Combined glenoid anteversion osteotomy and tendon transfers for brachial plexus birth palsy: early outcomes

Clinical Outcome of Lower Trapezius Muscle Transfer in Birth Brachial Plexus Palsy

BACKGROUND

Birth brachial plexus palsy (BBPP) can severely impair shoulder function by restricting external rotation and abduction, often leading to posterior subluxation or dislocation. Progressive shoulder dysplasia, a secondary condition of BBPP, further exacerbates functional disability by limiting shoulder function. Several techniques have been developed to address these challenges, including microsurgery, muscle transfer, and bony procedures. Recent reports on lower trapezius muscle transfer to the infraspinatus footprint demonstrate promising results in restoring shoulder biomechanics in adults. In this study, we aimed to treat patients younger than 7 years with BBPP through lower trapezius muscle transfer without allograft support.

PATIENTS AND METHODS

Between 2014 and 2018, 15 patients with BBPP and impaired shoulder external rotation and/or abduction (mean age, 22 months; range: 10 to 41 months) underwent lower trapezius muscle transfer surgery at our institution. A glenoid osteotomy was performed in patients without concentric joints, followed by the transfer of the lower trapezius muscle to the footprint of the infraspinatus. Patients were followed for an average of 25 months (range: 14 to 46 months). Outcomes assessed included shoulder external rotation, shoulder abduction, hand-to-mouth, hand-to-back, hand-to-neck, and Mallet scores.

RESULTS

Significant improvements were observed in hand-to-mouth, hand-to-neck, global shoulder abduction, global shoulder external rotation, and total Mallet scores (P < 0.01). A nonsignificant decrease in hand-to-back was noted (P > 0.05). Both shoulder external rotation and abduction increased significantly (P < 0.01). No complications were reported after the muscle transfer procedure.

DISCUSSION

Lower trapezius muscle transfer to the infraspinatus footprint markedly improves shoulder external rotation and abduction in children younger than 7 years without adverse effects on daily activities. This procedure is an effective treatment option for patients who present outside the optimal window for nerve transfer.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Age Influence Upon Glenohumeral Remodeling After Shoulder Axial Rebalancing Surgery in Brachial Plexus Birth Injury

BACKGROUND

Shoulder rebalancing procedures have been proven to provide satisfactory functional improvements in patients with shoulder external rotation (ER) deficit due to brachial plexus birth injury (BPBI). However, the influence of age at the time of surgery on osteoarticular remodeling remains uncertain. The purposes of this retrospective case series were (1) to assess the age impact on glenohumeral remodeling and (2) to determine an age limit after which significant changes can no longer be expected.

METHODS

We reviewed preoperative and postoperative magnetic resonance imaging data of 49 children with BPBI who underwent a tendon transfer to reanimate active shoulder ER, with (n=41) or without (n=8) concomitant anterior shoulder release to restore passive shoulder ER, at a mean age of 72 ± 40 months (19;172). Mean radiographic follow-up was 35 ± 20 months (12;95). Univariate linear regressions were used to assess the influence of age at the time of surgery upon changes of glenoid version, glenoid shape, percentage of the humeral head anterior to the glenoid midline, and glenohumeral deformity. Beta coefficients with 95% CI were calculated.

RESULTS

Improvements of glenoid version, glenoid shape, percentage of the humeral head anterior and glenohumeral deformity significantly decreased by 0.19 degrees [CI=(-0.31; -0.06), P =0.0046], 0.02 grade [CI=(-0.04; -0.01), P =0.002], 0.12% [CI=(-0.21; -0.04), P =0.0076], and 0.01 grade [CI=(-0.02; -0.01), P =0.0078] per additional month of age at the time of surgery, respectively. The threshold of 5 years was identified as the age at the time of surgery after which significant remodeling no longer occurred. No significant postoperative changes were observed in patients without glenohumeral dysplasia on preoperative magnetic resonance imaging.

CONCLUSION

In the setting of BPBI-related glenohumeral dysplasia, the younger the surgical axial rebalancing of the shoulder, the greater the glenohumeral remodeling seems to be. Such procedure seems to be safe in patients without significant joint deformity on preoperative imaging.

LEVEL OF EVIDENCE

Therapeutic-Level IV.

Recent Advances in the Treatment of Brachial Plexus Birth Injury

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation.

SUMMARY

Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.

Glenoid osteotomy with various tendon transfers for brachial plexus birth palsy: clinical outcomes

BACKGROUND

Posterior shoulder dislocation is one of the disabling complications of brachial plexus birth injury (BPBI), and various treatment options including capsule and surrounding muscles release for open reduction, humeral derotational osteotomy, and tendon transfers have been recommended to manage it. In the present study, we aimed to determine the clinical outcome of open reduction with soft tissue release, tendon transfer, and glenoid osteotomy in patients with BPBI and posterior shoulder dislocation or subluxation.

METHODS

From 2018 to 2020, 33 patients who underwent open reduction, glenoid osteotomy, and tendon transfer were included. The glenohumeral deformity was classified according to the Waters radiographic classification. Functional assessment was performed using the Mallet grading system before and at least 2 years after the surgery.

RESULTS

The patients were monitored for 26.88 ± 5.47 months. Their average age was 27.5 ± 14 months. Significant improvement was seen in the overall Mallet score (from 13.5 to 18.91 points) and its segments including hand-to-mouth, hand-to-neck, global abduction, global external rotation, abduction range of motion (ROM), and external rotation ROM. Hand-to-back score and the presence of a Trumpet sign were significantly decreased in the postoperation phase (all P values < .001). The above-mentioned variables significantly changed for both infantile and noninfantile dislocations.

CONCLUSION

Our study demonstrated that open reduction along with glenoid osteotomy improves retroversion, and muscle strengthening with different muscle transfers is an effective technique for BPBI.

Transient neonatal shoulder paralysis causes early osteoarthritis in a mouse model

Neonatal brachial plexus palsy (NBPP) occurs in approximately 1.5 of every 1,000 live births. The majority of children with NBPP recover function of the shoulder. However, the long-term risk of osteoarthritis (OA) in this population is unknown. The purpose of this study was to investigate the development of OA in a mouse model of transient neonatal shoulder paralysis. Neonatal mice were injected twice per week for 4 weeks with saline in the right supraspinatus muscle (Saline, control) and botulinum toxin A (BtxA, transient paralysis) in the left supraspinatus muscle, and then allowed to recover for 20 or 36 weeks. Control mice received no injections, and all mice were sacrificed at 24 or 40 weeks. BtxA mice exhibited abnormalities in gait compared to controls through 10 weeks of age, but these differences did not persist into adulthood. BtxA shoulders had decreased bone volume (-9%) and abnormal trabecular microstructure compared to controls. Histomorphometry analysis demonstrated that BtxA shoulders had higher murine shoulder arthritis scale scores (+30%), and therefore more shoulder OA compared to controls. Articular cartilage of BtxA shoulders demonstrated stiffening of the tissue. Compared with controls, articular cartilage from BtxA shoulders had 2-fold and 10-fold decreases in Dkk1 and BMP2 expression, respectively, and 3-fold and 14-fold increases in Col10A1 and BGLAP expression, respectively, consistent with established models of OA. In summary, a brief period of paralysis of the neonatal mouse shoulder was sufficient to generate early signs of OA in adult cartilage and bone.

Brachial Plexus Birth Injuries

Brachial plexus birth injuries (BPBIs) are typically traction type injuries to the newborn that occur during the delivery process. Although the incidence of these injuries has overall decreased from 1.5 to around 0.9 per 1000 live births in the United States over the past 2 decades, these injuries remain common, with incidence holding fairly steady from 2008 to 2014. Shoulder dystocia is the strongest identified risk factor, imparting a 100-fold greater risk. The newborn's shoulder is caught behind the mother's pubic bone, and traction performed on the child during delivery results in injury to the brachial plexus. Other risk factors associated with BPBI include macrosomia (birthweight > 4.5 kg), heavy for gestational age infants, birth hypoxia, gestational diabetes, and forceps or vacuum-assisted delivery. Breech presentation has also been described as a risk factor in the past, but there have been more recent data that challenge this association.

Change in shoulder external rotation strength and motion after lower trapezius transfer to the infraspinatus in children with obstetric brachial plexus palsy

PURPOSE

Quantifying changes in shoulder external rotation range of motion and strength after lower trapezius transfer in children with obstetric brachial plexus palsy (OBPP).

METHODS

This prospective study included five children with sequelae of OBPP, with a mean age of 6.4 years (range: 4-12 years) who underwent lower trapezius tendon transfer to restore active external rotation (ER) of the shoulder. Pre-operatively and at a 12-month follow-up assessment, we analyzed the passive and active shoulder ER, the modified Mallet score, and the shoulder rotator muscles strength using an isokinetic device.

RESULTS

Clinical parameters improved significantly after trapezius transfer pre-operative passive ER from -8° (range: -20-0°) to 37° (range: 15-50°) (p = 0.035), the modified Mallet score from 13 (range: 10-15) to 18 (range: 17-19) (p = 0.035). Strength testing revealed improved ER muscle strength in all five cases; the mean Peak Torque increased from 1.95 to 4.46 N·m, albeit non-significantly (p = 0.062). Two patients exhibited a winged scapula post-operatively.

CONCLUSION

Lower trapezius transfer seems encouraging to restore shoulder external rotation in OBPP children but with non-significant strength improvement.

TRIAL REGISTRATION

18/07/31/5783, December 22, 2018.

Effect of Glenohumeral Reduction Type Combined With Tendon Transfer for Brachial Plexus Injury on Objective, Functional, and Patient-Reported Outcomes

PURPOSE

Glenohumeral (GH) joint reductions are frequently performed during tendon transfer surgery for brachial plexus birth injuries (BPBI); however, the effect of reduction method (none required, closed, surgical) has not been assessed. This study compared objective, functional, and patient-reported outcomes between children who underwent a tendon transfer and (1) did not require GH reduction, (2) required concomitant closed GH reduction, or (3) required concomitant surgical GH reduction.

METHODS

Fifty-four children with BPBI who previously underwent teres major and/or latissimus dorsi transfer with or without concomitant GH reduction participated. Joint reduction method was classified as none required (n = 21), closed (n = 9), or surgical (n = 24). Motion capture was collected in a neutral position, abduction, external rotation, and internal rotation. Glenohumeral joint angles and displacements were calculated. Joint angular displacements represented the differences between the joint angles in each terminal position and the joint angles of the arm at rest in the neutral position. A hand surgeon determined modified Mallet scores. Participants' parents completed the Brachial Plexus Profile Activity Short Form (BP-PRO-SF) to assess physical activity performance.

RESULTS

The no-reduction group had significantly less GH elevation than the surgical-reduction group for all positions and significantly less GH elevation than the closed-reduction group for the neutral, external rotation, and internal rotation positions. There were no differences in GH rotation angles. Glenohumeral joint displacements from neutral and modified Mallet scores were similar. The no-reduction group demonstrated significantly greater BP-PRO-SF scores than the surgical-reduction group.

CONCLUSIONS

Patients who underwent a closed or surgical GH joint reduction consistently displayed more GH elevation. Clinically, this corresponds to an abduction contracture. Whereas increased abduction contracture provided a benefit of greater overhead motion, modified Mallet scores were similar between groups. The surgical-reduction group demonstrated lower BP-PRO-SF outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Shoulder Release and Tendon Transfer following Neonatal Brachial Plexus Palsy: Gains, Losses, and Midline Function

BACKGROUND

Shoulder release and tendon transfer is frequently performed to address persistent weakness from neonatal brachial plexus palsy. Although postoperative improvements in motion are well described, associated deficits are poorly documented, and functional assessments are lacking. Loss of ability to reach midline can occur with surgery and may result in impairment. The purpose of this study was to comprehensively assess the gains, losses, functional changes, and patient-reported outcome associated with the authors' surgical approach.

METHODS

Consecutive patients undergoing surgery with 2-year follow-up were included (n = 30). Prospectively recorded assessments by therapists were reviewed. Changes were assessed by t test and Wilcoxon rank sum (p < 0.05).

RESULTS

Active external rotation and abduction improved and internal rotation diminished. Aggregate modified Mallet score increased with improvements in all subscales, except that hand to spine was unchanged and hand to belly decreased. Functional assessment using the Brachial Plexus Outcome Measure revealed an increase of aggregate score, with no decline in any subscales. Improvements were in hand to back of head, forward overhead reach, holds plate with palm up, opening large container, and strings bead. Aggregate patient self-report of appearance and function increased (from 18 to 23). Loss of ability to reach midline occurred in three patients (10 percent) who had extended Erb or total palsy and preoperative limitations of internal rotation.

CONCLUSIONS

Secondary reconstruction rebalances shoulder motion by increasing external rotation and abduction and reducing internal rotation. In this study, a conservative surgical approach results in overall improvement in task-based abilities and self-reported outcomes and preservation of internal rotation within a functional range.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique

Aims

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

Methods

All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up.

Results

All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016).

Conclusion

Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246–253.

Efficacy of 3 therapeutic taping configurations for children with brachial plexus birth palsy

STUDY DESIGN

Cross-sectional clinical measurement study.

INTRODUCTION

Scapular winging is a frequent complaint among children with brachial plexus birth palsy (BPBP). Therapeutic taping for scapular stabilization has been reported to decrease scapular winging.

PURPOSE OF THE STUDY

This study aimed to determine which therapeutic taping construct was most effective for children with BPBP.

METHODS

Twenty-eight children with BPBP participated in motion capture assessment with 4 taping conditions: (1) no tape, (2) facilitation of rhomboid major and rhomboid minor, (3) facilitation of middle and lower trapezius, and (4) facilitation of rhomboid major, rhomboid minor, and middle and lower trapezius (combination of both 2 and 3, referred to as combined taping). The participants held their arms in 4 positions: (1) neutral with arms by their sides, (2) hand to mouth, (3) hand to belly, and (4) maximum crossbody adduction (CBA). The scapulothoracic, glenohumeral and humerothoracic (HT) joint angles and joint angular displacements were compared using multivariate analyses of variance with Bonferroni corrections.

RESULTS

Scapular winging was significantly decreased in both the trapezius and combined taping conditions in all positions compared with no tape. Rhomboids taping had no effect. Combined taping reduced HT CBA in the CBA position.

CONCLUSIONS

Rhomboid taping cannot be recommended for treatment of children with BPBP. Both trapezius and combined taping approaches reduced scapular winging, but HT CBA was limited with combined taping. Therefore, therapeutic taping of middle and lower trapezius was the most effective configuration for scapular stabilization in children with BPBP. Resting posture improved, but performance of the positions was not significantly improved.

LEVEL OF EVIDENCE

Level II.

Systematic review of the effectiveness of Kinesio taping for children with brachial plexus injury

OBJECTIVE

The purpose of this systematic review was to investigate the effectiveness of Kinesio taping on upper limb motor function in children with brachial plexus injury.

DATA SOURCES

Articles were identified through searches of the following databases: OVID, Web of Science, Science Direct, PubMed, Google Scholar, and the Cochrane library.

METHODS

Studies were excluded if they were nonpeer-reviewed publications, opinion articles, or not reported in English. The methodological quality of the studies was assessed using the Methodological Index for Nonrandomized Studies.

RESULTS

Five studies met our inclusion criteria. Two studies were included in the meta-analysis. A significant change was limited only to scapulothoracic internal rotation in three positions.

CONCLUSIONS

Adding Kinesio taping to the physical therapy programme to manage children with brachial plexus injury is still questionable and may help functional improvement. However, this improvement may be limited depending on the technique or mode of application.

Motion Necessary to Achieve Mallet Internal Rotation Positions in Children With Brachial Plexus Birth Palsy

BACKGROUND

Upper extremity function in children with brachial plexus birth palsy (BPBP) is assessed with clinical tests such as the Mallet classification, which uses a hand to spine position to assess shoulder internal rotation, or the modified Mallet classification, which adds an additional internal rotation task (hand to belly). Children with BPBP frequently have difficulty performing the hand to spine task. This study compared scapulothoracic and glenohumeral (GH) parameters associated with successful completion of the hand to spine and hand to belly modified Mallet positions.

METHODS

Motion capture measurement of 32 children with BPBP was performed in hand on spine, internal rotation (hand to belly), hand to mouth, and maximal humerothoracic extension positions. Modified Mallet scores were determined by a hand surgeon.

RESULTS

Children with better hand to spine performance demonstrated significantly greater GH extension and a nonsignificant trend toward increased GH internal rotation compared with children with scores <3. Children with better internal rotation position performance demonstrated significantly greater GH internal rotation and no significant difference in GH extension. Hand on spine and internal rotation Mallet scores moderately correlated (Pearson r=0.469); however, 54% of children who could place their palms flat on their bellies could not reach behind their backs.

CONCLUSIONS

Successfully reaching behind one's back requires both internal rotation and extension, representing a multiplanar motion. The hand to belly performance is less affected by extension and should be considered for internal rotation assessment, particularly for children undergoing surgical intervention that may affect internal rotation.

LEVEL OF EVIDENCE

Level II.

The Effect of Scapular Position on Magnetic Resonance Imaging Measurements of Glenohumeral Dysplasia Caused by Neonatal Brachial Plexus Palsy

PURPOSE

Neonatal brachial plexus palsy (NBPP) frequently causes glenohumeral dysplasia. Quantification of this dysplasia on magnetic resonance imaging can determine the need for and the success of nonsurgical or surgical intervention. However, we hypothesize that the variable position of the scapula on the thorax between affected and unaffected shoulders affects dysplasia measurements.

METHODS

Magnetic resonance imaging studies were analyzed from 19 NBPP patients (ages 0.8-18 years; median, 2.4 years) without prior shoulder surgery. Three reviewers measured the glenoid version angle (GVA) and percentage of humeral head anterior to the midscapular line (PHHA) on standard axial images ("thoracic axial") and on reformatted axial images aligned perpendicular to the scapular plane ("scapular axial"), which corrects for scapulothoracic position. Scapular tilt and protraction were measured to assess their impact on the difference between thoracic and scapular GVA and PHHA measurements. Intra- and interrater reliability were calculated for GVA and PHHA on both views.

RESULTS

The GVA of the affected shoulder was significantly greater on thoracic than on scapular images, by an average of 5° and as much as 34°. The PHHA was significantly less in the affected shoulders on thoracic than on scapular images, by an average of 5% and as much as 33% of humeral head width. The difference in GVA, but not PHHA, between thoracic and scapular axial images in the affected shoulder correlated with scapular tilt. Unaffected shoulders showed no significant difference in GVA or PHHA between thoracic and scapular axial images. Interrater reliability ranged from fair to substantial and did not differ between thoracic and scapular images.

CONCLUSIONS

Thoracic axial images overestimate the severity of glenohumeral dysplasia in NBPP, owing at least in part to the variable position of the scapula on the thorax. This confounding effect must be considered in interpretation of axial quantitative measures of glenohumeral dysplasia in NBPP.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Glenoid morphology in obstetrical brachial plexus lesion: a three-dimensional computed tomography study

BACKGROUND

Obstetric brachial plexus lesion (OBPL) frequently leads to glenohumeral dysplasia, and excessive retroversion of the glenoid is among the best known developmental disturbances. Most analyses of the glenoid are based on 2-dimensional (D) imaging and do not address glenoid inclination or provide information on the glenoid in the sagittal plane. We aim to describe the 3-D deformity of the glenoid in children with OBPL.

METHODS

Preoperative computed tomography (CT) scans of the nonaffected and the affected scapula of 24 children (aged 5 to 12 years) with developmental disturbances after OBPL years were analyzed. The dimensions of the scapula and the deformation of the glenoid were visualized in 3-D.

RESULTS

The retroversion of the glenoid fossa was greater in all affected shoulders, and 2-D measurements significantly overestimated retroversion compared with angles measured in 3-D. The inclination of the glenoid fossa was altered, and a distal bony edge loss was observed on 3-D reformations in the sagittal plane. The reliability of the measured angles was excellent, and the κ agreement for the description of the glenoid form was substantial. Furthermore, the dimensions of the scapula were significantly smaller on the affected shoulders.

CONCLUSION

OBPL is indeed a 3-D disorder. Our measurements revealed excessive retroversion of the glenoid fossa, and the reliability of the 3-D CT measurements was superior to their 2-D counterparts. 3-D CT reformations of the glenoid in the coronal and the sagittal plane added further to 3-D understanding of glenoid morphology in OBPL. These new findings legitimatize a 3-D CT-based description of the glenoid deformities connected with OPBL.

Posterior open wedge osteotomy of the scapula neck for the treatment of advanced shoulder osteoarthritis with posterior head migration in young patients

BACKGROUND

Treatment of young, active patients with symptomatic glenohumeral osteoarthritis, excessive glenoid retroversion, and static posterior humeral subluxation is challenging. Correction of glenoid retroversion may lead to centric loading and perhaps recenter the humeral head. We describe the functional and radiologic outcomes after corrective osteotomy of the glenoid in this population of patients.

MATERIALS AND METHODS

In this retrospective study, we included 10 shoulders (8 patients) that were observed for a mean of 33.4 months (range, 24-52 months) after corrective osteotomy of the glenoid. The mean age at surgery was 41.5 years (range, 24-51 years). On standardized axial images, glenoid retroversion and posterior static humeral subluxation were measured preoperatively and postoperatively and at the final follow-up. At final follow-up, anterior and posterior axial radiographs were performed to determine humeral head position in different arm positions. Clinical follow-up included Constant-Murley score, subjective shoulder value, and patient satisfaction.

RESULTS

The mean Constant-Murley score improved significantly from 45.1 points (range, 24-71) to 64.1 points (range, 44-92; P < .001). The average degree of anterior flexion improved significantly from 117° (range, 50°-160°) to 143° (range, 110°-180°; P = .006). The mean glenoid retroversion changed from 16° (range, 11°-31°) preoperatively to 5° (range, 13° anteversion-16° retroversion; P = .003) at the final follow-up. The mean posterior static subluxation of the humeral head changed from 5 mm (range, 0-10 mm) preoperatively to 6 mm (range, 0-14 mm; P = .259) at the final follow-up.

CONCLUSIONS

This study shows that posterior open wedge osteotomy of the glenoid neck provides excellent correction of glenoid retroversion.

Therapeutic Taping for Scapular Stabilization in Children With Brachial Plexus Birth Palsy

OBJECTIVE. In this study, we aimed to assess whether therapeutic taping for scapular stabilization affected scapulothoracic, glenohumeral, and humerothoracic joint function in children with brachial plexus birth palsy and scapular winging.

METHOD. Motion capture data were collected with and without therapeutic taping to assist the middle and lower trapezius in seven positions for 26 children. Data were compared with one-way multivariate analyses of variance.

RESULTS. With therapeutic taping, scapular winging decreased considerably in all positions except abduction. Additionally, there were increased glenohumeral cross-body adduction and internal rotation angles in four positions. The only change in humerothoracic function was an increase of 3° of external rotation in the external rotation position.

CONCLUSION. Therapeutic taping for scapular stabilization resulted in a small but statistically significant decrease in scapular winging. Overall performance of positions was largely unchanged. The increased glenohumeral joint angles with therapeutic taping may be beneficial for joint development; however, the long-term impact remains unknown.

Imaging assessment of glenohumeral dysplasia secondary to brachial plexus birth palsy

Objective

To assess imaging parameters related to the morphology of the glenohumeral joint in children with unilateral brachial plexus birth palsy (BPBP), in comparison with those obtained for healthy shoulders.

Materials and Methods

We conducted a retrospective search for cases of unilateral BPBP diagnosed at our facility. Only patients with a clinical diagnosis of unilateral BPBP were included, and the final study sample consisted of 10 consecutive patients who were assessed with cross-sectional imaging. The glenoid version, the translation of the humeral head, and the degrees of glenohumeral dysplasia were assessed.

Results

The mean diameter of the affected humeral heads was 1.93 cm, compared with 2.33 cm for those of the normal limbs. In two cases, there was no significant posterior displacement of the humeral head, five cases showed posterior subluxation of the humeral head, and the remaining three cases showed total luxation of the humeral head. The mean glenoid version angle of the affected limbs (90-α) was -9.6º, versus +1.6º for the normal, contralateral limbs.

Conclusion

The main deformities found in this study were BPBP-associated retroversion of the glenoid cavity, developmental delay of the humeral head, and posterior translation of the humeral head.

Boston Children's Hospital approach to brachial plexus birth palsy

The treatment of infants with brachial plexus birth palsy (BPBP) continues to be a focus at Boston Children's Hospital. Over the last 15 years, there have been many developments in the treatment of infants with BPBP. Some of the greatest changes have emerged through technical advances such as the advent of distal nerve transfers to allow targeted reinnervation as well as through research to understand the pathoanatomical changes that lead to glenohumeral dysplasia and how this dysplasia can be remodeled. This review will discuss our current practice of evaluation of the infant with BPBP, techniques for microsurgical reconstruction, and prevention and treatment of secondary glenohumeral dysplasia.

Three dimensionality of gleno-humeral deformities in obstetrical brachial plexus palsy

The primary objective of this study was to test the hypothesis that gleno-humeral deformity in children and adolescent with obstetrical brachial plexus palsy is three-dimensional (3D). The study also compared the metrological properties of typical two-dimensional gleno-humeral measures to the newly developed 3D measures. Thirteen individuals (age = 11.8 ± 3.3 years) with obstetrical brachial plexus palsy participated in this IRB-approved study. 3D axial magnetic resonance images were acquired for both shoulders. Glenoid and humeral models were created in order to quantify 3D glenoid version, humeral head migration, and glenoid concavity. Two-dimensional (2D) measures were acquired as recommended in the literature. All measures were completed by two observers in this observer-blind study. Compared to the non-involved side, the glenoid was more retroverted (7.91°, p = 0.003) and inferiorly oriented (7.28°, p = 0.009). The humeral head was migrated more posteriorly (5.54 mm, p = 0.007), inferiorly (-3.96 mm, p = 0.013), and medially (-3.63 mm,p = 0.002). Eleven of the 13 glenoids were concave, based on the 3D glenoid models. The concurrent validity between three- and 2D measures were highly dependent of the parameter measured, the slice level used for the 2D analysis, and the presence/absence of pathology (0.63 < r < 0.91). The standard error of measurement for the 2D anterior-posterior version (>3°) was larger than that for the 3D measure of version (<1°) on the involved side. This study clearly demonstrated that the gleno-humeral deformation in obstetrical brachial plexus palsy is 3D, emphasizing the need for 3D subject specific gleno-humeral shape analysis for follow-up and treatment plans in children with obstetrical brachial plexus palsy.

Three-Dimensional Magnetic Resonance Imaging of Glenohumeral Dysplasia in Neonatal Brachial Plexus Palsy

BACKGROUND

Existing quantitative measurements of glenohumeral dysplasia in children with unresolved neonatal brachial plexus palsy (NBPP) have been mostly limited to the axial plane. The purpose of this study was to describe the three-dimensional (3D) pathoanatomy of glenohumeral dysplasia using 3D magnetic resonance imaging (MRI) reformations.

METHODS

3D MRI reformations of the scapula, glenoid labrum, and proximal part of the humerus were created from a volume-acquisition proton-density-weighted MRI sequence of both the affected and the unaffected shoulder of seventeen children less than six years of age with unresolved NBPP who had not undergone shoulder surgery. Glenoid retroversion and posterior humeral head displacement were measured on axial 2D images. Humeral head displacement in all planes, labral circumference, glenoid retroversion, glenoid declination, and scapular morphometric values were measured on 3D reformations. Contiguity of the humeral head with the labrum and the shape of the glenoid were classified. Measurements were compared between the affected and unaffected sides.

RESULTS

On 3D evaluation, the humeral head was completely posteriorly translated in ten patients but was never outside the glenoid labrum. Instead, in these patients, the humeral head was eccentrically articulating with the dysplastic glenoid and was contained by a posteriorly elongated labrum. Glenoid dysplasia was not limited to the axial plane. Less declination of the glenoid in the coronal plane correlated with greater 3D glenoid retroversion. Glenoid retroversion resulted from underdevelopment of the posterior aspect of the glenoid rather than overdevelopment of the anterior aspect of the glenoid. 3D measurements of greater glenoid retroversion and less declination correlated with 2D measurements of glenoid retroversion and posterior humeral head displacement.

CONCLUSIONS

Posterior humeral head displacement in NBPP should not be considered a simple "dislocation." Glenohumeral dysplasia is not limited to the axial plane. Abnormal glenoid declination may have potential implications for the evaluation and treatment of shoulder weakness and contractures.

Late reconstruction of brachial plexus birth palsy

Brachial plexus birth palsy (BPBP) presents to the physician on a clinical spectrum, and may substantially impair the child. Potential interventions to improve function for the child with BPBP include physical therapy, microsurgical nerve reconstruction and nerve transfers, soft-tissue balancing and reconstruction with musculotendinous transfers, and osteotomies. Some interventions, such as nerve reconstruction, are best performed in infancy; others, such as muscle transfers and osteotomies, are performed to treat manifestations of this condition that appear later in childhood. Although controversy continues to exist regarding the natural history and surgical management of these patients, recent literature has improved our understanding of surgical indications, anticipated outcomes, and potential complications. On the basis of current evidence, we present here the recommendations for surgical intervention in the upper extremity of children with BPBP, and encourage early referral to a brachial plexus specialist to establish care.

External Rotation Osteotomy of the Humerus to Salvage the Failed Latissimus Dorsi Transfer in Children With Erb Birth Palsy and Supple Congruent Shoulders

Management of the failed latissimus dorsi muscle transfer to restore shoulder external rotation has received little attention in the literature. We report on 6 children with Erb birth palsy and supple congruent shoulders and who underwent external rotation osteotomy to salvage a failed latissimus dorsi transfer. It is standard of care to do humerus osteotomies only to children with significant deformities of the glenohumeral joint. In the current article, the osteotomy was performed despite the presence of supple congruent shoulders because the osteotomy seemed the best and simplest option available. The functional outcome was satisfactory; with all patients reaching the occiput easily. Furthermore, there were improvement of the standing posture and improvement of the elbow flexion contracture. We conclude that the osteotomy procedure is a simple and effective option of management after a failed latissimus dorsi transfer.

Evaluation and management of brachial plexus birth palsy

Brachial plexus birth palsy can result in permanent lifelong deficits and unfortunately continues to be relatively common despite advancements in obstetric care. The diagnosis can be made shortly after birth by physical examination, noting a lack of movement in the affected upper extremity. Treatment begins with passive range-of-motion exercises to maintain flexibility and tactile stimulation to provide sensory reeducation. Primary surgery consists of microsurgical nerve surgery, whereas secondary surgery consists of alternative microsurgical procedures, tendon transfers, or osteotomies, all of which improve outcomes in the short term. However, the long-term outcomes of current treatment recommendations remain unknown.

Surgical correction of a rotational deformity of the shoulder in patients with obstetric brachial plexus palsy

We evaluated results at one year after surgical correction of internal rotation deformities in the shoulders of 270 patients with obstetric brachial plexus palsy. The mean age at surgery was 6.2 years (0.6 to 35). Two techniques were used: open subscapularis elongation and latissimus dorsi to infraspinatus transfer. In addition, open relocation was performed or attempted in all patients with subluxed or dislocated joints. A mixed effects model approach was used to evaluate the effects of surgery on internal and external rotation, abduction, flexion and Mallet score. Independent factors included operative status (pre- or post-operative), gender, age, the condition of the joint, and whether or not transfer was performed. The overall mean improvement in external rotation following surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was a mean decrease in internal rotation of between 27.6° and 34.4° in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the normal joint group. Abduction and flexion were unchanged following surgery. Adding a latissimus dorsi transfer did not result in greater improvement in the mean external rotation compared with elongation of the subscapularis alone.

Cite this article: Bone Joint J 2013;95-B:1432–8.

Combined Glenoid Anteversion Osteotomy and Tendon Transfers for Brachial Plexus Birth Palsy

Introduction

Combined glenoid osteotomy with tendon transfers is a new alternative procedure for patients with severe glenohumeral dysplasia secondary to brachial plexus birth palsy.

Step 1 MRI or CT for Preoperative Planning

Use axial plane MRI or CT for preoperative planning.

Step 2 Surgical Approach with Deltoid Elevation

Position the patient laterally, and undertake a posterior approach, including lateral elevation of the deltoid origin.

Step 3 Subscapularis Slide

Elevate the subscapularis from the scapula, provisionally reduce the humeral head, and apply gentle external rotation.

Step 4 Harvest of the Teres Major and Latissimus Dorsi Tendons

Incise the insertions of the teres major and latissimus dorsi from the proximal part of the humerus and perform a tenolysis.

Step 5 Posterior Approach to the Glenohumeral Joint

Open the posterior glenohumeral joint and assess overhead elevation.

Step 6 Assessment and Improvement of Abduction Contracture

Improve abduction contracture if it is marked.

Step 7 Harvest of Bone Graft

Harvest tricortical graft from the scapular spine or posterior aspect of the acromion.

Step 8 Scapular Neck Osteotomy

Undertake a posterior opening wedge osteotomy of the scapular neck.

Step 9 Posterior Opening Wedge at the Osteotomy Site

Insert the bone graft into the osteotomy site.

Step 10 Joint Closure and Infraspinatus Repair

Close the posterior aspect of the capsule and the infraspinatus.

Step 11 Transfer of the Teres Major and Latissimus Dorsi

Transfer the teres major and latissimus dorsi tendons into an osseous trough at the greater tuberosity.

Step 12 Closure and Immobilization

Repair the deltoid, close the wound in layers, and apply a shoulder spica cast.

Step 13 Postoperative Plan

Maintain the spica cast for five to six weeks; then initiate physiotherapy.

Results

In our series of thirty-two patients with severe glenohumeral dysplasia who underwent combined glenoid osteotomy and tendon transfers, early results suggest that the outcomes of this procedure are similar to those of proximal humeral external rotation osteotomy¹.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.