title: Navigating the gray zone: a guideline for surgical decision making in obstetrical brachial plexus injuries.
abstract: OBJECTIVE
  In the literature, the best recommendations are imprecise as to the timing and selection of infants with obstetrical brachial plexus injury (OBPI) for surgical intervention. There is a gray zone (GZ) in which the decision as to the benefits and risks of surgery versus no surgery is not clear. The authors propose to describe this category, and they have developed a guideline to assist surgical decision-making within this GZ.
  
  
  METHODS
  The authors first performed a critical review of the medical literature to determine the existence of a GZ in other clinical publications. In those reports, 47-89% of infants with OBPI fell within such a GZ. Complete recovery in those reported patients ranged from 9 to 59%. Using a prospective inception cohort design, all infants referred to the OBPI Clinic at McMaster Children's Hospital were systematically evaluated up to 3 years of age. The Active Movement Scale scores were compared for surgical and nonsurgical groups of infants in the GZ to identify any important trends that would guide surgical decision-making.
  
  
  RESULTS
  In the authors' population of infants with OBPI, 81% fell within the GZ, of whom 44% achieved complete recovery. Mean scores differed significantly between surgery and no surgery groups in terms of total Active Movement Scale score and shoulder abduction and flexion at 6 months. Elbow flexion and external rotation differed at 3 months.
  
  
  CONCLUSIONS
  There is compelling evidence that there is a group of infants with OBPI in whom the assessment of the risk/benefit ratio for surgical versus nonsurgical treatment is not evident. These infants reside within what the authors have called the GZ. Based on their results, a guideline was derived to assist clinicians working with infants with OBPI to navigate the GZ.
authors.affiliation: Divisions of Plastic Surgery, Department of Surgery, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada.
authors.forename: James R
authors.initials: JR
authors.lastname: Bain
authors.forename: Carol
authors.initials: C
authors.lastname: Dematteo
authors.forename: Deborah
authors.initials: D
authors.lastname: Gjertsen
authors.forename: Robert D
authors.initials: RD
authors.lastname: Hollenberg