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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. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to elucidate the decision-making experiences of youth with brachial plexus birth injuries who face preference-sensitive decisions regarding treatment options for a persistent elbow contracture.Methods: Transcripts, research-created drawings, and field notes from in-depth interviews with 5 young adults and 14 youth-parent dyads, and 15 participant observation sessions of families and clinicians in the clinic setting were deductively and inductively coded and thematically analyzed.Results: Youth's shared decision making was influenced by relational processes with their clinicians and parents. Youth's trust in their clinicians' recommendations for pursuing treatment and pressure from their parents to pursue or continue rehabilitation treatment affected how their voices were expressed and heard. Parental emotional adjustment to the birth injury played a role in parental perceptions of what was deemed their youth's best interest in the shared decision.Conclusions: The decision-making experiences of youth with brachial plexus birth injury illustrate the complexity of paediatric preference-sensitive decisions and the significance of social and emotional factors on these shared decisions.Practice Implications: Opportunity for youth to express their voice without external pressure during shared decision making is needed to make well-informed decisions based on their own values. Interventions such as decision coaching and decision support tools may help youth and parents to formally identify and discuss these relational processes. [ABSTRACT FROM AUTHOR]

Background: Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk.Methods: We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment.Results: Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement.Conclusions: In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to identify the functional and aesthetic factors associated with an elbow flexion contracture in children with a brachial plexus birth injury who identified their elbow flexion contracture as a problem. Materials and methods: A retrospective cross-sectional study of children with brachial plexus birth injury between 7 and 18 years was conducted to compare the characteristics of children who had treatment for an elbow flexion contracture with those who did not. Results: Fifty of the 200 children included in the study had treatment (one surgical release, 49 serial casting/splinting) for the elbow flexion contracture. Children who had treatment were an average 12.4 years of age, which was significantly older than those who did not have treatment. Elbow extension passive range of motion was an average −40.6° prior to treatment. Stepwise logistical regression model indicated that children who had treatment had greater severity in elbow contracture, higher Brachial Plexus Outcome Measure Activity scores, and lower Brachial Plexus Outcome Measure Self-Evaluation Appearance scores. Conclusions: In addition to severity of contracture and function, perceived appearance of the limb is important factor to evaluate in the management of elbow flexion contractures. Priority is often given to evaluate the functional implications of elbow flexion contractures in brachial plexus birth injury to determine recommendations for rehabilitation interventions such as serial casting and splinting. Findings in this study indicate that severity of contracture, upper extremity activity function, and perceived upper extremity appearance are important factors in the management of elbow contractures. In addition to upper extremity function, routine evaluation of perceived upper extremity appearance in children and adolescents is important in the management of elbow flexion contractures. [ABSTRACT FROM AUTHOR]

PURPOSE: To conduct a systematic review of studies on non-surgical and surgical interventions for elbow flexion contractures secondary to brachial plexus birth injury (BPBI). METHODS: MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched for randomized controlled trials, observational studies, and case series studies on treatment of elbow flexion contractures secondary to BPBI. Study quality was evaluated using the Effective Public Health Practice Project tool. RESULTS: Of the 950 records found, 132 full text articles were reviewed, and 3 cohort studies and 8 case series were included. The overall methodological quality of included studies was weak. The weak quality evidence demonstrated that significant gains in elbow extension passive range of motion (ROM) can be achieved with serial casting (range: 15 to 34.5 degrees) or elbow release surgery (range: 28.4 to 30.0 degrees). At best, a reduction to an elbow contracture between - 15.0 and - 18.8 degrees (casting) and - 8.0 and - 43.6 (elbow release surgery) can be achieved. Insufficient outcomes on elbow flexion ROM and strength were found in both non-surgical and surgical studies. CONCLUSION: The quality of evidence on the effectiveness of interventions for an elbow flexion contracture secondary to BPBI is weak. In the context of insufficient evidence on the risks of pursuing such interventions, it is prudent to attempt non-surgical interventions prior to surgery. Level of Evidence: : III – systematic review of level IV studies [ABSTRACT FROM AUTHOR]

PURPOSE: To synthesize the evidence on the prevalence and etiology of elbow flexion contractures secondary to brachial plexus birth injury (BPBI). METHODS: Using Arksey and O'Malley's scoping review framework, MEDLINE, EMBASE, PsycINFO, and CINAHL databases were searched, followed by a comprehensive grey literature search. Articles and abstracts of studies of all level of evidence on the prevalence, natural history, clinical presentation, etiology, and treatment of elbow flexion contractures in BPBI were included. RESULTS: Of the 884 records found, 130 full text articles were reviewed, and 57 records were included. The median prevalence of elbow flexion contracture in BPBI was 48%. The magnitude of the contractures was between 5 and 90 degrees. Contractures > 30 degrees were found in 21% to 36% of children. With recent clinical and lab studies, there is stronger evidence that the contractures are largely due to the effects of denervation causing failure in the growth of the affected flexor muscles, while muscle imbalance, splint positioning, and postural preferences play a smaller role. CONCLUSION: The etiology of elbow flexion contractures is multifaceted. The contribution of growth impairment in the affected muscles offers greater understanding as to why maintaining passive range of motion in these contractures can be difficult. [ABSTRACT FROM AUTHOR]

Background: Peripheral nerve palsies of the upper extremities presenting at birth can be distressing for families and care providers. It is therefore important to be able to identify patients whose diagnosis is compatible with full recovery so that their families can be reassured. Methods: We conducted a retrospective review of all infants presenting with weakness of the upper extremity to our clinic between July 1995 and September 2009. We also conducted a review of the current literature. Results: During the study period, 953 infants presented to our clinic. Of these patients, 25 were identified as having isolated radial nerve palsy (i.e., a radial nerve palsy in isolation with good shoulder function and intact flexion of the elbow). Seventeen infants (68.0%) had a subcutaneous nodule representing fat necrosis in the inferior posterolateral portion of the affected arm. Full recovery occurred in all patients within a range of one week to six months, and 72.0% of the patients (18/25) had fully recovered by the time they were two months old. Interpretation: Although the outcome of obstetrical brachial plexus palsy is highly variable, isolated radial nerve palsy in the newborn carries a uniformly favourable prognosis. [ABSTRACT FROM AUTHOR]