**6. Follow-up examination of newborn with BPBP**

A regular monthly follow-up of patients with BPBP is recommended for various reasons in the first 3 months of life. It helps in identifying the morphologic type of injury, adaptation to different therapy protocols based on the recovery, making decision about the timing of plastic neural reconstruction of plexus and to identify and address internal rotation contractures early in its course. Neuropraxic injury recovers fully by the second month and parents can be reassured. A flaccid limb with Horner's syndrome at 3 months mounts to an indication for plastic neural reconstruction [3, 16]. Waters et al. found that children with absent biceps function at 3 months had incomplete recovery [4, 17]. Children with recovering palsy after 3 months can be followed up every two monthly. The main purpose of these visits is to see the further development of power in muscle and to identify the development of early contracture in shoulder internal contracture. Botulinum toxin injections can be considered for patients developing progressive internal rotation contracture [5, 18]. The failure to bring a cookie to the mouth without bending torso more than 45° (Cookie test) at 9 months mounts to an indication for plexus exploration and reconstruction [6, 19].

meningoceles and by following the course of anterior and posterior roots from spinal cord to the respective exit foramen. But it has the disadvantage of radiation, the need of intrathecal contrast injection and the inability to reliably diagnose extra-foraminal injuries. These issues

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Different MRI sequences can give excellent imaging of intra-spinal as well as extra-spinal imaging of plexus. MRI can also give a clue about nerve edema, scarring and neuroma formation [14, 26]. Waters et al. reported an MRI axial image-based classification of glenohumeral deformity. It reliably measured the amount of glenoid retroversion and the percentage of humeral head anterior to mid-scapular line [15, 27]. Correlation was found between clinical parameters and MRI findings [16, 28]. The decision about surgical intervention is made on the defined congru-

Van der Sluijis et al. found humeral head retroversion in children with BPBP after performing simultaneous axial imaging of shoulder and distal humerus [16, 28]. However, Pearl et al. recently reported that the retroversion of humeral head on the affected side is usually less

Gilbert and Tassin were the first to report the comparison of conservative and surgical treatment of brachial plexus birth palsy infants in 1984 [30]. Both the groups with a similar clinical neurologic examination were compared. Sixty-three (63%) patients achieved Mallet IV shoulder function in surgical group while maximum Mallet III recovery was seen in patients with spontaneous recovery. About 27% of conservatively managed infants who showed full spontaneous recovery had gained biceps strength of MRC grade 3 by 2 months of age. Endstage improvement was incomplete in children whose biceps recovery was delayed beyond 3 months. This chapter recommended surgical intervention at 3 months, if biceps muscle has

Capek et al. [31] compared the outcome of graft repair (26 patients) versus neurolysis (16 patients) of conducting neuromas. End results were found to be more promising in nerve repair group. In patients with global injury, achieving hand function is crucial. Pondaag and Melessy have shown improved hand function after lower trunk reconstruction in about 70% of patient [32]. Gilbert and colleagues suggested that unlike adults, infants with brachial plexopathy may

It is imperative to differentiate avulsion injuries from ruptures to make microsurgical recommendations. Microsurgery is advised before 3 months of age in avulsion injuries, as

have the potential to regain hand function after nerve reconstructions.

*8.1.2. Decision about nerve repair and its timing*

compared to the normal side and discussed its merits in surgical planning [17, 29].

have made MRI the modality of choice for imaging brachial plexus [13, 25].

ency of glenohumeral joint on axial MRI imaging recently.

**8. Plastic neural reconstruction**

**8.1. Nerve repair**

*8.1.1. Basis of nerve repair*

not recovered by then.
