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Team Approach: Management of

Brachial Plexus Birth Injury
Sandra Schmieg, Abstract
MS, OTRL, CHT » Brachial plexus birth injury is an upper-extremity paralysis that occurs
from a traction injury to the brachial plexus during birth. Approx-
Jie C. Nguyen, MD, MS imately 10% to 30% of children with a brachial plexus birth injury have
Meagan Pehnke, residual neurologic deficits with associated impact on upper-limb
function.
MS, OTRL, CHT, CLT
Sabrina W. Yum, MD » Management of brachial plexus birth injuries with a multidisciplinary
team allows optimization of functional recovery while avoiding unnec-
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Apurva S. Shah, MD, MBA essary intervention. Early occupational therapy should be initiated with a
focus on range of motion and motor learning.

Investigation performed at Children’s » The need for microsurgical reconstruction of the brachial plexus can
Hospital of Philadelphia, be predicted based on early physical examination findings, and recon-
Philadelphia, Pennsylvania struction 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 second-
ary procedures, including botulinum toxin injection, subscapularis and
pectoralis lengthening, shoulder capsular release, shoulder tendon
transfer, and humeral osteotomy.

B
rachial plexus birth injury
(BPBI) is an upper-extremity
paralysis that typically occurs
during vaginal childbirth due
to traction. Shoulder dystocia and macro-
somia are the most common risk factors,
but breech delivery, instrumented delivery,
and hypoxia also independently increase
the risk of injury1. The prevalence of
BPBI in the United States decreased from
1.7 to 0.9 per 1,000 live births from 1997 to
2012 in the setting of decreasing rates of
macrosomia and increasing rates of multi-
parity and cesarean section1. Variations in
the reported rate may be attributed to
geographic differences in socioeconomic
deprivation, obstetric care, and birth
weight.
BPBI is typically diagnosed after birth
when there is a lack of spontaneous upper-
extremity movement (Fig. 1). Clinical
examination can distinguish BPBI from
pseudoparalysis in the setting of a birth
fracture or neonatal radial nerve palsy.
Fractures of the clavicle and the humeral
shaft are the most common birth fractures
but they are not associated with increased
risk of BPBI2. In children with an isolated
clavicular fracture, neurologic function
improves over the first few weeks of life,
suggesting pseudoparalysis that was medi-
ated by pain rather than peripheral nerve
injury. Persistent paralysis beyond fracture-
healing may suggest concurrent BPBI.
Humeral shaft fracture typically occurs on
the contralateral side of the BPBI. Neonatal
radial nerve palsy should be suspected when
there is absent digital and wrist extension
but intact shoulder elevation and elbow
flexion. The presence of ecchymosis or fat
necrosis along the posterolateral aspect of
the brachium is pathognomonic for neo-
natal radial nerve palsy3 and is not typically
seen with BPBI.

COPYRIGHT © 2020 BY THE Disclosure: The authors indicated that no external funding was received for any aspect of this work.
JOURNAL OF BONE AND JOINT The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the
SURGERY, INCORPORATED article (http://links.lww.com/JBJSREV/A612).

JBJS REVIEWS 2020;8(7):e19.00200 · http://dx.doi.org/10.2106/JBJS.RVW.19.00200 1

 | Te a m A p p r o a c h : M a n a g e m e n t o f B r a c h i a l P l e x u s B i r t h I n j u r y
Fig. 1
Initial presentation of a newborn with a left
upper trunk brachial plexus birth injury (Erb
palsy, Narakas type I). The photograph dem-
onstrates the classic “waiter’s tip” positioning
with the shoulder in a position of adduction
and internal rotation, the elbow in extension,
and the wrist in flexion.
Physical examination is the pri-
mary assessment tool when evaluating
a newborn. With careful examination
of specific muscle groups, the physi-
cian or therapist can determine the
pattern of nerve root involvement.
The clinician also should look for
ipsilateral ptosis or miosis to detect
associated Horner syndrome. Serial
evaluation of the newborn allows
the clinical team to monitor motor
recovery and formulate a treatment
plan.
Once a diagnosis of BPBI has been
established, there are multiple scoring
systems available to track neurologic
recovery and upper limb function. The
most commonly used and validated
systems include the Active Movement
Score (AMS), the Toronto Test score,
and the modified Mallet score. The
AMS comprises 15 spontaneous move-
ments; each score is based on active
movement without gravity and against
gravity4. The Toronto Test score com-
bines 5 essential movements (elbow
flexion, elbow extension, wrist exten-
sion, digital extension, and thumb
extension) and attempts to prognosti-
cate neurologic recovery with a com-
posite score5. The modified Mallet score
2 JULY 2020
is most useful for toddlers and older
children; it measures gross functional
movements (e.g., global shoulder
abduction, global shoulder external
rotation, and other movements, in-
cluding hand to mouth, hand to neck,
hand to spine, and hand to belly)6. No
scoring system is comprehensive, and
the different systems are difficult to
compare. For example, the modified
Mallet score does not correlate well with
the AMS or the Toronto Test score
because of its emphasis on shoulder
motion7. Overall, the most important
prognostic sign is return of antigravity
elbow flexion since delayed return of
biceps function has been associated with
inferior Mallet scores8.
While the majority of infants with
BPBI have full spontaneous neurologic
recovery, 10% to 30% of children are
left with permanent weakness, contrac-
ture, and loss of function9,10. The Nar-
akas classification system stratifies
prognosis based on nerve root involve-
ment11. Narakas type-I injuries (Erb
palsy) involve the upper trunk (C5-C6)
and represent 46% of patients. Ap-
proximately 80% of children in this
group make a full recovery. Narakas
type-II injuries involve the upper and
middle trunk regions (C5-C7) and rep-
resent 30% of patients. Only 60% of
these children make a full recovery.
Narakas type-III and IV injuries occur in
20% of patients. Type-III injuries rep-
resent a global plexopathy (flail limb);
type-IV injuries are the most severe and
include a flail limb and Horner syn-
drome. The vast majority of children
with global injuries do not make a
complete recovery.
Children with limited neurologic
recovery may be candidates for primary
reconstruction of the brachial plexus
with nerve-grafting or transfers. Micro-
surgical reconstruction can dramatically
improve strength and limb function.
Developmentally, children with per-
manent plexopathy experience delayed
skeletal maturation, and the affected
limb can have smaller dimensions—
typically 95% of the girth and length of
the unaffected extremity12,13. When
neurologic recovery is incomplete, 60%
to 80% of children develop some degree
of glenohumeral deformity that may
benefit from secondary procedures,
including subscapularis or pectoralis
lengthening, shoulder capsular release,
shoulder tendon transfer, or humeral
osteotomy.
Case Report
The family was informed that informa-
tion regarding the case would be sub-
mitted for publication, and they
provided consent.
A boy was delivered vaginally at 39
weeks of gestation with a birthweight of
3.66 kg. Delivery was complicated by a
left shoulder dystocia and resulted in a
left upper trunk BPBI and a right
humeral shaft fracture, which was im-
mobilized for 4 weeks in a soft wrap. At
initial presentation, there was no deltoid
or biceps activation (Fig. 1). He dem-
onstrated antigravity elbow, wrist, and
digital extension. Full passive shoulder
range of motion was noted. The patient
was followed monthly by the multidis-
ciplinary team with serial examinations
(Tables I and II). Return of biceps and
deltoid function was evident at 4
months. Clinical examination revealed a
worsening shoulder internal rotation
contracture between 2 and 5 months of
age, with no evidence of active shoulder
external rotation. The patient was
referred for baseline shoulder ultraso-
nography at 4 months of age and repeat
imaging at 5 months, which revealed a
posterior glenohumeral dislocation
(Figs. 2-A through 2-D). The medical
team recommended botulinum toxin
type-A injection in the subscapularis,
the pectoralis major, and the teres major
(Fig. 3), along with closed reduction and
spica casting with the shoulder in
external rotation. This procedure was
completed at 5 months of age, and the
cast was removed after 1 month.
Team Approach
Surgery
A multidisciplinary brachial plexus team
may include orthopaedic surgeons,
neurosurgeons, and plastic surgeons.
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TABLE I Active Movement Scores for the Infant in the Case Report*

Patient Age
Left-Side Movement 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months† 8 Months

Shoulder flexion 0 0 2 2 3 6
Shoulder adduction 7 7 7 7 7 7
Shoulder abduction 0 0 2 2 3 5
Shoulder internal rotation 7 7 7 7 7 7
Shoulder external rotation 0 0 0 0 0 2
Elbow flexion 0 0 2 6 6 6
Elbow extension 7 7 7 7 7 7
Supination 0 0 0 0 0 0
Pronation 7 7 7 7 7 7
Wrist flexion 7 7 7 7 7 7
Wrist extension 6 6 7 7 7 7
Thumb flexion 7 7 7 7 7 7 7
Thumb extension 7 7 7 7 7 7 7
Finger flexion 7 7 7 7 7 7 7
Finger extension 7 7 7 7 7 7 7

*The Active Movement Score (AMS) is completed during all clinical examinations to provide serial tracking of motor recovery and upper-extremity
function. The infant should be positioned to allow observation of the 15 upper-extremity movements, scored first in a gravity-reduced position until full
motion is observed and then progressing to an antigravity plane of movement. Gravity-eliminated score: 0 5 no contraction, 1 5 contraction but no
motion, 2 5 ,50% motion, 3 5 $50% motion, and 4 5 full motion. Antigravity score: 5 5 ,50% motion, 6 5 $50% motion, and 7 5 full motion.
†Immediately after shoulder spica cast removal and 1 month after botulinum injection.

The initial surgeon’s responsibility is to
confirm the diagnosis of BPBI in con-
junction with a neurologist or a physia-
trist and to monitor recovery. In many
multidisciplinary programs, multiple
surgeons evaluate the patient because of
the complex clinical decision-making.
Due to the variation in severity and the
complexity of the physical examination,
consensus is important.
Because of limitations in diagnos-
tic testing, the team must rely on phys-
ical examination to understand the
prognosis. Return of partial antigravity
elbow flexion by 2 months suggests that
the patient will ultimately experience
complete spontaneous neurologic
recovery11. However, Waters demon-
strated that if antigravity biceps function
does not return by 3 months, the child
will rarely experience complete recovery
and will likely have limitations in
shoulder strength and joint contrac-
ture8. Injury to the phrenic nerve and
Horner syndrome are individually con-
sidered prognostic for poor motor
recovery and are associated with nerve
root avulsion14,15. Phrenic nerve
injury results in paralysis of the hem-
idiaphragm and is diagnosed with
ultrasonography. Shah et al. demon-
strated that findings on physical
examination in the first 3 months of
life can predict the need for micro-
surgery, which is useful prognostic
information for the family16. In their
multicenter investigation, 4 early
physical examination factors inde-
pendently predicted microsurgery,

TABLE II Passive Range of Motion Measurements for the Infant in the Case Report*

Patient Age
Measurement 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months† 8 Months

Scapulohumeral angle (deg) 160 160 150 150 140 110 150
Shoulder external rotation in adduction (deg) 90 80 75 65 30 80 90
Shoulder external rotation in abduction (deg) 110 110 110 110 80 100 100
Elbow extension (deg) 0 0 0 0 0 0 0

*Clinical assessment of joint passive range of motion allows the team to identify onset of joint contractures to provide timely medical or therapeutic
interventions, such as use of orthoses. †Immediately after shoulder spica cast removal and 1 month after botulinum injection.

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 | Te a m A p p r o a c h : M a n a g e m e n t o f B r a c h i a l P l e x u s B i r t h I n j u r y

Fig. 2
Figs. 2-A through 2-D Ultrasound assessment of glenohumeral dysplasia. The alpha angle is formed between a line that is drawn along the posterior
scapular margin and another line that is drawn tangential to the humeral head from the posterior margin of the glenoid. An alpha angle of .30° is
abnormal. Humeral head translation is quantified by measuring the percentage of the humeral head that is displaced posterior to the axis of the
scapula, which is abnormal if it measures .50%42. Transverse ultrasound images over the posterior glenohumeral joint in the clinical case report were
obtained at 4 months of age, 5 months of age, and postintervention (9 months of age). Figs. 2-A and 2-B At 4 months, there was an irregular
ossification margin of the left posterior glenoid rim (Fig. 2-A arrowheads) when compared with the normal right glenoid (Fig. 2-B curvy arrow), but
there were normal alpha angles (left, 25°; right, 23°) and a normal PHHD (percentage of the humeral head displaced posterior to the axis of the scapula)
(left, 37%; right, 31%). Fig. 2-C At 5 months of age, the left glenohumeral joint demonstrated an abnormally increased alpha angle (32°) and PHHD
(52%). Fig. 2-D Following intervention, at 9 months of age, there was improved glenohumeral alignment. The PHHD is calculated by dividing the
diameter of the humeral head that is located posterior to the scapular line (short dashes) by the diameter of the entire head (short 1 long dashes) and
multiplying by 100.

including Horner syndrome as well
lack of antigravity elbow flexion, wrist
extension, and digital and wrist flexion
(Table III).
Microsurgical reconstruction of
the brachial plexus may be recom-
mended with nerve-grafting and/or
transfers in infants who do not dem-
onstrate adequate neurologic recovery.
In most cases, surgical intervention is
contraindicated when antigravity
biceps function recovers by 3 months.
Although evidence-based indications
for reconstruction are lacking, there is
general consensus that microsurgery
is indicated at 3 months of age for
Narakas type-III and IV injuries (global
injuries with or without Horner syn-
drome). However, the indications and
timing for microsurgery for Narakas
type-I and II injuries (upper trunk or
combined upper and middle trunk
lesions) continue to be deliberated.
Many surgeons use biceps recovery to
guide decision-making. The lack of
antigravity biceps function at 6 to 9
months has been cited as an indication
for microsurgery16. In the case report
described above, antigravity biceps
function returned at 4 months, and
reconstruction of the brachial plexus
was not recommended.
On serial examination, the
described infant demonstrated pro-
gressive loss of passive shoulder external
rotation. As described by Bauer et al.,
passive shoulder external rotation of
,60° with the arm at the side can
indicate posterior dislocation of the
humeral head17. The dislocation was
confirmed with shoulder ultrasonog-
raphy. We recommended botulinum
toxin type-A injections along with
closed reduction and spica casting with
the shoulder in external rotation. As
reported by Ezaki et al., reduction of
the shoulder could be maintained in
69% (24 of 35) of infants who undergo
botulinum toxin injection and spica
casting18. Greenhill et al. reported
higher rates of treatment failure with

4 JULY 2020 · VOLUME 8, ISSUE 7 · e 19.00200


Fig. 3
The patient underwent botulinum toxin type-
A injection of the subscapularis, pectoralis
major, and teres major muscles. In this pho-
tograph, the neurologist is performing a bot-
ulinum toxin injection to the pectoralis major
via palpation that was confirmed with
electromyography.
closed reduction and botulinum toxin
injections, particularly in infants with
,15° of passive shoulder external
rotation19. If closed reduction is per-
formed, the shoulder should be posi-
tioned with the arm close to the side
(,15° of abduction) and at .60° of
external rotation. Casting is typically
discontinued after 4 weeks, and therapy
is reinitiated. While our team recom-
mended closed shoulder reduction and
botulinum toxin injection for the
patient described above, other centers
might have recommended subscapu-
laris and pectoralis lengthening and
shoulder tendon transfer given the
severe loss of passive shoulder external
rotation and the possibility of treat-
ment failure with nonoperative
management.
Despite early recognition and
treatment, many infants develop persis-
tent or progressive glenohumeral dys-
plasia. This can be characterized with
magnetic resonance imaging (MRI). For
children with shoulder internal rotation
contracture and mild-to-moderate dys-
plasia (who are generally ,4 years of
age), treatment can include open or
arthroscopic anterior capsular release
and reduction of the shoulder joint with
subscapularis and/or pectoralis major
lengthening. For children with limita-
tions in shoulder strength, transfer of the
latissimus dorsi and teres major tendons
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to the rotator cuff also can be performed. impairment. Asymmetric chest wall
Although tendon transfers reliably movement or shortness of breath may
improve shoulder strength and motion, indicate diaphragmatic paralysis result-
concurrent reduction of the shoulder ing from phrenic nerve involvement.
joint is required to permit remodeling of The differential diagnosis for arm
the glenohumeral joint. Waters and Bae weakness should include a neonatal or in
demonstrated remodeling of glenohu- utero cerebral infarct, brain malforma-
meral dysplasia in 83% (19 of 23) of tion, or a mass lesion. Since intracranial
patients with combined intra-articular lesions typically present with hypertonia
and extra-articular procedures20. For and/or spasticity, the presence of brisk
older children with severe glenohumeral reflexes in a weak upper limb would
dysplasia that includes formation of a argue against the diagnosis of BPBI.
biconcave glenoid (generally at $4 years With intracranial lesions, careful exam-
of age), shoulder tendon transfers are ination of ipsilateral lower-extremity
not typically recommended. In these function frequently shows decreased
cases, an external rotation humeral movement as well. Central nervous sys-
osteotomy can reposition the arc of tem involvement, including neonatal
shoulder rotation and improve hypoxic-ischemic encephalopathy, a
function6. cerebral infarct, or spinal cord injury,
can occur concurrently with BPBI. MRI
Neurology of the brain and cervical spinal cord
The initial responsibility of a neurologist might be needed to confirm the diag-
in the multidisciplinary team is to con- nosis, along with ongoing neurologic
firm the diagnosis of BPBI. Patients with reexamination.
BPBI have lower motor neuron signs on Supplementing the physical
examination, including muscle atrophy, examination with a nerve conduction
hypotonia, weakness, and depressed or study (NCS) and electromyography
absent reflexes. Neurologic examination (EMG) can be helpful to determine the
is the mainstay of lesion localization, lesion location and the extent and
which has important treatment and severity of the injury, and to detect signs
prognostic implications. of reinnervation. An NCS and EMG can
Sensory assessment can be chal- support preoperative decision-making
lenging in neonates, but a global and are predictors of outcome after sur-
impression can be inferred by the gical repair. For example, the presence of
infant’s facial expression to noxious sensory response in the root(s) inner-
stimulation. Chewing and biting the vating the paretic muscle group is diag-
affected hand can suggest sensory nostic of root avulsion, which typically
TABLE III Physical Examination Predictors of Microsurgery*
No. of Early Physical Rate of
Examination Factors Microsurgery
0 0%
1 22%
2 43%
3 76%
4 93%
*In patients with BPBI, early physical examination findings independently predict
microsurgical intervention. These factors can be used to provide counseling in
early infancy for families regarding injury severity and help to plan for potential
microsurgical intervention. These findings include the presence of Horner syn-
drome, lack of antigravity elbow flexion, lack of antigravity wrist extension, and
lack of antigravity digital and wrist flexion16.
5
 | Te a m A p p r o a c h : M a n a g e m e n t o f B r a c h i a l P l e x u s B i r t h I n j u r y
carries a poor prognosis. However, the
practical utility of an electrophysiologi-
cal study has been controversial because
the technical difficulty in performing a
comprehensive examination can be
considerable and distressing for the
patient. The disparity between study
findings and later prognosis is also
sources of concern. Malessy et al.
described a simplified protocol that
showed excellent predictive value21. In a
prospective study, clinical testing of
elbow flexion and extension without
performing EMG of the biceps muscle
resulted in a correct prediction rate of
80.8%. Needle EMG increased the
percentage of correct predictions by
13%, to 93.6%, at 1 month of age.
Interestingly, prediction of severe BPBI
was better at 1 month than at 1 week or 3
months of age21. Surface EMG also can
help to evaluate for cocontraction,
which is believed to occur due to aber-
rant innervation and/or synkinesis.
In the case report described above,
we recommended botulinum toxin
type-A injection of the subscapularis, the
pectoralis major, and the teres major.
Botulinum toxin type A blocks the
release of acetylcholine at the presynap-
tic neuromuscular junction, resulting in
temporary weakness. It has been shown
to be an effective adjunctive treatment
for posterior shoulder subluxation or
dislocation when injected into the
shoulder internal rotators. Typically, 2
to 3 U/kg per muscle is injected at
multiple intramuscular points, with a
maximum total dose of 10 U/kg. Botu-
linum toxin injections also have been
reported with variable effectiveness for
triceps or biceps cocontraction or pro-
nator contracture in retrospective stud-
ies22. Although botulinum toxin type A
has been approved by the U.S. Food and
Drug Administration for treatment of
spasticity, the off-label nature of its use
with BPBI should be disclosed to par-
ents, and informed consent should be
obtained. With correct technique, bot-
ulinum toxin type-A injection appears to
be safe and well tolerated. Serious side
effects, including profound weakness,
dysphagia, and death, have been re-
6 JULY 2020
ported but typically have been associated
with large doses or in the presence of
comorbidities. There are 4 different
products that currently are available on
the market, including rimabotulinum
toxin B, onabotulinum toxin A, in-
cobotulinum toxin A, and abobotuli-
num toxin A. The lack of bioequivalence
of various proprietary preparations can
cause confusion and pose a risk to
patients.
Occupational Therapy
Therapeutic goals for the infant with
BPBI focus on maintaining joint
motion, maximizing strength, promot-
ing sensory awareness, and supporting
age-appropriate development23-25. The
occupational therapist plays a role in
assessing active movement in collabora-
tion with the surgeon. The team
approach to serial examination is crit-
ical for accurate clinical information
regarding neurologic recovery during
time-sensitive surgical decision-making.
Examination of the infant is difficult,
and the occupational therapist may have
greater opportunities for interaction to
observe new motor activity, providing
key information that may not be
observed by the full team.
Maintaining passive joint motion
is the primary initial focus of therapy and
a home program. The occupational
therapist will instruct the parent on safe
and effective passive range-of-motion
(PROM) exercises to complete fre-
quently throughout the day23. Shoulder
stretches are completed both with and
without scapular stabilization to maxi-
mize glenohumeral joint motion26,27.
Caregiver comfort with completing
PROM exercises routinely is critical to
maintain joint integrity.
Orthotic intervention may be
indicated to maintain joint integrity,
prevent contracture, and promote
function. In the infant with limited
active wrist or digital extension, a resting
orthotic is indicated to support the hand
in an extended position overnight23,28.
A dorsal wrist extension orthosis may be
used during the day to support a wrist
drop and provide a position for more
functional digit motion29. Limitations
in active shoulder external rotation and
forearm supination can result in com-
pensatory movement patterns, such as
trumpeting (compensatory shoulder
abduction), and the forearm can be
supported through the use of a supinator
strap that provides a more neutral fore-
arm position29. Serial examination of
passive motion should include moni-
toring of elbow flexion contractures.
Serial elbow extension orthoses can be
effective in improving range of motion
in the motivated patient with flexion
contractures that are .30°30. A SupER
(supination-external rotation) orthosis
(University of British Columbia) may be
recommended to passively position the
shoulder in external rotation and fore-
arm supination in order to address
internal rotation contracture or poste-
rior glenohumeral dislocation. This may
be indicated when end-range tightness is
identified or following a procedure to
address glenohumeral dislocation as
described in our case report. Pilot study
results suggest that use of this type of
orthosis may have a positive impact on
balanced shoulder growth and muscle
function31.
Strategies to maximize movement
and strength in targeted muscles are used
during occupational therapy and home
programs. Eccentric contractions are
first elicited through place-and-hold
exercises in gravity-reduced planes, with
progression to antigravity concentric
contractions. Targeted concentric con-
tractions and muscle activation can be
achieved through developmental posi-
tioning17. Kinesiology taping tech-
niques can be used to target specific
muscle facilitation or inhibition23,32.
Sensory strategies are used to
address altered cortical representation
and awareness of the affected limb17.
Provision of sensory experiences
through touch, gentle massage, and
texture rubs are initiated early in care and
used throughout recovery. Positioning
of the involved hand in the infant’s visual
field during developmental activities is
recommended. Gentle joint compres-
sion and weight-bearing promote joint
· VOLUME 8, ISSUE 7 · e 19.00200

proprioception33. The use of sensory or
motor-level electrical stimulation does
require future research but it can be used
as an adjunct to therapy to improve
cortical representation and muscle acti-
vation in poorly innervated muscles34.
Sensory-level stimulation can be used
to optimize the activation of spared
nerves to enhance cortical awareness.
Motor-level stimulation may be used
when active muscle movement is
demonstrated35.
Rehabilitation after nerve recon-
struction follows the principles outlined
above. Parents’ expectations for recovery
must be managed as nerve regeneration
occurs at approximately 1 in (2.54 cm)
per month, and no change in movement
is typically expected before 6 months. As
children with BPBI enter school age and
adolescence, they may experience
changes in muscle length and strength
during periods of growth, which may
impact function17. Progression of joint
contractures, loss of active movement,
and development of pain due to com-
pensatory movement patterns may
develop. Evaluation by an orthopaedic
Fig. 4
Figs. 4-A and 4-B MRI-based detection of a
pseudomeningocele. Coronal (Fig. 4-A) and
axial (Fig. 4-B) reformatted 3D high-resolution
fluid-sensitive images of a 3-month-old girl
showed a small right pseudomeningocele
(arrowheads) and no identifiable exiting
nerves. Note the appearance of normal exiting
ventral and dorsal nerves on the normal left
side (arrows).
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surgeon to assess the need for a second-
ary shoulder intervention is indicated if
the patient is not being actively followed
by a multidisciplinary team. Children
who are not candidates for surgical
intervention may benefit from episodic
therapy to address motion, strength,
activity adaptation, and motor training
to minimize habitual compensatory
movements23.
Radiology
Differentiation between neurapraxia
or mild axonotmesis and neurotmesis
or nerve root avulsion is critically
important as the former diagnoses
have potential for spontaneous recov-
ery while the latter require early sur-
gical intervention because treatment
effectiveness declines with time. Many
experts rely on physical examination to
determine injury severity, but some
also utilize noninvasive imaging early
after birth to complement the clinical
assessment and help define injury
severity36. Although computed
tomography (CT) myelography is
widely accepted for the evaluation of
|
nerve root avulsion, its use in children
is hindered by the need for sedation
and the use of ionizing radiation.
MRI with 3-dimensional (3D) fluid-
sensitive sequences to optimize the
visualization of exiting cervicothoracic
nerve roots is becoming the preferred
alternative36,37. In a cohort of 13
patients with BPBI who later under-
went reconstructive surgery, Soma-
shekar et al. found high-resolution 3D
MRI to be 75% sensitive and 82%
specific for nerve root avulsion36.
Indirect features of nerve injury
include the presence of a pseudome-
ningocele, asymmetric periscalene soft-
tissue edema, and downstream muscle
denervation changes38. Pseudome-
ningocele is a contained cerebrospinal
fluid leak that surrounds the injured
nerve root sleeve (Figs. 4-A and 4-B). In
children who are ,18 months old, a
pseudomeningocele is highly specific
for underlying nerve injury but lacks
sensitivity36,39. Asymmetric peri-
scalene soft-tissue edema may be more
sensitive for nerve injury and may
represent a posttraumatic scar or a
7
 | Te a m A p p r o a c h : M a n a g e m e n t o f B r a c h i a l P l e x u s B i r t h I n j u r y

Fig. 5
Figs. 5-A and 5-B MRI assessment of glenohumeral dysplasia. Three-dimensional dual echo steady state (DESS) cartilage-sensitive axial images of a
20-month-old girl with right BPBI show abnormally increased glenoid retroversion (236°) and decreased PHHA (percentage of the humeral head
anterior to the scapular axis) (25%) when compared with the normal left shoulder (211° and 50%, respectively). The PHHA is calculated by dividing the
diameter of the humeral head that is located anterior to the scapular axis (short dashes) by the diameter of the entire head (short 1 long dashes) and
multiplying by 100.

reparative neuroma, but it does not
allow the identification of the exact
level of involvement40. In a retro-
spective MRI review of a cohort of 37
patients with BPBI, Wandler et al.
found periscalene soft-tissue edema in
95% of the patients and a pseudome-
ningocele in 40% of the patients41.
Muscle denervation changes include
muscle edema during the active phase
and atrophy during the late phase38.
Given the rapid neurologic recovery
of the patient in our case report,
MRI of the brachial plexus was not
recommended.
Accurate clinical characterization
of glenohumeral dysplasia in children
with BPBI can be challenging42.
Ultrasonography and MRI are becom-
ing increasingly utilized to complement
the clinical assessment, to monitor
treatment response, and to determine
optimal timing for intervention.
Ultrasonography is the preferred initial
imaging modality to screen for sus-
pected glenohumeral malalignment
(posterior subluxation or dislocation)
and glenoid dysplasia42-45. Ultraso-
nography is performed using a high-
frequency linear transducer (9 to 15
MHz) and a posterior approach. The
infant often is seated on the parent’s lap
facing away from the sonographer. On
ultrasonography, glenohumeral align-
ment is defined by the alpha angle and
humeral head translation (Figs. 2-A
through 2-D).
MRI remains the noninvasive ref-
erence standard for the comprehensive
assessment of glenohumeral alignment
and the characterization of glenoid dys-
plasia, particularly in older children in
whom ultrasonography may be less
reliable due to formation of the humeral
head ossification centers40,43 (Figs. 5-A
and 5-B). Features of unresolved BPBI
include posterior humeral head transla-
tion and glenoid retroversion, which can
appear in infants as young as 3 months
old40,46. On MRI, proton-density-
weighted sequences are preferred; they
provide the highest signal-to-noise
ratio47. Axial images are most useful for
the evaluation of glenoid morphology
and glenohumeral alignment48,49. Gle-
noid version is measured between a line
drawn along the scapular axis and
another line drawn parallel to the surface
of the glenoid. Mild physiological
glenoid retroversion decreases with
time (26.3 6 6.5 in children who are
,2 years old and 22.1 6 5.9 in children
who are $2 years old)50,51, but with
BPBI, progressive glenoid retroversion,
hypoplasia, and dysplasia remodeling of
the posterior glenoid can be observed52.
Humeral head coverage is quantified by
measuring the percentage of the humeral
head that is anterior to the axis of the
scapula, which is normal when it is
between 40% and 55% and abnormal if
it measures ,35%52,53. These mea-
surements can be used to classify the
severity of glenohumeral dysplasia using
the criteria described by Waters et al.53.
Overview
Optimal management of a patient with
BPBI involves a multidisciplinary
approach and can include evaluation
and treatment by orthopaedic sur-
gery, plastic surgery, neurosurgery,
neurology, physiatry, occupational/
physical therapy, and radiology person-
nel. Our patient received coordinated
care from all disciplines through serial
examinations, medical interventions,
and therapeutic interventions. Because
of shoulder internal rotation contracture
and progressive posterior humeral head
dislocation that was demonstrated on
ultrasonography between 4 and 5
months of age, our patient was sched-
uled for botulinum toxin injection of the
pectoralis major, subscapularis, and teres
major muscles with concurrent closed

8 JULY 2020 · VOLUME 8, ISSUE 7 · e 19.00200


shoulder reduction and shoulder spica
cast application. The cast was removed
1 month later, and the patient wore a
SupER orthosis at night and during nap
time, with weekly therapy to maximize
the strength of the posterior shoulder
and scapular muscles. Repeat ultraso-
nography at 3 months after cast removal
revealed improved glenohumeral align-
ment. Substantially improved passive
and partial recovery of active shoulder
external rotation also were noted. The
patient will be followed by the multi-
disciplinary team periodically through-
out childhood to monitor his progress.
MRI of the shoulder may be indicated in
the future to better characterize residual
glenohumeral dysplasia and determine
the potential need for secondary shoul-
der surgery. The need for subscapularis
or pectoralis major tendon lengthening,
capsular release, or shoulder tendon
transfer remains a distinct possibility in
this case scenario, particularly given the
lack of antigravity shoulder external
rotation.
Sandra Schmieg, MS, OTRL, CHT1,
Jie C. Nguyen, MD, MS1,
Meagan Pehnke, MS, OTRL, CHT, CLT1,
Sabrina W. Yum, MD1,
Apurva S. Shah, MD, MBA1
1Children’s
Hospital of Philadelphia,
Philadelphia, Pennsylvania
Email address for A.S. Shah:
shaha6@email.chop.edu
ORCID iD for S. Schmieg:
0000-0001-8744-8788
ORCID iD for J.C. Nguyen:
0000-0002-6257-6860
ORCID iD for M. Pehnke:
0000-0001-7863-0991
ORCID iD for S.W. Yum:
0000-0002-5243-5546
ORCID iD for A.S. Shah:
0000-0002-9597-5665
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