Arthroscopic treatment for internal contracture of the shoulder secondary to brachial plexus birth palsy: report of a case series and review of the literature

Outcomes of glenohumeral dysplasia after brachial plexus birth injury using the Sup-ER orthosis

We investigated the efficacy of the supination-external rotation ('Sup-ER') orthosis, designed as a non-operative treatment to maintain normal anatomical growth of the shoulder, on the progression of glenohumeral dysplasia in patients with brachial plexus birth injuries. The Sup-ER orthosis was fabricated for 20 infants diagnosed with glenohumeral dysplasia after brachial plexus birth injuries and its success in correcting glenohumeral dysplasia was confirmed by objective calculations of the alpha angle on serial ultrasound findings and improvement in Active Movement Scale scores. Of the 20 patients, 14 had successful resolution of glenohumeral dysplasia, confirmed by shoulder abduction, shoulder flexion, external rotation and supination, Active Movement Scale scores and improving alpha angle measurements. Failure to rectify glenohumeral dysplasia, evidenced by worsening ultrasound findings and Active Movement Scale scores, necessitated a change to operative management in six patients.Level of evidence: IV.

Current Concepts in Brachial Plexus Birth Injuries: A Comprehensive Narrative Review

Background

Brachial plexus birth injury (BPBI) encompasses a spectrum of upper extremity paralysis cases following childbirth. The etiology of BPBI is multifactorial, involving maternal, obstetric, and neonatal associative factors. Despite opportunities for spontaneous recovery, recent literature demonstrates that a significant proportion of infants experience residual deficits and functional limitations as they age. Understanding the complex anatomy of the brachial plexus, clinical presentations of the pathology, diagnostic workup, current treatment options, and common secondary sequelae is instrumental for appropriate management of BPBI.

Methods

Following a comprehensive search strategy used by the authors to identify relevant literature relating to the progression, patho-anatomy, clinical presentation, management, and treatment of BPBI, this comprehensive narrative review outlines current approaches to assess, manage, and advance BPBI care.

Results

We advocate for prompt referral to specialized multicenter brachial plexus clinics for accurate diagnosis, timely intervention, and individualized patient-centered assessment. Further research is needed to elucidate mechanisms of injury, refine diagnostic protocols, and optimize long-term outcomes.

Conclusions

Collaboration between healthcare providers and families is paramount in providing comprehensive care for infants with BPBI. This review offers insights into the current understanding and management of BPBI, highlighting the importance of tailored approaches and intraoperative decision-making algorithms to optimize functional outcomes.

Surgical treatment of a nonunion following clavicle osteotomy in a child with a history of Erb's palsy: A case report

INTRODUCTION AND IMPORTANCE

Erb's palsy defined as muscle weakness and loss of motion caused by a nerve condition in the shoulder and arm. Children with Erb's palsy might underwent clavicle osteotomy as an appropriate surgical treatment method. However, few number of these patients who underwent clavicle osteotomy experienced nonunion and complained of shoulder deformity and pain. The aim of the present case report was to present new surgical treatment of a nonunion following clavicle osteotomy in a child affected by Erb's palsy.

CASE PRESENTATION

A six years old boy with a history of Erb's palsy who underwent clavicle osteotomy at age of 6 months was referred to hospital. There was a nonunion following clavicle osteotomy. The patient had right shoulder deformity and complained of its-related pain. To correct a nonunion following clavicle osteotomy in this case, middle third fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was used. After five months of follow-up, a clavicle nonunion and shoulder deformity was thoroughly corrected.

CLINICAL DISCUSSION

As clavicle osteotomy, the most commonly surgical method for Erb's palsy, has been demonstrated to not work effectively and cause nonunion in some cases, a new surgical method for correcting clavicle nonunion other than repeated clavicle osteotomy is needed. In the present case report, fibula auto grafting and fixing it to the cite of clavicle nonunion by pins was applied and demonstrated remarkable improvement.

CONCLUSION

Totally, use of fibula auto grafting and fixing it to the cite of clavicle nonunion by pins might be an effective surgical treatment for such cases.

Shoulder Reconstruction for Brachial Plexus Birth Injuries: An In-Depth Review and Case-Based Update

Brachial plexus birth injuries can result in significant shoulder dysfunction with limitations in range of motion, decreased strength, and risk of glenohumeral joint deformity. This comprehensive review examines current approaches for management of the shoulder including surgical reconstruction following these injuries. Serial clinical exams and selective imaging are critical to determine optimal timing of surgery based on recovery potential and joint pathology. Biceps recovery is monitored monthly from birth and, if absent by 5-6 months, serves as an indication for nerve reconstruction with nerve grafting, transfers, or both. Glenohumeral contracture, deformity, and dislocation commonly occur in infancy and are assessed by exam, ultrasound, and MRI scan. Procedural intervention is indicated when there is loss of passive external rotation, active motor weakness, and/or glenohumeral deformity/dislocation is present. Contracture release and joint reduction to center the humeral head on the glenoid is performed early when there are limitations in passive external rotation not resolved with therapy. Glenoid remodeling can occur when reduction is performed early (6 months to 2-3 years). Surgical options include (1) extraarticular contracture releases (e.g., botox, subscapularis slide) and closed reduction, (2) intraarticular arthroscopic/open release and reduction, and (3) contracture release/joint reduction combined with tendon transfers (latissimus-teres major most common). The lower trapezius transfer is increasingly used for active external rotation as it spares internal rotation strength and has an excellent line of pull reproducing that of the infraspinatus. For advanced joint deformity, humeral/ glenoid osteotomies are utilized. A nuanced, individualized approach is required considering the child's deficits, pathoanatomy, and age in a case-based manner. Open communication between providers and families is imperative to optimize care. This review provides a comprehensive analysis of current shoulder reconstruction approaches following brachial plexus birth injuries. Key Concepts•Failure of biceps recovery by 5-6 months for extraforaminal injuries (C5-C6; C5-C6-C7) indicates nerve surgery intervention between 5-9 months using nerve grafting, transfers, or a combination to restore function in the shoulder (and as for indicated elbow, forearm, and wrist).•Glenohumeral joint complications such as contracture, deformity, and dislocation often emerge during early infancy to the first 2-3 years due to incomplete recovery. Physical exams focus on the progressive limitations of external rotation (ER), and advanced imaging (ultrasound or MRI) is needed when passive ER falls below 30 degrees and/or there's posterior humeral head prominence.•In cases of glenohumeral deformity and dislocation, it's crucial to center and stabilize the humeral head on the glenoid during reduction. Early intervention (6 months to 2-3 years) can result in glenoid remodeling.•Surgical options range from extraarticular contracture releases, such as botox and subscapularis slide, to intraarticular arthroscopic or open release and reduction. Depending on patient age and deformity severity, reduction surgeries can be standalone or combined with tendon transfers. It's vital to adopt a patient-tailored, stepwise approach during surgery.•The latissimus dorsi-teres major transfer restores active external rotation, while the lower trapezius offers an alternative for active ER that preserves internal rotation strength. In situations with pronounced deformities in older patients, glenoid and humeral osteotomies can be performed.

Surgical Soft Tissue Management for Glenohumeral Deformity and Contractures in Brachial Plexus Birth Injury : A Systematic Review and Meta-analysis

PURPOSE OF THE REVIEW

Consensus on the effects of soft tissue surgical intervention in the management of brachial plexus birth injury (BPBI) sequalae is lacking. The purpose of this review is to examine the available literature on the functional and structural outcomes following soft tissue surgical management of BPBI sequalae.

RECENT FINDINGS

EMBASE, PubMed, and MEDLINE were searched for related literature from the point of database inception until April 2021. Relevant papers were screened by two reviewers independently and in duplicate. A meta-analysis was performed using a random effects model. A total of 25 studies (852 patients) were included in the review, with the number included in each meta-analysis varying based on outcome of interest. There were significant improvements from pre- to post-operative time points for the following measures: Mallet aggregate scores (5.0 points, p<0.0001), active external rotation in adduction (48.9°, p=0.003), passive external rotation in adduction (64.6°, p< 0.00001), active abduction (46.2°, p<0.00001), glenoid version (14.4°, p< 0.00001), and percentage of the humeral head anterior to the scapular line (17.53°, p< 0.00001). Furthermore, data revealed an overall complication rate of 9.3% (79/852 patients) and a major complication rate of 0.47% (4/852 patients). Patients with BPBI sequela experience statistically significant improvements in functional, structural, and range of motion outcomes of the GH joint following soft tissue surgical management. Understanding the ideal indications for each procedure and age of surgical management with future prospective studies will help to optimize surgical management of these patients.

Effect of arthroscopic shoulder release on shoulder mobility and bone deformity following brachial plexus birth injury: a systematic review and meta-analysis

BACKGROUND

Specific information to guide clinical practice is lacking for the effects of arthroscopic release on bone and joint deformities, as well as the additional benefits of tendon transfer, in children with brachial plexus birth injury. The aims of this study were (1) to evaluate changes in shoulder mobility and bone and joint deformity, (2) to evaluate the effect of release with and without tendon transfer on the same outcomes, and (3) to evaluate the perioperative and long-term complications.

METHODS

We conducted a systematic review and meta-analysis. Four databases were searched using relevant inclusion and exclusion criteria from inception until May 2020. The quality of articles was evaluated using the Methodological Index for Non-randomized Studies (MINORS) scale. Data regarding patients, interventions, and clinical and radiologic outcomes were reported.

RESULTS

Thirteen articles were included: 6 of low quality and 7 of moderate quality separated into 17 studies (266 children). The mean follow-up duration was 32.4 months (standard deviation, 15.2 months). Arthroscopic release significantly improved the Mallet score (standardized mean difference [SMD], 3.1 [95% confidence interval (CI), 1.5-4.7]; P < .001) and passive external rotation (SMD, 3.6 [95% CI, 2.3-4.9]; P = .02). The percentage of humeral head anterior (SMD, 1.3 [95% CI, 0.7-1.9]; P = .003) and glenoid retroversion (SMD, 1.4 [95% CI, 0.9-2]; P = .01) also improved. Descriptive analysis of the data suggested that concomitant tendon transfer further improved mobility. Recurrence of internal-rotation contracture was reported in 8 of 157 children.

DISCUSSION

This systematic review showed that arthroscopic release effectively improves both shoulder mobility and bone deformity, with few complications in young children with brachial plexus birth injury. As such, it seems reasonable to propose a stepwise approach starting with a release without transfer.

Triplanar Humeral Osteotomy for Restoration of Midline Function in Patients With Brachial Plexus Birth Palsy

Brachial plexus birth palsy resolves spontaneously in a majority of patients, however, others may have serious permanent dysfunction. Although nerve transfers or grafts are early options for treatment, many children have residual deficits or present too late for such procedures. In these patients, rotational osteotomy of the humerus may restore improved function and motion. Unfortunately, traditional humeral osteotomies only provide correction in a single plane, therefore appropriate correction of the typical residual deformity is incomplete. Here, we describe a novel technique for obtaining a calculated correction in 3 planes using a single osteotomy of the humerus on the basis of a mathematical equation. Nine patients are described here with an average of 35.4 months follow-up. Corrections were obtained in adduction, extension, and either internal or external rotation depending on the initial deformity and Modified Mallet scores were collected for each patient. There was 1 case of transient radial nerve palsy with no long-term complications overall.