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American Association for Hand Surgery

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Botulinum Toxin A Injection in Obstetric Brachial Plexus Palsy Improves Shoulder Function
Amr M Aly/Amr, MD, Amr Nabil, MD and Haitham Kamel Haroun, MD, Ain Shams University, Cairo, Egypt


Internal shoulder contracture is commonly seen after obstetric brachial plexus palsy (OBPP) with C5, C6 and C5, C6, C7 root injuries. It results from imbalance between strong internal shoulder rotators and weak recovering external rotators. Botulinum toxin A (BTX-A) is commonly used to treat abnormal spastic muscle. Our hypothesis is that injection of BTX-A in shoulder internal rotators will facilitate shoulder joint functional improvement in OBPP infants < 18 months.
Patients and Methods

A case series of fifteen infant with internal shoulder contracture and reinnervated shoulder abductors and external rotators with absence of shoulder dysplasia were injected with BTX-A into subscapularis, latissimus dorsi and pectoralis major muscles during the period between January 2017 and June 2020. Injection was done under general anaesthesia using nerve stimulator for injection site location. They were divided into two groups according to time of injection; Group 1 below one year of age (ten infants) and Group 2 above one year (five infants). They were followed for functional improvement using Active Movement Scale, recurrence of internal contracture and need for surgical interference.

In group 1 two infants were injected twice, shoulder abduction and external rotation were improved significantly without the need of surgical interference. In group 2 one infant was injected twice, shoulder abduction and external rotation improvement was insignificant, and all of the infants needed arthroscopic capsular release.

We suggest that temporarily weakening of shoulder internal rotators before the incidence of capsular contracture may avoid the need for surgical interference through balancing the forces on the shoulder joint.

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