Permanent Brachial Plexus Birth Injury: Helsinki Shoulder Protocol
Petra Grahn1, Tiina Pöyhiä2, Yrjänä Nietosvaara1,3
1Department of Pediatric Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Insights
Early detection and intervention for brachial plexus birth injury significantly improve outcomes. This includes passive exercises, ultrasound screening, Botox injections, and surgical options, leading to better shoulder function and reduced dysplasia.
Area of Science:
- Pediatric Orthopedics
- Neurology
- Regenerative Medicine
Background:
- Brachial plexus birth injury (BBP) is a significant concern, often leading to shoulder dysplasia.
- Early detection and intervention are crucial for improving long-term outcomes in affected children.
- Shoulder dysplasia detection has shifted to earlier ages with modern diagnostic approaches.
Purpose of the Study:
- To analyze the trends and effectiveness of interventions for brachial plexus birth injury and associated shoulder dysplasia.
- To evaluate the impact of early detection and treatment strategies on shoulder function and structural integrity.
- To assess the role of specific interventions like Botox and surgical reconstruction.
Main Methods:
- Retrospective analysis of 270 patients with permanent BBP from 1995-2021.
- Utilized ultrasound screening from 3-12 months for early detection of shoulder issues.
- Documented interventions including passive exercises, Botox injections, bracing, plexus reconstruction, and neurotization.
- Tracked age at detection of shoulder dysplasia and functional outcomes like shoulder relocation and external rotation.
Main Results:
- Shoulder dysplasia was diagnosed in 49% of patients.
- Age at detection of shoulder dysplasia decreased significantly in children born after 2009 (mean 3.9 months) compared to before 2000 (mean 5.4 years).
- Botox was administered to 57% of patients born after 2009.
- Shoulder relocation rates decreased (28% to 7%), while active shoulder external rotation improved (2° to 46°).
Conclusions:
- Early detection and timely interventions, including Botox and surgical options, are critical for managing BBP and shoulder dysplasia.
- While shoulder relocation rates decreased, functional improvements in active external rotation suggest benefits of modern treatment protocols.
- The shift towards earlier diagnosis and intervention has positively impacted the management of BBP-related shoulder complications.
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°.
