Utility of ultrasound-guided injection of botulinum toxin type A for muscle imbalance in children with obstetric brachial plexus palsy: Description of the procedure and action protocol

Neurologia (Engl Ed). 2019 May;34(4):215-223. doi: 10.1016/j.nrl.2016.12.006. Epub 2017 Mar 24.
[Article in English, Spanish]


Introduction: Obstetric brachial plexus palsy (OBPP) usually has a favourable prognosis. However, nearly one third of all severe cases have permanent sequelae causing a high level of disability. In this study, we explore the effectiveness of ultrasound-guided injection of botulinum toxin A (BoNT-A) and describe the procedure.

Patients and methods: We designed a prospective, descriptive study including patients with moderate to severe OBPP who were treated between January 2010 and December 2014. We gathered demographic data, type of OBPP, and progression. Treatment effectiveness was assessed with the Active Movement Scale (AMS), the Mallet classification, and video recordings.

Results: We gathered a total of 14 133 newborns, 15 of whom had OBPP (1.6 per 1000 live births). Forty percent of the cases had severe OBPP (0.4/1000), a dystocic delivery, and APGAR scores < 5; mean weight was 4038g. Mean age at treatment onset was 11.5 months. The muscles most frequently receiving BoNT-A injections were the pronator teres, subscapularis, teres major, latissimus dorsi, and pectoralis major. All the patients who completed the follow-up period (83%) experienced progressive improvements: up to 3 points on the AMS and a mean score of 19.5 points out of 25 on the Mallet classification at 2 years. Treatment improved muscle function and abnormal posture in all cases. Surgery was avoided in 3 patients and delayed in one. Adverse events were mild and self-limited.

Conclusions: Due to its safety and effectiveness, BoNT-A may be used off-label as an adjuvant to physical therapy and/or surgery in moderate to severe OBPP. Ultrasound may increase effectiveness and reduce adverse effects.

Keywords: Botulinum toxin A; Brachial plexus; Disocia de hombro; Ecografía; Neonatal neuropathy; Neuropatía neonata; Obstetric brachial plexus palsy; Parálisis braquial obstétrica; Plexo braquial; Shoulder dystocia; Toxina botulínica; Ultrasound.

Publication types

  • Observational Study

MeSH terms

  • Botulinum Toxins, Type A / administration & dosage*
  • Botulinum Toxins, Type A / adverse effects
  • Brachial Plexus Neuropathies / diagnostic imaging
  • Brachial Plexus Neuropathies / drug therapy*
  • Brachial Plexus Neuropathies / physiopathology
  • Female
  • Humans
  • Infant
  • Infant, Newborn
  • Movement / physiology
  • Pregnancy
  • Prospective Studies
  • Range of Motion, Articular
  • Treatment Outcome
  • Ultrasonography


  • Botulinum Toxins, Type A