Shoulder internal rotation contractures (IRC) are common sequela of brachial plexus birth injuries (BPBI). Botulinum toxin A (BTX-A) injection into targeted muscles has been described to facilitate functional improvement at the shoulder joint and prevent glenohumeral dysplasia. The purpose of this study was to assess the outcomes of BTX-A injections on shoulder IRC in children with BPBI.
We conducted a retrospective analysis of 47 children with shoulder IRC due to BPBI, who were treated with BTX-A. Shoulder passive external rotation in adduction and Active Movement Scale external rotation scores were recorded before and after BTX-A injection. We also recorded the number of children who underwent secondary surgical balancing procedures to improve shoulder motion after BTX-A injection.
Mean age at the time of injection was 12 months (range, 5–23 months). Subjects demonstrated a significant increase in passive external rotation of 46° (range, 10° to 90) at 4 months; an average improvement of 18° (range, –30° to 80°) persisted at 11 months after injection. A total of 28 patients (60%) underwent subsequent external rotation tendon transfer. At 5-year follow-up, 7 patients (15%) had adequate functional shoulder range of motion and did not undergo external rotation tendon transfer.
Botulinum toxin A injections result in improvement in IRC due to BPBI, which is sustained beyond the expected half-life of 3 months. As many as 15% of patients who have this treatment avoid external rotation tendon transfer.
Type of study/level of evidence
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- Assessment of current epidemiology and risk factors surrounding brachial plexus birth palsy.J Hand Surg Am. 2019; 44: 515.e1-515.e10
- Obstetrical brachial plexus injuries: incidence, natural course and shoulder contracture.Clin Rehabil. 2000; 14: 523-526
- Neurological recovery in brachial plexus injuries: an historical cohort study.Dev Med Child Neurol. 2004; 46: 76-83
- Impaired growth of denervated muscle contributes to contracture formation following neonatal brachial plexus injury.J Bone Joint Surg Am. 2011; 93: 461-470
- An approach to obstetrical brachial plexus injuries.Hand Clin. 1995; 11: 563-580
- Obstetric brachial plexus injuries.J Hand Surg Am. 2003; 3: 41-54
- Arthroscopic release and latissimus dorsi transfer for shoulder internal rotation contractures and glenohumeral deformity secondary to brachial plexus birth palsy.J Bone Joint Surg Am. 2006; 88: 564-574
- The early effects of tendon transfers and open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy.J Bone Joint Surg Am. 2008; 90: 2171-2179
- Evaluation of shoulder function after secondary surgery in children with neonatal brachial plexus palsy.J Pediatr Rehabil Med. 2015; 8: 187-196
- Correlation between external rotation of the glenohumeral joint and deformity after brachial plexus birth palsy.J Pediatr Orthop. 2004; 24: 189-193
- Glenoid deformity secondary to brachial plexus birth palsy.J Bone Joint Surg Am. 1998; 80: 659-667
- An MRI study on the relations between muscle atrophy, shoulder function and glenohumeral deformity in shoulders of children with obstetric brachial plexus injury.J Brachial Plex Periph Nerve Inj. 2009; 4: 5
- The role of botulinum toxin in the neurorehabilitation of young patients with brachial plexus birth palsy.Pediatr Rehabil. 2001; 4: 29-36
- Onabotulinum toxinA injection as an adjunct in the treatment of posterior shoulder subluxation in neonatal brachial plexus palsy.J Bone Joint Surg Am. 2010; 92: 2171-2177
- Central effects of botulinum toxin type A: evidence and supposition.Movement Disord. 2004; 19: 60-64
- Shoulder contracture and osseous deformity in obstetrical brachial plexus injuries.J Bone Joint Surg Am. 2003; 85: 316-322
- Botulinum toxin as an adjunct to motor learning therapy and surgery for obstetrical brachial plexus injury.Dev Med Child Neurol. 2006; 48: 245-252
- Botulinum toxin treatment of cocontractions after birth-related brachial plexus lesions.Neurology. 2000; 55: 112-114
- Botulinum toxin type-A and plaster cast treatment in children with upper brachial plexus palsy.Pediatric Rehab. 2006; 9: 165-170
- Botulinum toxin type A as an adjunct to the surgical treatment of the medial rotation deformity of the shoulder in birth injuries of the brachial plexus.J Bone Joint Surg Br. 2007; 89: 327-329
- Botulinum toxin for the treatment of motor imbalance in obstetrical brachial plexus palsy.Plastic Reconst Surg. 2013; 131: 1307-1315
- Botulinum toxin injection for internal rotation contractures in brachial plexus birth palsy: a minimum 5-year prospective observational study.J Pediatric Orthop. 2017; 37: e209-e215
- Botulinum neurotoxin as a therapeutic modality in orthopaedic surgery: more than twenty years of experience.J Bone Joint Surg Am. 2008; 90: 133-145
- External rotation predicts outcomes after closed glenohumeral joint reduction with botulinum toxin type A in brachial plexus birth palsy.J Pediatr Orthop. 2018; 38: 32-37
- Use of botulinum toxin type A in the management of neonatal brachial plexus palsy.PM R. 2014; 6: 1107-1119
- Ultrasound screening for posterior shoulder dislocation in infants with persistent brachial plexus birth palsy.J Bone Joint Surg Am. 2017; 99: 778-783
- The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy.J Hand Surg Am. 2002; 27: 470-478
- Update on management of pediatric brachial plexus palsy.J Pediatric Orthop. 2005; 14: 233-244
- External rotation as a result of suprascapular nerve neurotization in obstetric brachial plexus lesions.Neurosurgery. 2005; 57 ([discussion: 530–537]): 530-537
- Suprascapular nerve reconstruction in obstetrical brachial plexus palsy: spinal accessory nerve transfer versus C5 root grafting.Plast Reconstr Surg. 2011; 127: 2391-2396
- Spinal accessory nerve transfer outperforms cervical root grafting for suprascapular nerve reconstruction in neonatal brachial plexus palsy.Plast Reconstr Surg. 2015; 135: 1431-1438
- Reconstruction of the suprascapular nerve in brachial plexus birth injury: a comparison of nerve grafting and nerve transfers.J Bone Joint Surg Am. 2020; 102: 298-308
- Non sedated rapid volumetric proton density MRI predicts neonatal brachial plexus birth palsy functional outcome.J Neuroimaging. 2017; 27: 248-254
- Neonatal magnetic resonance imaging without sedation correlates with injury severity in brachial plexus birth palsy.J Hand Surg Am. 2017; 42: 335-343
- Non-anesthetized plexus technique for infant (BPBP) MRI evaluation (NAPTIME).(Available at:)https://clinicaltrials.gov/ct2/show/NCT03560999?cond=brachial+plexus+birth+palsy&cntry=US&state=US%3ACA&rank=2Date accessed: July 11, 2019
Published online: August 02, 2020
Accepted: June 16, 2020
Received: August 6, 2019
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
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