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Updated: Apr 29, 2026
Development of a Neonatal Rat Model for Brachial Plexus Birth Injury
Published on: March 27, 2026
An early shoulder repositioning program in birth-related brachial plexus injury: a pilot study of the Sup-ER protocol
Cynthia Verchere1, Kim Durlacher2, Doria Bellows3
1Department of Surgery, Division of Pediatric Plastic Surgery, University of British Columbia, 4480 Oak Street, K3-Ambulatory Care Building, Vancouver, BC V6H 3V4 Canada ; Division of Plastic Surgery, British Columbia Children's Hospital, 4480 Oak Street, K3 ACB, Vancouver, BC V6H 3V4 Canada.
Insights
Early use of a novel splint for infants with birth-related brachial plexus injury (BRBPI) improved arm function, reducing the need for surgery. This passive repositioning program shows promise for better outcomes in BRBPI recovery.
Area of Science:
- Pediatric Orthopedics
- Neonatal Care
- Rehabilitation Medicine
Background:
- Birth-related brachial plexus injury (BRBPI) affects 1.2/1,000 births, often leading to persistent weakness in external rotation and supination.
- Permanent skeletal imbalance can occur even with good recovery from BRBPI.
- A novel custom splint (Sup-ER splint) was developed for early infant shoulder passive repositioning in full external rotation (ER) and supination (Sup).
Purpose of the Study:
- To evaluate the effectiveness of a novel Sup-ER splint and passive repositioning program for infants with BRBPI.
- To assess functional recovery outcomes in infants treated with the Sup-ER protocol compared to historical controls.
- To determine if the intervention reduces the need for subsequent brachial plexus reconstruction surgery.
Main Methods:
- Retrospective review of 18 infants managed with the Sup-ER protocol (2008-2011).
- Comparison of recovery scores (Active Movement Scale - AMS) at 2 years with matched historical controls.
- Exclusion criteria included insufficient data, non-compliance, late initiation, and loss to follow-up.
Main Results:
- The Sup-ER group showed significantly better final scores at 2 years: 1.18 AMS points in supination (p=0.036).
- External rotation showed improvement (0.96 AMS points), though not statistically significant (p=0.13).
- Crucially, zero subjects in the Sup-ER group required brachial plexus reconstruction, compared to 13% of historical controls.
Conclusions:
- Early passive shoulder repositioning using the Sup-ER splint may enhance functional arm outcomes in infants with BRBPI.
- The intervention appears to reduce the necessity for surgical reconstruction.
- A multi-site randomized control trial is underway to further validate these findings.
Background:
Birth-related brachial plexus injury (BRBPI) occurs in 1.2/1,000 births in British Columbia. Even in children with "good" recovery, external rotation (ER) and supination (Sup) are often weaker, and permanent skeletal imbalance ensues. A preventive early infant shoulder passive repositioning program was created using primarily a novel custom splint holding the affected arm in full ER and Sup: the Sup-ER splint. The details of the splint and the shoulder repositioning program evolved with experience over several years. This study reviews the first 4 years.
Methods:
A retrospective review of BCCH patients managed with the Sup-ER protocol from 2008 to 2011 compared their recovery scores to matched historical controls selected from our database by two independent reviewers.
Results:
The protocol was initiated in 18 children during the study period. Six were excluded due to the following: insufficient data points, non-compliance, late splint initiation, and loss to follow-up. Of the 12 matches, the Sup-ER group final score at 2 years was better than controls by 1.18 active movement scale (AMS) points (p = 0.036) in Sup and 0.96 AMS points in ER (but not statistically significant (p = 0.13)). Unexpectedly, but importantly, during the study period, zero subjects were assessed to have the active functional criteria to indicate brachial plexus reconstruction, where previously we operated on 13 %.
Conclusions:
Early application of passive shoulder repositioning into Sup and ER may improve outcomes in function of the arm in infants with BRBPI. A North American multi-site randomized control trial has been approved and has started recruitment.
