Introduction The Narakas classification (NC) is frequently used to characterise Brachial Plexus Birth Injury (BPBI). Since Narakas defined 5 groups (1986) and revised these into 4 (1987), heterogeneity in the classification’s interpretation has been suspected, with resultant inconsistencies in communication, paucity of validated evidence and proposal of subgroups by Al-Qattan. This study investigates the interpretation of the NC in literature and explores the importance of standardisation to enhance its value in BPBI. Methods Literature searching identified papers from 1986 to 2025 inclusive. Full texts defining at least 1 Narakas group were included; papers discussing adult injury or sensory grading were excluded. Data on study characteristics and their application of the NC were collected and appraised in relation to the original NC. Results Fourty-seven studies between 1999 and 2025 were included. NC definitions were significantly heterogeneous, thus coded into 9 categories to highlight nuances. Most frequent references were Narakas 1987 (n=23), Al-Qattan 2009 (n=12), and Narakas 1986 (n=5), with low concordance between NC and appropriate references cited. 4-group (1 to 4) definitions were commonest (n=34), followed by 5-group (1 to 4 with 2a/2b, n=7). 61.7% used Horner syndrome to distinguish Groups 3 and 4. 59.6% did not specify timing of NC assessment. Conclusion Significant heterogeneity exists in the interpretation and description of the NC in BPBI. Key variable themes include number of groups used (4 versus 5), Horner syndrome as a discriminator and timing of assessment. Standardisation of the NC description is critical to ensuring consistency of communication when discussing BPBI.

Background: Restoration of elbow flexion is a primary goal of brachial plexus birth injury (BPBI) reconstruction. Fascicular nerve transfer strategies include single fascicular transfer (SFNT) and double fascicular transfer (DFNT), but pediatric comparative data are limited. Methods: A multicenter retrospective cohort study included children undergoing nerve transfer reconstruction for BPBI at two tertiary centers. Procedures included SFNT or DFNT. The primary endpoint was biceps-specific elbow flexion, measured using the Active Movement Scale (AMS) with the forearm in supination. Secondary outcomes included forearm supination AMS. Continuous variables were compared using Mann–Whitney U tests, and baseline-adjusted regression was used to evaluate associations between transfer type and postoperative outcomes. Results: Fifty-eight children met the inclusion criteria (17 DFNT, 41 SFNT). Cohorts were comparable in age at surgery and follow-up. Preoperative supinated elbow flexion was lower in the DFNT group (p=0.03). Final postoperative biceps-specific elbow flexion was equivalent between techniques (median AMS 6 vs 6; p=0.28), although improvement from baseline was greater following DFNT (p=0.02). Baseline-adjusted analysis showed no independent association between transfer type and postoperative outcome. C7 involvement was associated with worse elbow flexion recovery, and DFNT did not compensate for this effect. Conclusions: In this multicenter pediatric cohort, DFNT did not improve final biceps-specific elbow flexion compared with SFNT, suggesting routine sacrifice of additional donor fascicles may be unnecessary in BPBI reconstruction.

BACKGROUND: Brachial plexus birth injury (BPBI) can result in persistent deficits and scapulothoracic abnormal motion (STAM), limiting overhead function. While contralateral trapezius transfer has traditionally been described as a tertiary procedure in adults, we apply this technique during primary shoulder reanimation in children to provide early dynamic scapular stabilization. METHODS: Eight pediatric patients with nontransient BPBI, suboptimal shoulder function, and STAM underwent combined shoulder reanimation and contralateral trapezius transfer at a single institution. Outcomes included Active Movement Scale (AMS) scores for shoulder abduction, flexion, and external rotation; modified Mallet scores; and clinical assessment of scapular symmetry, medialization, and shrugging. Nonparametric analyses and Wilcoxon signed-rank tests were performed. RESULTS: All patients achieved volitional scapular control, restoration of scapular symmetry, and significant improvement in shoulder AMS scores and indicated modified Mallet domains. No patient required secondary surgery for shoulder function; one patient underwent additional elbow reanimation. CONCLUSIONS: Incorporation of contralateral trapezius transfer during primary shoulder reanimation provides early dynamic scapular stabilization, improves functional outcomes, and may reduce the need for secondary procedures in children with BPBI.

This retrospective study aimed to compare two methods of reconstruction of the suprascapular nerve in neonatal brachial plexus palsy. Patients who underwent suprascapular nerve reconstruction for neonatal C5–C6 +/- C7) brachial plexus palsy were included if they had at least 3 years follow-up. The results obtained after nerve surgery alone and at the end of the follow-up (after shoulder release surgery) were analysed. The primary outcome was the range of external rotation with the arm at the side. Thirty-three patients were included (19 nerve transfers, 14 nerve grafting). At last follow-up (mean 10.5 years), there was no significant difference in terms of active external rotation, range of active movement or Active Movement Scale scores for the shoulder. Active external rotation was obtained in 23 of 33 cases, 21 by nerve repair alone and two after additional shoulder release. In the present series, nerve transfer and nerve grafting provided similar results for the suprascapular nerve.

Hypothesis: Medial pectoral nerve to axillary nerve transfer will significantly improve shoulder abduction and flexion scores on the Active Movement Scale in patients with brachial plexus birth injuries. Methods: A prospective analysis of 37 patients with brachial plexus birth injuries who underwent surgery at a tertiary pediatric hospital was conducted from January 1, 2019 to December 31, 2025. Patients included in the study underwent axillary nerve (AXN) neurotization via medial pectoral nerve (MPN) donor with accompanying spinal accessory nerve to suprascapular nerve transfer and single or double fascicular nerve transfer for elbow flexion. The primary outcome was shoulder flexion (SF) and shoulder abduction (SA) assessed via the Active Movement Scale (AMS) at one and two years postoperatively. Data was further stratified by injury pattern, C5-C6 vs C5-C7, and age at surgery. Results: A total of 37 patients completed one year follow-up; 27 patients have completed two-year follow-up. Twenty patients had a C5-C6 injury and 17 had an injury involving C5-C7. The average AMS SF score preoperatively was 2.57 (SD .96), at one year 4.68 (SD 1.49) and at two years 5.07 (SD 1.47). The average SA preoperatively was 2.51 (1.15), at one year 4.57 (SD 1.42) and at two years 5.15 (SD 1.41). At two years post operative, 77.8% and 74.1% of patients achieved AMS scores of 5 or greater in SA and SF, respectively. Conclusion: This evidence supports MPN to AXN neurotization in restoring shoulder function in pediatric brachial plexus birth palsies.

Background Selective neurotization of the infraspinatus using the spinal accessory nerve aims to restore active ER in permanent BPBI, but long-term outcomes remain incompletely reported. The purpose of this study was to evaluate long-term shoulder function following selective infraspinatus neurotization. Methods Twenty-six patients with BPBI who underwent selective spinal accessory nerve neurotization of the infraspinatus were enrolled in a prospective follow-up (FU) program. Median age at surgery was 2.2 years (IQR 1.6–2.8) and at FU 9.7 years (IQR 7.3–12.8). Active shoulder range of motion was assessed at surgery and final follow-up by therapists specialized in BPBI care. Median follow-up was 8.2 years (IQR 5.5–11.0). Pre- and postoperative values were compared using the Wilcoxon signed-rank test, and the association between follow-up duration and external rotation improvement was assessed using Spearman rank correlation. Results Active ER in adduction improved from a median of 0° (IQR −20–0) at surgery to 42.5° (IQR 21–50) at final follow-up, corresponding to a median gain of 45° (IQR 25–50) (p < 0.001) (Figure 1). ER in abduction improved from 45° to 70° (median gain 17.5°, p < 0.001). Shoulder abduction improved from 120° (IQR 100–140) to 152.5° (IQR 125–175), with a median gain of 20° (IQR 10–40) (p < 0.001). Improvement in external rotation did not correlate with follow-up duration, suggesting that functional gains were maintained over time. Conclusion Selective spinal accessory nerve neurotization of the infraspinatus provides durable improvement in external rotation with secondary gains in shoulder abduction at long-term follow-up in patients with permanent BPBI.

Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer is essential to restore shoulder abduction and external rotation in infants with brachial plexus birth injuries (BPBI), particularly in cases involving root avulsions. We modified the supraclavicular approach technique by mobilising the distal SSN stump posteriorly towards the trapezius and SAN, reducing the coaptation distance and ensuring a tension-free repair. We hypothesise that this modification improves reliability and functional outcomes. A retrospective, single-centre, single-surgeon review of 15 infants with BPBI who underwent brachial plexus exploration including SAN-SSN transfer between May 2014 and February 2022 was performed. Patients were evaluated pre-operatively using the Toronto Test Score. Outcomes included active shoulder external rotation in adduction beyond neutral, shoulder abduction, and requirement of secondary shoulder procedures. Eight patients underwent the conventional technique and seven the modified approach. Baseline characteristics were comparable between groups, including age at surgery (139.3 [SD 22.3] vs 146.7 [SD 64.7] days, p=0.76) and pre-operative test scores (3.2 [SD 2.7] vs 3.1 [SD 2.0], p=0.96). The modified technique resulted in improved active external rotation (41.4 degrees [SD 13.1] vs 11.9 degrees [SD 25.1], p=0.02) however no observed difference in active shoulder abduction (83.8 degrees [SD 49.8] vs 83.6 degrees [SD 32.0], p=0.99). In addition, fewer patients required subscapularis release and none required external rotation transfer in the modified technique group, although the difference was not statistically significant. Posterior mobilisation of the distal SSN to shorten the SAN-SSN distance improves active external rotation and may reduce the need for secondary shoulder procedures.

INTRODUCTION: Multiple strategies exist for treatment of type I palsies with no consensus on optimal approach. Given the limited data to guide management, the purpose of this study was to assess outcomes of different treatments for failed Cookie test at 9 months of age. METHODS: Amongst 585 patients presenting, 75 underwent primary nerve reconstruction. Twenty-eight were treated for a failed Cookie test and had adequate 2-year follow-up. Seven had exploration and sural nerve grafting, twelve underwent grafting with SAN-SSN, and nine underwent distal nerve transfers with no brachial plexus exploration. Demographics, avulsions, and age at reconstruction were similar amongst the groups. Pre and post-operative active movement scale scores for shoulder (abduction, adduction, internal rotation, external rotation ), elbow (flexion, extension), forearm (pronation, supination), wrist (flexion, extension), finger (flexion, extension), and thumb (flexion, extension) and Mallet scale scores were compared by Kruskal-Wallis rank-sum test. RESULTS: Pre-operative AMS scores for all limb motions were similar for the 3 groups. There were greater improvements in shoulder flexion after graft with SAN-SSN (1,0.75-1) and distal transfer (1, 1-1) compared to graft alone (0, 0-0) (p<0.05). Improvements were similar for graft with SAN-SSN and distal transfer. Mallet scores 2-years post-op were similar amongst the 3 groups. CONCLUSIONS: Outcomes of graft with SAN-SSN and distal transfers were similar. Distal transfers may be considered as an alternative treatment if there are adequate donors (confirmed by EMG) for all targets. Further study of donor adverse effects is needed.

Aim: In obstetric brachial plexus palsy, restoring balance is as crucial as restoring movement. The Switch procedure effectively addresses the functional imbalance of the Beggar's Hand deformity. This study revisits clinical experiences and presents the biomechanical rationale for its effectiveness. Background: Supination deformity limits forearm rotation and hand function, with common soft tissue pronatoplasty techniques lacking clear understanding of their biomechanical principles. This study compares two methods: the Switch technique and brachioradialis rerouting, focusing on their contributions to forearm balance. Methods: Eight cadaveric upper extremities were tested, with four specimens undergoing the Switch technique and four receiving brachioradialis rerouting. Measurements of pronation and radial deviation were taken under controlled loads. Clinical follow-up was performed on 23 patients who underwent Switch surgery, evaluating their performance and satisfaction. Results: Brachioradialis rerouting produced greater isolated pronation (114.6°) compared to the Switch (60°), but the Switch also corrected radial deviation by 35.6°. Significant clinical improvements were observed in the Switch patients over an average follow-up of 99.4 months. Conclusion: While brachioradialis rerouting offers higher pronation torque, the Switch technique not only restores adequate pronation but also corrects deformities, promoting forearm harmony as a dynamic soft-tissue balancer.

Introduction Data regarding modern normative humeral development are limited and based on small samples utilizing 2D imaging and insufficiently rigorous measuring techniques. The aims of this study were threefold, 1) to define humeral size and shape measures spanning infancy to adulthood (ages 0.6-18.8 years, n = 52), 2) determine if uninvolved limb in children with unilateral BPBP can be control values, and 3) quantify the 3D humeral shape pathology in 32 children with BPBP. Methods Three-dimensional humeri models were generated by segmenting axial MR images from humeri (MIPAV/Geomagic) and quantified based on a best-fit ellipsoid to the humeral head, a cylinder representing the proximal humeral shaft, and the epicondylar axis (MATLAB). Quadratic regression defined the relationship between each parameter and age. Results and Conclusion Normal humeri exhibited a pattern of steady growth, anteversion, and declination throughout development that gradually tapered off towards adulthood. Size measurements had the strongest regressions with age (head diameter: R2=0.908; humeral length: R2=0.960; epicondylar width: R2=0.889, p<0.001). Version was more variable and less strongly related to age (R2=0.238, p<0.001), whereas inclination demonstrated the weakest relationship with age (R2=0.128, p<0.05). The data did not support that there is a single age at which adult values were attained. The results support the use of the contralateral limb as a control when unilateral pathology is present. Bone growth inhibition, humeral anteversion and declination were observed in the affected limb. Humeral declination has never been reported and has clinical significance for the treatment of impaired arm elevation.

HYPOTHESIS: Most brachial plexus birth injuries (BPBI) demonstrate spontaneous neurologic recovery. Glenohumeral dysplasia (GHD) is a well-recognized sequela in persistent deficits and arises from asymmetric joint forces and disrupted neuromuscular regulation of growth. Infants with early neurologic recovery—often classified as “transient” BPBI and consistent with Seddon neuropraxia—are frequently discharged without further imaging or follow-up. We hypothesized that a subset of these infants remains at risk for GHD despite early recovery. METHODS: We performed a retrospective review of BPBI patients treated at a single academic institution between 2021 and 2025. Per institutional standard of care, all infants ≥6 weeks of age underwent routine shoulder ultrasound screening regardless of neurologic examination or apparent recovery. Patients with available imaging were classified as transient or persistent injury based on multidisciplinary consensus. Transient recovery was defined as Active Movement Scale (AMS) scores of 7 within two months. Three blinded reviewers independently measured glenoid alpha angles on ultrasound images using ImageJ software. Inter- and intra-observer reliability were assessed with intraclass correlation coefficients. RESULTS: Among 105 patients with ultrasound imaging, 10 (9.5%) met criteria for neurologically transient BPBI. GHD was identified in 4 of these infants (40%). All affected patients were female, born to multiparous mothers, and experienced shoulder dystocia. Reliability for alpha angle measurements exceeded 0.95. SUMMARY: A substantial proportion of infants with transient BPBI demonstrate early GHD on ultrasound. Physical examination alone may underestimate ongoing vulnerability of the developing shoulder. Routine imaging-based surveillance of BPBI infants, regardless of apparent neurologic recovery, may be warranted.

Background: Alpha angles are used to identify glenohumeral subluxation in infants with birth brachial plexus palsy (BBPP). Current literature identifies 30° as the upper limit of normal based on 13 ultrasounds. The aim of this study is to determine the normative alpha angle based on ultrasound of the unaffected side in a large cohort of infants with BBPP. Methods: From 2011-2026, infants with BBPP received screening ultrasound of bilateral shoulders at multiple time points. They were batched into age cohorts <3 months, 3-4 months, 5-6 months and ≥ 7 months to coincide with achievement of developmental milestones. Exclusion criteria were any fracture of the unaffected side and hypoxic ischemic encephalopathy, as these could impact extremity use. Results: Preliminary analysis of 124 ultrasounds showed a mean of 26.71° (median 26, SD 5.76, range 10-45°). Twenty-four infants (19%) had alpha angles >30°, range 31-45°, with a mean of 35.41° (median 34, SD 4.07). When subdivided by age, the mean for infants < 3months was 27.94° (median 27, SD 6.68); 3-4 months was 26.38° (median 26, SD 5.77); 5-6 months was 27.08° (median 26, SD 3.81), and ≥ 7 months was 22.71° (median 24, SD 5.99). Additional data analyses will be available at the time of the meeting. Conclusions: The average alpha angle is 27° with a trend toward higher measurements in younger infants. Therefore, when performing screening ultrasound in BBPP, the contralateral side should be imaged to determine the baseline and intervention thresholds adjusted accordingly.

In patients with obstetric brachial plexus injury (OBPI), glenohumeral dysplasia is known to affect shoulder function and may influence surgical outcomes. This study aimed to evaluate the impact of glenohumeral dysplasia on postoperative shoulder rotational balance. A total of 44 surgically treated patients (20 females, 24 males) were included. The affected side was right in 26 and left in 18 cases. Clinical involvement was classified as Narakas Type 1–2 in 38 (86.4%) and Type 3–4 in 6 (13.6%) patients. According to the Waters classification, patients with significant dysplasia were assigned to Group A (Waters 3–7, n=14), while those without dysplasia were assigned to Group B (Waters 1–2, n=30). Group A underwent combined surgery (anterior release and tendon transfer). Group B was subdivided into Group B1 (combined surgery, n=12) and Group B2 (tendon transfer only, n=18). Changes (Δ) in Mallet scores between Groups A and B showed no significant differences in global external rotation, hand-to-spine, or internal rotation (p>0.05). However, the improvement in hand-to-neck scores was significantly greater in Group A (p=0.024). Subgroup analysis comparing combined procedures (Group A vs. B1) demonstrated that the presence of dysplasia did not significantly influence changes in global external or internal rotation, whereas improvement in hand-to-neck function remained significantly greater in Group A (p=0.017). Postoperative improvement in external rotation appears to be more pronounced in patients with glenohumeral dysplasia, while internal rotation decreases similarly regardless of dysplasia. These findings suggest that glenohumeral dysplasia may differentially influence functional outcomes following reconstructive shoulder surgery in OBPI patients.

Purpose Glenohumeral dysplasia(GHD) is a recognized sequela of brachial plexus birth injury(BPBI), but its earliest manifestations are not well defined. This study aimed to characterize glenohumeral morphology in young infants with BPBI using MRI, determine the prevalence of early changes, and assess associations with clinical and injury-related factors. Methods A multicenter retrospective review was conducted of infants who underwent brachial plexus MRI between 28 days and 4 months of age. Infants were included if both glenohumeral joints were visualized. Morphologic measures included Waters classification, percent humeral head anterior to the scapular line (PHHA), glenoid version, and glenoid version deviation (GVD). Clinical variables included Narakas classification, recommendation for nerve surgery, passive shoulder external rotation, and Active Movement Scale scores. Results Thirty-one infants met inclusion criteria. Nineteen (62%) demonstrated early glenohumeral changes, including 7 with both glenoid deformity and humeral head subluxation. Despite these abnormalities, there was substantial overlap in mean PHHA and glenoid version between affected and contralateral shoulders. No significant associations were found between imaging findings and clinical measures, Narakas group, or recommendation for nerve surgery. Passive shoulder external rotation remained within normal range, even in infants with more pronounced dysplasia. Conclusions Early glenohumeral changes are common in infants with BPBI but may be subtle and difficult to distinguish from normal variation. Clinical findings and injury severity were not associated with early dysplasia, suggesting that measurable functional limitations may develop later. Longitudinal studies are needed to clarify the natural history and prognostic significance of these early findings.

Background: Internal rotation contracture following obstetric brachial plexus injury (OBPI) may progressively lead to severe glenohumeral dysplasia, posterior humeral head subluxation, and major functional limitation. Current management increasingly favors joint-centered reconstruction aimed at restoring glenohumeral congruity in advanced dysplastic shoulders. Purpose: To evaluate the clinical and radiological outcomes of glenoid osteotomy in children with severe glenohumeral dysplasia secondary to OBPI. Methods: A retrospective review was conducted on 33 children treated with glenoid osteotomy between 2014 and 2025. Preoperative assessment included clinical evaluation using the Mallet score and CT scan analysis to assess glenoid retroversion, posterior humeral head subluxation, and severity of dysplasia. Surgical management was individualized according to glenohumeral morphology and included glenoid osteotomy associated, when required, with soft-tissue release and/or tendon transfer. Outcomes were assessed at a mean follow-up of 6.4 years. Results: Significant improvement was observed in shoulder external rotation, abduction, and global Mallet score. Radiological evaluation demonstrated improved humeral head centering with substantial glenohumeral remodeling in most patients. Functional improvement was maintained at latest follow-up. No major complications or significant recurrence were observed. Conclusion: Glenoid osteotomy addresses the underlying articular deformity and represents a valuable reconstructive option in severe glenohumeral dysplasia secondary to OBPI. Careful preoperative assessment of glenohumeral morphology is essential to optimize surgical strategy and outcomes.

Aim: To examine the relationship between active shoulder external rotation recovery and passive glenohumeral mobility in children with upper-trunk brachial plexus birth injury (BPBI) after nerve surgery. Method: This observational cohort included children with upper-trunk BPBI who underwent primary surgery of the C5 and/or C6 spinal nerves with 2 or more years of follow-up. Linear mixed models were used to analyse passive and active external rotation in adduction at ages 1, 3, 5, 7, and 15 years, adjusted for diagnosis and suprascapular nerve reconstruction strategy (grafting, transfer, neurolysis). Results: We included 322 children (142 males and 180 females), with a mean (SD) follow-up of 7 years 7 months (4 years 7 months); median age at surgery was 5 months (interquartile range = 4–6 months). Active external rotation increased on average by 2.1°per year (95% confidence interval [CI] = 1.4° to 2.8°, p< 0.001), while passive external rotation decreased on average by 2.6° per year (95% CI = 2.2° to 3.0°, p < 0.001). Passive external rotation was on average 65° (95% CI = 62° to 68°, p< 0.001) greater than active external rotation. The difference decreased by 4.5° per year (95% CI = 3.8° to 5.2°,p < 0.001). At age 15 years, a difference of 36° (95% CI = 29° to 43°) remained. Interpretation: Passive external rotation is not the explanatory limiting factor in the restoration of active external rotation after nerve surgery in children with upper-trunk BPBI.

Purpose: The spinal accessory nerve (SAN) is frequently utilized as a donor for reinnervation of the suprascapular nerve (SSN) in the reconstruction of brachial plexus injuries (BPI), and this procedure can be performed using either the anterior or posterior approach. This study aimed to compare postoperative shoulder functional outcomes following the anterior and posterior approaches. Methods: Between 2017 and 2022, 48 adult patients with complete palsy following a closed BPI underwent surgery. Inclusion criteria were surgery performed at least 9 months after injury, patients aged between 16 and 60 years, and a minimum follow-up period of 2 years. A total of 38 patients met these criteria. The anterior approach was performed in 18 patients, while the posterior approach was used in 20. Shoulder function was assessed at the 2-year follow-ups, including shoulder abduction strength, range of motion (ROM), and external rotation (ER) strength and ROM. Results: The posterior approach group demonstrated significantly greater shoulder abduction strength and ER strength compared to the anterior approach group. The median shoulder abduction ROM in the posterior approach group was significantly greater than that of the anterior approach group. The median shoulder ER ROM of the posterior approach group was also significantly greater than that of the anterior approach group. Conclusions: The posterior approach in SAN transfer to SSN resulted in superior shoulder function outcomes compared with the anterior approach. These findings suggest that the posterior approach may be preferable for optimizing shoulder function recovery in adult patients with complete BPI.

Aim: To review outcomes and complications of shoulder reconstruction, including accessory to suprascapular nerve transfer, after traumatic supraclavicular brachial plexus injury. Methods: Patients undergoing accessory to suprascapular nerve transfer between 2001 and 2023 were identified. Transfers were performed via an anterior approach preserving upper trapezius innervation. When possible, the axillary nerve was reconstructed using C5 nerve grafts or transfer of the medial head of triceps branch. Results: Forty-six patients (mean age 31 years) were included, most injured in road traffic accidents. Mean surgical delay was 96 days. Axillary nerve reconstruction was performed in 36 cases. Follow-up was available for 41 patients (mean 36 months). Median active shoulder abduction was 80° (range 30-180). Median external rotation was 0° (-40 to 70). No patients over 40 years achieved >90° abduction. Median abduction for patients who had nerve grafts for the axillary nerve was 90° (30-180), 70° (range 30-160) for triceps nerve transfers, and 50° (30 – 90) for those with no repair (p = 0.04). Shoulder abduction decreased with increasing extent of the initial injury, 110° for C5-6, 80° for C5-7, 80° for C5-8, and 40° for C5-T1 (p = 0.006). Five patients developed scapular instability related to lower trapezius weakness. Conclusions: Accessory to suprascapular nerve transfer combined with axillary nerve reconstruction can achieve satisfactory shoulder abduction, although outcomes are influenced by patient and injury factors. Nerve grafting of the axillary nerve should be considered when the C5 root is viable, and the risk of scapular instability must be recognised.

INTRODUCTION Spinal accessory to suprascapular transfer is an effective surgical option for traumatic brachial plexus injuries for shoulder abduction and external rotation. MATERIALS AND METHODS This retrospective case series between February 2014 to February 2025. Total of 42 cases of upper and total plexus injuries underwent neurotization. Inclusion criteria included irreparable injuries to spinal roots C5, C6, C7, C8 and T1. Surgery was done within 3 to 12 months of injury. Procedure used for shoulder - transfer of spinal accessory to suprascapular in all. All procedures done through posterior approach. Somsak procedure done in 20. For elbow flexion, Oberlin in 32 patients, Oberlin I and II in 14 patients. In pan plexus injury - for elbow flexion intercostal to musculocutaneous transfer was done in 10. RESULTS Motor recovery based on MRC scoring. In shoulder abduction, 30 scored M4, M3 in 8, M2 in 2 and M1 in 2. In external rotation - M4 in 12, M3 in 12, M2 in 14, M1 in 4. Suprascapular and spinal accessory transfer through posterior approach is a consistent procedure to achieve functional recovery of shoulder abduction after upper and pan plexus injuries but outcome of external rotations were quite disappointing. CONCLUSION In young patients with short denervation time, direct transfer close to the target muscle decided good functional outcome. Terminal branch of spinal accessory to suprascapular nerve transfer is a common procedure to restore shoulder abduction. Posterior approach allows transfer closer to the target muscle and treat possible double crush injury to nerve.

Since its introduction in 1994, Oberlin’s technique has marked a turning point in the treatment of partial brachial plexus palsies. On the basis of this seminal concept, the authors have progressively refined surgical techniques for elbow reanimation over the past two decades. Emerging limitations of the original procedure have been critically analyzed and gradually overcome, resulting in improved overall outcomes. Medial cord transfer techniques (using one or two fascicles from the medial cord as donors), along with their variants concerning the recipient nerve— i.e. transfer to the musculocutaneous nerve, first reported in 2014, and to the anterior contribution of the upper trunk, first reported in 2017—have become the cornerstone of this strategy. Their specific indications and the results obtained in more than 500 patients are presented and discussed.

BACKGROUND Treatment priority in C5-C6-C7 brachial plexus root avulsion is the recovery of shoulder function through reinnervation of shoulder muscles. The medial pectoral nerve is a potential donor for axillary nerve transfer, but outcomes are sparsely reported. This study reports the results of medial pectoral nerve transfer to the axillary nerve. METHODS We conducted a retrospective analysis of 12 patients with traumatic brachial plexus injury (C5-C6-C7 root avulsion) who underwent medial pectoral nerve transfer to the axillary nerve. Sociodemographic and clinical characteristics, including electromyography findings, were documented. We assessed postoperative shoulder abduction strength and range of motion. Statistical analyses compared pre- and post-surgery outcomes and contrasted our results with those from a study using spinal accessory nerve transfer to the suprascapular nerve. RESULTS Post-surgery, the mean shoulder abduction range of motion was 65.45°, with a median strength of M2. Significant improvement was noted compared to preoperative values. However, outcomes did not significantly surpass those from spinal accessory nerve transfer. Electromyography showed a low incidence of motor unit action potentials in the deltoid. CONCLUSION Medial pectoral nerve transfer to the axillary nerve did not yield superior results in shoulder abduction and deltoid reinnervation in our group of patients. At present, different nerve donors may also need to be considered for deltoid muscle reinnervation in patients with C5-C6-C7 root avulsion to achieve better shoulder abduction recovery.

ABSTRACT BACKGROUND AND OBJECTIVES: Nerve transfers are crucial to upper brachial plexus reconstruction, and we describe a posterior approach for harvesting an ulnar nerve fascicle to reanimate posterior targets in C5–C7 injuries. METHODS: Twelve patients with traumatic upper brachial plexus injuries underwent staged nerve reconstruction between 2018 and 2025, including transfer of a selected ulnar nerve fascicle harvested through a posterior arm approach. The fascicle was transferred to the anterior branch of the axillary nerve or, in selected cases, to the motor branch of the long head of the triceps with outcomes assessed at ≥18 months RESULTS: Nine patients completed follow-up, all achieving meaningful functional recovery (MRC M3–M4) of shoulder abduction or elbow extension without clinically significant ulnar donor morbidity. CONCLUSION: Posterior approach for ulnar nerve fascicle harvest is a safe, reproducible technique that expands donor options for deltoid and triceps reanimation in extended upper BPIs.

Purpose: Tendon transfers are a routine procedure used to improve hand function in brachial plexus injuries; however, muscles from forearm donors are not always available for transfer. In this situation a proximal muscle may be used. This study describes transfer of the brachialis muscle to the forearm muscles to reconstruct finger flexion in patients with traumatic brachial plexus injuries. Methods: In 5 patients age between 21-55 years the brachialis muscle was transferred to the flexor digitorum profundus and the flexor pollicis longus to restore finger and thumb flexion with the goal of reconstructing a key pinch and hook grasp. Other procedures like wrist artrodesis bone graft to 1st web space pronator teres transfer to EDC were also performed The patients had final assessments between 10 and 12 years after surgery. Results: Brachialis transfer to the flexor digitorum profundus and the flexor pollicis longus resulted in active motion with full range of digital flexion in the 2 patients who had partial flexion before surgery, and for the 4 patients who had no finger flexion before surgery it resulted in a pulp-to-palm distance 0f 2.5-6 cm (median 4.3). Conclusions: Brachialis muscle transfer to the forearm muscle constitutes a valid strategy in the reconstruction of finger and thumb flexion after brachial plexus injury when forearm donor muscles are not available.

Background: A guiding principle of nerve transfers is to use healthy nerve donors. There is a lack of literature exploring if and when abnormal nerve donors can successfully reanimate upper extremity nerve injury. Objectives: To understand when abnormal nerve donors are used at a multidisciplinary nerve transfer clinic and to characterize the factors that influence outcomes when using an abnormal nerve donor. Results: 30 participants who received upper extremity nerve transfers consented to participation. Of these participants, five individuals received nerve transfers using an abnormal nerve donor, which was characterized by abnormal strength and reduced motor unit recruitment on needle EMG to donor-innervated muscles. All of the participants had traumatic brachial plexopathy. Surgical interventions included medial triceps to axillary (n = 2), brachialis to AIN (n = 1), ADM to recurrent median motor (n = 1), and median fascicle to musculocutaneous (n = 1) nerve transfers. Most participants had no pre-operative recipient muscle strength. Three individuals achieved 4/5 MRC grade strength in recipient muscles after surgery; these individuals all had 4/5 strength in donor-innervated muscles prior to surgery. Two participants had poor recovery in recipient muscle function after surgery. One individual had less than antigravity donor-innervated muscle strength prior to surgery. The other participant received a triceps to axillary nerve transfer in the context of a significant scapular fracture, with an irreparable suprascapular neuropathy. Conclusion: Recipient muscle function can potentially be improved in select individuals with the use of abnormal nerve donors, particularly if pre-operative donor-innervated muscle strength is 4/5.

The Oberlin transfer is widely regarded as one of the most reliable procedures for restoration of elbow flexion following upper brachial plexus injury. Published series consistently report excellent functional outcomes and negligible donor-site morbidity. Consequently, the procedure is often perceived as technically straightforward and biologically safe. However, this perception may underestimate the importance of donor nerve selection and fascicular harvest in patients with limited residual hand function. Methods We reviewed a referral series of nine patients presenting after failed Oberlin reconstruction performed at external institutions. All patients developed immediate postoperative hand weakness and were referred because of persistent donor-related deficits, failure of elbow flexion recovery, or both. Clinical findings, grip strength, and elbow flexion outcomes were analyzed. Permanent hand motor deficits were observed in all patients. Ulnar nerve dysfunction predominated, with intrinsic muscle paralysis, clawing and marked grip strength reduction. Six of nine patients also failed to achieve useful elbow flexion recovery. The coexistence of donor-site morbidity and recipient failure suggests a common underlying mechanism: insufficient donor nerve reserve, inappropriate fascicular selection, excessive intraneural manipulation or a combination of these factors. Several patients subsequently required secondary reconstructive procedures. This series does not challenge the effectiveness of the Oberlin procedure itself. Rather, it highlights an underrecognized concept: donor nerves are not universally expendable. In patients with extended upper plexus lesions, particularly C5-C8 patterns with T1-hand involvement, donor nerve vulnerability may compromise both hand function and elbow reinnervation. Awareness of donor nerve vulnerability may represent an important step toward safer patient selection.

Introduction Management of upper trunk (C5-C6) brachial plexus injuries favors nerve transfers over grafting in the adult, but the comparative benefit in infants is unclear. This study compared functional outcomes and secondary surgery rates after nerve grafting versus nerve transfer in infants with operative C5-C6 injuries. Methods We performed a retrospective cohort study of patients undergoing nerve reconstruction for BPBI at Boston Children’s Hospital (2000-2025) using our institutional registry. The cohort included patients with C5-C6 injuries treated with primary nerve surgery. All subjects had ≥2 years of follow-up with AMS and/or Toronto scores. Patient characteristics were summarized by treatment type, and multivariable regression compared outcomes controlling for age at surgery and baseline physical exam scores. Results Fifty-four patients were treated with nerve grafting and 69 underwent nerve transfers. Nerve graft patients were younger (6 vs 7 months) with lower baseline Toronto (2 vs 6) and AMS scores (48 vs 63). After adjusting for baseline AMS and age at procedure, nerve transfer showed no clear advantage at each time point, with overlapping 95% confidence intervals and point estimates favoring nerve graft at 24 months. There was no difference in secondary procedure rates between groups. Conclusion Despite lower baseline physical exam scores, graft patients showed greater improvement, leading to equivalent outcomes at 2 years. Nerve grafting and nerve transfer achieve similar motor recovery, supporting continued use of grafting. Surgical selection should remain individualized based on injury pattern and spontaneous recovery.

Background: The relationship between Brachial Plexus Birth Injury (BPBI) and humeral shaft fractures (HSF) remains poorly described. This study examines the association between birth-related HSFs and BPBI. Methods: In this retrospective case-control study (11/2011-11/2022), we included BPBI patients with a concurrent HSF. Two control groups included BPBI patients without fractures and HSF patients without BPBI. Medical records provided demographics, perinatal data, BPBI disease severity measurements, and surgical indications. Nonparametric and categorical statistical tests were performed with post hoc correction, with significance at p-adj<0.05. Results: Of 1136 BPBI patients, 23(2.0%) had a concomitant birth-related HSF. Among 42 HSF patients, 18(42.9%) had a contralateral BPBI, 5(11.9%) had an ipsilateral BPBI, and 19(45.2%) had no associated BPBI. Contralateral and ipsilateral injuries were associated with shorter follow-up than BPBI without fracture (40.5 months, 1, 137.5). Contralateral injury was associated with lower rates of transient BPBI (11.1%, 80%) and higher rates of primary surgery (66.7%, 0%) than ipsilateral injury. Contralateral injuries were associated with higher rates of shoulder dystocia compared to ipsilateral injuries and no BPBI (100%, 40%, 70.6%). Conclusions: HSF incidence in this BPBI population was 20.25 per 1000 live-births, exceeding 0.10 per 1000 reported in the general population. All patients with ipsilateral injuries had full resolution of BPBI and HSF healing within 1 year, indicating less severe injury patterns, while contralateral injuries better resembled previously described BPBI outcomes as well as the control group. These findings emphasize the importance of evaluating both arms for BPBI when a birth-related HSF is present.

Background: Interposition nerve grafting is widely used for reconstructing neonatal brachial plexus palsy (NBPP). While the sural nerve graft has historically been the gold standard, the supraclavicular nerve offers the advantage of plentiful donor nerve graft within the operative field. This study reports the outcomes of using supraclavicular nerve grafts for NBPP reconstruction. Methods: We performed a single-center retrospective review of patients with NBPP who underwent supraclavicular nerve grafting between January 2011 and 2023 with ≥18 months of follow-up. Demographic characteristics, injury location, surgical details, preoperative and postoperative Active Movement Scale (AMS) scores, and additional therapies were recorded. Results: Thirty-three patients met the inclusion criteria. Reconstruction was performed at a median of 9.7 [5.9, 17.8] months of age. Most (87.9%) had upper trunk injuries, primarily right-sided (69.7%). Average operative time was 5.48 ± 1.2 hours. At a median follow-up of 25.5 months, over 60% of patients achieved initial motor recovery (>2-point AMS improvement) in shoulder and elbow flexion, and >50% achieved antigravity function (AMS ≥5) in most, but not all, movements. Patients operated on after 12 months had less favorable outcomes, including reduced movement in some cases. Complication rate was low, with two wound infections (6.1%) and one case of transient elevated hemidiaphragm (3.0%). Conclusion: Early supraclavicular nerve graft is an effective donor for NBPP reconstruction, providing favorable motor recovery and antigravity strength. Timing of surgery plays a crucial role in optimizing functional outcomes, with earlier repairs showing the best results. Secondary procedures may be performed to maximize functional recovery.

Objective: This study aimed to compare the outcomes of nerve grafting and nerve transfer for SSN reinnervation in upper trunk BPBI. Methods: A retrospective study (1990-2020) on prospectively collected data of children with a C5-C6 or C5-C6-partial C7 BPBI who underwent SSN grafting or transfer, with a minimum follow-up of 2 years. Outcome was assessed in degrees of active External Rotation (ER) and Mallet subscores for hand-to-mouth, hand-to-head, and ER. The frequency of secondary shoulder procedures (tendon transfer and/or anterior release) in both groups was also analyzed. Results: We included 245 patients with a mean follow-up of 7.6 ± 4.3 years: 179 (73%) underwent C5-SSN grafting and 66 (27%) XIN-SSN transfer. The nerve transfer group demonstrated an active range of ER that was 30° (95% CI 12°-49°, p = 0.002) larger than that of the nerve grafting group, adjusted for sex, birth weight, and diagnosis. At age 3 years, 33% of children achieved Mallet IV ER after nerve transfer compared with 17% after nerve grafting (p = 0.002). Hand-to-mouth and hand-to-head scores were similar between the groups. The 10-year cumulative risk of subsequent shoulder procedures was 30% (95% CI 23%-37%) for nerve grafting and 24% (95% CI 13%-35%) for nerve transfer (nonsignificant). Conclusions: XIN-SSN transfer results in superior active ER compared to nerve grafting. Future studies should investigate whether the long-term impact of trapezius muscle loss is acceptable, to determine whether nerve transfer should be prioritized over grafting in the presence of a graftable C5 root.

Aim: To examine the relationship between active shoulder external rotation recovery and passive glenohumeral mobility in children with upper-trunk brachial plexus birth injury (BPBI) after nerve surgery. Method: This retrospective analysis included children with upper-trunk BPBI who underwent primary surgery of the C5 and/or C6 spinal nerves with 2 or more years of follow-up. Linear mixed models were used to analyse passive and active external rotation in adduction at ages 1, 3, 5, 7, and 15 years, adjusted for diagnosis and suprascapular nerve reconstruction strategy (grafting, transfer, neurolysis). Results: We included 322 children (142 males and 180 females), with a mean (SD) follow-up of 7 years 7 months (4 years 7 months); median age at surgery was 5 months (interquartile range = 4-6 months). Active external rotation increased on average by 2.1° per year (95% confidence interval [CI] = 1.4° to 2.8°, p < 0.001), while passive external rotation decreased on average by 2.6° per year (95% CI = 2.2° to 3.0°, p < 0.001). Passive external rotation was on average 65° (95% CI = 62° to 68°, p < 0.001) greater than active external rotation. The difference decreased by 4.5° per year (95% CI = 3.8° to 5.2°, p < 0.001). At age 15 years, a difference of 36° (95% CI = 29° to 43°) remained. Interpretation: Passive external rotation is NOT the explanatory limiting factor in the restoration of active external rotation after nerve surgery in children with upper-trunk BPBI.

LOSS OF INTERNAL ROTATION: A Severe Complication After Anterior Shoulder Release (About 46 Cases) A. Benamirouche, F. Bessaa, A .Gilbert INTRODUCTION We report here our observations about 46 cases have lost their internal rotation after anterior release. 46 anterior releases operated on by other surgers in other departments. 32 boys / 14 girls. Mean age 3,2 years, average 20 months to 5 years. 35 Erb’s palsy and (11) Erb + C7 palsies. All in internal contracture attitude with horn sign of minimum 80º Operating protocol was available in 34 cases: 20 resections of the coraco-humeral ligament and the upper side of the capsule; 14 sections of the upper 1/3 of the subscap tendon. Results: Physical exam: attitude in external rotation of the shoulder at rest. Lack of internal active rotation of the shoulder: 33 can’t reach their belly. 16 have a lack of medial active rotation of 40 – 60º 17 cases no medial rotation at all 13 can reach their belly in flexion of their wrist Excess of external rotation in 4 cases Deficit in medial rotation is aggravated with LD transfer Discussion: Stiffness in medial rotation is due to the retraction of the soft tissues, mainly the subscapularis muscle, the anterior capsule and the coracohumeral ligament. the risks of this anterior release surgery are, anterior dislocation during extensive release and loss of active medial rotation. Conclusion : the release of the sub-scapularis described by Carlioz and Brahimi and popularized by Gilbert is the most physiological technique,

Impaired shoulder function, particularly external rotation, has a significant impact on the overall function of the upper extremity. This limitation is common in patients with obstetric brachial plexus palsy who have undergone reinnervation, either spontaneously or following surgical treatment. To improve shoulder abduction and external rotation, joint release combined with nerve transfer is commonly performed. In selected cases, tendon transfer may also be indicated. We retrospectively reviewed a series of 32 patients treated between 2021 and 2024 with the aim of improving shoulder function in children aged 9 to 28 months and objectively evaluating the functional recovery achieved after surgery. Our results suggest that preoperative assessment of the motor function of the supraspinatus, infraspinatus, deltoid, and biceps muscles is essential. When the compound muscle action potential of these muscles is less than 50% of that of the contralateral healthy side, joint release combined with nerve transfer is indicated and appears to significantly improve functional recovery of the shoulder

Objective: This study evaluated intra-operative factors on functional hand recovery. Methods: A retrospective analysis was performed on a consecutive series of children with total BPBI who underwent nerve reconstructive surgery (1994-2020). We evaluated the association between intra-operative factors (i.e. the number of proximal stumps, the selection of proximal versus distal targets, and selective coaptation to motor fascicles) and hand outcome, measured by the Raimondi score. A Raimondi score of ≥3 was defined as functional outcome. Results: 43 children with complete loss of continuity of C8 and T1 were included in the analysis, average age at surgery was 4.2 months. After primary surgery, 47% (20/43) achieved a functional outcome, and following secondary procedures, 53% (23/43) attained a functional hand (mean follow-up 8 years). The number of available proximal stumps was significantly related with hand function outcome (p=0.042). In the four children where only one stump was available, only one child had a functional outcome (25%), while all children with four proximal stumps (5/5) achieved functional outcomes, children with two or three stumps achieved a functional hand status in 43% and 50%, respectively. Conclusion: Achieving functional hand recovery in children with total BPBI is feasible following primary nerve reconstruction and increase after secondary surgical interventions. Future research should optimize surgical strategies, particularly in cases where intra-plexal donor nerves are limited. Multicenter studies are necessary to further elucidate the ideal nerve root reconstruction strategy for achieving optimal hand function in children with complete BPBI.

Introduction: Indian data integrating the entire spectrum of birth palsy—from natural history to functional outcomes—remain limited. Aim: To describe the clinical profile, natural history, predictors of spontaneous recovery, prevalence and impact of co-contractions, indications and outcomes of primary nerve reconstruction and secondary shoulder surgery, and long-term functional results in a prospective cohort of 114 infants with BBPP. Methods: Infants and children (≤10 years) with BBPP were evaluated using a standardised protocol. Data on demographics, obstetric risk factors, age at presentation, Narakas grade, co-contractions, electromyography (EMG), MRI, conservative management, BTX, primary nerve surgery and secondary procedures were recorded. Functional outcomes were assessed using the Modified Mallet score (shoulder function), Modified Medical Research Council (MMRC) grading (muscle strength) and Raimondi score (hand function). Results: 114 children were included; 52% were male and 63% had right-sided palsy. Narakas types I–IV accounted for 44.7%, 42.0%, 4.3% and 8.8% respectively. Shoulder dystocia was present in 69%). Overall, 71 children (62.3%) achieved satisfactory spontaneous recovery, while 43 (37.7%) underwent primary nerve reconstruction between 3 and 9 months. 74 children underwent secondary shoulder surgery. In the surgical group, MMRC scores improved significantly across all major muscle groups, and Raimondi scores improved from 2.76 ± 0.58 to 4.30 ± 0.50 (p ≪ 0.001), indicating a shift from non-functional to useful hand. In the spontaneous group, Conclusion: Absence of antigravity biceps at 3 months, Narakas grade, hand involvement, co-contractions and delayed referral were strong predictors of poor spontaneous recovery and the need for early nerve reconstruction.

In adult traumatic brachial plexus cohorts, around two thirds of patients have at least one root avulsion. Early surgical exploration and nerve reconstruction avoids losing critical time for meaningful reinnervation. Accurate identification of preganglionic lesions within the first post‑traumatic weeks remains difficult, as clinical examination and electrodiagnostic studies are unreliable. Several studies have evaluated the diagnostic accuracy of MRI for detecting root avulsions on subacute or late cohorts of traumatic adult brachial plexus injuries, generally reporting only modest sensitivity and specificity. The performance of high‑resolution MRI in the acute phase is still uncertain. Therefore, we evaluated the accurately of high‑resolution MRI in detection of cervical root avulsions within the first 4 weeks after adult traumatic brachial plexus injury. From our ATBPI database of 241 cases we evaluated 80 cases (n=45 ultra-early). We compared the radiological diagnosis of cord–root continuity, pseudomeningocele, intradural hemorrhage, dorsal root ganglion displacement per root with perioperative findings. Clinical findings (Horner's syndrome, deafferentiation pain and complete dermatomal anaesthesia) were added to the analysis. Findings will be discussed and a strategy to improve diagnostic accuracy is presented.

Purpose: To assess the degree of brain plasticity in patients with neonatal brachial plexus palsy (NBPP) treated with contralateral C7 nerve transfer, using the Plasticity Grading Scale (PGS). Methods: During a recent visit to Ankara, Turkey, one of the authors (MS) independently examined a series of patients who had previously been operated on by the senior author (GL). Eligible patients had NBPP and underwent a nerve transfer from the contralateral healthy C7 root to one or more targets within the affected brachial plexus several years earlier. The primary outcome was the PGS score. Results: Twelve NBPP patients were included. All achieved a Medical Research Council (MRC) grade of M4 in the targeted muscles, together with a very good sensory recovery. By contrast, all transfers received a PGS score of 1 for motor function (poor independence between donor and acceptor, and poor voluntary control by the donor), while all patients showed very good plasticity in sensory recovery, including independent sensation discrimination between the two upper limbs. Conclusion: In contrast to previous reports on intraplexal (homolateral) nerve transfers, our findings suggest that infants with NBPP have a markedly lower capacity for plastic cortical motor rewiring when the donor is the contralateral C7 root, and better results for sensory independent recovery. This does not diminish the clinical value of the procedure — on the contrary, all patients achieved an MRC grade of M4 — but it has important implications for how plasticity should be conceptualized and counseled in this patient group.

OBPP is a complex form of peripheral nerve damage, the long-term functional consequences of which depend largely on the extent and location of the initial lesion. A common question of parents at an early stage relates to the development of handedness from their children. Handedness is approximately 25% genetically determined, but external factors also have a significant influence on its development. We investigate the relationship between patients’ handedness and the injury pattern identified intraoperatively, including the determination of the extent of injury during primary exploration of brachial plexus. In our retrospective analysis we included patients with OBPP who underwent surgical exploration. The lesions were categorised according to the Bahm classification. Handedness was assessed using the Edinburgh Handedness Inventory (EHI). A statistical analysis was performed to investigate correlations between lesion severity, the affected side and the development of dominant hand function. The results suggest that the initial characteristics of the lesion may have a significant influence on subsequent handedness. In particular, patients with more severe lesions were more likely to show a shift in handedness to the contralateral, unaffected side. However, a preference for the unaffected side can also be observed in cases of less severe injury. The present data underscore the importance of a differentiated intraoperative classification for the prognostic assessment of functional outcomes. A better understanding of the relationship between injury pattern and handedness can contribute to the optimisation of individual treatment and rehabilitation strategies and offers important implications for counselling the families of affected children.

Obstetrical brachial plexus injury (OBPI) requires specialized rehabilitation across surgical and developmental stages. Aquatic occupational therapy (AQT) leverages buoyancy and hydrodynamic properties to facilitate upper extremity motor recovery, yet evidence supporting its use in OBPI remains limited. This study evaluates functional outcomes following AQT in a pediatric OBPI cohort. A retrospective cohort analysis of 16 pediatric patients with OBPI who received AQT was conducted. Primary outcomes included the Active Movement Scale (AMS), Mallet Scale, and passive shoulder range of motion. Pre- and post-AQT outcome measures were compared using the Wilcoxon signed-rank test. The cohort was predominantly female (75%), with left-sided involvement in 68.75% of patients and a mean birth weight of 4.05 ± 0.96kg. 75% underwent surgery prior to AQT, with AQT initiated a mean of 732 ± 1210.5 days postoperatively. Patients completed 11.88 ± 4.29 sessions over 8.38 ± 2.45 weeks. Mallet Scale scores improved significantly following AQT (20.17 ± 2.86 to 22.33 ± 5.05; p= 0.026). AMS scores showed a positive trend (69.83 ± 21.8 to 76.09 ± 22.78; p=0.074), while passive shoulder range of motion remained stable. AQT is associated with significant improvements in functional upper extremity performance in pediatric OBPI, evidenced by Mallet Scale gains and a positive trend in active movement. Given considerable variability in surgical history and time to AQT initiation (732 ± 1210.5 days), these findings suggest AQT may confer functional benefit across diverse clinical presentations. Larger prospective studies are needed to establish standardized protocols and define optimal intervention timing in this population.

Purpose: The Brachial Plexus Outcome Measure (BPOM) - Activity Scale is an outcome measure of upper limb activity limitation in children with BPBI. The purpose of this research was to evaluate studies of the BPOM measurement properties and evaluate the BPOM cutoff score of ≤3 as an indicator of upper limb reconstructive surgical candidacy. Methods: A scoping review was conducted using the COSMIN checklist. Concurrently, a retrospective cohort study was conducted of children with BPBI (4 to 18 years) who completed the BPOM to evaluate the sensitivity and specificity of the ≤3 score to discriminate children who had shoulder, elbow/forearm, and wrist surgeries. Results: The scoping review included 6 studies with very good (27%, n=4), adequate (7%, n=1), doubtful (20%, n=3) and inadequate (47%, n=7) quality. Using the COSMIN, the BPOM - Activity Scale was found to have strong internal consistency, excellent construct validity, and good reliability. The retrospective study included 251 children with BPBI that completed the BPOM – Activity Scale. The sensitivity and specificity of the ≤3 scores had acceptable to excellent discriminating ability for shoulder (90%, 72%, 0.81 AUC), elbow/forearm (89%, 90%, 0.89 AUC), and wrist (80%, 93%, 0.86 AUC) surgeries. Sensitivity, specificity and AUC were highest at the ≤ 3 score compared to other cutoff scores. Conclusion: The BPOM - Activity Scale has adequate measurement properties; however, additional evidence on its content validity and reliability is necessary. The ≤3 cutoff score was able to identify children with BPBI who may benefit from upper limb reconstructive surgery.

Background: For children with BPBI, alignment in patient priorities and patient reported outcome measures (PROMs) is necessary to foster patient-centered decision-making. A PROM well-aligned with the population’s treatment priorities is unavailable. We applied a patient-centered approach to develop a PROM for children with UE impairment. Methods: The International Classification of Functioning, Disability, and Health was the theoretical framework used to develop the Upper Extremity Life Impact Measure – Youth (UE LIM-Y). First, self-identified treatment goals of children with UE impairment were linked to the ICF to determine UE LIM-Y measurement constructs. Second, semi-structured interviews with pediatric hand therapists identified their desired measurement constructs. Combined patient and clinician construct data informed UE LIM-Y questions. Next, iterative rounds of cognitive interviews performed with children with UE impairment informed UE LIM-Y refinement. Lastly, UE LIM-Y acceptability testing was performed with separate patient and clinician populations Results: UE LIM-Y questions measure patient-identified treatment priorities which also align with clinician identified constructs. These include pain; specific hand/arm functions; participation in play, sports, performing arts; and ADLs. The UE LIM-Y was refined based upon three rounds of participant cognitive-interview data. The patient-informed UE LIM-Y revisions improved the measure’s reading level from 6.9 to 2.5 grade level. The UE LIM-Y met acceptability with patients only following round 1 testing. After further revision and round 2 testing, UE LIM-Y met thresholds for acceptability for both populations. Conclusion: Patient-oriented development and testing has established UE LIM-Y’s content validity ensuring this new PROM will be useful in facilitating patient-centered care.

Background: Supination deformity is a debilitating complication after obstetric brachial plexus palsy (OBPP). The most common treatments are forearm osteotomy or biceps rerouting. When considering biceps rerouting the prevailing notion is that postoperative active motion will not exceed preoperative passive motion. We wanted to examine if this was really the case, or if an early rerouting over time could increase active pronation beyond the original passive pronation. Material and methods: This register-based study includes ten patients with a pronounced supination deformity. Mean age at surgery was 5.6 (range 4-10) years and follow up was 6.7 (3.4-8.8) years. The rerouting was performed via a single anterior incision and the arm was protected in a cast for five weeks with the elbow in 90⁰ flexion and the forearm pronated as much as possible. Results: The average gain in active pronation was 45⁰ (0-150). None of the children lost active pronation, one lost 25⁰ of passive pronation with no gain in active pronation. Four patients had better postoperative active pronation than their passive pronation had been preoperatively. There were no major complications. Conclusion: Biceps rerouting seems to be a safe procedure that will improve pronation in patients with a supination deformity after OBPP. For some the active postoperative pronation will be better than the passive preoperative pronation. This study does not help in selecting which patients will benefit the most from the surgery, nor does it tell us what the ideal age for the procedure is.

Nerve transfers for restoration of function following obstetric brachial plexus palsy (OBPP) are increasing in popularity. While nerve transfers provide reliable functional gains subtle impairments may be under-recognized, and the long-term impact of donor nerve sacrifice during development remains unclear. Methods 20 years of theatre log books were reviewed from the single national tertiary referral centre. Nineteen patients who underwent nerve transfer surgery for OBPP were identified. Retrospective chart review was performed of prospectively collected data. Pre and post intervention Active Movement Scale (AMS), Toronto score, Mallet and Modified Mallet score were collated. Functional independence Measure (FIM) scale was also recorded. Statistical analysis was performed with SPSS. Results 41 motor nerve transfers were performed on 19 patients, with up to 10 years follow up. Nerve transfers included spinal accessory to suprascapular nerve (n=18), single/double Oberlin transfer (median/ulnar to biceps/brachialis) (n=12), long head triceps (radial) to axillary (n=5), medial pectoral nerve to triceps (n=1), medial pectoral nerve to musculocutaneous (n=1), intercostal to musculocutaneous (n=3), intercostal to triceps (n=1) and cervical plexus to c7 (n=1). Donor deficits noted were wrist drop (n=7), reduced abduction (n=5), reduced shoulder elevation (n=2). Conclusion This is the largest study to date reporting exclusively on donor site morbidity following nerve transfer for OBPP. Nerve transfers provide meaningful functional improvements, supporting their growing role in reconstructive strategies. However, the study also emphasises the need for more standardised reporting of donor site morbidity to better inform pre-operative decision-making in patients who already have substantially impaired limb function.

INTRODUCTION Children with brachial plexus birth injuries (BPBI) report difficulty performing everyday tasks and lower quality of life than typically developing peers. Reachable workspace assesses areas that an individual can reach with their arms. Inner workspace, used for activities such as dressing, may be more important to patients than outer workspace, used for reaching tasks. Therefore, we hypothesized that inner workspace would demonstrate stronger correlations to patient-reported outcomes (PROs) than outer workspace. METHODS Twenty-two children with BPBI or their parents completed the Pediatric Outcomes Data Collection Instrument (PODCI). Affected limb inner and outer reachable workspace were measured with three-dimensional motion capture using real-time feedback to guide the participants. Percent workspace reached was calculated for inner and outer workspaces. Pearson correlations were assessed between PODCI UE scores with percent workspace reached in selected inner and outer regions. RESULTS For inner workspace, there was a strong correlation between PODCI UE and inner, anterior thoracic workspace (R=0.74, p<0.01) and moderate correlations with anterior head (R=0.45, p=0.04) and anterior abdomen (R=0.58, p=0.01) regions. For total outer workspace, there was a moderate correlation with PODCI UE (R=0.42, p=0.05). DISCUSSION Inner reachable workspace demonstrated a stronger relationship to PODCI UE scores than outer workspace. While many surgeries for BPBI focus on improving reach, the findings of this study suggest that tasks using close-to-body manipulation of objects are of greater importance to patient/parent perception of function. These findings inform clinicians regarding patient/parent priorities related to UE mobility that can help direct management for children with BPBI.

Background/Purpose: Brachial plexus birth injury (BPBI) is defined by motor sequelae. Broader neurodevelopmental outcomes remain poorly characterized. We evaluated neurodevelopmental outcomes after BPBI versus matched controls. Methods: Using the TriNetX US Collaborative Network, we identified children BPBI (ICD-10: G54.0) diagnosed before age 1 at well-child encounters since January 2015.Controls had similar encounters without BPBI. Propensity score matching (1:1) balanced 21 demographic and perinatal characteristics, including prematurity, birth weight, birth trauma, intracranial hemorrhage, hypoxic ischemic encephalopathy, cerebral palsy, hearing loss, and chromosomal abnormalities. Ten-year outcomes included diagnoses (global developmental delay, motor delay, speech/language delay, autism, ADHD), service-based validators (speech-language pathology, neurobehavioral testing, ADHD pharmacotherapy), and well-child encounter frequency. Results: After matching, 463 patients per cohort were analyzed (mean follow-up 4.2 years). BPBI was associated with elevated risk and earlier diagnosis of global developmental delay (24.4% vs. 12.5%; RR 1.95, 95% CI 1.46-2.60; p<0.001), motor delay (14.0% vs. 6.7%; RR 2.10, 95% CI 1.39-3.15; p<0.001), and speech/language delay (23.8% vs. 17.9%; RR 1.33, 95% CI 1.03-1.71; p=0.029). Affected children had more speech/language encounters (6.0 vs. 3.8, p=0.034), supporting diagnostic validity. ADHD pharmacotherapy was elevated (RR 2.55, 95% CI 1.28-5.05; p=0.005) despite non-significant ADHD diagnosis (RR 1.64, p=0.131). Autism, overall well-child encounter frequency, and neurobehavioral testing did not differ. Conclusions: BPBI confers a multi-dimensional neurodevelopmental burden beyond motor impairment, with elevated risks of global, motor, and speech/language delays and greater pharmacotherapy for attentional symptoms. Equivalent utilization and screening argue against ascertainment bias, supporting broad-spectrum developmental surveillance and early multidisciplinary referral.

PURPOSE: Brachial plexus birth injuries (BPBI) occur in approximately 1 in 1,000 live births. While some patients recover spontaneously, others develop residual functional deficits and deformities that persist into adulthood. This study aimed to evaluate the long-term sequelae in adults with BPBI. METHODS: Adult patients with BPBI were retrospectively identified from a multidisciplinary brachial plexus clinic between 2005 and 2023. Patients younger than 18 years at follow-up were excluded. Demographics, injury type, deformities, range of motion, hand function, and pain levels were assessed. RESULTS: Forty-three patients were included, of whom 19 were male. The mean age was 26 years (range 15–61). Upper trunk injuries were present in 21 patients (49%), upper and intermediate trunk involvement in 9 (21%), and pan-plexal injuries in 13 (30%). The primary reasons for clinic presentation were lack of function (n=32), pain (n=14), and contracture (n=9). Limb length inequality was the most common deformity, affecting 51.2% of patients, followed by elbow flexion contracture (48.8%) and internal rotation contracture (27.9%). No active external rotation was observed in 26 patients (60%). Mean elbow range of motion was 103° (60–140°). Mean active forearm pronation and supination were 30° and 36°, respectively. Good hand function was reported in 20 patients, whereas 19 reported limited to poor function. Residual pain was present in 17 patients (37%). CONCLUSION: Adults with BPBI frequently experience persistent deformities, pain, and functional limitations, highlighting the long-term impact of BPBI on quality of life and the need for continued follow-up beyond childhood.

The posterior appoach is a rarely used surgical technique for thoracic outlet syndrome (TOS). Concieved in 1960's and rebranded in 1970's as subscapular approach it gradually fell out of favor as a primary procedure and remained as back-up procedure for removal of first rib residuals in recurrent cases. In 2015 the senior author developed modified posterior upper rib(s) excision and decompression (PURED) procedure for primary surgical treatment of TOS. PURED allows total first and accessory (if present) rib(s) resection as well as visualisation and decompression of the entire brachila plexus and subclavian vessels. More than 100 TOS patients have been operated bu using this technique. Exposure was achieved via minimally invasive intermuscular triangle corridor described by the author. In all cases, total first and accessory (if present) rib(s) resection was carried out from costo-vertebral joint to costo-cartilage juction. Middle scalenectomy and release of fibro-muscular and vascular bands carried out for brachial plexus and subclavian vessels decompression. The outcomes were evaluated both subjectively and objectively. Subjectively all patients reported either excellent/good outcomes. There were no unchanged, fair or poor outcomes. Subjectively, neurological and/or vascular improvements were noted in all patients. There were neither worsenign of pre-existing neurological/vascular symptoms nor any complications related to the procedure. In conclusion, PURED procedure offers strong alternative to existing techniques used for surgical treatment of TOS. Its advantages include unprecedented access to entire brachial plexus and subclavian vessels as well as ability to totally remove upper rib(s) and perform soft tissue release.

Background: Considerable variation exists in strategies for diagnosis and treatment of neurogenic thoracic outlet syndrome (NTOS). The aim of this study was to gather and evaluate different treatment plans from high volume NTOS surgeons for standardized case scenarios. Methods: Six case scenarios were distributed to 19 self-designated Level IV expert NTOS surgeons. These included standardized patients presenting with Gilliat-Sumner hand, upper plexus involvement with scapular winging, pectoralis minor syndrome, electrically negative TOS with pain and sensory changes only, NTOS with concomitant distal double crush compression neuropathies and recurrent NTOS following previous first rib resection. Results: The most common investigation ordered was a cervical spine or brachial plexus MRI. The preferred surgical approach was a supraclavicular approach, with the majority of experts also recommending a concomitant pectoralis minor tenotomy. In the presence of scapular winging, some surgeons would perform a long thoracic nerve neurolysis or nerve transfer. In the absence of motor symptoms, all experts would recommend surgery only after failure of conservative treatment. With findings suggesting concomitant distal nerve compression sites, the most common recommendation was a comprehensive surgical approach to decompress the brachial plexus and distal sites simultaneously. A smaller proportion of experts preferred a “distal first” approach. Conclusions: Consistent trends were seen in recommendations for workup and treatment of NTOS patients. Hand surgeons have a tendency towards 1) a supraclavicular approach for brachial plexus decompression; 2) increased preference for rib-sparing scalenectomy over first rib resection; 3) preference for concomitant or staged surgery to address distal nerve compression sites.

Purpose: Neurogenic thoracic outlet syndrome (NTOS) often coexists with distal upper extremity nerve entrapments, including carpal and cubital tunnel syndromes. The optimal timing of surgical decompression-simultaneous versus staged remains unclear. Methods: A retrospective cohort study using the TriNetX database evaluated three comparisons of same day versus staged peripheral nerve decompression relative to NTOS surgery. Comparison of outcomes including acute pain, chronic pain, opioid use, and emergency department visits at 3-months, 1-year, and 2-years was performed after propensity score matching. Results: Same-day combined carpal/cubital and NTOS surgery was associated with lower opioid use at 3 months (RR 0.71,95% CI 0.56–0.91) and 1 year (RR 0.67,95% CI 0.55–0.81), and lower chronic pain at 1 year (RR 0.41,95% CI 0.22–0.77). There were sustained reductions at 2 years for both opioid use (RR 0.69,95% CI 0.57–0.82) and chronic pain (RR 0.53,95% CI 0.33–0.84). Compared with carpal/cubital release prior to NTOS (distal first approach), same-day surgery did not demonstrate significant differences. Compared with procedures after NTOS (proximal first approach), same-day surgery reduced opioid use at 3 months (RR 0.73,95% CI 0.56–0.95), 1 year (RR 0.69,95% CI 0.56–0.85), and 2 years (RR 0.74,95% CI 0.63–0.87), and reduced chronic pain at 1 year (RR 0.56,95% CI 0.31–1.00) and 2 years (RR 0.57,95% CI 0.36–0.90). Conclusions: Same-day combined decompression of distal nerve entrapment sites with NTOS was associated with lower opioid use and chronic pain, suggesting a benefit to this approach when clinically appropriate. A distal first approach may also be appropriate.

Introduction: Thoracic outlet syndrome (TOS) can be primary—intrinsic to pathology within the thoracic outlet—or secondary—occurring with shoulder dysfunction. We describe the incidence of shoulder pathologies in pediatric and young adult populations with TOS. Methods: We reviewed the charts of tertiary care pediatric hospital patients meeting criteria for diagnosis of TOS between 2010 and 2025. Patients with an additional diagnosis of shoulder injury or pathology were included in the analysis. Patients with shoulder injury occurring after initial TOS diagnosis were excluded. Results: 35 of 226 patients met inclusion criteria (age 14 to 30, mean 17.2, SD = 3.18). Posterior labral tear (n = 9, 25.7%), other labral tear (n = 8, 22.9%), and multidirectional instability (MDI, n = 6, 17.1%) were commonly associated. 16 (45.7%) of the cases were successfully managed nonoperatively for TOS by addressing the shoulder pathology, including 8 patients treated surgically at the shoulder. Another 18 underwent TOS surgical treatment, of whom 8 had previously had shoulder surgery and 1 underwent shoulder treatment post TOS release. One patient was lost to follow up. Conclusion: Posterior and other labral tears were the leading shoulder pathology among adolescents and young adults with secondary TOS, comprising approximately half of the cohort. Shoulder pathology, particularly posterior labral tear, should be considered as a possible contributing factor to TOS and should be ruled out or managed prior to TOS surgical intervention, as approximately half of all patients with secondary TOS do well without thoracic outlet decompression.

Background: In patients with joint hypermobility, thoracic outlet syndrome (TOS) decompression is often a last resort due to concerns of surgical complications. However, the incidence of joint hypermobility and its impact on TOS decompression surgery is not well characterized. 
Methods: Retrospective chart review was conducted on pediatric and young adult patients who were diagnosed with TOS between January 2010 and August 2022. Patients were identified as ‘hypermobile’ (HM) if they had a documented history of joint hypermobility or other hypermobility symptoms. Results: Of 97 TOS patients, 36 (37.1%) had documented hypermobility. HM patients who received surgical decompression had significantly higher Beighton criteria scores (6.4) as compared to those who did not receive surgery (4.3). Significant improvements in Roos, Wright, and Adson testing were seen in HM patients post-surgery and no significant differences in intra-operative complication rates between HM and non-HM patients. Conclusions: Significant clinical improvement following thoracic outlet decompression surgery was seen in HM patients without an increase in intra-operative complication rates. Surgical decompression for TOS should be considered for hypermobile patients to the same extent as patients with no documented hypermobility.

Background: Thoracic outlet syndrome (TOS) comprises compression syndromes of the neurovascular bundle at the upper thoracic aperture and may be arterial, venous, or neurogenic. Neurogenic TOS remains diagnostically challenging, particularly when clinical symptoms are present without clearly verifiable pathology. High-resolution ultrasound may improve preoperative assessment by visualizing soft-tissue structures surrounding the brachial plexus and enabling dynamic functional examination. This study evaluated the correlation between preoperative high-resolution ultrasound findings and intraoperative findings in surgically treated TOS. Methods: We performed a retrospective chart review of patients treated for TOS. Forty-three cases were identified. Inclusion criteria were confirmed TOS with an indication for surgery and preoperative high-resolution ultrasound of the brachial plexus. Demographic data, ultrasound findings, and intraoperative findings were analyzed. Results: Twenty-eight cases met the inclusion criteria. Twenty-four patients were female (86%), and median age was 43 years (IQR 33–49). TOS localization was supraclavicular in 15 cases, infraclavicular in 4, and combined in 9, resulting in 24 supraclavicular and 13 infraclavicular sites. Muscular pathologies showed sensitivities of 27% in the supraclavicular region and 50% in the infraclavicular region, with 100% specificity in both regions. Connective tissue pathologies showed 80% sensitivity and 93% specificity in the supraclavicular region, but 10% sensitivity and 100% specificity in the infraclavicular region. Conclusion: High-resolution ultrasound showed high specificity for surgically confirmed soft-tissue pathologies in TOS and may support surgical planning when positive. However, due to limited sensitivity, normal findings do not exclude TOS. Ultrasound should therefore be integrated into a multimodal diagnostic approach.

Thoracic outlet syndrome (TOS) remains one of the most inconsistently diagnosed and variably treated conditions in upper extremity surgery despite more than a century of clinical experience. Existing paradigms classify TOS into neurogenic, arterial, and venous subtypes, yet fail to identify the precise anatomical site of compression, resulting in imprecise clinical assessment and non-targeted surgery. We propose an anatomy-based framework that reconceptualises TOS as a multi-level compression syndrome occurring across three distinct anatomical regions: the interscalene, retroclavicular, and retropectoral spaces. Symptoms, provocative tests, imaging findings, and operative strategies can be logically correlated with the specific level of compression within this corridor. This approach demonstrates that neurogenic and arterial TOS frequently coexist at the interscalene level because the lower trunk and subclavian artery occupy the same confined anatomical space, while venous TOS is anatomically distinct and predominantly retroclavicular. We present a simplified regional examination protocol centred on the scapular elevation sign, together with an investigation and treatment algorithm directed at the pathological compressive structure rather than a fixed operative approach. Contemporary evidence supports targeted rib-sparing decompression with scalenectomy, ligament release, subclavius excision, or pectoralis minor tenotomy according to the identified region of pathology, reserving first rib resection for selected vascular or bony lesions. This anatomy-directed framework transforms TOS from an imprecise syndrome into a condition amenable to structured clinical reasoning and precise surgical treatment.

One important aim of secondary surgery is to correct impairment of the rotational balance at the level of arm and forearm. Where at arm level the most frequent deformity is a medial rotation contracture, at the forearm we mostly encounter a supination deformity. Surgical correction involves splinting, tendon transfers and humeral or radius osteotomies. To establish correct diagnosis and plan a sound surgical strategy, it is mandatory to consider how the rotational balance of the arm influences forearm rotation. We therefore measured passive and active rotational movements at arm and forearm level in 10 healthy volunteers and will show how arm rotational position affects active and passive prosupination and how this interdependency influences surgical decision making and functional outcome in patients suffering from sequelae of brachial plexus injury.

Background: Contractures following neonatal brachial plexus injury (NBPI) involve impaired longitudinal muscle growth, which can be rescued in animal models by inhibiting myostatin signaling, although surprisingly not through canonical molecular pathways. Using a mouse NBPI model, we investigated noncanonical myostatin signaling pathways to elucidate contracture mechanisms and identify additional targets for contracture therapies. Methods: First, we identified which noncanonical myostatin signaling pathways are activated after NBPI. Next, we pharmacologically inhibited those pathways after NBPI to determine the effects on contractures as well as downstream signaling targets/genes. Finally, we used a myoblast culture system to determine the roles of relevant genes in myotube growth. Results: Activity of the noncanonical c-Jun N-terminal kinase (JNK) signaling pathway was increased after NBPI. Treatment with the JNK inhibitor, SP600125, reduced JNK activity and contractures. Among downstream JNK signaling targets, expression of the Lmna gene, encoding the nuclear envelope proteins Lamin A/C, was upregulated after NBPI and reduced by SP600125. Immunohistochemistry after NBPI revealed overabundance of Lamin A/C proteins in abnormally shaped and positioned myonuclei. Myoblasts cultured with Lmna overexpression failed to achieve normal elongated myotube morphology. Conclusion: Contractures after NBPI involve increased JNK signaling leading to abnormal myonuclear morphology with Lmna overexpression in vivo, which prevents muscle cell elongation in vitro. JNK inhibition prevents Lmna overexpression and reduces contractures, revealing a new potential target for contracture therapies. Given Lamin A/C’s known roles in nuclear stiffness and mechanosensing, reducing Lamin A/C overabundance may also improve the responsiveness of contractures to mechanical stimuli such as passive stretching.

Background: Contractures following neonatal brachial plexus injury (NBPI) involve two primary muscle pathologies: impaired longitudinal growth, driven by myostatin signaling, and increased fibrosis, driven by TGF-β signaling. In mouse models, myostatin or TGF-β inhibition alone does not fully correct contracture pathology. This study utilizes a mouse NBPI model to investigate Latent TGF-β Binding Protein-4 (LTBP4, an endogenous myostatin and TGF-β inhibitor) as a potential target regulating muscle growth, fibrosis and contractures. Methods: After identifying Ltbp4 in a genome-wide screen for genes regulating muscle elongation, we assessed muscle Ltbp4 expression after NBPI with and without treatment with decitabine, a hypomethylating agent that rescues contractures. Next, we created global NBPI in wildtype mice (C57BL/6) and in mice with a loss-of-function Ltbp4 mutation (DBA2/J), assessing contractures, muscle growth, and fibrosis four weeks later. Results: Ltbp4 expression was reduced by NBPI but rescued by decitabine. DBA2/J mice developed worse shoulder contractures than wildtypes, accompanied by worsened subscapularis longitudinal muscle growth, as measured by sarcomere overstretch, and worsened pectoralis fibrosis, as measured by hydroxyproline content. Conclusion: Contractures are associated with reduced Ltbp4 expression, and LTBP4 dysfunction worsens contractures, muscle growth, and fibrosis, supporting a central role for LTBP4 in contracture pathology. If confirmed by ongoing gain-of-function experiments, these findings suggest that enhancing LTBP4 function, such as with an LTBP4 agonist in clinical trials for Duchenne’s muscular dystrophy (DMD), could simultaneously address muscle growth, fibrosis, and contractures after NBPI. Furthermore, because naturally occurring LTBP4 gene variants modify DMD phenotypes, similar variants may explain NBPI contracture variability.

Background: Traumatic brachial plexus injuries often require nerve transfers to restore lost function. Functional recovery depends on both peripheral reinnervation and central reorganization. A 4-point Plasticity Grading Score (PGS) has been proposed to clinically quantify this reorganization. This study examined whether PGS reliably reflects underlying neurophysiological changes across anatomically and functionally distinct donor nerves, by correlating electromyographic (EMG) findings with PGS following Oberlin nerve transfers and phrenic nerve–musculocutaneous nerve (PN–MCN) transfers. Methods: Two single-center prospective cohort studies were conducted using the same methodological framework. The first enrolled patients who underwent PN–MCN transfer; the second enrolled patients after double Oberlin nerve transfers. In both cohorts, needle electromyography (EMG) was performed under standardized conditions targeting donor-command activation and voluntary elbow flexion. Motor unit potentials (MUPs) were categorized using a 5-point scale within a 150 ms interval. Plasticity was independently rated using the PGS. Results: Thirty-two patients were included: 20 underwent double Oberlin transfer, and 12 underwent PN–MCN transfer. In both cohorts, EMG activity under donor-command conditions correlated negatively with PGS scores and with MUPs recorded during voluntary elbow flexion. Oberlin transfers yielded better median PGS scores than PN–MCN transfers. Complete donor–recipient neural disconnection was rarely observed. Conclusions: Across two distinct nerve transfer models, EMG-measured activation of donor and acceptor motor programs correlated significantly with PGS-assessed neural plasticity. These findings support PGS as a valid clinical instrument for measuring brain plasticity after a nerve transfer. Complete cortical disconnection was uncommon, and most patients retained residual donor motor influence.

Background: Nerve autografts remain the gold standard for reconstruction of peripheral nerve gaps; however, recovery is often incomplete in long-gap injuries. For nerve gaps exceeding 3cm, meaningful recovery is achieved in approximately 50% of patients. Mesenchymal stem cell (MSC) supplementation has shown promise but remains poorly studied in autografts. We evaluated bone marrow–derived (BMSCs), adipose-derived (ADSCs), and olfactory ecto-mesenchymal derived stem cells (OSCs) as adjuncts to nerve autografts. We hypothesized that OSCs, because of their neural crest origin and neurotrophic properties, would demonstrate superior regenerative potential. Methods: Eighty Lewis rats underwent reconstruction of a 10mm sciatic nerve defect using autografts alone or supplemented with ADSCs, BMSCs, or OSCs. 1million allogeneic MSCs were delivered in 1mL fibrin glue (Tisseel©). Functional, electrophysiological, histological, and graft revascularization outcomes were assessed at 12 and 16weeks. Results: Early lymphocyte phenotyping showed no evidence of immunologic intolerance or rejection. At 12weeks, BMSC- and OSC-treated autografts demonstrated significantly improved compound muscle action potentials (CMAPs) compared with autografts alone. This effect persisted at 16weeks in the OSC group (p=0.01). BMSC and OSC supplementation also improved muscle weight and isometric tetanic force, although without statistical significance. Immunofluorescence analysis for PGP9.5, S100, and CD34, as well as vascular volume assessment, demonstrated favorable trends in the BMSC and OSC groups. Conclusions: MSC supplementation may enhance outcomes after nerve autografting, with OSCs showing the most sustained functional benefits. Further studies using larger nerve defects or delayed repair models may help clarify the potential role of MSCs in more clinically challenging scenarios.

Background: Mesenchymal stem cell (MSC) supplementation is a promising strategy to enhance peripheral nerve regeneration; however, identifying an effective and clinically translatable delivery method remains a major challenge. Tisseel© fibrin glue offers several advantages, including widespread clinical use in peripheral nerve surgery, biocompatibility, ease of intraoperative handling, and immediate translational potential. Nevertheless, its capacity to support MSC survival while preserving regenerative activity has not been fully established. This study evaluated Tisseel© fibrin glue as a delivery vehicle for different MSCs. Methods: Embryonic Sprague Dawley rat DRGs (E15) were co-cultured with allogeneic Lewis rat MSCs, including bone marrow-derived MSCs (BMSCs), adipose-derived MSCs (ADSCs), and olfactory ecto-mesenchymal stem cells (OSCs)(n=9/groups). MSCs were embedded in 80µL of Tisseel© fibrin glue at 80,000 cells/gel. Control groups included DRGs cultured with or without fibrin glue alone. Neurite regeneration was assessed by live imaging over 72hours (Incucyte©), measuring longest neurite length and total neurite outgrowth (Image-Pro software©). Schwann cell proliferation was evaluated by immunofluorescence, and MSC viability within fibrin glue was assessed through Day7 using live/dead staining and MTS assays. Results: All MSC populations maintained high viability (>95%) through Day7. ADSCs demonstrated greater metabolic activity at 24hours and Day4, resulting in faster in vitro gel degradation. All MSC-treated groups showed significantly greater neurite length (p<0,001), global neurite outgrowth (p<0,001), and Schwann cell proliferation (p<0,001) compared with controls groups. Conclusions: Tisseel© fibrin glue is a simple, surgically applicable, and clinically translatable MSC delivery platform for peripheral nerve repair and may support optimization of future cell-based regenerative therapies.

Traumatic brachial plexus injury can affect postural control and gait stability, particularly under challenging conditions. This study aimed to compare postural control and upper limb and trunk kinematics during tandem gait between indi-viduals with traumatic brachial plexus injury and healthy controls. A prospective cross-sectional study was conducted with 40 participants (20 with unilateral traumatic brachial plexus injury and 20 controls). Tandem gait over a 3-meter distance was evaluated using a three-dimensional motion capture system (Vicon Systems), 120 Hz. Postural control was assessed using computerized dynamic posturography (Equitest, NeuroCom International) through the Sensory Organization Test (SOT). Individuals with brachial plexus injury performed worse during tandem gait (20.72 cm/s, 95% CI: 15.88 to 25.56 vs 29.09 cm/s, 95% CI: 24.96 to 33.23 and 16.32 vs 11.97 seconds. Kinematic analysis revealed reduced range of motion in the sagittal plane at the shoulder and elbow on the affected side. Postural control was also impaired with lower scores in SOT 5 and 6, composite and vestibular scores. Moderate negative correlations were found between postural control (SOT 5, SOT 6, and composite scores) and upper limb range of motion on the unaffected side (ρ -0.31 to -0.39, p < 0.05), suggesting increased upper limb movement as a compensatory strategy in response to reduced postural control. These results highlight a sensorimotor reorganiza-tion in which impaired vestibular integration drives compen-satory unaffected upper limb strategies to sustain dynamic stability under challenging gait conditions in individual with traumatic brachial plexus injury.

Introduction: The purpose of this study is to compare pain interference in young adults with BPBI to matched controls without a diagnosed musculoskeletal condition and/or upper limb impairment, based on the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Brief Pain Inventory outcomes data. Secondary objectives were to compare pain intensity between groups, examine the relationship between upper limb function and pain, and identify common areas of pain using self-reported body maps. Methods: A cross-sectional study comparing 26 young adults with BPBI and 26 age- and sex-matched controls was conducted using standardized patient-reported outcome measures. Mann-Whitney U tests, Spearman correlations, and Fisher’s Exact Tests were used to analyze group differences and associations. Results: Compared to controls, BPBI participants (n = 21, 81%) reported pain beyond everyday types of pain and had significantly higher pain interference and upper limb activity limitation (p <.001). Pain interference was strongly positively correlated with activity limitation. Prevalence of ipsilateral truncal and upper extremity pain was significantly higher than in the same regions on the unaffected side (p < .004). However, the unaffected posterior neck, shoulder joint, upper and lower back, hand, and wrist demonstrated elevated reports of pain. Conclusions: Young adults with BPBI experience widespread pain that interferes with daily life which is greater than previously recognized. These experiences contrast to pain reported in childhood, which is typically low intensity and episodic. Pain screening in adolescence and adulthood, including potential overuse of the unaffected side, are recommended.

Objective The success of brachial plexus reconstruction depends on accurate assessment of nerve root viability, particularly C5. This study prospectively evaluated Schwann cell viability using intraoperative frozen-section analysis and compared the findings with chronicity, MRI, and surgical decision-making. Methods Patients undergoing exploration for brachial plexus injury were prospectively evaluated. Frozen-section samples were obtained from accessible, clinically relevant C5–C7 roots, and Schwann cell viability was recorded as a percentage. Avulsed roots were not sampled, and intact roots were not routinely biopsied. MRI findings were classified per root as rupture, avulsion, or intact. Time from injury to surgery was analyzed in relation to viability. Reconstruction included root grafting and transfers when indicated. Results Ten patients were included, and 25 roots were analyzed. Schwann cell viability was ≥50% in 14 roots (56%), whereas low or absent viability was found in 11 roots (44%). Among 10 sampled C5 roots, 9 (90%) showed ≥50% viability and 1 (10%) showed 0% viability. In patients operated on within four months, C5 viability was largely preserved. No significant association was found between time to surgery and C5 viability (p > 0.05). Some roots interpreted as ruptured or intact on MRI showed complete viability loss, indicating discordance between imaging and biological status. Viable roots were yellowish, elastic, and vascularized; nonviable roots were dull, inelastic, and poorly vascularized. Additional transfers included Oberlin, Oberlin–Mackinnon, and contralateral C7. Conclusion Intraoperative frozen-section analysis provides biologically relevant information on nerve root viability and may guide root grafting and alternative reconstruction in brachial plexus surgery.

Neuropathic upper limb pain in patients with past brachial plexus injury,non-manageable with pain medication,undermines patient’s rehabilitation, whilst often stimulates psychotic episodes and stress. Stimulation of the peripheral nerves aims to alter and improve the perception of pain, in order to reduce the patient-reported pain levels. The aim of this study is to present the results of using peripheral nerve stimulation in order to alter the brain perception of chronic neuropathic pain. From 2021 to 2025 8 patients,5 men and 3 women were selected for implantation of stimulator electrodes to peripheral nerves for treating dysesthesia,chronic pain and great discomfort with VAS score 10. All patients underwent a preliminary procedure with a trial device for a 15-day period to determine the efficacy of the method.Having noticed over 50% of pain relief,all patients were submitted for the implantation of the permanent device in a minimum period of 8 months. In all cases,a nerve stimulator electrode, of approximately 60 cm length, with 7 distal poles was introduced over each nerve. All patients reported significant pain relief right after the introduction of the trial. Two months post -op, all patients reported pain relief at least 60%. PNS of the upper limb is a minimal invasive therapeutic technique to address patients with brachial plexus injuries, who present chronic neuropathic pain, based on a targeted electrical stimulation of specific peripheral nerves, median and ulnar, aiming to alter the transmission of the pain signals to the central nervous system improving remarkably the quality of life.

Introduction Brachial plexus injuries significantly impair quality of life. Successful outcomes can be achieved by timely intervention with use of nerve transfers. In addition, our center has implemented an innovative rehabilitation approach, the Home Observed Motor Education (HOME) Protocol, following nerve transfers to enhance the functional recovery. Methods This prospective cohort study includes all adult patients with brachial plexus palsy from January 2014 to December 2023. Comprehensive clinical evaluations, MRI, and electrophysiological studies were conducted. Exploration done under loupe magnification, nerve transfers were performed followed by a three-week immobilization period. Rehabilitation incorporated galvanic stimulation and the HOME Protocol, with bi-monthly follow-ups extending up to 18 months. Results The study involved 423 patients, predominantly males aged 25-35 years, with injuries primarily resulting from motorcycle accidents. Common injuries included upper plexus avulsions (C5, C6) and pan-brachial plexus (C567, C8, T1) palsy. Initial functional recovery was observed at 6-8 months, with patients achieving M4 to M5 muscle power. Utilizing the HOME Protocol, patients successfully resumed daily activities, including agricultural tasks and personal care, demonstrating significant improvement in limb function. Conclusion Nerve transfers are crucial for functional restoration in brachial plexus injury. The implementation of the HOME Protocol post-surgery has proven effective, underscoring the importance of tailored, patient-centered rehabilitation strategies that promote recovery and improve quality of life.

Introduction Traumatic Brachial Plexus Injuries (TBPI) are life changing and can lead to permanent changes in function and pain within the arm and hand. Historically, TBPI research has reflected the priorities of researchers and clinicians rather than those with personal experience of living with a TBPI. The James Lind Alliance (JLA), supported by the National Institute for Health Research (NIHR), has developed a rigorous methodology for increasing public engagement in research by giving an equal voice to patients, caregivers, and healthcare providers to ensure that their concerns are represented in future health research programmes. These projects are called Priority Setting Partnerships (PSPs). Methods A JLA PSP, comprised of patients, caregivers and clinicians, was created and completed to agree future research priorities in adult TBPI. JLA PSP methodology was followed throughout. Results Initial survey: 154 respondents replied to an initial survey generating 704 questions. These were assessed, grouped and combined to create 68 summary questions or ‘uncertainties’. Three were excluded after literature review suggested they had already been answered by research. Interim survey: 79 respondents answered an interim prioritisation survey, choosing their top ten from the summary questions. Workshop: 9 patients, 2 caregivers, and 11 clinicians met, discussed, and ranked the top 22 questions from the interim survey to identify the top ten research priorities. Psychology, physical therapy treatments, and management pathways were among the top ranked priorities. Conclusion These results will inform researchers and funding bodies about research priorities for patients, caregivers, and clinicians to direct future research on TBPI.