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Purpose: The prevalence of neonatal brachial plexus palsy (NBPP) has been increasing since the early 1980s. No known studies have examined long-term psychological health and quality of life (QOL) in young adults. The purpose of this study was to investigate the psychosocial and intellectual aspects of NBPP during adolescence into young adulthood., Methods: A total of 31 patients were enrolled in the adolescent group (16 to 18 y) and 25 in the young adult group (23 to 28 y). Clinical assessment included functional ability, range of motion and strength, weight and body mass index, and education level. Patients were administered measures of psychiatric symptomatology, self-concept, QOL, and cognitive function., Results: Narakas injury level for the adolescent group included 11 level I, 6 level II, 8 level III, and 6 level IV. The young adult group had 10 level I, 2 level II, 9 level III, and 4 level IV. The degree of physical impairment determined by the Modified Mallet Classification showed persistent impairment in both groups. The average DASH scores were higher than the normal range for the adolescent and young adult groups. Forty-five percent of the adolescents and 68% of the young adults were either overweight or obese. All received high school diplomas with 20 of the young adults pursuing higher education.Scores on measures of psychiatric symptomatology and self-concept showed that both groups fell within the normal range. QOL for both groups was also within the normal range. All participants scored average to above average on the cognitive assessment. All measurements were patient reported., Conclusions: Patients with NBPP can adapt and participate in most activities. This patient sample demonstrated persistent functional limitations and a higher rate of comorbid obesity. However, these patients function psychologically and cognitively within the normal range and many have pursued higher education., Level of Evidence: Level IV.

Fetal macrosomia is associated with a 14-fold increased risk of brachial plexus birth palsy (BPBP), and is a predictor of childhood obesity. The purpose of this study was to identify the relationships between BPBP, fetal macrosomia, and childhood obesity. We retrospectively reviewed 214 children with BPBP. The average age was 8 years and 53% had a Narakas 1 grade BPBP. Overall, 49% of children were normal weight, 22% overweight, and 29% obese. Of the children with a history of fetal macrosomia, 41% were obese; a statistically significant difference. Overall quality of life scores, however, were not correlated with obesity.

Objective: To report the incidence of neonatal brachial plexus palsy with and without ipsilateral clavicle fracture in a population of newborns and to compare the prognosis between these subgroups., Methods: This was a retrospective review of 3,739 clavicle fractures and 1,291 brachial plexus palsies in neonates over a 24-year period from a geographically defined health care system with reference to county-wide population data., Results: A referral clinic for children with brachial plexus palsies evaluated 1,383 neonates, of whom 320 also had ipsilateral clavicular fracture. As a result of referral patterns within the region, it is likely that this represents nearly all infants from the area with persistent brachial plexus injury after 2 months of age. Among the children evaluated without concomitant clavicular fracture, 72% resolved spontaneously (154/214); among those with concomitant clavicular fracture, 74% healed spontaneously (55/74). Limiting the analysis to neonates delivered at Parkland Memorial Hospital and assuming that those neonates with a discharge diagnosis of brachial plexus injury with or without clavicular fracture who did not present to the referral brachial plexus injury clinic had complete resolution, 94.4% without clavicular fracture resolved and 98.1% with clavicular fracture resolved (P=.005)., Conclusions: The risk of persistent neurologic deficit from a birth-related brachial plexus palsy is lower than what has been reported, and the presence of a clavicle fracture may improve the likelihood of recovery., Level of Evidence: III.

Background: Botulinum toxin A is used to treat contractures in children with spasticity by temporarily interfering with neural transmission at the motor end plate. In infants with brachial plexus palsy, posterior shoulder subluxation and dislocation are the result of muscle imbalance, in which neurologic recovery is evolving, and spasticity is not a deforming force. We postulated that temporary weakening of the shoulder internal rotator muscles with botulinum toxin A would facilitate reduction of the glenohumeral joint in such infants with early posterior shoulder subluxation or dislocation., Methods: Thirty-five infants with posterior subluxation or dislocation of the shoulder due to brachial plexus palsy were treated with botulinum toxin A between January 1999 and December 2006, and were followed for a minimum period of one year. Records were reviewed for the severity of the palsy, age at time of treatment, recurrence of subluxation or dislocation, and the subsequent need for further treatment to reduce the glenohumeral joint., Results: The average age at the time of shoulder reduction and botulinum toxin-A injection was 5.7 months. Six patients had a second injection. Reduction of the shoulder was maintained in twenty-four (69%) of the thirty-five patients. There were no complications related to the use of botulinum toxin A., Conclusions: Although there may be specific risks associated with its use, botulinum toxin-A injection into the internal rotator muscles is a useful adjunct to the treatment of early posterior subluxation or dislocation of the shoulder in infants with neonatal brachial plexus palsy, and may help to avoid the need for open surgical procedures to restore or maintain shoulder reduction.

Background: Ultrasonographic evaluation of the hip in infants is considered both reliable and reproducible in the diagnosis of developmental dysplasia of the hip. Ultrasonographic evaluation of the shoulder in infants has been reported as a valuable diagnostic aid in dysplastic development following neonatal brachial plexus palsy. To our knowledge, there has been no study of the intraobserver reproducibility and interobserver reliability of sonography of the shoulder in infants with and without suspected posterior shoulder dislocation., Methods: Two identical but randomly ordered sets of the same deidentified sonographic images of shoulders in infants were given to radiologists, pediatric orthopaedists and orthopaedic residents, and fellows with varying degrees of experience in the evaluation of shoulder pathology in infants, who measured the position of the humeral head relative to the axis of the scapula. Intraobserver reproducibility and interobserver reliability of the measurements were assessed., Results: For the position of the humeral head with respect to the glenoid in both normal and abnormal conditions, the Pearson correlation coefficient for intraobserver reproducibility was 0.91 and the intraclass correlation coefficient for interobserver reliability was 0.875. For estimating the percentage of the humeral head posterior to the axis of the scapula, the Pearson correlation was 0.85 and the intraclass correlation coefficient was 0.77., Conclusions: Ultrasonographic examination of the shoulder in infants to assess for the position of the humeral head with respect to the scapula showed high intraobserver reproducibility and interobserver reliability. It is recommended as a reliable technique for evaluating shoulder position in infants with neonatal brachial plexus palsy.

Background: An important prognostic factor in neonatal brachial plexus palsy is the time interval to biceps muscle recovery. Although the natural history is not clear, biceps muscle recovery after more than three months of age has been used to predict poor long-term shoulder function. The absence of biceps muscle function at three months of age has been adopted as an indication for early brachial plexus microsurgery, in an attempt to improve recovery. To provide a benchmark for outcome comparison, the long-term outcome of patients with absent biceps muscle function at three months of age was studied., Methods: Between 1980 and 1992, 170 patients with neonatal brachial plexus palsy were entered into a prospective study in which details of the birth and serial clinical examinations were recorded. Patients were grouped according to the level of injury and the time interval to biceps muscle recovery. Twenty-nine patients were observed to have absent biceps muscle function at three months of age. Twenty-eight of those patients were available for long-term followup at a mean age of eleven years and one month. At the time of follow-up, patients answered a questionnaire and underwent manual muscle strength testing, sensory evaluation, and grading of their shoulder function according to Gilbert's modification of the Mallet score, in which the function was graded as II, III, or IV with class I (no function) and V (normal) eliminated. The level of injury and the time that biceps muscle function returned were compared with the final outcomes., Results: The level of injury was C5-C6 in thirteen (46%) of our twenty-eight patients with absent biceps muscle function at three months of age, C5-C7 in five (18%), and pan-plexus (C5-T1) in ten (36%). Biceps contraction was observed by six months of age in twenty patients (71%), including all thirteen patients with a C5-C6 level of injury. Twenty-two patients did not have surgery on the brachial plexus, but nine of those patients had subsequent orthopaedic procedures. At the time of follow-up, twenty-seven of the twenty-eight patients had at least antigravity biceps muscle function. Patients who regained biceps muscle function between three and six months of age had better scores for abduction (p = 0.04) and for hand-to-neck (p = 0.05) and hand-to-back (p < 0.001) function than did patients who regained biceps muscle function after six months of age. Patients with a C5-C6 lesion had better scores for external rotation (p = 0.04) and for hand-to-neck (p = 0.05), hand-to-mouth (p < 0.01), and hand-to-back (p < 0.001) function than did patients with a pan-plexus lesion. Twelve (55%) of the twenty-two patients who did not have brachial plexus surgery had a class-IV shoulder (good function) according to the modified Mallet score. Of the twelve patients with a C5-C6 level of injury who did not have brachial plexus surgery, eight had a class-IV shoulder., Conclusions: This study indicated associations between prolonged neurological recovery and a more extensive level of injury and worse long-term shoulder function. Patients with a C5-C6 injury and absent biceps muscle function at three months of age often have good long-term shoulder function without brachial plexus surgery.

Background: Glenoid dysplasia and posterior shoulder subluxation with resultant shoulder stiffness is a well-recognized complication in infants with neonatal brachial plexus palsy. It is generally considered to be the result of a slowly progressive glenohumeral deformation secondary to muscle imbalance, physeal trauma, or both. Recent publications about infantile posterior shoulder dislocation have suggested that the onset of dysplasia occurs at an earlier age than has been previously recognized. The prevalence of early dislocation in infants with this disorder has not been previously reported, to our knowledge., Methods: We studied 134 consecutive infants with neonatal brachial plexus palsy who were seen at our institution over a period of two years. All infants were examined at monthly intervals to assess neurological recovery and the status of the upper extremity until recovery occurred or a treatment plan was established. The type of brachial plexus involvement was classified. Specific clinical signs associated with subluxation and dislocation were recorded. These included asymmetry of skin folds of the axilla or the proximal aspect of the arm, apparent shortening of the humeral segment, a palpable asymmetric fullness in the posterior region of the shoulder, or a palpable click during shoulder manipulation. The infants who were identified as having these clinical signs were evaluated with ultrasonographic imaging studies., Results: Eleven (8%) of the 134 infants had a posterior shoulder dislocation. The mean age at the time of diagnosis was six months (range, three to ten months). There was no correlation between the occurrence of dislocation and the type of initial neurological deficit. A rapid loss of passive external rotation between monthly examinations indicated a posterior shoulder dislocation., Conclusions: Posterior shoulder dislocation can occur earlier (before the age of one year) and more rapidly in infants with neonatal brachial plexus palsy than has been appreciated previously. As with developmental dysplasia of the hip, a high index of suspicion, recognition of clinical signs, and the use of ultrasonography will allow the diagnosis to be established. Following early diagnosis, attention should be focused on improving the stability and congruency of the shoulder joint.