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Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline
Christopher J Coroneos1,2, Sophocles H Voineskos1,2, Marie K Christakis3
1Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
Insights
This guideline provides evidence-based recommendations for managing obstetrical brachial plexus injury (OBPI) in newborns. It emphasizes timely referral to multidisciplinary care and outlines criteria for surgical nerve repair to improve outcomes.
Area of Science:
- Pediatric Surgery
- Neurology
- Evidence-Based Medicine
Background:
- Obstetrical brachial plexus injury (OBPI) management has historically lacked standardized evidence-based guidelines.
- Key gaps exist in referral timing, surgical indications, and expertise distribution for OBPI care.
- Multidisciplinary centers are crucial for optimal OBPI management.
Purpose of the Study:
- To establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI).
- To address critical gaps in OBPI care, including evidence utilization, referral timing, surgical management, and expertise.
- To provide clear recommendations for healthcare providers treating infants and children with upper extremity injuries.
Main Methods:
- An electronic modified Delphi approach was used to achieve consensus among Canadian experts.
- A multidisciplinary working group, comprising clinicians from 10 Canadian centers, was formed.
- Previous meta-analysis on nerve repair and Canadian epidemiology data informed the guideline development.
Main Results:
- Seven key recommendations were established to guide OBPI identification, referral, and treatment.
- Recommendations include early physical examination, referral by one month, and inclusion of specific expertise in multidisciplinary centers.
- Specific criteria for microsurgical nerve repair and standardized outcome measures (Narakas classification, AMS, BPOM) were defined.
Conclusions:
- The guideline establishes a framework for consistent, evidence-based OBPI management across Canada.
- It promotes a network for future research and guideline refinement.
- A structured referral form and recommendations are available to support primary care providers.
Objective:
The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise.
Setting:
The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries.
Participants:
The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres.
Outcome Measures:
An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed.
Results:
7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery.
Conclusions:
The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.
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