I'm Megan Struble, I'm part of the Academy's education team. And on behalf of the pediatric rehabilitation community and Mary Dubon, who cannot be with us today, I'm pleased to welcome Marissa Orsorio. Dr. Orsorio received her degree from Ohio University and completed her PM&R residency at the University of Cincinnati and her fellowship training at Cincinnati Children's. She is an Associate Professor at the University of Washington and the Division Chief for Pediatric Rehab Medicine at Seattle Children's Hospital. Her core clinical and research interests are in brachial plexus palsy and tone management. And with that, again, I'm thrilled that you're here today, Dr. Orsorio, and I will turn it over to you. Hi again. All right, we have a lot of slides to get through, so please feel free to ask questions. Even during the presentation, Megan will be monitoring the chat and can interrupt me as we go along. Thank you. I have no financial relationships or disclosures to discuss. I will be discussing off-label use of botulinum toxin. So for the objectives, we're going to review the risk factors associated with birth brachial plexus palsy, identify the injury types and the natural history, discuss a bit about shoulder subluxation, and I'll present an algorithm for management. So there are several risk factors that place a newborn at risk for brachial plexus injury. On the maternal side, we have gestational diabetes, which can lead to large babies. There's also an association with previous difficult deliveries. So often the babies are larger with each subsequent pregnancy. So if the prior delivery was difficult, then the next is likely to also be hard and potentially result in a brachial plexus palsy because the next infant will be even bigger. On the fetal side, the risk factors are large for gestational age. They have large heads, large bodies, and potentially also breech position, which can lead to a lower trunk injury. During the birth process, we have, of course, what everyone knows about, which is shoulder dystocia. Use of vacuum and forceps has also been associated with high risk for brachial plexus injury, and that makes, of course, a lot of sense because these are larger babies who are having a harder time coming out. And then there is the association with hypoxic injury. So hypoxia ends up being a risk factor because there are often lots of difficulties with the delivery and how the baby is being extracted. So that can potentially be associated with brachial plexus injury. In a fairly recent U.S. population study of over 5 million births from 1997 to 2012, they found that there was an increased risk for brachial plexus injury if the baby was female, if the baby was Black or Hispanic. Interestingly, though, white babies tended to be higher likely to have macrosomia and large gestational age, and that's new from prior population studies where it showed that babies who were Black or Hispanic were more likely to be larger because there was uncontrolled gestational diabetes and less prenatal care. So there's been a slight shift based on the current data. We also have to consider other injuries that could go along with the brachial plexus injury or could possibly mimic the brachial plexus injury. So babies with complex deliveries can sustain a hypoxic injury. They could have stroke or potentially have a congenital spinal cord injury or an injury during birth. And this can present as arm weakness. So it's important for us to obtain a good history and physical exam to evaluate for these other potential etiologies. Then there's fracture. So fracture involving the clavicle or the humerus means that the babies are not going to be moving their arms because it is painful. So in an infant with a clavicle fracture, they may move their arms distally, being able to flex at the elbow and move the hand, but they're not gonna move at the shoulder because that's gonna cause pain. With a humerus fracture, they may move a bit at the shoulder, but they're maybe not going to move at the elbow as much because of the pain around the humerus and then distally they'll have movement. So it's really important for us to understand the neuroanatomy and the movement patterns to really decipher if their quote unquote weakness is due to pain or that fits a nerve root pattern or it might be the result of something else. And of course, given these traumatic births, it's often seen that you can have a fracture that goes along with it. Other types of injuries would be a radial nerve palsy where a baby has a wrist drop that can look often like what we classically think of as Erb's palsy with the wrist being down. The result of in utero positioning where there can be compression on the nerves, radial nerve that can cause injury. But you would be able to kind of tease this out with your physical exam and your history. And then lastly, in more severe cases of brachial plexus palsy you can have the phrenic nerve essentially be injured because C3, 4, and 5 are potentially injured along with the brachial plexus. So this would present as infants who have difficulty with their breathing. They have asymmetric chest or abdomen excursion during respiration. So moving on to our physical exam, what we need to do is have a thorough head-to-toe evaluation looking for other potential problems besides their brachial plexus injury. We don't want to miss things like hydrocephalus or developmental hip dysplasia because these are easily treatable conditions. So we will focus on the entirety of the infant. We're looking at anterior fontanel. We're checking for a Horner syndrome. So they'll have ptosis and meiosis which can be a sign of a more severe palsy. Checking of course for clavicle calluses and humeral calluses suggesting that they had had a fracture history. We're looking at their neck for full range of motion and assessing whether or not they have torticollis. Often when the babies are coming out, their head is going one way, the shoulder is going the other way from the shoulder dystocia. And that puts a strain on the neck muscles in addition to the brachial plexus injury. And so often their torticollis is looking away from the side of their injury. We should also be inspecting their general musculoskeletal system. So we're looking for extra creases. We're looking for abnormal dimples. These kinds of things can be a sign of shoulder dislocation or subluxation. And so I'll point out to you in this picture, we have a baby who has an extra crease up here in the humeral area. And then the axillary fold is a little bit deeper. It goes up a bit higher than the other side. And so those are signs that there might be shoulder subluxation or dislocation. And then of course, all these babies are having the arms hang down at the side, adducted at the side, so they're gonna develop rashes and other things that we should be checking for to make sure that we're treating their skin as well. And it's important to also check their tone. Often you'll find that they're more hypotonic on their brachial plexus injury side, but there's always the chance that you could detect hypertonicity. So in a baby who's had a traumatic birth and potentially hypoxic injury, they might present as having hypertonicity in the other extremities. So we're certainly doing a thorough neurologic examination. And then lastly, we perform a Moro exam. So getting the babies to raise their arms up and bring them in might be an easier ask, taking advantage of the reflex to see how much they can abduct their arm and flex their elbow if you're not able to tickle them enough to encourage a lot of movement. We'll talk a little bit more in detail about some of the assessments that we use as we go through the management pieces. So now we're gonna talk about the injury types and the expectations for recovery. This is classic Herb's palsy or the waiter's tip posture. This posture shows what the baby has in terms of the movements and therefore what the baby is lacking. So the arm is adducted at the side, the shoulder is internally rotated, the elbow is extended, the forearm is pronated, and the wrist is flexed. In this picture, you might also be able to appreciate that there's less muscle bulk on the affected side compared to the other side. Now, the dreaded brachial plexus diagram. I really felt like I didn't solidly understand the brachial plexus until I was doing months and months of EMG as a resident. But now I feel like I can take this 30-foot view and break it down really more simply. So C5 is the big controller of your shoulder muscles. So that controls your shoulder abduction, your shoulder external rotation, some of your shoulder flexion. C6 is primarily your elbow flexion. Of course, there's lots of crossover, but for simplicity's sake, let's say C6 is your elbow flexion. C7 is your extensors, your elbow extension. C8 and C1, of course, control your hand. So when you think about them in broader terms like that, you can then start to piece together where the sites of injury might be. The incidence of brachial plexus injury in the United States has been decreasing over time. At a prior population study, the incidence was 1.7 per 1,000 live births, and now it's 0.9 per 1,000 live births. So thankfully, the incidence is dropping, but the amount of work that we need to do to help these babies remains pretty significant. So 50% of the cases will involve the upper plexus, so C5 and C6, which is also referred to as Erb's palsy. 25% will involve the upper middle, which is also called extended Erb's palsy, so that's C5, C6, and C7. And then the other 25% would be your entire plexus palsy. These cartoons show the different injury types. Most pediatricians and other providers know about neuropraxic or stress injuries here in this first box. These make up the vast majority of brachial plexus injuries, usually about 90% is what's quoted in the literature. So in this situation, the nerves have been stretched, and so the arm is temporarily weak. You get that neuropraxia, the arm is not working, but over the course of a couple of days, the arm starts moving again, and by about three to four weeks, the arm is generally back to normal. These are not the kids that we see in brachial plexus clinic. Infants come to our clinic at one month of age because this tends to weed out the number of kids who have pure neuropractic injuries and are gonna recover on their own, and then we see the ones that are, of course, more severe. On the left side of your screen, you'll see pictures depicting significant injuries with ruptures and avulsions. We'll talk more about the management of these kinds of injuries. And then below the neuropractic category, we have the neuromas. So in neuroma, this is where the majority of patients will fall who are outside of that neuropraxia category. These patients have neuromas where there has been probably micro tearing of the neural structure, and so the body creates scar tissue to try and repair the neural structure and repair the damage. There's a wide spectrum of recovery within this category where for some, the scar tissue is minimal and well-arranged and organized so that the nerve signals are easily able to pass through to the muscle. And on the other end of the spectrum, the scar tissue is more gnarly, it's very thick and disorganized, and not a lot of that signal will be able to pass through. So those babies are often ones who are going on to have surgery, in addition to the ones who have ruptures and avulsions. This is a diagram of why we see Horner syndrome associated with brachial plexus injury. So when a baby has Horner syndrome, this suggests a disruption of those pre-ganglionic sympathetic fibers that travel along with T1s. So in here with T1, you can see that the sympathetic chain is here right directly alongside it. So if T1 has had an avulsion, you're going to see an effect to those proximal pre-ganglionic sympathetic fibers, and therefore it's affecting how this travels along the sympathetic chain, and you're going to get that Horner syndrome. So in the literature, you will also read about another way to classify the brachial plexus injuries, and this is the Neurakos classification. This was the original way that all injuries were labeled. This table specifically talks about what that natural recovery looked like. So type 1 would be the equivalent of an Erb's palsy with C5 and C6 affected, and about 80% of these cases will have good spontaneous recovery of function with slight bit of deficit. Type 2 are your extended Erb's palsy cases where you have C5, C6, and C7 affected, and about 60% of these infants will have quote-unquote good recovery. And then type 3 and type 4 are your pan-plexus injuries where you have with and without Horner syndrome, and these are, of course, are surgical cases. So you can see that in type 3 for a pan-plexus with no Horner, we have 30 to 50% recovery of the shoulder and elbow function, but very limited hand function, and then in someone who has complete without Horner, they're not going to have much in the way of spontaneous recovery and definitely need to have surgery. I want to briefly go through the modified Mallet scale. This is an important scale that we use to assess a child's movements, and it'll be important when we talk about the natural recovery on the next slide. So as you can see on the left-hand side, we have all of the movements listed, abduction, external rotation, hand behind the head, hand behind the back, hand to mouth, and internal rotation to touch the belly, and then they're graded one through five, one being they have no function ability to do that, five is that they have normal function, and then there's different gradations in between. This slide looks at what happens when you have biceps recovery come back and how this relates to the function as we measure it on the Mallet score. So on the left side, we have our Mallet one to five, five being the best, and on the x-axis, we have the time to biceps recovery. So what you can see here is that at one month, if the baby is recovering their biceps function, they're bending their elbow at one month of age, they're very likely to go on to have full recovery of all of those movements on the Mallet, the shoulder abduction, the external rotation, hand behind the head, hand to mouth. And as time goes on, their scores go down such that if you're not recovering a lot of biceps function by six months of age, you're most likely to have a score of two on the mallet, which means you can't abduct the arm past 30 degrees. You can't rotate past neutral. The baby can't get their hand behind their head. They have a marked trumpet whenever they're bringing their hand to their mouth. That's a vastly different ability to function based on how long it takes to get there. And now we're going to talk about how to manage these cases. We use this algorithm here at Seattle Children's, and it's based off of Howard Clark's work at the Hospital for Sick Children in Toronto, and we're going to go through this in a bit of detail. Next few slides. First, though, I want to focus on shoulder subluxation. Shoulder subluxation is a secondary consequence of brachial plexus injury, and it's thought to be caused by a muscle imbalance at the shoulder. So your shoulder essentially acts as a pulley, and one side of the pulley is pulling while the other side is not, and that's where your brachial plexus injury comes in. That naturally will put the humeral head into a more posterior position, which can lead to shoulder subluxation. The literature reports an incidence between 8% and 33% within the first year of life, and at our center, we have seen about 63% of our babies experiencing shoulder subluxation. The reason that this is important is that shoulder subluxation can lead to deformation of the glenohumeral joint, and this can limit how the child uses the arm, even if the nerve recovery is near-complete. I often demonstrate for the parents. When I internally rotate my arm all the way in and I try to abduct my arm, I reach a mechanical limitation. I can't go any further, and this simulates what it's like for shoulder subluxation, but then when I reduce my shoulder, I can lift my arm all of the way up. So it can get confusing when you're thinking about how to treat the babies and whether or not to undergo surgery if you haven't really examined the shoulder for possible subluxation. It can look like a baby is limited in how far they can abduct the arm when really it's a mechanical limitation and not necessarily a limitation of the muscle and the nerve. There can be exam findings, of course, that are consistent with shoulder subluxation. You have loss of passive range of motion for external rotation. You have that deep axillary crease that we just talked about, the extra skin folds, and then the shortening of the upper arm segment, but these are not always present. Our center showed that of all of the babies that were having shoulder subluxation, that 74% of them had a normal clinical exam, so there was a small percentage that actually had any of these clinical findings. So how do we measure it? So MRI is the gold standard for really looking at what's happening at the shoulder, but it has its drawbacks. There's a large cost to doing the testing. Some of the babies may require anesthesia to have the test, and when we talk about lifetime risk with anesthesia, we want to minimize these things. So ultrasound has really become a more popular method of detecting shoulder subluxation because of its lower cost. It can be done in real time with the baby awake and has been shown to be reliable and reproducible. Here we'll go through a couple of ultrasounds. So this part up here is posterior. This part is anterior, and this bright white line across is the scapula. The curved white line here is your glenoid, and then this is your humeral head. So we measure the angles on the ultrasound called the alpha angle. So you measure it by taking a line through the edge of the glenoid through the occipic nucleus of the humeral head, and then you draw your sort of parallel line from the edge of the glenoid up through the most posterior portion of the humeral head, and that creates your alpha angle. So for this baby, on her right side, we have an alpha angle that looks pretty typical. Typical is less than 30 degrees. And then on her affected side, her injury side, this is a baby that we were showing earlier that had the deepened axillary crease and the extra fold and the humeral segment shortening, and you can see that more of that humeral head is posterior to the scapula, so that creates a much larger alpha angle indicating shoulder subluxation. So back to the algorithm that we had developed, we're looking for monitoring the shoulders, and this is really based on work that was done by a group in Finland who showed that 55% of their babies with shoulder subluxation had abnormal ultrasounds as early as three months of age, and then by six months of age, 89% were showing shoulder subluxation on their ultrasound. So we go through, and at one month, three months, three months, six months, and nine months, we're checking these shoulder ultrasounds to ensure that we have proper alignment of the glenohumeral joint. At one month, we're doing it if there's clinical indicators, so if they have less than 30 degrees of external rotation on passive range of motion or other clinical signs, then we'll evaluate that with the ultrasound. We routinely get them on babies who are three or six months of age, regardless of their clinical exam, and that's, again, of course, because we found that the vast majority have no clinical findings and are experiencing shoulder subluxation. And then at nine months, again, we would do that if there were any clinical indicators. So as far as the treatment is concerned, we are watching their alpha angles, and if they are generally above 30 or have loss of range of motion, we're pursuing Botox and casting for the shoulder. And Botox and casting, there have been several studies that have supported its use. It's shown to be helpful at reducing the shoulder subluxation, and the target muscles are those big internal rotators, your subscapularis, your pec major, your latissimus or teres major. The studies have shown that most of the babies can maintain the glenohumeral reduction for a year at least, about 69% of the children. And then there's still a great debate about whether or not that helps in the long term to prevent kids from experiencing further shoulder subluxation or having glenohumeral dysplasia and eventually potentially needing tendon transfer surgery. There was a small prospective study done that looked at 15 patients who had received Botox compared to 60 controls, and the patients who received Botox improved, but 67% of them ended up having to have tendon transfer surgery, whereas another study had shown that only 15% of their patients had to have tendon transfer at a five-year follow-up. So the jury really is still out about what the long-term benefit is, but at least in the short term, it seems to be quite useful for reducing the shoulder and helping the children, the babies, and eventually toddlers to move their arms better. Our colleagues out of Vancouver, BC, have been trying a splinting protocol to see if we can prevent the shoulder subluxation from even happening in the first place. They developed this splint called the SUBR splint. It stands for supination and external rotation, and this is the position that keeps the glenohumeral joint well reduced. In this pilot study that was listed here, Dr. Verchere and her group had found that there was a trend toward improvement in their overall functioning scores, especially for supination and external rotation, of course, but none that were statistically significant at that point. And so they have set out to do a multi-center trial with the splints, but the study results are not yet published. This is something that we're doing in our center as well and are looking at whether or not helping the babies so more to come in the future. Now we're going to talk about nerve surgery and the treatment of the nerves itself. So first I want to go through a couple of the measures that we use in our clinic, and these are the same measures that you'll see if you look at the literature on brachial plexus injury. This is the Toronto scale, so it has five movements, elbow flexion, extension, wrist extension, finger extension, and thumb extension, and then these are graded based on how much they can move the joint. This is important because we use this scale to help us determine whether or not a baby needs to go to surgery sooner rather than later. This next scale is called the active movement scale, and it was developed out of SickKids, and again it goes through a range of movements for the shoulder, the elbow, the hand, and is graded based on gravity-eliminated movement and a scale within gravity-eliminated and then against gravity movement. So as I said earlier, we based our treatment algorithm on the SickKids model and the evidence that they've provided in the literature for when to take babies onto surgery, and here you can see that about 70% to 90% of the babies don't require nerve surgery. So it's really a small percentage of kids who go on to have surgery who are not in that neuropraxic category. These are all the kids that are coming to a brachial plexus center who have more significant injuries. At one month of age, if the baby has a flail arm and a Horner syndrome, we're presuming that they have evulsions and ruptures, and time is muscle. So the longer we wait without any neural connection to those muscles, the more atrophy that we're getting and the less likely we'll have a good outcome if we wait on doing surgery. At three months, this is where the Toronto score comes in. So we grade all of their movements as you see listed here, and if they're less than a 3.5, that generally is an indicator there are some form of ruptures or evulsions and they're going to need to go to surgery soon. It doesn't take a lot to get a higher score on the Toronto, so these are definitely the more affected babies. At six months and nine months, this is where the majority of the kids live. We're watching their progress over time on the AMS scale, and if they really haven't met our benchmarks and haven't shown much progression, they'll go to surgery at six months. And then our final call is at nine months of age where they do the famous cookie test. So they have to be able to bring their arm up fully into gravity to bring a cookie to their mouth. And the literature supports that if a child is unable to pass the cookie test, then they are more likely to benefit from surgery than not. Over the years, our algorithm for how we do the surgeries has evolved as new research has become available. Previously, everyone was getting nerve reconstruction, but now we consider nerve transfers in lieu of nerve reconstruction, and so we'll talk about that a bit more in a few slides. So anyone who has evulsions or ruptures, anyone who's not passing that Toronto scale is going to go on to have primary reconstruction. Those babies who more fit into the neuroma category at six and nine months of age, they're going to potentially go on to either have primary reconstruction or nerve transfer. And then beyond 12 months, nerve transfers are considered more on a case-by-case basis and are dependent on a lot of different factors, whether or not we think the child would benefit. I pull this slide back up to just remind you about the different types of injury because now next we're going to go through the types of surgery that happen. So in a panplexus injury or an extended ERBs down to C7, you're likely to have a combination of those neuromas, ruptures, and evulsions. These require nerve reconstruction because you really can't just attach end to end on the nerves. Nerve grafting is necessary to really make that scaffolding that you need to allow the axons to regrow through and get to the end organ, the target muscle. Serral nerve grafts are harvested from both of the legs and used for the reconstruction. And then at our center, we do a spinal accessory nerve to suprascapular nerve transfers to power the infraspinatus and get external rotation of the arm. Here you see a drawing of a serral nerve grafting. Our surgeon, Dr. J, has been trained in plastics and he does an excellent job of hiding these scars in the natural folds of the legs. So you can see one is here in the popliteal fossa that hides very well. The other one is in the ankle creases and one in the middle of the leg, which kind of gives the babies and kids a look of like a well-defined calf. Historically, the incisions were made straight down the back of the leg and they had very large scars as a result. But now, technique is a bit different and much better for the children. As most of you are, I'm sure, aware, serral nerve, it just applies sensation to the outside of your ankle. So it's one that can be easily harvested and not have any major deficits or issues with borrowing those nerves. This is what they see when they look under the microscope in these situations. So here we have an upper trunk neuroma and this is your C7 dorsal root ganglion. So this should not be seen because it's supposed to be so proximal. And when this is seen, there's an indication that there has been an avulsion in this area. This is what it looks like after the nerves are cleaned up and the grafts are put into place. The grafts are attached with some fiber and glue that you can see remnants of here. They don't necessarily need to do the tedious sewing of the nerves and it tends to hold very well with the glue in place. So now we're moving to the next category of kids where they have C5, C6 lesions that aren't recovering sufficiently and we're considering nerve surgery. So in this case, you could still excise the neuroma, take that part out and then do the reconstruction with the nerve grafts, or you can opt to do a nerve transfer. So these pictures to the right show the different types of nerve transfer. So down here we have what's called the oberlin. So you have a branch of the ulnar nerve that's borrowed and attached over to your musculocutaneous to power the biceps. You have your radial, a portion of your radial coming up to supply the axillary and then spinal accessory nerve is borrowed to innervate the infraspinatus, your suprascapular nerve and then your infraspinatus. Our colleagues in Alberta, Canada, did a study comparing match groups who underwent the triple nerve transfer, the over limb, the radial, to axillary, and the spinal accessory to suprascapular. And they compared the triple nerve transfer group to a nerve reconstruction group. And what they found was that the triple nerve transfer patients had similar improvements in their elbow flexion, their shoulder abduction and flexion, and they had improved supination and external rotation compared to the nerve reconstruction group at two years post. So their nerve reconstruction group did not have the spinal accessory to suprascapular nerve transfers done like we do at our center, so they were purely just doing the reconstruction. So this is really showing that there's at least the same improvements in recovery with triple nerve transfer as you get with nerve reconstruction, but there are also a lot of benefits. So there's decreased operative time, there's decreased length of stay, decreased cost. And they also looked at what are the consequences of borrowing these donor nerves, and what they found was that when you borrow a branch of the radial nerve, you're not really downgrading elbow extension strength. When you borrow from the ulnar nerve, you're not getting wrist drop, you're getting normal wrist strength. So there's essentially very little downside to borrowing healthy donor nerves. This is a picture of what it will look like to have the nerve grafting done, or I'm sorry, the nerve transfer done in a radial patient. So here we have the radial nerve going to the tricep. And then this is a branch that they've taken out of the radial nerve, and then this is the axillary nerve up here. They then just do a coaptation of the two nerves together to now supply the axillary nerve and the deltoid to improve shoulder abduction function. Lastly, I would like to talk about tendon transfer surgery and what happens to the babies as they're getting older. So this is our algorithm for how we treat the shoulders once the kids are above a year of age. So after they've required their nerve surgery or not, we're still evaluating whether or not they get sufficient return, particularly of external rotation function, to make sure that they can do those functional activities like reach behind their head or grooming activities that they can arc their arm back to be able to throw a ball, that they can reach into a cabinet to pull items down. So this is where a lot of that functional piece comes in. So if a baby has loss of range of motion in external rotation or loss of about 30 degrees of range of motion over the course of time, then we're going to go ahead and get another potential shoulder ultrasound. And depending on whether or not it's abnormal, we will go on to get an MRI and look at whether or not there's evidence of glenohumeral dysplasia, which is measured by the water score. Most of our babies are undergoing tendon transfer around that two years old, somewhere between two and four years old, based on this criteria. Megan, I think I saw something pop up in the chat. Is there a question? There's not a question of yet, just a solicitation for questions. Okay. Dr. Brandenburg has joined us, so she'll help facilitate that. So Dr. Brandenburg to the rescue. So as you can see in this diagram, there is a large mismatch between the muscles. You have four really strong internal rotator muscles, and one, essentially one, the other one's not listed here, but essentially one muscle that does the workhorse for external rotation, and that's your infraspinatus. So even if there's a fair re-innervation to the infraspinatus, this could be very easily overpowered by such strong internal rotator muscles. So the idea behind the tendon transfer is to move a portion of those internal rotator muscles and reattach their insertion from the inside of the humerus, as you can see here, the latissimus and your teres major, and reroute those to be on the outside of the humerus, so that now when those muscles pull, you're actually getting external rotation ability. There have been quite a few studies looking at tendon transfer and all of the benefits. I've listed a couple in particular here. So the improvements that we see is in both active and passive range of motion, their external rotation significantly increases. When we look at the Malay classification, their function really improves such that they can get hands behind their head and they can rotate their arms. On the assisting hand assessment, there have been improved scores. On the pediatric outcome data collecting instrument, there have been increases in upper extremity physical and global functioning. And then the brachial plexus outcome measure scores, those have all shown improvement as well. The downside to the tendon transfer is that you lose your ability to get your hand behind your back. And that's a fair tradeoff, because there's not a lot that we do in this plane to get hand behind the back, and certainly the kids will have another arm that they can utilize for activities that they need to in that plane. And then the other potential concern is that they can lose the ability to get hand to belly. So that's a big functional risk, because you're working with managing your pants and managing things for toileting, and so losing your ability to get your hand to your belly could be significant. But in the right surgical hands, that has been shown to be minimal, and the kids will often get hand to belly by using wrist flexion. In the final slides here, I wish I could go into all of the things that happen for long-term management and everything that happens after this infant and toddler stage, but maybe that's for another talk. What I will say is we should think like a rehab doctor. So the name of the game for the kids after they're beyond the surgical stage is to think about contracture prevention. How is their workstation set up, or their school ergonomics set up? What are we doing about preventing their pain, musculoskeletal discomfort? What kinds of adaptive equipment do they need to accomplish all of their goals, and what kinds of recreation can they get into with some of the limitations that they have in their arm? So there's lots more that I think we can do, and I hope that everybody has a rehab doc in their breakout room because I think that there's a lot that we can do there. This is a list of the comprehensive integrated programs across North America. There are four in Canada, and quite a lot between the East Coast and the Midwest, which is where most of us tend to be. And now I can take questions. Dr. Ansario, thank you so much. I apologize for my tardiness, and I thank you and Megan for your flexibility in getting all of this going and running. Your talk was fantastic. And we do have some questions, and if we have time, I have a couple of questions, too, for you. Awesome. First of all, from Dr. Hung, asked, with the neuropraxia, 80% recovered spontaneously. What about the other 20% that doesn't go on to recover? Do you go through the same algorithm of treatment for them? So that was a little, I think, misleading. So the 80% were the kids who were not just neuropraxic injury. They were the more significant brachial plexus palsies. It's 90% of total brachial plexus injuries are neuropraxia. So that 10% breaks down into the ones who are C5, C6, extended ERBs, and then panplexus palsy. And so that 80% of the C5, C6 that are not neuropraxia are getting good recovery. And it's that 20% who then end up having surgery. Ah, okay. Thank you for breaking that down for us. Yeah. Another question from Dr. Lee. When do you decide to do the Botox injection and casting? Is it as soon as shoulder subluxation is evident? Or do you wait a little bit longer until spontaneous recovery is unlikely in those babies that are more like six to nine months old? Great question. We tend to do the treatment of Botox and casting as soon as possible because we don't want glenohumeral dysplasia to set in. The longer that shoulder is subluxed, the more likely they are to have issues with the development of the glenohumeral joint. So depending on the timing, if we think that they're a baby who, you know, so they're getting their screening ultrasound at three months of age. And if we're finding shoulder subluxation at that time, we're also sort of weighing whether or not we think that they're going to end up needing surgery in the near future. So they might be one of those children who's at that six-month mark that we would do surgery. And in that case, we're going to save them the extra anesthesia and extra time under to just do everything bundled at once. But if it's not clear that they're really going to need surgery, then we're going to fix the glenohumeral joint now because, like I said before, that piece of it could cloud the picture for whether or not they need nerve surgery. So if their shoulder is really subluxed and they're having trouble abducting the arm, it may be a mechanical issue and not as much related to the nerve. Thank you. A couple more questions. Is there a role for EMG in nerve conduction studies? I'm glad somebody asked that. So there has been some literature to support doing EMG early on. And really, the biggest thing is if you have motor units found in your biceps by about one month of age, prognostically, this is a good prognostic indicator. So you're going to go on to have a pretty good recovery and may not need surgery. So in our center, we tend to use it for that reason and not as much for the diagnosis piece of whether or not they have avulsions and ruptures. We're just following the clinical exam. I would say that the other role for EMG in these cases is for surgical planning. So if a child had potentially some initial weakness on their triceps testing when they first come to us, and then we're getting to the point of thinking about surgery and wanting to do nerve transfers, we're going to do EMG to the radial nerve and all three heads of the triceps to just make sure that that nerve has really fully recovered and is a viable donor for the nerve transfers that we're going to do. So it does help a lot in our surgical management. I'm just curious, for doing those EMGs, are you sedating the babies, or are you doing it with the babies awake? Awake. Wow. They tend to do very well, and you give them a little sugar water, and they calm right down, or they nurse, and then it's okay. Awesome. And that was Dr. Chinarian who had that question, so thank you so much for that. Another question, can you elaborate on your Botox experience? What are the typical muscles and doses, frequency, and timing? Great. So we tend to do latissimus, subscap, and PEC. We're dosing at a – generally we're not maxing out under 10 per kilo for these babies, and so generally we're using somewhere between 70 to 100 units and then splitting them between the three muscles that we're targeting. And I assume that's the Onabotulinumtoxin A that you're using for that? Yes. And are you doing any sort of dilution with it, or is it like 100 units and 1 ml? Yes. Do you repeat that at all? No. I take that back. We are diluting it a little bit more to get spread, so that's – I think that it has been up to 3 ml, depending on the size of the child. Do you repeat that? We have in some cases where the child just seemed to have this refractory shoulder that would come back out, but I'm not sure that it's proven to be as successful. If you have to repeat it, these are often kids that definitely go on to have tendon transfer surgery because they have such mismatch in the shoulder muscles. And what's the earliest that you think about doing these injections? Generally right after three months of age, because that's when they're getting their first ultrasound. Do you have trouble getting insurance approval for these? Always. It takes us probably about a month to get the approval, so I guess the kids are more like four months old when they're getting it. But there's often a peer-to-peer that has to happen to get the approval because they're just not recognizing it as a treatment, even though we have a lot of literature that says it's effective and we can prevent future issues. It's a little bit of a fight. I can imagine. Sometimes we have it even for the spasticity ones, and we have so much literature for that. I'm just curious, with the splinting and the casting that you do in these babies, do they have any differences then in their development because they are restrained or in a certain position for a long time? Yeah, so thanks for asking that, too. We often counsel the families that because they're in the cast for six weeks after these injections, that they are going to have a little bit of a delay in their milestones. Most of the time the babies are going into cast at about four months, so they may miss a little bit of that rolling. They may be a little bit delayed in their sitting, but they tend to catch up pretty quickly. Most of these kids, because of their brachial plexus injury, are not crawling in the typical fashion, but it's really where we see rolling and sitting that might be a bit on the delayed side. Interesting. I was just seeing them in those splints was just thinking, hmm, I wonder if they have some trouble. Clearly, we haven't used a whole lot of that where I am at, and it's good to have those pieces to know that there are some other things that we can do to help them beyond the therapies and beyond the Botox injections. I don't see that there are any other questions at this point in time. I didn't know if there was anything else that you wanted to add or something that came up as we were going through the questions. I'm just thrilled to be asked to present on this topic and to share a bit about what we're working on here and hope that people can carry this forward for the future and make sure that the kids are getting the kind of care that they need. Thank you so much. I really appreciate you presenting on this topic with such breadth and depth and providing us these updates that are so helpful for all of our practices, both our trainees and those of us who've been in practice for a little while longer. With that, I would say thank you all for your attendance today. Please watch this also after the fact to catch those pieces, too. Thank you, Dr. Osorio, and thank you, Megan, for putting this on.

brachial plexus palsy

risk factors

shoulder subluxation

management algorithm

birth injuries

nerve surgery

head-to-toe evaluation

Botox

tendon transfer surgery