only when necessary. Predictive modeling in obstetrics in third-trimester evaluations may statistically predict risks of birth complications like fracture and BPBP.

Brachial Plexus Birth Palsy: Practical Concepts for Radiologists.

Brachial plexus birth palsy (BPBP) is classified as a preganglionic or postganglionic injury based on the site of injury. Most patients recover spontaneously and are followed up with clinical evaluation; however, permanent sequelae are not uncommon. For patients with persistent neurologic deficits, clinical and radiologic evaluation is crucial. Untreated BPBP can progress to significant sequelae, such as muscle contractures and glenohumeral dysplasia (GHD). Timely characterization of these entities based on different imaging modalities is a high priority for optimal patient outcomes. We describe the anatomy and pathogenesis, as well as the different imaging modalities involved in the evaluation and classification of BPBP and GHD.

Analysis of Results of Contralateral Hemi-C7 Root Used for Restoring Hand Function in Global Birth Brachial Plexus Palsy

To analyze the outcome of the use of contralateral hemi-C7 for the restoration of hand function in patients with birth brachial plexus global palsy. From 2004 to 2017, 19 infants with Narakas types III and IV birth brachial plexus palsy underwent transfer of contralateral hemi-C7 (posterior division of the contralateral C7 root) to the lower trunk or medial cord on the affected side. All the patients were evaluated for shoulder function using the Gilbert and Mallet scores, elbow flexion using the modified Medical Research Council score for children, and hand function using the Raimondi score. After the surgery, the children were followed-up at 3-month intervals for the first year and6-month intervals thereafter. Hand function achieving Raimondi scores of 3-5 was considered a useful outcome. The patients were followed-up for a mean duration of 88 months, with a minimum of 35 and a maximum of 192 months of follow-up. All patients attained a Gilbert score of ≥3, whereas 9 patients attained a score of ≥4. Similarly, all patients attained a minimum aggregate Mallet score of 15, and 9 patients attained a score of ≥20. All patients attained a modified Medical Research Council score of ≥3, used for assessing elbow flexion. Useful hand function was attained in 73% (14/19) of the cases (a Raimondi score of ≥3). There was no clinically recorded deficit on the donor side. Contralateral hemi-C7 transfer in infants with brachial plexus root avulsions helped regain useful hand function in 73% (14/19) of the children treated. Therapeutic IV.

False Negativity in Towel Test for Elbow Flexion Assessment in Brachial Plexus Birth Palsy. Can We Attribute to Handedness?

Objectives: The towel test is considered as a reliable clinical examination finding to test the elbow flexion in Brachial plexus birth palsy. A mature central nervous system makes this test positive at 6 months’ time and those who failed the test require microsurgical exploration and nerve repair/transfers for upper limb functions. Not all infants pass in this test. Majority of the children develop a clear hand preference at 6 months of age. We hypothesize the validity of the towel test in brachial plexus birth palsy children between 6 and 9 months of age and the possibility of mother and infant handedness in the false-negative tests. Materials and Methods: A retrospective analysis conducted between 2015 and 2019 about the utility of “towel test” involving 12 boys and 11 girls was analyzed and interpreted. The side involved in these infants and the mother's handedness was also noted. Based on the age, side, gender, and mother-handedness, the results of towel tests were statistically interpreted. Results: The mean age of the infants involved was 6.6 months (range 6–9 months). Twenty children (87%) had positive tests. Three (13%) infants (male = 2; female = 1) had false-negative test. There was no action on the normal side to remove the towel but weak movements in the affected upper limb persisted to try and remove the towel. The left-hand mother's infant had false-negative towel test, which was found statistically significant (P &lt; 0.01). Conclusion: Clinicians should know that false negativity may coexist while using the towel test and handedness could be a possibility in them. In such conditions, additional tests can be used to assess the ongoing motor recovery in brachial plexus birth palsy children between 6 and 9 months of age.

Upper-limb function in Brachial Plexus birth palsy: Does the Pediatric Outcomes Data Collection Instrument correlate with the Brachial Plexus Outcome Measure?

Functional outcome assessment for children with brachial plexus birth palsy (BPBP) is essential. We aimed to investigate the association between the Brachial Plexus Outcome Measure (BPOM) and the Pediatric Outcomes Data Collection Instrument (PODCI) in children with BPBP and healthy matched controls, and to explore upper-limb function and the discriminative properties of the two tests. Thirty children, aged 6–14 years, diagnosed with BPBP and undergoing shoulder tendon transfer and 20 age-matched healthy controls were included. In both groups, the Turkish version of the PODCI, used to evaluate daily living activities, was implemented. The Turkish version of the BPOM, specifically developed for BPBP, was applied in children with BPBP. Test results, demographic and clinical characteristics were recorded. The mean age of children with BPBP was 8.53 ± 2.53 years and their BPOM Activity scale score was 42.93 ± 8.28. The PODCI Upper Extremity Function score (74.97 ± 23.49 vs. 100) and the PODCI Global Functioning score (89.20 ± 7.73 vs. 99.36 ± 7.73) were significantly lower in the BPBP group (p < 0.01). While there was a significant and very strong relationship between the BPOM Activity and PODCI Global Functioning scores (r = 0.845; p = 0.037), no correlation was found between the BPOM Self-Evaluation scale and PODCI Global Functioning score (r = 0.456; p = −0.141). The PODCI correlated with the BPOM Activity scale, providing an appropriate alternative measurement for upper-limb function in children with BPBP after shoulder tendon transfer.

THE PRONATING RADIUS OSTEOTOMY FOR CORRECTING THE SUPINATION DEFORMITY IN BRACHIAL PLEXUS BIRTH PALSY

Objective: Severe supination deformity may be seen in brachial plexus birth palsy (BPBP). The aim of this study was to determine the efficacy of pronating radius osteotomy in the management of this deformity. Material and Methods: BPBP patients with severe supination deformity were included in this study and they were operated between November 2003 and December 2015, by the same operative team. Pronating radius osteotomy was performed and internal fixation was maintained either by Kirschner wires or semitubular plates. In some patients, tendon transfers were performed during the same operation for the restoration of shoulder and thumb abduction and wrist extension. Results: Forty one patients had supination deformities caused by BPBP. The mean age was 9.2 years (4-22). The mean follow-up was 5 years (1-7). The mean active pronation was -60° before the operation, and the passive one was -10°. The mean active pronation of the patients was 9° after the operation, and the passive one was 45°. The mean active supination of the patients was 75° before the operation, and the passive one was 85°. The mean active supination of the patients was 45° after the operation, and the passive one was 65°. One malunion was detected at the second year after the operation (1/41). Three patients had low pronation degrees during the follow-up (3/41). Conclusion: Satisfactory postural and functional improvement can be achieved with the use of pronating radius osteotomy for patients with severe supination contractures.

Restoration of Forearm Supination Deformity in Brachial Plexus Birth Palsy

Amac: Dogumsal brakialpleksus paralizisi sonrasi gelisen onkol supinasyondeformitesi, hem fonksiyonelligi hem de gorunumu olumsuz yonde etkileyen ciddi sekellerden biridir. Supinasyondeformitesinin erken evrelerinin tedavisinde yumusak doku girisimleri kullanilirken, gec donemde kemik girisimlerine ihtiyac duyulur. Bu calismada farkli evrelerdeki onkol supinasyondeformitelerininrestorasyonu icin kullanilan yontemler ve sonuclari incelenmistir . Hastalar ve Yontem: Onkol supinasyondeformitesinin restorasyonu amaciyla opere edilen toplam 43 cocuk (ortalama yas 8.2) calismaya dahil edildi.Bu hastalardan 18 tanesine yumusak doku girisimleri, 25 tanesine kemik girisimleri uygulandi.Yumusak doku girisimi olarak 14 hastada ise brakioradialis reroutingpronatoplasti, 4 hastada biseps re-routingproseduru; kemik girisimleri olarak 10 hastada radius rotasyon osteotomisi, 11 hastada radius basi eksizyonuve 9 hastadadistalradio-ulnarsinositoztercih edildi. Tum hastalarin ameliyat oncesi ve sonrasi aktif ve pasif onkol supinasyon ve pronasyon dereceleri goniometrik olarak olculdu. Bulgular: Brakioradialisreroutingpronatoplasti ve bicepsreroutingteknigi icin ameliyat oncesi ve sonrasi ortalama aktif pronasyon acisi sirasiyla-32,8°’den 30,7°’ye ve -40°’den 42,5°’ye yukselmistir. Radius rotasyon osteotomisi, radius basi eksizyonuve distalradioulnarsinostozyapilan hastalarin ameliyat oncesi ve sonrasi aktif pronasyon acilari sirasiyla; -70°’den -4°’ye, -53°’den 43°’ye, -80°’den-19°’ye ilerlemistir . Sonuc: Dogumsal brakialpleksus paralizisinin gec donem onkol sekellerinden olan supinasyondeformitesinin tedavisinde kullanilan gerek yumusak doku gerekse de kemige yonelik palyatif cerrahi girisimler ile tatmin edici duzeyde fonksiyonel ve postural duzelme elde edilebilmekt edir.

Reliability of Towel Test for Elbow Flexion Assessment in Brachial Plexus Birth Palsy

Abstract Background and Objectives The towel test is a reliable and straightforward technique to find elbow flexion in brachial plexus birth palsy. This study evaluates the role and reliability of towel test in children at 6 and 9 months of age. Materials and Methods We conducted the towel test in 30 consecutive children at 6 and 9 months of their ages between 2015 and 2020. We recorded the results along with the side involved in these children and the mother’s handedness. Based on the results of towel tests, we did a statistical correlation. Results Sixteen of the 30 children were boys. Twelve of the 30 children had left-side involvement. Four mothers were left handed. Four (13%) infants (male = 3; female = 1) had false-negative towel test at 6 and 9 months. There is a significant correlation between the left-hand mother’s and infant who had false-negative towel test (p &lt; 0.01) Conclusion The towel test is reliable and straightforward to assess the elbow flexion at 6 and 9 months. It can be falsely negative in 13% of children because of handedness. Mother’s handedness is crucial and should be recorded during the children assessment. Alternate tests will further evaluate the elbow flexion in such false-negative towel-tested brachial plexus birth palsy children.

Structures contributing to the shoulder contracture in brachial plexus birth palsy. An intraoperative biomechanical study.

Internal rotation contracture of the shoulder is a common sequel of the brachial plexus birth palsy. The purpose of this study is to describe the surgical method used in our centre and to measure the effect of sequentially releasing several anatomical structures that have been ascribed as the cause of the contracture. Twenty-four consecutive patients were operated on with an open release. We documented the increase in passive external rotation after each surgical step. We found small gains in passive external rotation when performing coracoidectomy and division of the upper part of the subscapularis tendon; 4° (95% confidence interval [CI] 2°-6° p < 0.01) and 6° (95% CI 4°-8° p < 0.01), respectively. A substantial gain in external rotation occurred when dividing the entire subscapularis tendon, 43° (95% CI 38°-48°, p < 0.01). Our findings indicate that a clinically relevant surgical release of the contracture requires lengthening of the entire subscapularis musculo-tendinous unit.Level of evidence: IV.

The outcome of soft-tissue release and tendon transfer in shoulders with brachial plexus birth palsy.

BackgroundShoulder involvement in brachial plexus birth palsy is common, and the adduction, internal rotation contracture deformity often requires some form of surgical treatment. There are very few long-term reports on release of contracted muscles and tendon transfers, especially in older children. We are reporting the single-center results of such a surgery with detailed outcome analysis.MethodsThe prospectively collected data from brachial plexus birth palsy cases who had undergone contracture release and tendon transfer were retrospectively studied and examined. The new Mallet and functional scores were compared with the original data forms and then analyzed. The radiographic evidence of glenoid dysplasia and its correlation with age and functional outcome was assessed.ResultsA total of 82 cases with surgery at mean age of 9.5 ± 5.09 years and a follow-up of 8 ± 3.8 (3-20) years entered the study. Of these, 56% of cases had 7 to 20 years of age at surgery. Fifty-four (66%) patients had only shoulder surgery, and 28 (34%) required additional reconstructive surgeries for hand and wrist. Moderate to severe glenohumeral dysplasia was present in 38%. The preoperative Mallet score of 10.6 ± 2.97 improved to 19.3 ± 3.39 (P < .001). Eighty-one percent of patients showed improvement in “reaching face” functions, 71% in “above head” functions, and 74% in “midline functions.” The cases with lack of improvement in midline function mostly belonged to pan-plexus injuries. Noticeable subjective and objective improvement was also observed in cases with glenohumeral dysplasia in their Mallet and functional scores (P < .001). The improvement in function and subjective satisfaction of 92% was observed irrespective of age at surgery.ConclusionSoft-tissue release and tendon transfer for brachial plexus birth palsy shoulder can improve function and limb appearance even in older children and young adults and even in the presence of glenohumeral dysplasia.

How brachial plexus birth palsy affects motor development and upper extremity skill quality?

This study aimed to investigate the gross motor functions including head control, midline crossing, and rolling, and the relationship between these developmental skills and upper extremity skill quality in children with neonatal brachial plexus palsy (NBPP). A total of 106 children with NBPP, aged 10-18months, were included in this study. Injury severity was determined with the Narakas Classification. The gross motor function measurement lying and rolling sub-scale was used to evaluate gross motor functions including head control, midline crossing, and rolling, while the Quality of Upper Extremity Skills Test was applied to assess the upper extremity skill quality. The assessments were performed only once during routine physiotherapy controls. As the severity of injury increased, developmental skill capacity decreased and upper extremity skill quality deteriorated (ps = 0.0001). There was a strong positive correlation between these developmental skills and upper extremity skill quality (ps = 0.0001). Developmental skills are affected by NBPP. Rehabilitation programs aimed at increasing the quality of upper extremity skills should be included in neurodevelopmental treatment approaches.

Upper limb kinematics after Latissimus Dorsi transfer in children with brachial plexus birth palsy

BackgroundBrachial plexus birth palsy remains a frequent condition and one of its treatments is to transfer the Latissimus Dorsi tendon to the infraspinatus muscle. The aim of this study was to analyse, for the first time, the three-dimensional kinematic effects of this operation on the upper limb joints during the five Mallet tasks and their correlation with clinical parameters. MethodsKinematic analysis was performed using an electromagnetic device. An Index of Improvement taking into account the angle in preop and postop, the reproducibility and the angle of a control group was developed. Three groups of patients were analysed: sixteen patients (mean: 10,5 years) for the reproducibility, thirty children (mean: 9,5 years) for the control group and ten patients (mean: 8 years 7 months) who were operated. FindingsThe humerothoracic and glenohumeral external rotations improved during the external rotation, the neck and the abduction tasks and worsened during the spine task. The glenohumeral external rotation worsened during the mouth task. The Humerothoracic abduction improved during the abduction and the neck tasks. The elbow flexion improved for the neck task. Differences were observed between patients and correlations were obtained between the Index of Improvement and clinical parameters. InterpretationUsing kinematics allows to better analyse the evolution of joint angles after the latissimus dorsi transfer. The Index of Improvement allows to quickly analyse the effect of the operation for each angle and each patient. This effect depends on clinical parameters.

Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy

Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.