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. 2023 Jul 14;37(2):108–116. doi: 10.1055/s-0043-1768940

Permanent Brachial Plexus Birth Injury: Helsinki Shoulder Protocol

Petra Grahn 1,✉, Tiina Pöyhiä 2, Yrjänä Nietosvaara 1,3
PMCID: PMC10371410  PMID: 37503533

Abstract

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°.

Keywords: brachial plexus birth injury, infraspinatus, neurotization, botox, shoulder contracture, shoulder, subluxation, ultrasound, screening, glenohumeral joint, dysplasia, external rotation

The first surgical repair of brachial plexus birth injury (BPBI) in Finland was done in 1971. 1 Since then, the treatment of patients with BPBI has been refined through continuous research and development. A multidisciplinary treatment protocol for BPBI was developed in Helsinki Children's Hospital between 2000 and 2009, and it has recently been accepted as a national treatment guideline.

Neurologic recovery has been classified to complete or incomplete. Incomplete recovery is defined as permanent loss of strength in any muscle innervated by the brachial plexus. Most children that have sustained a temporary BPBI experience complete recovery by 3 months of age. 2 3 4 We define BPBI as permanent, if it has not resolved completely during the first year of life. Over the years, the term “permanent” has been interpreted in different ways, which explains partially the relatively large variation in the reported recovery rates between 66 and 92%. 2 5 The reported incidence for BPBI varies between 0.4 and 3.8 per 1,000 live births, 4 6 7 8 9 10 and incidence for permanent injury 0.1 to 1.6, respectively. 3 4 10 11 Some recent studies show a decreasing trend in the incidence of BPBI, which can, at least partly, be attributed to the increased rate of cesarean deliveries and improved training of midwives for shoulder dystocia emergencies. 6 7 12 The mean calculated risk for permanent BPBI in Helsinki is 0.1 per 1,000 vaginal live births. 12 Shoulder dystocia is the biggest risk factor for BPBI, followed by instrumented vaginal delivery, macrosomia, and maternal diabetes. 7 8 9 10 11 12 13 14 Ethnicity has also been reported as an important risk factor, as black, Asian, and Hispanic infants seem to be more likely to sustain a BPBI in comparison to Caucasians. 7 14 About half of BPBI occur without any of the abovementioned risk factors. 8 13

Most authors classify BPBI into upper-, complete plexus involvement, and flail upper limb-type injuries as described by Narakas in 1987. 15 Upper plexus injuries comprise up to 80% of BPBI involving C5 and C6 roots, with or without C7 root involvement. Children with upper plexus injuries have a functioning hand. In complete plexus involvement, all cervical roots, with or without T1, are injured often involving C7 and/or C8 avulsions. In children with complete plexus involvement also hand function is compromised and at worst the affected upper limb can be completely flail with no motor function and no sensation. Clark and Curtis developed the Active Movement Scale (AMS) as a diagnostic and prognostic tool 16 for BPBI patients. The 3-month Toronto Test Score (3MTS), 17 which is a subset of the AMS, classifies children with BPBI as those who can benefit from early reconstructive surgery and those who might not. A score under 3.5 at 3 months of age strongly suggests that plexus reconstruction is indicated.

Magnetic resonance imaging (MRI) is a noninvasive imaging modality that has replaced the need for cervical computer tomography with intrathecal contrast medium. Heavily T2- weighted sequences (CISS 3D, True FISP 3D, balanced fast field echo [BFFE], FIESTA) provide high-quality images, which reveal pseudomeningoceles (PMCs) as well as individual ventral and dorsal roots. Cerebrospinal fluid acts as a natural contrast agent around nerve roots and allows the detection of root avulsions ( Fig. 1 ). 18 19 In addition, MRI allows for evaluation of both bone and cartilage structures revealing glenoid retroversion and possible subluxation of the humeral head. 20

Fig. 1.

Fig. 1

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Magnetic resonance imaging (MRI) images showing injury to the brachial plexus. ( A ) Left image: coronal high-resolution balanced fast field echo (BFFE) image from a 3-month-old girl with left-sided brachial plexus birth injury (BPBI). Normal nerve roots C7-Th1 are seen on the right side (arrows), while there are pseudomeningoceles on the left side (asterisk). Right image: Axial high-resolution BFFE image. Normal ventral and dorsal C8 roots are seen on the right side (arrows), while on the left side there is a pseudomeningocele with absent C8 roots (asterisk). ( B ) MRI image of a 4-month-old boy with BPBI on the left side. Neuroma (white arrows) is located between scalenus anterior and scalenus media muscles on the left affected side. ( C ) Left image: Axial T1-weighted image of the right normal glenohumeral joint. Right image: Affected left shoulder of a 4-year-old boy with BPBI on the left side. Severe retroversion of the left posterior glenoid fossa (pseudoglenoid) with an abnormal glenopolar angle (GSA), PHHA (percentage of humeral head anterior to the middle of the glenoid fossa) 7%. On the normal side GSA is –3 and PHHA is 47%.

Neonates that have sustained a permanent BPBI injury are prone to develop muscle contractures due to disruption of neural connections to the muscle. 21 22 Absent or poor motor function in combination with muscle contractures leads to limited passive range of motion (ROM) mainly affecting the shoulder and elbow. Structural changes of the glenohumeral joint appear at 1 to 12 months of age in up to half of children suffering from a permanent BPBI. 1 4 23 24 Children with permanent BPBI thus have a high risk of posterior shoulder subluxation during their first year of life, which untreated may lead to a permanently deformed glenohumeral joint and arthrosis later in life. 25 Ultrasound (US) has been shown to be a good investigation method of shoulder instability and can be used to detect posterior subluxation of the humeral head already from an early age in patients with BPBI ( Fig. 2 ). 4 26 US can also be used for detection of neuromas, which can be seen in rupture-type root injuries. 4

Fig. 2.

Fig. 2

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Measurement of α-angle using ultrasound (US). Congruency of the glenohumeral joint is assessed during the dynamic phase of the study where the shoulder is scanned throughout full range of internal and external rotation in adduction with elbow flexed at 90 degrees. Normal position is defined as an α-angle ≤ 30°. Shoulder subluxation is defined as α-angle > 30° which if reducible, returns to a value corresponding the uninjured side in full external rotation. ( A ) US image of the normal left glenohumeral joint of a 1-month-old boy. Left image: without tracing. Middle image: with tracing. Right image: α-angle is within normal limits (20°). Ossified nucleus of humeral head is located ventral to posterior scapular line. OC, ossification center of humeral head; CG, cartilaginous glenoid. ( B ) US image of a 3-month-old girl with permanent brachial plexus birth injury on the right side. Normal finding on the left unaffected side and posterior subluxation of the right humeral head, α-angle is 40°.

HUS New Children's Hospital, Helsinki, Finland

HUS New Children's Hospital is a tertiary treatment center for patients with BPBI serving a population of approximately 2.2 million people in Southern Finland. A pediatrician examines all newborn in our catchment area at 0 to 2 days of age and all neonates with a flail upper extremity are referred to our BPBI clinic at discharge from the maternity hospital. Parents of children with impaired, but not flail, upper limb functions receive instructions for passive ROM exercises by a physiotherapist at the maternity hospital. The child is reassessed by a physiotherapist at 2 and 4 weeks of age. Children with incomplete neurologic recovery at 4 weeks are referred to our outpatient clinic to be examined by our multidisciplinary BPBI team (hand surgeon with minimum level 4 expertise, 27 occupational therapist, physiotherapist, and registered nurse).

Extent of the injury is graded to either upper plexus injury affecting the shoulder and elbow (and in some patients also wrist function), to complete plexus injury affecting the shoulder, elbow, wrist, and hand function, or to flail upper extremity with no movement in the affected limb at all. Patients presenting with a flail limb or 3MTS below 3.5 are scheduled for a cervical MRI under anesthesia. Plexus reconstruction is recommended to patients with avulsion(s) detected on MRI or with a 3MTS < 3.5. 17 We have discontinued the use of electromyography due to poor prognostic value. 28 We use a supraclavicular transverse approach generally without osteotomy of the clavicle. Root injuries are most often repaired with 20 to 30 mm sural grafts after resection of the neuroma.

We define BPBI as permanent, if the child has any clinically evident limited active, or passive ROM or decreased strength of the affected limb at 1 year of age. Our multidisciplinary BPBI team assesses all children with permanent BPBI on a regular basis at set time intervals from 1 month of age (at 3, 6, 9, and 12 months, and 2, 4, 7, 10, 14, 16, and 18 years). We use a goniometer to register patients' active and passive ROM of both shoulders, elbows, wrists, and fingers at each appointment. Limb length (cm) is recorded bilaterally by measuring the distance from acromion to medial epicondyle, medial epicondyle to dorsal wrist joint, and wrist joint to the tip of the middle finger. Grip and pinch strength in kilograms are measured using a dynamometer, sensation with monofilaments in children older than 6. Possible pain or hypersensitivity is registered.

Since 2010 all children with permanent BPBI have been screened for shoulder dysplasia using dynamic shoulder US until they reach 1 year of age. Botulinum toxin-A (BTX) treatment of shoulder internal rotators is recommended if shoulder dysplasia is evident (alpha-angle > 30°) or if passive external rotation (ER) of the shoulder is < 70 degrees. Secondary surgery (neurotization, shoulder relocation, tendon transfer, rotation osteotomy) is considered throughout follow-up and recommended if evaluated as beneficial ( Fig. 3 ). We have treated 270 patients with permanent BPBI since 1995 ( Table 1 ).

Fig. 3.

Fig. 3

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Helsinki treatment algorithm for brachial plexus birth injury. 3MTS, 3 months test score; MRI, magnetic resonance image; ER, external rotation; SAN, spinal accessory nerve; SSNI, infraspinatus branch of suprascapular nerve; LT, lower trapezius muscle; IS, infraspinatus muscle.

Table 1. Birth data of patients.

Sex Birth weight Injured side Type of delivery
142 girls
128 boys		 4.2 kg (range 2.7–5.6, SD 0.6) 148 right
119 left
3 bilateral		 255 normal
13 breech
2 C-section
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Abbreviations: C-section, cesarean section; SD, standard deviation.

Note: Birth data of all 270 patients treated at HUS New Children's Hospital between 1995 and 2021. All except three children (gestational age 36 + 4, 29 + 3, and 28 + 6) were born full-term.

Root Avulsion Diagnosis with Cervical MRI

Our MRI protocol is based on the results of our cervical MRI study of 34 consecutive children, who were considered as candidates for plexus reconstruction between 2007 and 2015. 19 Findings on MRI and in surgery were compared to calculated sensitivity and specificity. Findings were also evaluated with regards to clinical outcome at a mean follow-up of 5 years (range 2–9 years). The MRI studies were done under general anesthesia and were analyzed by a pediatric radiologist with more than 5 years of experience in cervical MRI. Type and number of root injuries (total avulsion, partial avulsion, thinned roots, no avulsion), as well as location of PMCs were registered. Total root avulsion was defined as both anterior and posterior roots avulsed from the spinal cord. Partial avulsion was defined as either anterior or posterior root avulsed from the spinal cord. Thinned roots visualized on MRI were interpreted as partial rupture of either anterior or posterior rootlets. 18

Sensitivity and specificity for total avulsions and PMC on MRI were calculated in relation to the intraoperative findings. Sensitivity and specificity of MRI in detecting total root avulsions were 0.88 and 1, respectively. We concluded that root avulsion(s) on MRI and flail upper extremity at birth are both good indicators for nerve surgery in BPBI. When looking at the patient outcome (active antigravity shoulder, elbow, wrist, and finger ROM ratio of injured vs. uninjured), partial root avulsion alone or in combination with thinned rootlets had no clinical significance. Our study also confirmed previous publications with regards to evaluation of neuroma on MRI as well as changes in glenoscapular angle. 18 25

High-Resolution MRI Protocol (3T Philips Medical Systems, Ingenia 5.7)

After running the localizer sequences, T1-weighted spin-echo images in the sagittal plane are obtained followed by T2-weighted spin-echo images in the axial, sagittal, and coronal planes. Slice thickness for coronal T2 is 2 mm and for all others 3 mm. MR myelography is performed using a BFFE sequence in the coronal and axial planes with 0.5 mm reconstructed slice thickness. The T2-weighted axial sequences cover both shoulders ( Fig. 1 ).

Helsinki Shoulder Protocol for Detection and Treatment of Shoulder Dysplasia

We had no standardized prevention or treatment algorithm for shoulder sequelae in BPBI patients before the year 2000 when the development of our current protocol started. The current version of our shoulder protocol has been in regular use since 2010 and is since 2022 the national guideline for treatment of BPBI in Finland. Great emphasis is put on early passive ROM exercises that are commenced already at the maternity hospital. Physiotherapists specialized in BPBI assess all children with diagnosed or suspected BPBI before discharge from birth hospital and make a reassessment at 2 weeks of age. The injured upper limb is not immobilized unless the child has a concomitant unstable clavicle or humerus fracture. Parents are instructed to perform passive ROM exercises of all joints with diminished active ROM. Special emphasis is given to passive shoulder ER exercises in adduction, which should be performed simultaneously on both the affected and healthy side ( Fig. 4 ). Also, shoulder abduction, ER, and internal rotation in abduction, elbow extension, and forearm rotation exercises are important. Children who have not gained full active and passive ROM by 1 month of age are referred to our BPBI clinic. Dynamic US shoulder screening is scheduled at 3, 6, and 12 months for all patients with incomplete recovery ( Fig. 5 ).

Fig. 4.

Fig. 4

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Range of motion (ROM) exercises are taught to the parents in the maternity hospital by a physiotherapist. Parents are instructed to work both arms throughout full ROM many times daily; external rotation in adduction ( A ), external rotation and internal rotation in 90-degree abduction ( B , C ), and shoulder abduction ( D ).

Fig. 5.

Fig. 5

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Helsinki ultrasound shoulder screening protocol for brachial plexus birth injury. US, ultrasound; ER, external rotation; IS, infraspinatus muscle; IU, international units; BTX, botulinum toxin A.

A dynamic US technique to detect posterior shoulder subluxation in BPBI was first reported in 1998 29 and has thus been proven a reliable method in detecting shoulder dysplasia and incongruency in children with BPBI ( Fig. 2 ). 4 23 26 30 The benefit of the US in comparison to MRI is that it requires no sedation, and a dynamic evaluation of the shoulder joint can be performed. In a dynamic US scan of the shoulders, the patient's arm is kept in adduction with the elbow in 90-degree flexion. The arm is then rotated in this adducted position to full external and internal rotation, while the radiologist evaluates a possible change in the humeral head position. Normal position is defined as an α-angle ≤ 30°. 26 If the humeral head is in an abnormal position in neutral or internal rotation (α-angle > 30°) but corresponds to the healthy side in ER (α-angle ≤ 30°) in a full-term, healthy, normally developing child we inject 100 international units of BTX equally divided between the subscapular, pectoralis major, teres major, and latissimus dorsi complex muscles, and apply a shoulder spica brace for 6 weeks ( Fig. 6 ). If the shoulder is congruent on US, but the child has < 70 degrees of passive ER in adduction we recommend the forementioned BTX treatment with bracing. After removal of the brace parents continue passive ROM exercises of all missing active movements of the affected upper extremity. Shoulder position is verified by US 8 weeks from BTX.

Fig. 6.

Fig. 6

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Thoracobrachial external rotation brace is applied after injection of 100 IU of botulin toxin-A (BTX). BTX is equally divided to subscapular, pectoralis major, and teres major/latissimus dorsi muscles in children less than 1 year old with limited passive external rotation in adduction (≤ 70 degrees) or with posterior shoulder subluxation verified by ultrasound. The brace is worn continuously for 6 weeks. After brace removal range of motion exercises are continued. Shoulder congruency is confirmed by ultrasound 2 weeks later.

We perform open relocation of the glenohumeral joint, subscapular tendon lengthening, and recession of the coracoid process in children with irreducible posterior shoulder subluxation or dislocation. 25 31 32 We recommend neurotization of the suprascapular nerve branch to the infraspinatus muscle (SSNI) with the spinal accessory nerve (SAN) in children with congruent shoulders and active abduction ≥ 90 degrees, but no active ER in adduction by 1.5 years of age ( Fig. 3 ). As we do not know the upper age limit for SAN to SSNI we consider the lower trapezius transfer as an option in older children. 31

Surgical Technique: SAN pro SSNI

A transverse skin incision is made at the scapular spine. The trapezius muscle detached from the scapular spine. SAN is identified just medial to scapula and dissected free both distally and proximally, preserving as many proximal branches to the upper trapezius as possible. An interval between the infraspinatus and the periost of the scapular spine is created. SSNI is identified at the glenoid notch, where it lies next to the suprascapular artery. SSNI is tested with a nerve stimulator (neurotization is continued even without a visible contraction of infraspinatus muscle). SSNI is transected at the glenoid notch, SAN as distally as necessary to perform a direct neurorrhaphy with two 10-0 nonabsorbable sutures and fibrin glue. Shoulder is worked through its full ROM to ensure that the anastomosis will hold before the glue is applied. Trapezius fascia is sutured back to the scapular spine avoiding compression on the transferred SAN. Skin is closed with absorbable sutures. Postoperative immobilization is not needed ( Fig. 7 , surgical video link).

Fig. 7.

Fig. 7

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Schematic drawing of spinal accessory nerve transfer to the infraspinatus branch of the suprascapular nerve. Coaptation is done with fibrin glue. Strength of the anastomosis is checked by working the shoulder through full range of motion before wound closure. The shoulder is immobilized by collar and cuff for 1 week.

Our Experience with Helsinki Shoulder Protocol

We recently compared the functional outcome in 54 children with permanent BPBI treated with our current protocol to 154 patients treated before our protocol was developed at mean 5 years of age (range 4 to 6 years, standard deviation [SD] 1). 24 Active and passive shoulder ER in adduction and modified Mallet scores were significantly better in children born 2010 or later compared to children born before 2009 ( p  < 0.05) ( Table 2 ).

Table 2. Five-year follow-up results of Helsinki shoulder protocol.

Birth year
1995–2009 (SD)		 Birth year
2010–2015 (SD)		 p -Value
Age 5.4 (0.6) 5.5 (0.7) 0.4
Passive ER in adduction 49.5 (30.6) 72.6 (19.5) < 0.001
Active ER in adduction 13.0 (32.7) 46.9 (27.0) < 0.001
Active abduction 134.2 (40.7) 135.9 (39.7) 0.8
Mallet ER 3.1 (0.8) 3.8 (0.6) < 0.001
Mallet IR 3.2 (1.1) 3.2 (1.1) 0.9
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Abbreviations: ER, external rotation; IR, internal rotation; SD, standard deviation.

Note: Patients were evaluated at mean 5.4 years (SD 0.7, range 4.4–6.4). All children born after 2009 have gone through our shoulder protocol. Range of motion is expressed in degrees.

During the study period 75 children were given BTX injections (17 children had more than one BTX injection) with no adverse effects. 24 No association of the child's birth weight or the extent of BPBI with posterior shoulder subluxation ( p  = 0.83) was observed, whereas a 3MTS of 3.3 to 7.4 correlated positively with posterior shoulder subluxation during the first year of life ( p  = 0.004). The rate of shoulder relocation declined significantly from 28% (15/54) in children born before year 2000 to 7% (5/76) in children born after 2009.

Our specific SAN pro SSNI neurotization has proven safe and effective at mean follow-up of 4 years (range 2–5 years, SD 1). 33 Active ER in adduction improved by mean 57 degrees (range 40–95 degrees, SD 20) in 12/14 of our patients, active ER in abduction by mean 56 degrees (range 30–85, SD 20) and active abduction by mean 27 degrees (range 10–60, SD 13) in all 14 patients. We have continued to use SAN pro SSNI neurotization successfully to restore active shoulder in an additional 17 patients. The downside of our technique is that lower trapezius tendon transfer cannot be performed if the neurotization would fail. Our only two failures occurred in children that had only 30 degrees passive shoulder ER in adduction at the time of surgery, and whose internal shoulder contracture progressed after the neurotization.

Treatment Proposal for Prevention and Management of Shoulder Sequalae in Patients with Permanent BPBI

In line with our findings, we propose that a physiotherapist teaches the parents of all newborns with BPBI individualized instructions to perform daily passive ROM exercises. Special emphasis should be put on shoulder, especially on passive ER exercises in adduction ( Fig. 4 ). All children without complete neurologic recovery during the first 3 months should undergo regular dynamic US screening at 3, 6, and 12 months of age ( Fig. 5 ). Plexus reconstruction is indicated in children with root avulsion(s), flail upper extremity, or a 3MTS below 3.5. BTX injections to all internal rotators and a 6-week spica bracing is recommended to children that develop internal rotation contracture (passive shoulder ER in adduction < 70 degrees), or to children that have posterior shoulder subluxation detected clinically or with US. Open shoulder relocation is indicated in children with posterior shoulder subluxation/dislocation, that does not reduce in internal shoulder rotation ( Fig. 3 ). Rotation osteotomy of the humerus is an option in older children. SAN pro SSNI transfer is our method of choice to restore active shoulder ER rotation in adduction in children with congruent glenohumeral joints between 2 and 6 years of age. Lower trapezius transfer is an option in older children. Passive ROM exercises of all affected joints, as well as regular follow-up should be continued throughout growth in children that have sustained a permanent BPBI.

Summary

In our population-based study shoulder incongruence and dysplasia developed in nearly half of the children, who had sustained a permanent BPBI. 24 The risk of posterior shoulder subluxation in children with permanent BPBI is especially high (30–50%) during the first year of life. 1 4 23 24 Posterior shoulder subluxation leads to permanent glenohumeral deformity and limited shoulder ROM, if left untreated. 23 34 35 Therefore, regular US shoulder screening is recommended to children with permanent BPBI for early detection and treatment of posterior shoulder subluxation. 24 Maintenance of good passive shoulder ROM, plexus reconstruction in select patients, treatment of posterior subluxation with BTX injections and bracing, timely open shoulder relocation, and restoration of active ER with neurotization or tendon transfers appear to keep shoulders of children that have sustained a permanent BPBI in place with improved function. 24 32 36 37 38

The main goal of BTX treatment is to maintain or restore congruence of the shoulder joint and ease passive shoulder ROM exercises until spontaneous recovery or surgical restoration of infraspinatus function. There is, however, no consensus about the right dosage, targets, timing, or efficacy of BTX injections. 39 Dosages between 7.4 and 10 IU/kg have been used. Some authors advocate treating only subscapular and pectoralis major muscles, whereas other inject all four internal shoulder rotators. 39 40 41 42 Greenhill et al 41 and Singh et al 42 reported giving the first BTX injection at mean 1 year of age to their patients who had mean passive ER in adduction below 25 degrees. They also reported that BTX treatment resulted in good active ER in adduction, without the need for further procedures, in approximately 15% of their patients, whereas approximately 65% of the patients had later shoulder surgery, respectively. We administered a high dose of BTX at an earlier age to children with less severe contracture at time of injection. This could explain at least partly, why the risk of secondary shoulder surgery is lower in our patients compared to the previous studies.

Restoration of active ER either with neurotization or tendon transfer should be considered in children, who do not gain at least Mallet grade III shoulder function before 3 years of age to prevent shoulder dysplasia. 21 37 43 44 45 A congruent shoulder is a prerequisite for both muscle or nerve transfers, which underlines the importance of early diagnosis and treatment of posterior shoulder dislocation. Traditionally, latissimus dorsi and/or teres major transfers to infra- or to supraspinatus tendon have been used to improve shoulder ER, but better results have been claimed recently with lower trapezius transfer. 31 37 46 Neurotization of the whole suprascapular nerve or its infraspinatus branch (SSNI) with SAN might be the best option, however. 33 47 48 49

We recommend neurotization of the infraspinatus muscle at approximately 2 years of age as spontaneous recovery of its function is unlikely after 1.5 years of age. 3 The oldest child that we have so far treated successfully with SAN pro SSNI was nearly 5 years old; however, children in this age group might benefit more from tendon transfers. 31 Preoperative electromyography and MRI studies to evaluate the viability of the infraspinatus should be considered if SAN pro SSNI is considered in older patients. The gain from tendon transfers seems to subside over time, 50 and while our midterm results are promising, 33 we still do not know how the presented technique will stand the test of time. A prospective study comparing the results of tendon transfer to specific neurotization of the infraspinatus would be advantageous.

We have shown that most shoulders in children with permanent BPBI can be kept in place with daily passive ROM exercises, targeted plexus reconstruction, US screening, prompt treatment of shoulder internal rotation contracture and posterior shoulder subluxation with BTX and bracing, open shoulder relocation, and SAN pro SSNI transfer in select cases.

Footnotes

Conflict of Interest None declared.

References

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