1. Reza Sh. Kamrani M.D. Orthopaedic Hand Surgeon TUMS, Shariati Hospital Isfehan UMS Annual Meeting 2-4 / 12 / 1391

2. Neon. 1-3 m3-6 m6-12 m 1-3 y3-6 y6-12 yAdoles. Physical therapy PT/Release TT Osteotomy

3. Neon. 1-3 m3-6 m6-12 m 1-3 y3-6 y6-12 yAdoles. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Conservative treatment PT OT Butolonium Toxin Surgical release ??? Arthroscopic release Open release Open reduction Glenoid osteotomy (Gleno-Humeral anatomy) CT-MR (Gleno-Humeral anatomy) CT-MR Release TT Humeral Osteotomy Release TT Humeral Osteotomy +/_ Arthroscopic release Open release Open reduction Glenoid osteotomy Upper, Midd, Low Ant, Med Latismus Dorsi +/_ Teres maj Shoulder Elbow Forearm Hand

4. Neon. 1-3 m3-6 m6-12 m 1-3 y3-6 y6-12 yAdoles. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Conservative treatment PT OT Butolonium Toxin Surgical release ??? Arthroscopic release Open release Open reduction Glenoid osteotomy (Gleno-Humeral anatomy) CT-MR (Gleno-Humeral anatomy) CT-MR Release TT Humeral Osteotomy Release TT Humeral Osteotomy +/_ Arthroscopic release Open release Open reduction Glenoid osteotomy Upper, Midd, Low Ant, Med Latismus Dorsi +/_ Teres maj Shoulder Elbow Forearm Hand

5. Neon. 1-3 m3-6 m6-12 m 1-3 y3-6 y6-12 yAdoles. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Conservative treatment PT OT Butolonium Toxin Surgical release ??? (Gleno-Humeral anatomy) CT-MR (Gleno-Humeral anatomy) CT-MR Release TT Humeral Osteotomy TT Humeral Osteotomy +/_ Arthroscopic release Open release Open reduction Glenoid osteotomy Upper, Midd, Low Ant, Med Latismus Dorsi +/_ Teres maj Shoulder Elbow Forearm Hand

6. Neon. 1-3 m3-6 m6-12 m 1-3 y3-6 y6-12 yAdoles. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Conservative treatment PT OT Butolonium Toxin Surgical release ??? (Gleno-Humeral anatomy) CT-MR (Gleno-Humeral anatomy) CT-MR Release TT Humeral Osteotomy Arthroscopic release Open release Open reduction Glenoid osteotomy Upper, Midd, Low Ant, Med Latismus Dorsi +/_ Teres maj Shoulder Elbow Forearm Hand

7. Neon. 1-3 m3-6 m6-12 m 1-3 y3-6 y6-12 yAdoles. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Conservative treatment PT OT Butolonium Toxin Surgical release ??? (Gleno-Humeral anatomy) CT-MR (Gleno-Humeral anatomy) CT-MR Release TT Humeral Osteotomy Arthroscopic release Open release Open reduction Glenoid osteotomy Upper, Midd, Low Ant, Med Latismus Dorsi +/_ Teres maj Shoulder

8. Neon. 1-3 m3-6 m6-12 m 1-3 y3-6 y6-12 yAdoles. Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Conservative treatment PT OT Butolonium Toxin Surgical release ??? (Gleno-Humeral anatomy) CT-MR

9. Neon. 1-3 m3-6 m6-12 m 1-3 y Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Conservative treatment PT OT Butolonium Toxin Surgical release ??? (Gleno-Humeral anatomy) CT-MR Indication Time of surgery Kind of surgery

10. Alain GilbertHoward Clarke Biceps < 3/5 in 3m.Coockey sign in 9m. spectrum

11. Alain GilbertHoward Clarke Biceps < 3/5 in 3m.Coockey sign in 9m. spectrum

12. Alain GilbertHoward Clarke Biceps < 3/5 in 3m.Coockey sign in 9m. spectrum

13.  White zone  Poor biceps + Impaired hand in3m.  Poor biceps 6m.  Gray zone  Poor biceps3-6m

14.  Neurolysis  Nerve repair  Nerve graft  Nerve transfer

16. ADULT BP INJ.OBSTETRIC BP INJ.  Adult  Infant  Shorter regeneration distance  Stronger potential for regeneration  Greater capacity for brain adaptation

18. ADULT BP INJ.OBSTETRIC BP INJ.  Classic nerve transfer .Intra plexus  Avulsion is more common .  Classic nerve transfer .Intra plexus  Avulsion is less common ..

19. ADULT BP INJ.OBSTETRIC BP INJ.  Goal

20. ADULT BP INJ.OBSTETRIC BP INJ.  Goal  Elbow flexion  Shoulder stability  Goal  Elbow flexion  Shoulder reanimation

21. ADULT BP INJ.OBSTETRIC BP INJ.  Goal  Elbow flexion  Shoulder stability  Medial border sensation  Wrist and finger function  Intrinsic function  Goal  Hand function  Elbow flexion  Shoulder reanimation

22.  Classic nerve graft is currently the most common approchroach for BPBP

23.  But new nerve transfers is more and more popularised

24. ADULT BP INJ.OBSTETRIC BP INJ.  New nerve transfers  Becomes standard approach  New nerve transfer  Becomes more and more popularised  Acc. To Sup. Scap may be the most common

27. Neon. 1-3 m3-6 m6-12 m 1-3 y Close observation PT Microsurgical BP repair Neurolysis Nerve repair Nerve graft Nerve transfer Microsurgical BP repair Conservative treatment PT OT Butolonium Toxin Surgical release ??? (Gleno-Humeral anatomy) CT-MR Indication Time of surgery Kind of surgery

28.  23 months old boy  BPBP  Under observation from 5 months old  Shoulder Passive ROM is gradually reduced in spite of physical/occupational therapy  Shoulder plain X-ray is almost normal

31.  What is the treatment?

34.  Use  Dysport  Dry vial = 500IU  Dilution with normal saline  Total dose 20-25 U/kg  1cc/location  Price = 5,000,000R./1,200,000R.F  Painful injection  Nervelocator guided injectin

36. New born Sling PT/OT 1-3 y 3-6 m Under-observation good Prog. Passive should. ROM Active elbow flexion PT/OT Aggress. PT/OT 3-6 m visit 6 w visit Br Plex microsurgery good bad Soft tissue release Passive Should. ROM Dysport injection good bad 6 w visit good bad good bad Passive Should. ROM good bad Humerus osteotomy? Should. CT/MR OR, Glenoid osteotomy, Arthroscopic release 3-6 m visit