An early shoulder repositioning program in birth-related brachial plexus injury: a pilot study of the Sup-ER protocol.
BACKGROUND
Birth-related brachial plexus injury (BRBPI) occurs in 1.2/1,000 births in British Columbia. Even in children with "good" recovery, external rotation (ER) and supination (Sup) are often weaker, and permanent skeletal imbalance ensues. A preventive early infant shoulder passive repositioning program was created using primarily a novel custom splint holding the affected arm in full ER and Sup: the Sup-ER splint. The details of the splint and the shoulder repositioning program evolved with experience over several years. This study reviews the first 4 years.


METHODS
A retrospective review of BCCH patients managed with the Sup-ER protocol from 2008 to 2011 compared their recovery scores to matched historical controls selected from our database by two independent reviewers.


RESULTS
The protocol was initiated in 18 children during the study period. Six were excluded due to the following: insufficient data points, non-compliance, late splint initiation, and loss to follow-up. Of the 12 matches, the Sup-ER group final score at 2 years was better than controls by 1.18 active movement scale (AMS) points (p = 0.036) in Sup and 0.96 AMS points in ER (but not statistically significant (p = 0.13)). Unexpectedly, but importantly, during the study period, zero subjects were assessed to have the active functional criteria to indicate brachial plexus reconstruction, where previously we operated on 13 %.


CONCLUSIONS
Early application of passive shoulder repositioning into Sup and ER may improve outcomes in function of the arm in infants with BRBPI. A North American multi-site randomized control trial has been approved and has started recruitment.
Department of Surgery, Division of Pediatric Plastic Surgery, University of British Columbia, 4480 Oak Street, K3-Ambulatory Care Building, Vancouver, BC V6H 3V4 Canada ; Division of Plastic Surgery, British Columbia Children's Hospital, 4480 Oak Street, K3 ACB, Vancouver, BC V6H 3V4 Canada.
Cynthia
C
Verchere
Department of Occupational Science & Occupational Therapy, University of British Columbia, T325-2211 Wesbrook Mall, Vancouver, BC V6T 2B5 Canada ; Occupational Therapy Department, BC Children's Hospital, 4480 Oak Street, K3 ACB, Vancouver, BC V6H 3V4 Canada.
Kim
K
Durlacher
Physiotherapy Department, British Columbia Children's Hospital, 4480 Oak Street, K3 ACB, Vancouver, BC V6H 3V4 Canada.
Doria
D
Bellows
Department of Orthopedics, St. Paul's Hospital, University of British Columbia, 1081 Burrard St, Vancouver, BC V6Z 1Y6 Canada.
Jeffrey
J
Pike
Department of Surgery, Division of Pediatric Plastic Surgery, University of British Columbia, 4480 Oak Street, K3-Ambulatory Care Building, Vancouver, BC V6H 3V4 Canada.
Marija
M
Bucevska
Birth-related brachial plexus injury; Obstetrical brachial plexus palsy; Protocol; Splint; Sup-ER; Sup-ER splint