Related Experiment Video
Updated: Mar 25, 2026
Arthroscopic Management of Massive Irreparable Rotator Cuff Tears: Whole Rotator Cable Reconstruction Using Proximal Biceps Tendon Autograft
Published on: June 6, 2025
External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial
Dustin A Greenhill1, Kevin Wissinger2, Arianna Trionfo1
1Department of Orthopaedic Surgery & Sports Medicine, Temple University Hospital.
Insights
Botulinum toxin type A (BTX-A) injections combined with casting can improve shoulder outcomes in children with brachial plexus birth palsy. Pretreatment passive external rotation greater than 30 degrees predicts success, but many still need further intervention.
Area of Science:
- Pediatric Orthopedics
- Neuromuscular Disorders
- Rehabilitation Medicine
Background:
- Limited research exists on outcomes of adjunct botulinum toxin type A (BTX-A) injections for shoulder internal rotator muscles during closed reduction and spica casting in pediatric brachial plexus birth palsy.
- This study aims to report success rates and identify pretreatment predictors for this specific treatment approach.
Purpose of the Study:
- To evaluate the success rates of closed shoulder reduction with BTX-A and spica casting in children with brachial plexus birth palsy.
- To identify pretreatment clinical and physical examination findings that predict successful outcomes.
Main Methods:
- A retrospective review of children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting.
- Exclusion criteria included concomitant shoulder surgery or microsurgery within 8 months. Follow-up was at least 1 year.
- Data collected included palsy severity, age, physical examination scores, passive external rotation (PER), and need for subsequent orthopaedic procedures. Success was defined by absence of repeat reduction or procedures, and adequate external rotation.
Main Results:
- Of 49 patients, 65% required repeat reduction (closed or surgical). Only 16% achieved adequate active external rotation without further intervention.
- Increased pretreatment passive external rotation (PER) and Active Movement Scale external rotation scores were significant predictors of optimal treatment success (P=0.01 and P=0.02, respectively).
- Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Patients with pretreatment PER >30 degrees were considered successes, while those with PER <15 degrees were failures.
Conclusions:
- Pretreatment passive external rotation (PER) exceeding 30 degrees is a strong indicator for successful outcomes following shoulder closed reduction with BTX-A and cast immobilization.
- Despite positive predictors, a significant proportion of patients experience residual shoulder subluxation or external rotation deficits, necessitating further interventions.
Background:
Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success.
Methods:
Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation.
Results:
Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures.
Conclusions:
Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention.
Level Of Evidence:
Level IV-therapeutic.
More Related Videos
09:14Surface Electromyographic Biofeedback as a Rehabilitation Tool for Patients with Global Brachial Plexus Injury Receiving Bionic Reconstruction
Published on: September 28, 2019
05:25Knotless Independent Double-Row Repair and Biceps Augmentation for Anterosuperior Rotator Cuff Tears
Published on: January 23, 2026