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Pediatric Traumatic Brachial Plexus Injury: Epidemiology, Treatment, and Outcomes
Malka Forman, MD1; David S Liu, MD1; Anna Rothenberg, BS1; Peter M Waters, MD2; Andrea S Bauer, MD3
1Boston Children's Hospital, Boston, MA; 2Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA; 3Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA

Introduction:
Traumatic brachial plexus injuries (BPIs) in children are rare, reported to consist of 1% of all BPIs. We aim to report on the characteristics and patterns of injury, treatment options used, outcomes, and complications to help guide treatment plans and expected outcomes for this devastating injury.
Materials and Methods:
A retrospective cohort was created of patients age ?26 years with traumatic BPI from a single institution who presented January 2001–December 2020. Patient demographics, condition, and treatment characteristics were summarized at presentation. Outcome measures were summarized at presentation and latest follow-up with use of the Active Movement Scale (AMS), Toronto Test score, and Mallet classification system. Comparisons in follow-up were conducted across those who required primary nerve surgeries such as graft or transfer and those who did not, and across those who underwent one or multiple secondary procedures versus those who did not, using Student’s t-tests, Wilcoxon rank sum tests, or chi-squared tests as appropriate.
Results:
Fifty-nine traumatic BPI cases were identified, including 17 males and 42 females. Average age at presentation was 15.2 years. The majority of injuries occurred during motor vehicle accidents (37%) or sports (27%). Fifty-nine percent of injuries were isolated to the upper trunk, while the rest were global palsies (41%). Of the 41 patients who underwent an MRI, 15 (37%) had pre-ganglionic injury, whereas 24 (59%) had post-ganglionic injuries. Fractures were identified in 16/59 (27%) of cases. Thirty patients underwent nonoperative treatment, 14 underwent primary reconstruction only, 4 underwent secondary reconstruction only, and 11 underwent both. After treatment, there were improvements in AMS (57 to 85.4), Toronto (8 to 10), and Mallet (11.6 to 16.8) scores. There was no statistical difference in functional outcomes for patients who underwent primary reconstruction only, secondary reconstruction only, or both. Further, among the primary reconstruction options, nerve graft and nerve transfers did not show any difference in functional outcomes.
Conclusions:
Compared to the adult traumatic BPI population, there are a significantly lower percentage of males (29%) and pre-ganglionic injuries (37%). Among treatment options of primary reconstruction (including nerve graft and transfer), secondary reconstruction, or a combination of both, there are no statistical differences in outcome measures at follow-up. Nerve grafts continue to be a viable option for pediatric brachial plexus injuries.


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