In a population-based sample of 771 children with cerebral palsy, 34% developed an upper-limb contracture. Contracture development started at preschool age. The first affected movements were wrist extension and supination. Passive range of motion decreased with age. High Manual Ability Classification System level was the most important predictor of contractures.

Aim To describe the use of upper‐limb botulinum neurotoxin A (BoNT‐A) treatment in a population‐based sample of children with cerebral palsy (CP), by investigating whether factors may be related to a first upper‐limb BoNT‐A treatment and whether passive range of motion (ROM) is related to a first BoNT‐A treatment after adjustment for confounders. Method Data from five regions in Sweden, in the national registry and follow‐up programme for CP (CPUP), were collected for children with spastic or dyskinetic CP assessed between 2000 and 2017. CP subtypes, functional classification levels, and traffic‐light‐based passive ROM categories were investigated. Data were analysed with logistic regression (odds ratios). Results Of a total of 496 children (317 males, 179 females; median 2 years, interquartile range 1–5 years, range 1–15 years at first measurement occasion), 22% (n = 108) had received upper‐limb BoNT‐A treatment, 45% of whom by 1 to 3 years of age. Those classified in Manual Ability Classification System levels IV and V showed the highest crude odds ratio for a first upper‐limb BoNT‐A treatment. Children with full passive ROM with tightness at the end of the movement range were most likely to receive an upper‐limb BoNT‐A treatment, also after adjustment for confounders. Thumb and forearm muscles were the most targeted at the first upper‐limb BoNT‐A treatment. Interpretation Full passive ROM with tightness at the end of the movement range increases the likelihood of a first upper‐limb BoNT‐A treatment. This new traffic‐light category is an aspect to consider in the dialogue about upper‐limb BoNT‐A. What this paper adds Among children receiving upper‐limb botulinum neurotoxin A (BoNT‐A), 45% had their first treatment before the age of 4 years. Thumb and forearm muscles were the most treated with BoNT‐A, finger flexor muscles the least. Full passive range of motion with tightness was related to first upper‐limb BoNT‐A treatment.