Shoulder deformities from obstetrical brachial plexus paralysis

Reduced Clavicle Length Indicates the Severity of Scapular Misalignment in Obstetric Brachial Plexus Lesions

(1) Background: Although most brachial plexus birth palsies show some spontaneous recovery, secondary operations are likely to follow. Accordingly, due to the loss of muscle innervation, the growth of the affected limb and the shoulder girdle is reduced. This is associated with pathological scapula positioning and rotation. The objective of this work was to clarify the relationship between length differences of the two clavicles and different types of scapular dyskinesia. (2) Methods: Twenty-five patients suffering from brachial plexus birth palsy were included in this retrospective study. There were eighteen female and seven male patients with a mean age of 10 years (2 to 23 years). CT scans of the thoracic cage, including both shoulder joints and both clavicles, were obtained preoperatively between 2010 and 2012. Radiographic measurements were taken of the axial plane and 3D reconstructions were produced. Functional evaluations of possible movement and scapular dyskinesia were performed. (3) Results: We found an increasing difference in the length of the clavicle (both in absolute and relative terms) in the children with more pronounced scapular dyskinesia. Additionally, with increasing clavicle length differences, the scapula was positioned in a deteriorated angle compared to the healthy side. Significant positive correlations were identified for the age and absolute difference of the clavicle length and the length and width of the scapula on the affected side. (4) Conclusion: Scapular dyskinesia, which is a common finding in brachial plexus birth palsy, is strongly related to reduced clavicle growth. Reduced clavicle length (which is a relatively easily examinable parameter) compared to the healthy side can be used to estimate the extent of scapular malpositioning on the thoracic cage. The extent and severity of scapular dyskinesia increases with augmented differences in the length of the clavicle.

Clavicle lengthening, a novel operation technique to reduce pain in brachial plexus birth injury patients

BACKGROUND

Brachial plexus birth injury (BPBI) can lead to an imbalance of shoulder musculature that can lead to glenohumeral contractures, and joint and osseous deformities. Glenoid hypoplasia, lengthening of coracoid and acromion, protraction, lateral rotation and elevation of the scapula, and shortening of the clavicle can be observed. As a consequence, the trapezius, levator scapulae, rhomboid, and supraspinatus muscles are overloaded in daily activities causing pain, which can be difficult to treat conservatively. It is hypothesized that operative lengthening of the clavicle may lead to a more anatomic position of the scapula and periscapular muscles, which, as a consequence, may lead to less overloading pain. This study presents the results of this new technique in patients with BPBI.

MATERIALS AND METHODS

Seven patients (median age 20 years) were included and underwent a lengthening osteotomy of the clavicle at the affective side. Preoperatively, the osseous deformities were confirmed with a computed tomography scan. Patient-reported outcome measures, Disabilities of Arm, Shoulder and Hand score, and Mallet score were evaluated pre- and postoperatively.

RESULTS

After a median of 42 (interquartile range [IQR]: 8.0) months' follow-up, all patients were satisfied with the result. The median numeric rating scale for satisfaction was 8.0 (IQR: 2). Pain decreased from a median numeric rating scale of 7.0 (IQR: 2) preoperatively to 2.0 (IQR: 3) at the final follow-up. The median Mallet score was 14.5 (IQR: 1) preoperatively and 14 (IQR: 0) at the final follow-up. The median Disabilities of Arm, Shoulder and Hand score was 36.7 (IQR: 24.1) at the final follow-up. All patients returned to their normal work without changes in working conditions.

CONCLUSION

Short-term follow-up shows that in patients with BPBI with a short clavicle at the affected side and malposition of the scapula, a lengthening osteotomy of the clavicle is a safe and promising technique to reduce pain based on overloading, without deterioration of shoulder function.

Formation of a physiological reverse shoulder joint

Congenital shoulder deformities are rarely seen in orthopaedic practice. Proximal humeral defects and glenoid hypoplasia have been reported separately in the literature. We present a case involving a 31-year-old woman having a cosmetic problem with her upper arm who was diagnosed with reverse shoulder joint deformity. This article presents the clinical, radiological and biomechanical findings of a physiological reverse shoulder joint. This is the first such reported case.

Morphometric analysis of the association of primary shoulder reconstruction procedures with scapular growth in obstetric brachial plexus paralysis patients

BACKGROUND

Obstetric brachial plexus paralysis (OBPP) has been associated with shoulder deformities, scapular growth, and shoulder function impairment. The absence of balanced muscular forces acting on the scapula has been considered responsible for scapula dysplasia and impaired growth as compared with the normal side. Scapula growth impairment may also lead to shoulder and upper extremity dysfunction. This study aims at showing the association of primary nerve reconstruction with the restoration of scapular bone growth potential.

METHODS

This is a retrospective review of 73 patients with OBPP who underwent primary shoulder reconstruction. Patients were categorized for assessment and analysis into group A, global paralysis; group B, Erb's palsy; and group C, Erb's palsy with C7 root involvement. Scapular posteroanterior and lateral X-rays were obtained in which four scapula dimensions were manually measured. The growth discrepancy depending on the applied treatment was investigated.

RESULTS

The highest improvement was noted in scapular height in the Erb's palsy group who underwent simultaneous neurotization of the suprascapular and axillary nerves. The oblique axis was more improved in the Erb's palsy group while both big and small widths were more improved in the Erb's palsy with C7 root involvement group in patients who underwent concomitant neurotization of the suprascapular and the axillary nerves. Functional improvement correlated positively with growth improvement in all groups and scapular dimensions.

CONCLUSION

Scapula growth and shoulder function improvement were higher in patients with Erb's palsy. Simultaneous axillary and suprascapular nerve neurotization provided the best outcome in both functional and growth restoration.

Geometry of the proximal humeral articular surface in young children: a study to define normal and analyze the dysplasia due to brachial plexus birth palsy

BACKGROUND

Little is known regarding the morphology of the proximal humerus in growing children. This study reports bilateral magnetic resonance imaging measurements in children with internal rotation contractures from birth palsy, hypothesizing that dysplasia alters normal humeral sphericity and symmetry.

METHODS

We studied 25 children with unilateral internal rotation contractures (mean age, 3.7 years) for humeral shape by bilateral magnetic resonance imaging studies at the mid-glenoid level. Local radii of curvature were compared for symmetry and orientation.

RESULTS

Neither side showed uniform radii (sphericity), but normal humeri showed symmetry lost in dysplasia. Internal rotation contractures were correlated with flattening of the anterior humeral head (P = .0002). All heads were flatter in the region of articular contact. The skew axis (the largest cross-sectional diameter of the proximal humerus) was collinear with the articular surface centerline in normal humeri, an alignment often lost with dysplasia, resulting in a skew axis angle. The severity of glenoid deformity correlated with progressive posterior displacement of the humeral head center (P < .0003).

CONCLUSION

The normal humeral articular surface in the young child is not spherical and is flatter in the middle than at the periphery but is symmetric about its central axis. Internal rotation contractures result in loss of this symmetry with characteristic flattening of the anterior humeral head and development of a skew axis angle.

CLINICAL RELEVANCE

Posterior displacement of the humeral head center of rotation beyond 50% of the calculated head radius warrants vigilance and possibly surgical intervention because there is a high likelihood for development of a pseudoglenoid.

True congenital dislocation of shoulder: A case report and review of the literature

The dislocation of a shoulder joint in infancy is extremely rare and is usually the result of traumatic birth injuries, a sequel to brachial plexus injury, or a true congenital dislocation of shoulder. With more advanced obstetric care, the incidence of first two types has drastically decreased. We report a case of true congenital dislocation of shoulder, second of its kind, in a child who was delivered by cesarean section thereby negating any influence of trauma. We report the case because of its rarity, and review the available literature on this topic. We also discuss the management options when encountered with such a rare case scenario.

Range of motion and strength after surgery for brachial plexus birth palsy

BACKGROUND

There is little information about the range of motion (ROM) and strength of the affected upper limbs of patients with permanent brachial plexus birth palsy.

PATIENTS AND METHODS

107 patients who had brachial plexus surgery in Finland between 1971 and 1998 were investigated in this population-based, cross-sectional, 12-year follow-up study. During the follow-up, 59 patients underwent secondary procedures. ROM and isometric strength of the shoulders, elbows, wrists, and thumbs were measured. Ratios for ROM and strength between the affected and unaffected sides were calculated.

RESULTS

61 patients (57%) had no active shoulder external rotation (median 0° (-75-90)). Median active abduction was 90° (1-170). Shoulder external rotation strength of the affected side was diminished (median ratio 28% (0-83)). Active elbow extension deficiency was recorded in 82 patients (median 25° (5-80)). Elbow flexion strength of the affected side was uniformly impaired (median ratio 43% (0-79)). Median active extension of the wrist was 55° (-70-90). The median ratio of grip strength for the affected side vs. the unaffected side was 68% (0-121). Patients with total injury had poorer ROM and strength than those with C5-6 injury. Incongruity of the radiohumeral joint and avulsion were associated with poor strength values.

INTERPRETATION

ROM and strength of affected upper limbs of patients with surgically treated brachial plexus birth palsy were reduced. Patients with avulsion injuries and/or consequent joint deformities fared worst.

Unilateral glenoid hypoplasia: a case report and review of the literature

Glenoid hypoplasia is a relatively rare alteration that in most cases involves the pectoral girdle in a bilateral and symmetrical manner. In general, glenoid hypoplasia is associated with skeletal changes such as hypoplasia of the humeral head or changes in the morphology of the acromion and of the coracoid. We describe a rare case of unilateral glenoid hypoplasia without instability and not involving humeral head. The patient was managed effectively with nonoperative measures that featured specific rehabilitation exercises for the shoulder.

Our experience with secondary reconstruction of external rotation in obstetrical brachial plexus palsy

BACKGROUND

Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy.

METHODS

From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed.

RESULTS

There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees).

CONCLUSION

Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

Ossification of the proximal humerus in children with residual brachial plexus birth palsy: a magnetic resonance imaging study

BACKGROUND

Children with residual brachial plexus birth palsy may develop deformities of the humeral head and the glenoid. Surgical treatment has been described to maximize function and to lessen deformity by means of glenohumeral remodeling. The timing and technique of surgical intervention have not been resolved. The timing of the appearance on magnetic resonance imaging of the ossific nuclei in patients with brachial plexus birth palsy has not been described. We examined the timing of ossification about the proximal humerus. Our hypothesis was that the timing of ossification of the proximal humerus differs between the side involved in brachial plexus palsy and the uninvolved side.

METHODS

A retrospective study was performed of 117 children with residual brachial plexus birth palsy (aged 5 mo to 10 y) who had magnetic resonance imaging scans of the bilateral shoulders performed at our institution between 2000 and 2007. All axial slices were reviewed by a single observer for evidence of ossification of the humeral head epiphysis, the greater tuberosity, and the lesser tuberosity, as well as for evidence that the 3 were coalesced. Statistical analysis was performed to compare the involved and uninvolved sides.

RESULTS

The appearance of the greater tuberosity ossific nucleus on the involved side was significantly delayed. There was a trend towards delay in the appearance of the lesser tuberosity ossific nucleus and the coalescence of the 3 ossific nuclei on the involved side. The duration during which ossification of the involved brachial plexus side occurred was generally shorter compared with the uninvolved side.

CONCLUSION

There is delay in the ossification of the involved side in brachial plexus birth palsy, and a shorter duration of ossification.

Electromyography, nerve action potential, and compound motor action potentials in obstetric brachial plexus lesions: validation in the absence of a "gold standard"

OBJECTIVE

Obstetric brachial plexus lesions (OBPLs) are caused by traction to the brachial plexus during labor. Typically, in these lesions, the nerves are usually not completely ruptured but form a "neuroma-in-continuity." Even in the most severe OBPL lesions, at least some axons will pass through this neuroma-in-continuity and reach the tubes distal to the lesion site. These axons may be particularly prone to abnormal branching and misrouting, which may explain the typical feature of co-contraction. An additional factor that may reduce functional regeneration is that improper central motor programming may occur. Surgery should be restricted to severe cases in which spontaneous restoration of function will not occur, i.e., in neurotmesis or root avulsions. A major problem is how to predict whether function will be best after spontaneous nerve outgrowth or after nerve reconstructive surgery. When a decision has been made to perform an early surgical exploration, what to do with the neuroma-in-continuity can be a problem. The intraoperative appraisal is difficult and depends on experience, but even in experienced hands, misjudgment can be made.

METHODS

We performed an observational study to assess whether early electromyography (at the age of 1 month) is able to predict severe lesions. Additionally, the value of intraoperative nerve action potential and compound motor action potentials was investigated.

RESULTS

Severe cases of OBPL can be identified at 1 month of age on the basis of clinical findings and needle electromyography of the biceps. This outcome needs independent validation, which is currently in progress. Nerve action potential and compound motor action potential recordings show statistically significant differences on the group level between avulsion, neurotmesis, axonotmesis, and normal. For the individual patient, a clinically useful cutoff point could not be found. Intraoperative nerve action potential and compound motor action potential recordings do not add to the decision making during surgery.

CONCLUSION

The absence of a "gold standard" for the assessment of the severity of the OBPL lesion makes prognostic studies of OBPL complex. The currently available assessment strategies used to obtain the best possible solutions are discussed.

Brachial plexus birth injury: US screening for glenohumeral joint instability

PURPOSE

To prospectively evaluate the use and optimal timing of ultrasonographic (US) screening for posterior shoulder subluxation in infantswith brachial plexus birth injury (BPBI).

MATERIALS AND METHODS

Approval of the ethics committee and informed consent of guardians was obtained. This population-based prospective study included neonates with BPBI who were born in Helsinki from January 1, 2003 through December 31, 2006, and in whom BPBI was verified with sequential clinical examinations. US was performed at 1, 3, 6, and 12 months. Size (width and height) of the humeral head and its ossification center and congruency of the shoulder (alpha angle) were measured. Frequency of BPBI and permanent changes were evaluated. This study also included patients who were referred from the tertiary catchment area. For statistical analysis, 95% confidence intervals were calculated, and analysis of variance was performed.

RESULTS

BPBI was seen in 132 of 41980 neonates (3.1 per 1000). In 27 cases (0.64 per 1000), BPBI did not heal during the 1st year of life and was considered permanent. The humeral head and its ossification center were smaller on the affected side in permanent BPBI. Nine patients with permanent palsy had posterior subluxation of the humeral head depicted with US (alpha angle, >30 degrees ). In five patients, posterior subluxation [corrected] was detected at 3 months. Nineteen of 21 patients with BPBI from the tertiary catchment area had permanent palsy. Ten of 19 patients developed posterior subluxation of the shoulder, which was verified with US. Altogether, three of these cases were not detected by surgeons. Posterior subluxation of the humeral head developed during the 1st year of life in one-third of patients with permanent BPBI. In more than one-half (55% [five of nine]) of the patients, posterior subluxation [corrected] was detected with US at 3 months, and in 89% (eight of nine), it was detected at 6 months.

CONCLUSION

US is a fast and useful tool for diagnosis of posterior subluxation of the humeral head, and examination of the glenohumeral joint should be performed at 3 and 6 months of age in infants with BPBI if symptoms persist.

Permanent brachial plexus birth palsy does not impair the development and function of the spine and lower limbs

Permanent brachial plexus birth palsy (BPBP) impairs the function of the affected upper limb. Avulsion type root injuries may damage the cervical spinal cord. Whether abnormal function of an upper limb affected by BPBP has any observable effects on the development of the locomotion system and overall motor function has not been clarified in depth. A total of 111 patients who had undergone brachial plexus surgery for BPBP in infancy were examined after a mean follow-up time of 13 (5-32) years. Patients' physical activities were recorded by a questionnaire. No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that only few patients were unable to participate in normal activities such as: bicycling, cross-country skiing or swimming. Not surprisingly, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities.

The biceps tendon as a measure of rotational deformity in residual brachial plexus birth palsy

BACKGROUND

Children with residual brachial plexus birth palsy often develop internal rotation contractures with subsequent glenohumeral dysplasia seen on axial imaging. Coronal deformity (characterized by humeral head subluxation), and angular deformity (characterized by glenoid retroversion) have been defined. We hypothesize that the location of the biceps tendon characterizes rotational deformity.

METHODS

A retrospective study was performed on 91 children (average age 3.2+/-2.2 y) who lacked external rotation beyond neutral and had magnetic resonance imaging (MRI) scans of bilateral shoulders performed at our institution between 2000 and 2007. The charts were reviewed for the measurement of the external rotation of the involved shoulder with the arm adducted and the scapula stabilized. The glenoscapular angle (glenoid version), the percentage of the humeral head anterior to the middle of the glenoid fossa (PHHA), and the angle of rotation of the biceps tendon (biceps angle) were measured on MRI scans of both shoulders. Statistical analysis was performed to compare these MRI measurements for the involved and uninvolved sides, and to identify the correlations between them and the external rotation.

RESULTS

The average biceps angle was 47.9+/-15.2 degrees on the uninvolved side and 26.2+/-15.0 degrees on the involved side. The average differences between the 2 shoulders in the biceps angle (21.7+/-20.5 degrees), the version (18.9+/-15.0 degrees), and the PHHA (19.8+/-13.6%) were all significant (P<0.001). Only the biceps angle correlated significantly with external rotation (P<0.001). This correlation remained significant even when the version and the PHHA were held constant (P=0.004).

CONCLUSION

The biceps angle is a measure of rotational deformity in patients with residual brachial plexus birth palsy, and correlates better with external rotation than either the glenoid version or the PHHA. The biceps angle may be a useful measure of rotational glenohumeral deformity before and after surgery.

Recovery potential after postnatal shoulder paralysis. An animal model of neonatal brachial plexus palsy

BACKGROUND

Injury to the brachial plexus during birth results in paralysis of the upper extremity in as many as one in 250 births and can lead to substantial functional deficits in the shoulder. The goal of this study was to characterize the development of bone and joint deformities in paralyzed neonatal shoulders and to assess the improvement of these deformities after muscle function recovery with use of an animal model.

METHODS

Intramuscular injections of botulinum toxin were used to paralyze the supraspinatus, infraspinatus, and posterior deltoid of the left shoulders of mice at birth. Seventy mice were divided into three groups: Botox, recovery, and normal. The twenty-five mice in the Botox group received botulinum toxin injections until they were killed. The twenty mice in the recovery group received botulinum toxin injections for different durations and then were allowed injection-free recovery periods until they were killed. The twenty-five mice in the normal group received saline solution injections until they were killed. Radiographs were used to measure shoulder and elbow contractures. Microcomputed tomography was used to examine anatomical parameters of the supraspinatus muscle, humerus, and scapula.

RESULTS

The Botox group showed bone and joint deformities including delayed mineralization and flattening of the humeral head, hypoplasia, and introversion (i.e., anteversion) of the humerus, contractures of the shoulder and elbow, hypoplasia of shoulder muscles, hypoplasia of the scapula, and hypoplasia and retroversion of the glenoid. In the recovery group, a significant trend toward normal properties was observed with longer recovery periods (p<0.05). However, only soft-tissue contractures of the shoulder and elbow were resolved completely with the longest recovery period.

CONCLUSIONS

This mouse model successfully simulates human neonatal brachial plexus palsy, reproducing most of the bone and joint deformities found in the human condition. The deformities started to develop early in the postnatal period in the paralyzed shoulders and progressed with longer durations of paralysis. Early restoration of muscle function completely resolved the soft-tissue contractures of the shoulder and elbow. However, osseous deformities of the humerus and scapula were never resolved completely. These findings demonstrate the time-dependence of reversibility of musculoskeletal deformities in developing shoulders with neurological deficits.

Arm rotated medially with supination - the ARMS variant: description of its surgical correction

BACKGROUND

Patients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SHEAR deformity commonly occurs in conjunction with Medial Rotation Contracture (MRC) of the arm. OBPI also causes muscle imbalances at the level of the forearm, that lead to a fixed supination deformity (SD) in a small number of patients. Both MRC and SD will cause severe functional limitations without surgical intervention.

METHODS

Fourteen OBPI patients were diagnosed with MRC of the shoulder and SD of the forearm along with SHEAR deformity during a 16 month study period, with eight patients available to long-term follow-up (age range 2.2 - 18 years). Surgical correction of the MRC was performed as a triangle tilt or humeral osteotomy depending on the age of the child, after which, the patients were treated with a radial osteotomy to correct the fixed supination deformity. Function was assessed using the modified Mallet scale, examination of apparent supination and appearance of the extremity at rest.

RESULTS

Significant functional improvements were observed in patients with surgical reconstruction. Mallet score increased by an average of 5.2 (p < 0.05). Overall forearm position was not significantly changed from an average of 5 degrees to an average of 34 degrees maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.

CONCLUSION

The simultaneous presence of two opposing deformities in the same limb will visually offset each other at the level of the wrist and hand, giving the false impression of neutral positioning of the limb. In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder. Both of these deformities require surgical attention, and the presence of concurrent MRC and SD should be monitored for in OBPI patients.

A simple effective design for a thermoplastic shoulder spica following secondary surgery for obstetrical brachial plexus palsy

Secondary shoulder surgery is frequently needed to improve shoulder contracture and movement after obstetrical brachial plexus palsy. This surgery comprises subscapularis release coupled in half the cases with tendon transfers, and is generally performed from ages three to nine years. Postoperatively, a shoulder splint is used to immobilize the shoulder in a position that maintains the released position and prevents tension on the tendon transfer, if performed. A thermoplastic splint design that is light and effective is presented.

The early effects of tendon transfers and open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy

BACKGROUND

Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint dysplasia in patients with brachial plexus birth palsy. The objective of the present investigation was to determine the effects of tendon transfers and open glenohumeral reduction on shoulder function and dysplasia in patients with preexisting joint deformity secondary to brachial plexus birth palsy.

METHODS

Twenty-three patients with preexisting glenohumeral deformity underwent latissimus dorsi and teres major tendon transfers to the rotator cuff with concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis and open glenohumeral joint reduction for the treatment of internal rotation contracture and external rotation weakness. Shoulder function was assessed with use of the modified Mallet classification system and the Active Movement Scale. Glenoid version and humeral head subluxation were quantified radiographically, and glenohumeral deformity was appropriately graded. The mean duration of clinical and radiographic follow-up was thirty-one and twenty-five months, respectively.

RESULTS

Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 10 points preoperatively to 18 points postoperatively (p < 0.01). The mean modified Mallet score for external rotation improved from 2 to 4 (p < 0.01). Similarly, the mean Active Movement Scale score for external rotation improved from 3 to 6 (p < 0.01). The mean Mallet hand-to-spine score improved from 1 to 2 (p < 0.01). The mean Active Movement Scale score for internal rotation remained constant at 6. Radiographically, the mean glenoid version improved from -39 degrees preoperatively to -18 degrees postoperatively (p < 0.01). The mean percentage of the humeral head anterior to the middle of the glenoid similarly improved from 13% to 38% (p < 0.01). The mean glenohumeral deformity score improved from 3 to 2 (p < 0.01). Nineteen (83%) of the twenty-three patients demonstrated glenohumeral remodeling; one patient had progressive worsening of glenohumeral deformity.

CONCLUSIONS

Tendon transfers to the rotator cuff, combined with musculotendinous lengthenings and open reduction of the glenohumeral joint, improve global shoulder function and lead to glenohumeral joint remodeling in the majority of selected patients with mild-to-moderate preexisting glenohumeral dysplasia secondary to brachial plexus birth palsy. Future study of the long-term outcomes of these procedures will help to clarify the ultimate effect on glenohumeral joint function.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Scapular deformity in obstetric brachial plexus palsy: a new finding

While most obstetric brachial plexus palsy patients recover arm and hand function, the residual nerve weakness leads to muscle imbalances about the shoulder which may cause bony deformities. In this paper we describe abnormalities in the developing scapula and the glenohumeral joint. We introduce a classification for the deformity which we term Scapular Hypoplasia, Elevation and Rotation. Multiple anatomic parameters were measured in bilateral CT images and three-dimensional CT reconstruction of the shoulder girdle of 30 obstetric brachial plexus palsy patients (age range 10 months–10.6 years). The affected scapulae were found to be hypoplastic by an average of 14% while the ratio of the height to the width of the body of scapula (excluding acromion) were not significantly changed, the acromion was significantly elongated by an average of 19%. These parameters as well as subluxation of the humeral head (average 14%) and downward rotation in the scapular plane were found to correlate with the area of scapula visible over the clavicle. This finding provides a classification tool for diagnosis and objective evaluation of the bony deformity and its severity in obstetric brachial plexus palsy patients.

Secondary reanimation procedures in late obstetrical brachial plexus palsy patients

The varying degrees of spontaneous reinnervation that occur in untreated obstetrical brachial plexus palsy leave characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Early microsurgical reconstruction of the affected plexus leads to a more rewarding overall function of the upper arm, but residual deformities might appear later which are similar, although less serious, than those observed in untreated cases. Secondary procedures of the shoulder, elbow, forearm, and hand will improve the appearance and function of the upper extremity in late cases of obstetrical brachial plexus. Careful preoperative planning is mandatory and a multistage approach should be applied, depending on the type of palsy and the age of the patient.

Management of birth brachial plexus palsy

INTRODUCTION

The indications for surgical repair of congenital brachial plexus palsy are controversial. Our objective was to determine the results of early brachial plexus surgery following obstetric-induced brachial plexus palsy.

METHODS

We performed a retrospective analysis of the outcome of 58 cases of brachial plexus surgery. The indication for operation consisted of the presence of less than antigravity strength in the biceps, triceps, and deltoid muscle groups at 6 months of age. Data gathered prospectively, previously, showed the likelihood of improvement with less than antigravity strength in these cases to be poor.

RESULTS

Follow-up data were obtained on 52 of the 58 cases. Overall mean follow-up was 2 years. Twelve patients had more than 3 years follow-up (mean 5.5 years, range 3-11.5 years). Significant improvement was seen in all injury patterns i.e., C5-C6, C5-C7, and C5-C8, T1. Greater than antigravity strength in the biceps, triceps, and deltoid muscle groups was seen in the majority of cases at follow-up.

CONCLUSIONS

Repair of obstetrical brachial plexus palsy in children at 6 months of age that is based on less than antigravity strength in the biceps, triceps, and deltoid muscle groups produces improvement in functional capabilities. Children with obstetrical brachial plexus palsy should be referred soon after birth to a center that specializes in the treatment of this type of palsy.

MRI of rotator cuff muscle atrophy in relation to glenohumeral joint incongruence in brachial plexus birth injury

PURPOSE

To evaluate rotator cuff muscles and the glenohumeral (GH) joint in brachial plexus birth injury (BPBI) using MRI and to determine whether any correlation exists between muscular abnormality and the development of glenoid dysplasia and GH joint incongruity.

MATERIALS AND METHODS

Thirty-nine consecutive BPBI patients with internal rotation contracture or absent active external rotation of the shoulder joint were examined clinically and imaged with MRI. In the physical examination, passive external rotation was measured to evaluate internal rotation contracture. Both shoulders were imaged and the glenoscapular angle, percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) and the greatest thickness of the subscapular, infraspinous and supraspinous muscles were measured. The muscle ratio between the affected side and the normal side was calculated to exclude age variation in the assessment of muscle atrophy.

RESULTS

All muscles of the rotator cuff were atrophic, with the subscapular and infraspinous muscles being most severely affected. A correlation was found between the percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) and the extent of subscapular muscle atrophy (r(s)=0.45, P=0.01), as well as between its ratio (r(s)=0.5, P P=0.01). Severity of rotator cuff muscle atrophy correlated with increased glenoid retroversion and the degree of internal rotation contracture.

CONCLUSIONS

Glenoid retroversion and subluxation of the humeral head are common in patients with BPBI. All rotator cuff muscles are atrophic, especially the subscapular muscle. Muscle atrophy due to neurogenic damage apparently results in an imbalance of the shoulder muscles and progressive retroversion and subluxation of the GH joint, which in turn lead to internal rotation contracture and deformation of the joint.

Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy

BACKGROUND

Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint deformity in patients with brachial plexus birth palsy. The objective of this investigation was to determine the effects of correction of external rotation weakness and internal rotation contractures with tendon transfers and extra-articular soft-tissue releases on glenohumeral development in patients with brachial plexus birth palsy.

METHODS

Twenty-five patients with brachial plexus birth palsy who underwent latissimus dorsi and teres major tendon transfers to the rotator cuff-with or without concomitant musculotendinous lengthenings-were evaluated clinically and radiographically before the operation and at a minimum of two years (average, forty-three months) postoperatively. Shoulder function was prospectively assessed with use of the modified Mallet classification system, in which aggregate shoulder function is assigned a score of 5 to 25 points. Glenoid version and humeral head subluxation were quantified with magnetic resonance imaging or computed tomography, and glenohumeral deformity was graded.

RESULTS

Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 13 points preoperatively to 18 points postoperatively (p < 0.01). As seen radiographically, the mean glenoid retroversion improved from 22 degrees preoperatively to 16.5 degrees postoperatively (p = 0.012). The mean posterior humeral head subluxation improved from 30% to 37% (p = 0.03). No patient had progressive worsening of the glenohumeral deformity.

CONCLUSIONS

Latissimus dorsi and teres major tendon transfers to the rotator cuff, combined with appropriate extraarticular musculotendinous lengthenings, significantly improved global shoulder function but led to only modest improvements in glenoid retroversion and humeral head subluxation. No profound glenohumeral remodeling occurs after these extra-articular rebalancing procedures, even when they are performed in patients of a young age. While the long-term clinical and radiographically apparent effects at skeletal maturity are uncertain, soft-tissue rebalancing procedures alone were found to have halted the progression of, but not to have markedly decreased, glenohumeral dysplasia at the time of a two to five-year follow-up.

Posterior shoulder dislocation in infants with neonatal brachial plexus palsy

BACKGROUND

Glenoid dysplasia and posterior shoulder subluxation with resultant shoulder stiffness is a well-recognized complication in infants with neonatal brachial plexus palsy. It is generally considered to be the result of a slowly progressive glenohumeral deformation secondary to muscle imbalance, physeal trauma, or both. Recent publications about infantile posterior shoulder dislocation have suggested that the onset of dysplasia occurs at an earlier age than has been previously recognized. The prevalence of early dislocation in infants with this disorder has not been previously reported, to our knowledge.

METHODS

We studied 134 consecutive infants with neonatal brachial plexus palsy who were seen at our institution over a period of two years. All infants were examined at monthly intervals to assess neurological recovery and the status of the upper extremity until recovery occurred or a treatment plan was established. The type of brachial plexus involvement was classified. Specific clinical signs associated with subluxation and dislocation were recorded. These included asymmetry of skin folds of the axilla or the proximal aspect of the arm, apparent shortening of the humeral segment, a palpable asymmetric fullness in the posterior region of the shoulder, or a palpable click during shoulder manipulation. The infants who were identified as having these clinical signs were evaluated with ultrasonographic imaging studies.

RESULTS

Eleven (8%) of the 134 infants had a posterior shoulder dislocation. The mean age at the time of diagnosis was six months (range, three to ten months). There was no correlation between the occurrence of dislocation and the type of initial neurological deficit. A rapid loss of passive external rotation between monthly examinations indicated a posterior shoulder dislocation.

CONCLUSIONS

Posterior shoulder dislocation can occur earlier (before the age of one year) and more rapidly in infants with neonatal brachial plexus palsy than has been appreciated previously. As with developmental dysplasia of the hip, a high index of suspicion, recognition of clinical signs, and the use of ultrasonography will allow the diagnosis to be established. Following early diagnosis, attention should be focused on improving the stability and congruency of the shoulder joint.

Shoulder contracture and osseous deformity in obstetrical brachial plexus injuries

BACKGROUND

The purposes of this study were to determine the prevalence of and the association between shoulder contracture and osseous deformity in a cohort of children with an obstetrical brachial plexus injury and to identify the risk factors for these complications.

METHODS

In a retrospective cohort study, all children with an obstetrical brachial plexus injury who had been born between January 1991 and January 1998 at one academic medical center and all those with the same diagnosis who had been born elsewhere during the same period and were referred to the medical center within six weeks after delivery were evaluated at fixed time-intervals by one examiner. The patients underwent a final orthopaedic, neurological, and radiographic examination at a mean age of 3.7 years (range, one to seven years). Shoulder contracture was defined as a decrease in the passive range of motion in one or more directions compared with the range on the unaffected side. Osseous deformity was defined as a nonspherical humeral head or an abnormal glenoid.

RESULTS

The prevalence of a shoulder contracture of >10 degrees was 56% (twenty-nine of fifty-two patients), and the prevalence of an osseous deformity was 33% (sixteen of forty-eight patients with complete radiographic follow-up). In the children in whom complete neurological recovery was delayed (i.e., recovery was more than three weeks after birth), the prevalence of shoulder contracture was 54% (thirteen of twenty-four patients) and the prevalence of osseous deformity was 26% (six of twenty-three patients). A strong association was noted between shoulder contracture and osseous deformity (p = 0.004). Directly after birth, the presence of a clavicular fracture was the only factor that was associated (p = 0.016) with the development of an osseous deformity (but not with a shoulder contracture). At a later stage, speed and extent of neurological recovery were related to shoulder contracture and osseous deformity. An asymmetric appearance was noticed in children who had a contracture, including those who had complete neurological recovery.

CONCLUSIONS

The prevalence of shoulder contracture and osseous deformity in children with obstetrical brachial plexus injury was high, even in those with complete neurological recovery. These complications were strongly associated with one another. No symptom that appeared immediately after birth was identified as a factor that would predict the development of future shoulder contracture. A clavicular fracture was found to be significantly associated with the development of an osseous deformity at a later stage.

Glenohumeral deformity secondary to brachial plexus birth palsy

Ninety-four patients who had brachial plexus birth palsy were entered into a prospective study to evaluate the association between persistent palsy, age-related musculoskeletal deformity, and functional limitations. Of these patients, forty-two had either computerized tomography or magnetic resonance imaging to assess the presence and degree of incongruity of the glenohumeral joint, deformity of the humeral head, and hypoplasia of the glenoid as part of the preoperative planning for a reconstructive operation. Functional ability was rated with use of the classification of Mallet, on a scale of 1 to 5. The mean glenoscapular angle (the degree of retroversion of the glenoid) on the affected side was -25.7 degrees compared with -5.5 degrees on the unaffected side. Twenty-six (62 per cent) of the forty-two shoulders had evidence of posterior subluxation of the humeral head, with a mean of only 25 per cent (range, 0 to 50 per cent) of the head being intersected by the scapular line. Progressive deformity was found with increasing age (p < 0.001). The natural history of untreated brachial plexus birth palsy with residual weakness is progressive glenohumeral deformity due to persistent muscle imbalance. The status of the glenohumeral joint must be addressed when the choice between tendon transfer and humeral derotation osteotomy for reconstruction of the shoulder is considered for these patients.

Obstetrical brachial palsy

Obstetrical brachial palsy (OBP) (also known in its various forms as Erb's palsy, Klumpke's paralysis, Erb-Duchenne palsy) complicates a very small proportion of births. Furthermore it seems likely that many cases recover with little in the way of remaining deficit but it is equally certain that some cases will not recover. There is increasing evidence that microsurgical help at an early stage can improve the prognosis in some cases. Scepticism exists about the role of surgery and many cases are referred too late for primary nerve surgery. Specialist surgical advice, specialist physiotherapy and where appropriate, either early nerve surgery or secondary reconstructive procedures at a later date can improve the condition of many of these children. This review condenses many of the current opinions and highlights areas of developing knowledge and debate.

Obstetrical brachial plexus injury in newborn babies delivered by caesarean section

The hand surgeon is frequently involved in the medicolegal assessment of birth palsy cases. Although brachial plexus injury has been reported in newborns delivered by Caesarean section, it is difficult to determine if these cases are due to excessive force when delivering the infant from the uterus or whether the palsy is related to other factors. We have studied our series of 16 cases of obstetrical brachial plexus palsy with special attention to the newborn baby delivered by Caesarean section. We have reviewed the English literature over the last decade and found that birth palsy in newborns delivered by Caesarean section is extremely rare (1% of all birth palsy cases). The differentiation between brachial plexus injury caused by forcible delivery and congenital upper limb palsy from other causes is discussed.

Klumpke's birth palsy. Does it really exist?

Erb's palsy is the most common obstetric brachial plexus injury followed by total plexus palsy. The distribution of Klumpke's birth palsy with modern obstetric practice is unknown. In this paper, we studied the distribution of Klumpke's birth palsy in our series of 235 consecutive cases of obstetrical brachial plexus injury and determined the incidence of this type of palsy to be 0.6% as cited in the English literature over the last decade.

Glenoid hypoplasia: assessment by computed tomographic arthrography

Four cases of an uncommon congenital skeletal anomaly, isolated bilateral glenoid hypoplasia, are presented with discussion of the possible pathogenesis and clinical significance. Bilateral computed tomographic arthrography of the shoulder demonstrated thickening of the inferior glenoid cartilage in two cases. The technique was of value in the symptomatic shoulder revealing the location of a contrast medium filled cleft within the posterior cartilage in one case and the true configuration of the glenohumeral joint in the second case, when the degree of deformity had rendered plain radiographs and conventional arthrography uninterpretable.