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American Association for Hand Surgery

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Prevalence and Distribution of Risk Factors in Brachial Plexus Birth Injuries (BPBI)
Mary Claire B Manske, MD, Shriners Hospital for Children Northern California and University of California Davis, Sacramento, CA, Patricia E Miller, MS, Boston Children's Hospital, Boston, MA and Andrea S Bauer, MD, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA

Introduction
Several risk factors (RF) for brachial plexus birth injury (BPBI) have been identified, but the frequency and distribution of these factors and their association with severe injuries or brachial plexus nerve surgery is unknown. The purpose of this study is to evaluate the prevalence and distribution of RF in infants with BPBI, and to determine if the type or frequency of associated factors is related to BPBI severity.
Materials & Methods
We conducted a multicenter, retrospective cohort study of infants with BPBI who were prospectively enrolled in the TOBI (Treatment and Outcomes of Brachial plexus Injury) database. Demographic data, birth characteristics and BPBI RF were summarized to determine their prevalence and distribution. The cohort was stratified by injury severity (Horner's sign versus no Horner's sign and need for nerve surgery versus no nerve surgery) and groups were compared using chi-squared and Fisher's exact tests to determine their association with individual RF and number of RF.
Results
Seven-hundred-ninety-six infants with BPBI were included in the analysis. Infants had a mean 4.2 1.6 RF with nearly all (795/796) reporting at least one RF. The most common factors included shoulder dystocia (96%), no clavicle fracture (91%), difficult delivery (84%), parity >1 (61%) and birthweight >4000g (55%); these factors commonly occurred in combination with other RF (Figure 1).
Ten percent (74/778) of the cohort had Horner's syndrome, and 28% (222/796) underwent nerve surgery. Asphyxia at delivery (p=0.03, p=0.03) and NICU admission (p=0.001, p=0.003) were significantly associated with the presence of a Horner's sign and nerve surgery. Increasing number of RF was associated with Horner's sign (p=0.02) and nerve surgery (p=0.002). 43% of BPBI infants admitted to the NICU and 34% with asphyxia underwent nerve surgery.

Conclusions
Improved understanding of BPBI RF and their association with injury severity and nerve surgery is needed to facilitate prevention efforts, as well as support the importance of prompt referral to brachial plexus providers. We found that most infants with BPBI had multiple RF, and increasing number of RF was associated with injury severity and nerve surgery. In addition to the traditional RF, NICU admission and asphyxia were associated with increased injury severity, suggesting these infants sustained a more substantial trauma. These RF should prompt early referral to a brachial plexus treatment center.


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