This manuscript will review the literature and focus on the present controversies regarding the natural history, microsurgical treatment, and secondary shoulder reconstructive surgery in infants with brachial plexus birth palsies. Surgical indications, expected outcomes, and complications will be addressed. The controversy regarding the timing of microsurgery in extraforaminal ruptures will be addressed in detail. The developments in assessment and care of glenohumeral deformity with magnetic resonance imaging scans, arthroscopic and open reductions, and tendon transfers about the shoulder will be discussed. Recommendations for microsurgery and shoulder reconstruction will be based on the present evidence from the literature.