Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy.

PURPOSE: Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP. METHODS: This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity). RESULTS: Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients. CONCLUSION: Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.

Holistic assessment of dimethoate toxicity in Carcinus aestuarii's muscle tissues.

Dimethoate (DMT) is one of the most harmful and commonly used organophosphate pesticides in agricultural lands to control different groups of parasitic insects. However, this pesticide is considered a dangerous pollutant for aquatic organisms following its infiltration in coastal ecosystems through leaching. Yet, our investigation aimed to gain new insights into the toxicity mechanism of DMT in the muscles of the green crab Carcinus aestuarii, regarding oxidative stress, neurotransmission impairment, histological aspects, and changes in lipid composition, assessed for the first time on the green crab's muscle. Specimens of C. aestuarii were exposed to 50, 100, and 200 µg DMT L-1 for 24 h. Compared to the negative control group, the higher the DMT concentration, the lower the saturated fatty acids (SFA), and the higher the monounsaturated fatty acids (MUFA). The significant increase in polyunsaturated fatty acid n-6 (PUFA n-6) was related to the high release, mainly, of linoleic acid (LA, C18: 2n6) and arachidonic acid (ARA, C20: 4n6) levels. Biochemical biomarkers showed that DMT exposure promoted oxidative stress, highlighted by increased levels of hydrogen peroxide (H2O2), malondialdehyde (MDA), advanced oxidation protein product levels (AOPP), and protein carbonyl (PCO). Furthermore, the antioxidant defense system was activated, as demonstrated by the significant changes in the enzymatic activity of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and reduced glutathione (GSH) levels associated with an adaptation process of C. aestuarii to cope with the DMT exposure. This pesticide significantly impairs the neurotransmission process, as evidenced by the inhibition of acetylcholinesterase (AChE) activity. Finally, several histopathological changes were revealed in DMT-treated crabs, including vacuolation, and muscle bundle loss.This research offered new insights into the toxic mechanism of DMT, pointing to the usefulness of fatty acid (FA) composition as a sensitive biomarker in littoral crabs.

Alteration of redox status and fatty acid profile in gills from the green crab (Carcinus aestuarii) following dimethoate exposure.

Dimethoate is a broad-spectrum organophosphate insecticide and acaricide. Through various pathways, such as runoff and drift, dimethoate can reach marine environment, and easily impact common organisms in coastal areas, close to agriculture lands, namely crustaceans. The purpose of this study was to investigate the potential effects of dimethoate exposure (50, 100, and 200 µg/l), for 1 day, on a wide range of markers of oxidative stress and neurotransmission impairment, as well as fatty acids composition and histopathological aspect in the gills of the green crab Carcinus aestuarii. A significant increase in n-3 polyunsaturated fatty acids series, namely the eicosapentaenoic acid (C20: 5n3) and its precursor alpha-linolenic acid (C 18: 3n3) in dimethoate-treated crabs was recorded. Concerning n-6 polyunsaturated fatty acids, we noted a high reduction in arachidonic acid (C20:4n-6) levels. Dimethoate exposure increased the levels of hydrogen peroxide, malondialdehyde, lipid hydroperoxides, protein carbonyl, and caused the advanced oxidation of protein products along with enzymatic and non-enzymatic antioxidant-related markers. Acetylcholinesterase activity was highly inhibited following exposure to dimethoate in a concentration-dependent manner. Finally, deleterious histopathological changes with several abnormalities were noted in exposed animals confirming our biochemical findings. The present study offered unique insights to establish a relationship between redox status and alterations in fatty acid composition, allowing a better understanding of dimethoate-triggered toxicity.

Self-biting behavior in patients with neonatal brachial plexus palsy.

PURPOSE: Self-biting behavior in patients with neonatal brachial plexus palsy (NBPP) has been associated with finger amputation. Our objective is to describe the incidence of this complication, risk factors, and clinical management. METHODS: We retrospectively analyzed 612 patients with NBPP. There were 303 males and 309 females. 51.8% of patients had C5-C6 lesions, 28.9% had C5-C7, 18.9% had C5-T1, and 0.3 had C7-T1 involvement. RESULTS: We identified 15 patients with self-biting behavior (2.5%). Ten patients had C5-T1 lesions, and five had C5-C7 lesions. Eight patents were submitted to brachial plexus surgery and seven were not. This behavior appeared between 8 and 46 months of life (mean 23.5), and it was always temporary. There was no difference between operated and non-operated patients (p > 0.05), and no correlation between age at surgery and age of appearance of self-biting behavior (p > 0.05). Physical restriction was effective in treating this complication and we had no case of finger amputation. CONCLUSION: Self-biting behavior is a rare complication of NBPP, and it is usually associated with severe motor involvement. The behavior duration is limited to a few months. This condition can be effectively treated with physical restriction to prevent hand biting.

Sir William Thorburn and the first published report of the surgical repair of a brachial plexus injury.

This historical vignette presents some aspects of the life of the English surgeon Sir William Thorburn and details of the first published report of the surgical repair of a brachial plexus stretch injury in an adult.

True neurogenic thoracic outlet syndrome: late outcomes from a surgical series.

BACKGROUND: True neurogenic thoracic outlet syndrome (TNTOS) is rare, and evaluation of surgical treatment is limited to a few studies in the literature. The purpose of this study is to present the results from a surgical series of 21 patients with TNTOS. METHODS: Retrospective analysis on 21 patients diagnosed with TNTOS who underwent surgery. Demographic data and neurological status were characterized, and patients were classified in accordance with a pre-established scale for assessing the severity of hand impairment before and after surgery. Neuropathic pain was assessed using a visual analogue scale (VAS) and functional disability was quantified using the QuickDASH questionnaire. The results from before and after surgery were compared using the Wilcoxon test, and the significance level was taken to be 5%. RESULTS: There was a significant difference in VAS values from before to after the operation (Wilcoxon test: p = 0.0001; r = 0.86). Most patients (90%) improved after surgery, and in 85% of these patients, the VAS improvement was greater than 50%. Improvement in hand function occurred in seven patients (33.3%), and in most of these cases (28.6%), this improvement was classified as mild. Most patients (93.3%) showed moderate to very severe functional disability at the end of the follow-up. CONCLUSION: After surgery, only one-third of the cases showed improvement in motor function and most patients had significant functional disability. However, the improvement regarding pain was significant. Surgery to control this symptom should be recommended, even in cases of late presentation and severe motor impairment.

Co-exposure of zinc oxide nanoparticles and multi-layer graphenes in blackfish (Capoeta fusca): evaluation of lethal, behavioural, and histopathological effects.

Zinc oxide nanoparticles (ZnO NPs) and multi-layer graphenes (MLGs) are widely used, and due to the lack of appropriate wastewater treatment may end up in the aquatic environment, with unknown consequences to biota. The main purpose of this study was to assess the acute toxicity, histopathological and behavioural changes caused by the exposure of ZnO NPs and MLGs, alone and combined, to the blackfish Capoeta fusca. The estimated mean 96 h-LC50 for ZnO NPs was 4.9 mg L-1 and 68.4 mg L-1 for MLGs. In combination, MLGs increased the acute toxicity of the ZnO NPs. The effects of the different NPs on the gills included hyperplasia, aneurisms, and fusion of the lamellae. In the intestine, exposure to the NPs resulted in an increase in the number and swelling of goblet cells and tissue degeneration. Loss of balance, restlessness, erratic and abnormal swimming patterns were the most common behavioural changes seen in the ZnO NPs' exposed blackfish. In contrast with the acute toxicity findings, MLGs decreased the histopathological and behavioural effects of the ZnO NPs on both gills and intestinal tissues as well as fish behaviour. Our experimental results illustrated insights into the simultaneous exposure assessment of metal-based NPs and carbon nanomaterials, although further research is needed on the interactions exposure of these substances to interpreting the toxicological effects of metal-based nanomaterials seen in exposed organisms.

Antiinflammatory activity of natural triterpenes-An overview from 2006 to 2021.

Terpenes are one of the most abundant classes of secondary metabolites produced by plants and can be divided based on the number of isoprene units (C5 ) in monoterpenes (2 units-C10 ), sesquiterpenes (3 units-C15 ), diterpenes (4 units-C20 ), triterpenes (6 units-C30 ), etc. Chemically, triterpenes are classified based on their structural skeleton including lanostanes, euphanes, cycloartanes, ursanes, oleananes, lupanes, tirucallanes, cucurbitanes, dammaranes, baccharanes, friedelanes, hopanes, serratanes etc. Additionally, glycosylated (saponins) or highly oxidated/degraded (limonoids) triterpenes could be found in nature. The antiinflammatory effect and action as immunomodulators of these secondary metabolites have been demonstrated in different studies. This review reports an overview of articles published in the last 15 years (from 2006 to 2021 using PubMed and SciFinder database) describing the antiinflammatory effects of different triterpenes with their presumed mechanism of action, suggesting that triterpenes could be appointed as natural products with future pharmaceutical applicability.

Structural Elucidation of an Atropisomeric Entcassiflavan-(4ß→8)-Epicatechin Isolated from Dalbergia monetaria L.f. Based on NMR and ECD Calculations in Comparison to Experimental Data.

A rare dihydoxyflavan-epicatechin proanthocyanidin, entcassiflavan-(4ß→8)-epicatechin, was isolated from Dalbergia monetaria, a plant widely used by traditional people from the Amazon to treat urinary tract infections. The constitution and relative configuration of the compound were elucidated by HR-MS and detailed 1D- and 2D-NMR measurements. By comparing the experimental electronic circular dichroism (ECD) spectrum with the calculated ECD spectra of all 16 possible isomers, the absolute configuration, the interflavan linkage, and the atropisomers could be determined.

Exploring Chemical Diversity of Phorbas Sponges as a Source of Novel Lead Compounds in Drug Discovery.

Porifera, commonly referred to as marine sponges, are acknowledged as major producers of marine natural products (MNPs). Sponges of the genus Phorbas have attracted much attention over the years. They are widespread in all continents, and several structurally unique compounds have been identified from this species. Terpenes, mainly sesterterpenoids, are the major secondary metabolites isolated from Phorbas species, even though several alkaloids and steroids have also been reported. Many of these compounds have presented interesting biological activities. Particularly, Phorbas sponges have been demonstrated to be a source of cytotoxic metabolites. In addition, MNPs exhibiting cytostatic, antimicrobial, and anti-inflammatory activities have been isolated and structurally characterized. This review provides an overview of almost 130 secondary metabolites from Phorbas sponges and their biological activities, and it covers the literature since the first study published in 1993 until November 2021, including approximately 60 records. The synthetic routes to the most interesting compounds are briefly outlined.

Characterization of Antibacterial Proanthocyanidins of Dalbergia monetaria, an Amazonian Medicinal Plant, by UHPLC-HRMS/MS.

Dalbergia monetaria is an Amazonian plant whose bark is widely used to treat urinary tract infections. This paper describes a bio-guided study of ethanolic extracts from the bark and leaves of D. monetaria, in a search for metabolites active against human pathogenic bacteria. In vitro assays were performed against 10 bacterial strains, highlighting methicillin-sensitive Staphylococcus aureus and methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. Fractioning of the extracts was performed using instrumental and classical techniques, and samples were characterized by UHPLC-HRMS/MS. Ethyl acetate fractions from bark and leaves showed similar antibacterial activities. EAFB is enriched in isoflavone C-glucosides and EAFL enriched in proanthocyanidins. Subfractions from EAFL presented higher activity and showed a complex profile of proanthocyanidins constructed by (epi)-cassiaflavan and (epi)-catechin units, including dimers, trimers and tetramers. The fragmentation pattern emphasized the neutral loss of cassiaflavan units by quinone-methide fission. Fraction SL7-6, constituted by (ent)-cassiaflavan-(ent)-cassiaflavan-(epi)-catechin isomers, showed the lowest MIC against the S. aureus and P. aeruginosa with values corresponding to 64 and 32 µg/mL, respectively. Cassiaflavan-proanthocyanidins have not been found previously in another botanical genus, except in Cassia, and the traditional medicinal use of D. monetaria might be related to the antibacterial activity of proanthocyanidins characterized in the species.

Surgical treatment of birth-related brachial plexus injuries: a historical review.

This historical review presents the relevant data about the evolution of the surgical treatment of neonatal brachial plexus palsy. Starting with the first clinical description by Smellie in 1754, we will present the initial enthusiasm for the surgery followed by a lack of interest that lasted many years, the resurgence of interest in operative management in the 1970s, and the consolidation in the 1980s of surgery as the standard indication in cases of neonatal brachial plexus palsy without a functional spontaneous recovery.

Long-term evaluation of hand function in children undergoing Oberlin and Oberlin-like procedures for reinnervation of the biceps muscle.

PURPOSE: Long-term evaluation of hand function in children who underwent transfer procedures to reinnervate the biceps muscle, using fascicles from the ulnar and median nerves as donors. METHODS: In the last follow-up evaluation, the children underwent a neurological examination, and their hand status was classified according to the Raimondi grading system for hand function. Two physical measurements, the child health assessment questionnaire (CHAQ) and the Sollerman hand function test, were applied to assess upper extremity function. RESULTS: Eight children were re-evaluated. In four the donor fascicle was from the ulnar nerve and in four from the median nerve. The average interval between surgery and the last evaluation was 8.3 years (range 6-10 years). Five patients scored 5 points in the Raimondi grading system, and 3 patients scored 4 points. The results from the CHAQ ranged from 0.03 to 0.41. The results from the Sollerman test were between 60 and 77 for the affected upper limb and between 65 and 79 for the dominant upper limb. CONCLUSION: Nerve transfer of a fascicle from the ulnar or median nerve to the biceps motor branch in children with neonatal brachial plexus palsy does not result in hand dysfunction.

Diagnostic accuracy of imaging studies for diagnosing root avulsions in post-traumatic upper brachial plexus traction injuries in adults.

BACKGROUND: There is no consensus about which type of imaging study, computed tomography myelography (CTM) or magnetic resonance imaging (MRI), provides better information concerning root avulsion in adult brachial plexus injuries. METHODS: Patients with upper brachial plexus traumatic injuries underwent both CTM and MRI and surgical exploration. The imaging studies were analyzed by two independent radiologists and the data were compared with the intraoperative findings. The statistical analysis was based on dichotomous classification of the nerve roots (normal or altered). The interobserver agreement was assessed using Cohen's Kappa. The accuracy of CTM and MRI in comparison with the intraoperative findings was evaluated using the same methodology. RESULTS: Fifty-two adult patients were included. CTM tended to yield slightly higher percentages of alterations than MRI The interobserver agreement was better on CTM than on MRI for all nerve roots: C5, 0.9960 (strong) vs. 0.145 (poor); C6, 0.970 (strong) vs. 0.788 (substantial); C7, 0.969 (strong) vs. 0.848 (strong). The accuracy regarding the intraoperative findings was also higher on CTM (moderate, kappa 0.40-0.59) than on MRI (minimal, kappa 0.20-0.39) for all nerve roots. Accordingly, the overall percentage concordance (both normal or both altered) was superior in the CTM evaluation (approx. 70-75% vs. 60-65%). CTM was superior for both sensitivity and specificity at all nerve roots. CONCLUSION: CTM had greater interobserver agreement and higher diagnostic accuracy than MRI in adult patients with root avulsions due to brachial plexus injury.

The Relationship between Vitamin D Levels, Injury and Muscle Function in Adolescent Dancers.

Vitamin D has been shown to benefit a diverse range of health functions including muscle function. The aim of the present study was to identify serum 25(OH)D3 levels in a sample of adolescent dancers and compare them to muscle function and injury incidence. We incorporated a cross-sectional design to study 49 pre-professional male and female dancers (17±4.44 yrs, 52.1±6.72 kg, 1.63±0.07 m) in full-time training in Bazil. Serum 25[OH]D3 was analyzed by Enzyme-linked Immunosorbent Assay; quadriceps and hamstring peak torque and muscle fatigue were measured by isokinetic dynamometer at 60 and 300° s-1. Injury type and location in the previous 6-months were determined by self-report questionnaire. Participants were categorized into 2 groups: normal or insufficient/deficient (>or<30 ng/ml 25[OH]D3). Results indicated the normal serum 25[OH]D3 group had significantly lower fatigue rates than the insufficient/deficient group (p<0.05) but not for the other muscle function parameters. Fifty-seven percent of participants reported at least 1 injury. The most common were sprains (33%) and tendinopathies (19%). Injured dancers had significantly lower peak torque at 60°/s. The link between serum 25[OH]D3 and reduced muscle fatigue resistance has not been shown before, though the underlying mechanisms aren't apparent and the link between muscular strength and injury has been previously evidenced.

Restoration of shoulder external rotation by means of the infraspinatus muscle reinnervation with a radial nerve branch transfer.

Background: Although reinnervation of the suprascapular nerve is frequently obtained through brachial plexus surgery, reestablishment of infraspinatus muscle function is rarely achieved.Methods: The viability of transfer of the radial nerve to the nerve branch to the infraspinatus muscle was determined anatomically, including histomorphometrical analysis on 30 adult cadavers. Eleven adult patients were then treated using the proposed nerve transfer.Results: The branch to the medial head was more suitable for the nerve transfer. In one cadaver, nerve transfer was impossible because there was no donor of sufficient length. According to axon counts, the branches to the lateral and medial heads had sufficient numbers of axons (means = 994.2 ± 447.6 and 1030.8 ± 258.5, respectively) for reinnervation of the branch to the infraspinatus (means = 830.2 ± 241.2 axons). In the surgical series, one patient was lost in the follow-up and only two patients achieved a good result from the transfer. Recovery of external shoulder rotation started 14 months after surgery in one patient and 8 months in the other. The first patient reached 90° of external rotation 6 months later and the second, achieved 120°of shoulder external rotation 6 months after surgery . Four other patients recovered small amounts of movement: 20, 35, 40 and 45°.Conclusions: Although anatomically feasible, the proposed nerve transfer resulted in a small number of good clinical outcomes.

Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children.

PURPOSE: The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years. METHODS: We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months. RESULTS: The majority of cases were complete lesions (56/53.8%). Erb's palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb's palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases. CONCLUSIONS: There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).

Motor trajectories of preterm and full-term infants in the first year of life.

BACKGROUND: Motor development occurs throughout periods of motor skill acquisition, adjustment and variability. The objectives of this study were to analyze and compare biological and health characteristics and motor skill acquisition trajectories in preterm and full-term infants during the first year of life. METHODS: Two thousand, five hundred and seventy-nine infants (1,361 preterm) from 22 states were assessed using the Alberta Infant Motor Scale. Multivariate General Linear Model, t-tests, ANOVA, and Tukey tests were used. RESULTS: An age × group significant interaction was found for motor scores. On follow-up tests full-term infants had higher scores in prone, supine, sitting and standing postures that require trunk control from 9 to 10 months of age; although this advantage was observed for sitting from the second month of life. CONCLUSION: During the first trimester of life, preterm infants have higher scores in the supine and standing postures. Regarding motor trajectories, from newborn to 12 months, the period of higher motor acquisition was similar between full-term and preterm infants for prone (3-10 months), supine (1-6 months), and standing (6-12 months). For the sitting posture, however, full-term infants had a period of intensive motor learning of acquisition from the first to 7 months of life, whereas for preterm infants a shorter period was observed (3-7 months). CONCLUSION: Although the periods of higher motor acquisition were similar, full-term infants had higher scores in more control-demanding postures. Intervention for preterm infants needs to extend beyond the first months of life, and include guidance to parents to promote motor development strategies to achieve control in the higher postures.

Functional outcome of spinal accessory nerve transfer to the suprascapular nerve to restore shoulder function: Results in upper and complete traumatic brachial plexus palsy in adults.

BACKGROUND: Shoulder stability, abduction and external rotation are vital for the performance of usual daily tasks. AIMS: To compare the functional outcomes in the shoulder following spinal accessory to suprascapular nerve transfer (SASNT). PATIENTS AND METHODS: Comparison of the outcome of adult patients with upper traumatic brachial plexus palsy undergoing SASNT with patients with complete palsy submitted to the same procedure. STATISTICAL ANALYSIS: Ranges of motion were compared via the Mann-Whitney U test. The percentages of patients with a favorable outcome were compared by the chi-square test. All tests were two-tailed and P values <0.05 were considered statistically significant. RESULTS: SASNT was performed in 76 patients: 23 cases (30.2%) of upper-plexus injuries and 53 cases (69.7%) of complete brachial plexus palsy. Good shoulder abduction was achieved in 15 patients (65.2%) with upper plexus palsy and a good external rotation in 5 (21.7%). In those patients with a good recovery, the average range of motion (ROM) was 53° for shoulder abduction and 71.2° for external rotation. Thirty-six patients (67.9%) with complete palsy had a good shoulder abduction recovery with 30.7° of average ROM, but only 3 patients (5.6%) recovered a good shoulder external rotation with 68.3° of average ROM. There was no statistical difference for the abduction outcome, but the external rotation outcome was superior in the upper plexus palsy group. CONCLUSION: SASNT is a consistent procedure to achieve functional recovery of shoulder abduction after a partial or complete plexus injury, but the outcomes of external rotation were quite disappointing in both the groups.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement.

PURPOSE: Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. METHODS: We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. RESULTS: The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. CONCLUSION: Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.