Journal of Hand Therapy 27 (2014) 335e340

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Journal of Hand Therapy

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CREDIT ARTICLE #331.

Practice Forum

Sup-ER orthosis: An innovative treatment for infants with birth

related brachial plexus injury
Kim M. Durlacher MRSc, BScOT, CHT a, b, c, *, Doria Bellows BScPT d, Cynthia Verchere MD, FRCSC e, f, g
a

Department of Occupational Therapy, British Columbia Childrens Hospital, Vancouver, Canada

Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada
Department of Physical Therapy, University of British Columbia, Vancouver, Canada
d
Department of Physiotherapy, British Columbia Childrens Hospital, Vancouver, Canada
e
Division of Pediatric Plastic Surgery, Department of Surgery, BC Childrens Hospital, Vancouver, Canada
f
Department of Surgery, University of British Columbia, Vancouver, Canada
g
Child & Family Research Institute, Vancouver, Canada
b
c

Impairments in active and passive range of upper extremity supination and shoulder external rotation are
common sequelae for children with delayed recovery from birth related brachial plexus injury. Orthotic
intervention may complement traditional treatment strategies commonly employed in the newborn period.
These authors describe their custom fabricated orthosis designed to balance shoulder growth and muscular
function, and improve prognosis of long term functional outcomes for children with birth related brachial
plexus injury. e VICTORIA PRIGANC, PhD, OTR, CHT, CLT, Practice Forum Editor
.

Birth related brachial plexus injury (BRBPI) occurs in 0.9e4.6/

1000 births globally,1e6 with spontaneous recovery of functional
levels reported to occur in 50e92% of patients.1,2,6e9 Almost universal outcomes of BRBPI, even for children with otherwise good
recovery, are impairments in both active and passive range of
upper extremity supination (Sup) and shoulder external rotation
(ER).4,6,10 Poorly positioned (Fig. 1) and contracted shoulder
musculature, and associated skeletal changes can secondarily
prevent full range of even otherwise recovered muscle action, and
potentially result in signicant functional consequences.9 While
awaiting maximal nerve recovery, traditional treatment goals
have included prevention of joint contractures, strengthening of
recovering muscles, sensory stimulation, and encouraging developmental milestones.9
Ter Steeg, Hoeksma, Dijkstra, Nelissen & De Jong (2003) reported that shoulder bracing for BRBPI was recommended in the
rst half of the twentieth century, but subsequently advised against
with inference made to concerns related to the development of
shoulder ER and abduction contractures associated with orthotic
* Corresponding author. BC Childrens Hospital Occupational Therapy
Department e Rm K1-200, 4480 Oak Street, Vancouver, Canada V6H 3V4. Tel.: 1
604 875 2123; fax: 1 604 875 3220.
E-mail address: kdurlacher@cw.bc.ca (K.M. Durlacher).

use, and henceforth is seldom mentioned in modern literature.10

However, orthotic use is described by Chan (2002) as one of the
most useful modalities to prevent joint contractures, minimize
deformities, and substitute loss of motor control following a peripheral nerve injury.11 Ter Steeg et al (2003) concluded that the use
of arm braces during the period of accid palsy of the shoulder
muscles be reconsidered, but could only be justied after a randomized clinical trial (p. 7).10
Purpose of this orthosis
Our clinic team speculated that if the arm could be practically,
safely, and comfortably supported for the majority of the day in a
position of the most glenohumeral congruity achievable and with
the tightest muscles held lengthened (i.e. into forearm supination
and shoulder external rotation) then the normal anatomic growth
of the shoulder may be better maintained until nerve recovery
allowed for active movement to return.12 Indications for use of the
Sup-ER orthosis (Fig. 2) include infants presenting with major
weakness or tightness of shoulder ER, beyond the recovery period
anticipated for a neuropractic injury. At our center, based on
clinical assessment of the child at about 4e8 weeks of age,
dening criteria include tightness in passive range of motion of
shoulder external rotation (any angle of less than 180
from the

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K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340

Fig. 3. Waistband pattern.

 2 D-rings and rivets, or thermoplastic hooks

 Hapla eece
 Super wrap by Fabrifoam
Fig. 1. Typical arm resting posture in BRBPI.

Fabrication
abdomen in ER), and/or, using the Toronto Active Movement
Scale,13 a score of ER  2, and/or Sup  2.12
Materials used
 1.6 mm aquaplast (or preferred light weight thermoplastic),
preferably not perforated
 Neoprene plush
 Velcro
- Hook and loop
- Adhesive and non-adhesive

Fig. 2. Right arm Sup-ER orthosis (With kind permission from Springer Science and
Business Media).12

Waistband
 See Fig. 3 for pattern and required measurements.
 Trace pattern and cut out neoplush.
 Sew Velcro closures to waist band and nappy strap (Fig. 8).
Long arm orthosis
1. To create a pattern, measure the babys arm length from the
distal metacarpal phalanges to top of the humerus, and arm
circumference at largest part. This will give you a rectangular
pattern.
 Cut out thermoplastic.
2. Punch a hole for the thumb, positioned about 1 inch from long
edge and 3/4 inch from width edge of thermoplastic.
3. With the arm positioned in 15e20
wrist extension, and
maximum tolerated supination and elbow extension, slide
thumb through the hole and mold the thermoplastic on the
anterior surface of the arm/hand, wrapping circumferentially to
secure the thermoplastic in place while positioning. Stay as high
up the arm as possible.
4. Once thermoplastic has cooled, remove from the infants arm
and trim edges as needed.
 Do not trim the thumb hole too large as the orthosis may
rotate on the hand if the infant is resisting the supinated
position.
 Clear the distal palmar crease.
 Cut proximal end on an angle to optimize orthotic length
laterally without impinging on the axilla.
5. Line edges with hapla eece (for comfort).
6. Anchor Velcro strap across dorsal hand (Fig. 4), to assist caregivers in securing the orthosis on the arm.
7. Attach Velcro straps (using rivet and D-ring for added adjustability, or thermoplastic hook) at (1) lateral elbow, and (2)
proximal/anterior aspect (Fig. 6).
 These straps should be long enough to extend from the
orthosis to the posterior aspect of the trunk, to secure the arm
in SUP and shoulder ER when the baby is lying supine.

K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340

337

(Figs. 6 and 7). You may also cut slits in the wrap to thread the Dring through.
Note: The direction of pull of the wrap and maintaining arm
supination while wrapping are key to maintaining the supination
position of the arm.
Part 2
1. Apply the waistband, pulling the nappy strap up between the
legs, like a diaper (Figs. 8 and 9).
2. Gently move the shoulder into ER and secure the Velcro straps
from the top of the arm and elbow to the posterior aspect of the
waistband (Fig. 10).
Note: Always position the shoulder with your hands, using
straps to secure. Do not use straps to pull the shoulder into
position.
Wear schedule

Fig. 4. Apply orthosis (With kind permission from Springer Science and Business
Media).12

Assembly
Part 1
1. With the palm facing up (supination), apply the orthosis to the
anterior aspect of arm/hand (Fig. 4).
2. Secure soft Velcro strap over dorsum of hand.
3. With the arm still in supination, apply the super wrap. Thread
thumb through the hole that you have cut approximately 1
inches from the end, with end of the wrap pointing into the palm
(Fig. 5). Loop wrap around the hand, and through a second
thumbhole to secure. Apply gentle even tension, with pull in the
direction of supination. Overlap the wrap by approximately half
its width as you proceed up the arm, avoiding the hooks/D-rings

Fig. 5. Apply wrap.

The recommended wear schedule will depend on the infants

age and clinical assessment. Ideally orthotic use is initiated by 3
months of age, up to 6 months of age. While the orthosis may be
introduced to older babies, tolerance to use (and thus family
participation) may present a greater challenge with more established contractures and/or patterns of movement of the involved
limb. An intensive period of full time orthotic use (i.e. 22 h per
day) is typically recommended initially, to build acceptance to
wear, and optimize the orthotic benets during the infant period.
During this stage parents are instructed to remove the entire
orthosis at least two times per day to perform range of motion
exercises, encourage age appropriate developmental activities,
and address skin care needs. Additionally, removal of the shoulder
Velcro straps (Part 2) is recommended when the child is feeding or
traveling in a car seat. This schedule is gradually tapered to night
and nap times to promote increasing opportunities for age
appropriate developmental stimulation in the growing child.

Fig. 6. Strap placement.

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K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340

Fig. 7. Wrap complete.

Regular monitoring and assessment of the childs condition and

orthotic t are important to maintain efcacy of orthotic positioning and t, and to support individual developmental progress
and recovery from BRBPI.
Caregiver education and participation are keys to successful
implementation of this orthotic program. The importance of
continued range of motion exercises, sensory stimulation, and age
appropriate developmental play, in addition to orthotic use, are
emphasized.

Fig. 8. Waistband.

Early ndings
A recent pilot study of the Sup-ER orthosis protocol12 completed
at our center demonstrated the Sup-ER group nal score at two
years of age was better than controls by 1.18 Toronto Active
Movement Scale13 points in Sup and 0.96 Toronto Active Movement
Scale13 points in ER. In addition, an unexpected nding was that no
subjects during the study period were assessed to have the active
functional criteria to indicate brachial plexus reconstruction, when
previously 13% were operated on at our center.
Summary
In combination with active physiotherapy, use of the Sup-ER
orthosis to passively position the affected arm into external

Fig. 9. Waistband application complete.

Fig. 10. Rotation strap application (With kind permission from Springer Science and
Business Media).12

K.M. Durlacher et al. / Journal of Hand Therapy 27 (2014) 335e340

rotation and supination for recommended periods of time during

infancy, may have a positive effect on balanced shoulder growth,
muscular function, and prognosis for long term outcomes in patients presenting with BRBPI. Formalized outcome studies are
currently in development.
References
1. Hardy AE. Birth injuries of the brachial plexus: incidence and prognosis. J Bone
Joint Surg Br. Feb 1981;63-B(1):98e101.
2. Rubin A. Birth injuries: incidence, mechanisms, and end results. Obstet Gynecol.
Feb 1964;23:218e221.
3. Levine MG, Holroyde J, Woods Jr JR, Siddiqi TA, Scott M, Miodovnik M. Birth
trauma: incidence and predisposing factors. Obstet Gynecol. Jun 1984;63(6):
792e795.
4. Hoeksma AF, Wolf H, Oei SL. Obstetrical brachial plexus injuries: incidence,
natural course and shoulder contracture. Clin Rehabil. Oct 2000;14(5):523e526.
5. Chauhan SP, Rose CH, Gherman RB, Magann EF, Holland MW, Morrison JC.
Brachial plexus injury: a 23-year experience from a tertiary center. Am J Obstet
Gynecol. Jun 2005;192(6):1795e1800. discussion 1800e1792.

339

6. Lagerkvist AL, Johansson U, Johansson A, Bager B, Uvebrant P. Obstetric brachial

plexus palsy: a prospective, population-based study of incidence, recovery, and
residual impairment at 18 months of age. Dev Med Child Neurol. Jun
2010;52(6):529e534.
7. Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natural
history of obstetrical brachial plexus palsy. Plast Reconstr Surg. Apr 1994;93(4):
675e680. discussion 681.
8. Gilbert A. Repair of the brachial plexus in the obstetrical lesions of the
newborn. Arch Pediatr. Mar 2008;15(3):330e333.
9. Waters PM. Update on management of pediatric brachial plexus palsy. J Pediatr
Orthop B. Jul 2005;14(4):233e244.
10. ter Steeg AM, Hoeksma AF, Dijkstra PF, Nelissen RG, De Jong BA. Orthopaedic
sequelae in neurologically recovered obstetrical brachial plexus injury. Case
study and literature review. Disabil Rehabil. Jan 7 2003;25(1):1e8.
11. Chan RK. Splinting for peripheral nerve injury in upper limb. Hand Surg. Dec
2002;7(2):251e259.
12. Verchere C, Durlacher K, Bellows D, Pike J, Bucevska M. An early shoulder
repositioning program in birth-related brachial plexus injury: a pilot study of
the Sup-ER protocol. Hand. March 2014;9(2):187e195. http://dx.doi.org/
10.1007/s11552-014-9625-y.
13. Curtis C, Stephens D, Clarke HM, Andrews D. The active movement scale: an
evaluative tool for infants with obstetrical brachial plexus palsy. J Hand Surg
Am. May 2002;27(3):470e478.

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JHT Read for Credit

Quiz: #331

Record your answers on the Return Answer Form found on the

tear-out coupon at the back of this issue or to complete online
and use a credit card, go to JHTReadforCredit.com. There is
only one best answer for each question.
#1. The article identies the following as commonly problematic
motions with birth related brachial plexus injuries
a. supination and internal rotation
b. external rotation and supination
c. pronation and supination
d. internal and external rotation
#2. Spontaneous functional recovery is reported at approximately
a. 25e50%
b. 95%
c. 75%
d. 50e90%
#3. One of the primary aims of the orthosis is to rest the upper extremity in a position which facilitates
a. minimum brachioradialis activity
b. minimum teres minor activity

c. maximum glenohumeral congruity

d. maximum biceps relaxation
#4. The following may be accurately said of this work: it is a
a. completed study with solid ndings
b. preliminary investigation with encouraging ndings
c. case study
d. a clinical report with no intension being viewed through a
scientic lens
#5. The name Sup-ER is a clever play on the word super
a. true
b. false
When submitting to the HTCC for re-certication, please batch your
JHT RFC certicates in groups of 3 or more to get full credit.