Interactive associations of sex and hyperlipidemia with calcific tendinitis of the shoulder in Taiwanese adults

Calcific tendinitis (CT) of the shoulder is a painful disorder usually identified in individuals aged 40 and 60 years. The estimated global prevalence of CT is 2.7% to 36%. We examined the association of hyperlipidemia and sex with CT of the shoulder using Taiwan Biobank (TWB) and the National Health Insurance Research Database (NHIRD).Data were available for 9903 TWB participants who were recruited between 2008 and 2015. We used multiple logistic regression analysis to estimate the odds ratios (OR) and 95% confidence intervals (CI) for CT of the shoulder.Overall, 1564 women, and 1491 men were identified with hyperlipidemia. Women, compared to men, had higher odds of CT of the shoulder (OR, 1.53; 95% CI, 1.08-2.16). Hyperlipidemia, compared to no hyperlipidemia, was associated with an increased risk of CT (OR, 1.40; 95% CI, 1.02-1.93). The test for interaction was significant for sex and hyperlipidemia (P = .006). After stratification, the odds ratio for CT was 1.95 (95% CI, 1.30-2.92) in women and 0.82 (95% CI, 0.48-1.39) in men, respectively. Compared to men with no hyperlipidemia, the odds ratio was 0.86 (95% CI, 0.53-1.38) for men with hyperlipidemia and 2.00 (95% CI, 1.29-3.10) for women with hyperlipidemia.Importantly, our findings indicated that the risk for CT of the shoulder was higher among Taiwanese women with hyperlipidemia. However, CT risk among their male counterparts with hyperlipidemia was not significant.

Effectiveness and safety of early intramuscular botulinum toxin injections to prevent shoulder deformity in babies with brachial plexus birth injury (POPB-TOX), a randomised controlled trial: study protocol

INTRODUCTION

In children with brachial plexus birth injury (BPBI), denervation of the shoulder muscles leads to bony deformity in the first months of life, reducing active and passive range of motion (ROM) and causing activity limitation. The aim of this multicentre randomised controlled trial is to evaluate the effectiveness of botulinum toxin injections (BTI) in the shoulder internal rotator muscles of 12-month-old babies in limiting the progression of posterior subluxation of the glenohumeral joint, compared with a sham procedure mimicking BTI. The secondary aims are to evaluate the effectiveness of BTI in (1) limiting the progression of glenoid retroversion and three-dimensional (3D) deformity and (2) improving shoulder ROM and upper limb function, as well as to confirm the tolerance of BTI.

METHODS AND ANALYSIS

Sixty-two babies with unilateral BPBI and a risk of posterior humeral head subluxation will be included. Only those with at least 7% posterior subluxation of the humeral head compared with the contralateral shoulder on the MRI will be randomised to one of two groups: 'BTI' and 'Sham'. The BTI group will receive BOTOX injections at the age of 12 months in the internal shoulder rotator muscles (8 UI/kg). The sham group will undergo a sham BTI procedure. Both groups will undergo repeated shoulder MRI at 18 months of age to quantify changes in the percentage of posterior migration of the humeral head (primary outcome), glenoid version and 3D bone deformity. Clinical evaluations (passive shoulder ROM, active movement scale) will be carried out at baseline and 15 and 18 months of age. The mini-assisting hand assessment will be rated between 10 and 11 months and at 18 months of age. Adverse events will be recorded at least monthly for each child.

ETHICS AND DISSEMINATION

Full ethical approval for this study has been obtained. The findings will be disseminated in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

EudraCT: 2015-001402-34 in European Clinical Trial database; NCT03198702 in Clinical Trial database; Pre-results.

Expression of DUX4 in zebrafish development recapitulates facioscapulohumeral muscular dystrophy

Facioscapulohumeral muscular dystrophy (FSHD) is a common form of muscular dystrophy characterized by an asymmetric progressive weakness and wasting of the facial, shoulder and upper arm muscles, frequently accompanied by hearing loss and retinal vasculopathy. FSHD is an autosomal dominant disease linked to chromosome 4q35, but the causative gene remains controversial. DUX4 is a leading candidate gene as causative of FSHD. However, DUX4 expression is extremely low in FSHD muscle, and there is no DUX4 animal model that mirrors the pathology in human FSHD. Here, we show that the misexpression of very low levels of human DUX4 in zebrafish development recapitulates the phenotypes seen in human FSHD patients. Microinjection of small amounts of human full-length DUX4 (DUX4-fl) mRNA into fertilized zebrafish eggs caused asymmetric abnormalities such as less pigmentation of the eyes, altered morphology of ears, developmental abnormality of fin muscle, disorganization of facial musculature and/or degeneration of trunk muscle later in development. Moreover, DUX4-fl expression caused aberrant localization of myogenic cells marked with α-actin promoter-driven enhanced green fluorescent protein outside somite boundary, especially in head region. These abnormalities were rescued by coinjection of the short form of DUX4 (DUX4-s). Our results suggest that the misexpression of DUX4-fl, even at extremely low level, can recapitulate the phenotype observed in FSHD patients in a vertebrate model. These results strongly support the current hypothesis for a role of DUX4 in FSHD pathogenesis. We also propose that DUX4 expression during development is important for the pathogenesis of FSHD.

[Evaluation of physical fitness in children of pre-school age including postural problems]

BACKGROUND

Pre-school age is a period of intensive development when children shape their posture, habits and motor memory. In recent years an increased incidence of postural problems has been observed among children and adolescents. This process results from civilisation progress and sedentary life style. Most of the early-detected abnormalities are of a functional nature and are relatively easy to correct. However, if no preventive measures are taken, deformities of bones and joints may develop which are difficult to treat and result in serious health disorders. The aim of our study was to evaluate physical fitness in children of pre-school age depending on diagnosed postural problems.

MATERIALS AND METHODS

The study included 64 children aged 6-7 years, in which abnormalities of body posture were diagnosed using the Wolański method. The children were classified into two groups. Group 1 comprised children with abnormalities in the chest and shoulder girdle, and group 2 comprised children with lower limb abnormalities. Physical fitness was evaluated using the Modified Wrocław Test for Physical Fitness by B. Sekita (1988).

RESULTS

We found a statistically significant difference (p = 0.0148) between groups in a 20 m run. Test results demonstrated that dysfunctions of lower limbs influenced the times for longer distance runs, but no statistically significant difference was found between the groups for shuttle run times. Children from group 2 had lower long jump scores compared to group 1, but the difference was not statistically significant. A statistically significant difference (p = 0.0375) was found for medicine ball throw scores. Children from group 1 had higher scores. This can be explained by the higher number of boys in that group, who have greater physical strength than girls.

RESULTS

Abnormalities of lower limbs in the studied group of children had a statistically significant influence on reduced physical fitness measured with the Sekita test. Abnormalities of the shoulder girdle and chest in the studied group of children had no effect on reduced physical fitness measured with the Sekita test.

Point mutation of an EYA1-gene splice site in a patient with oto-facio-cervical syndrome

Mutations of the EYA1 gene (8q13.3) are the most common known cause of the branchio-oto-renal dysplasia (BOR), an autosomal dominant disease that includes developmental defects of branchial arch structures, middle and/or inner ear and kidney. The distinction between BOR and other dysplasias, such as oto-facio-cervical syndrome (OFC), is challenged by frequent association of the former to other diverse malformations, and by variable expressivity even within the same family. OFC is characterized by trophic alterations of the facies and shoulder girdle in addition to the malformations seen in BOR. Recent characterization of one OFC patient shed some light on the controversy over whether OFC and BOR are the same disease, and led to the hypothesis that OFC is caused by contiguous deletions of EYA1 and adjacent genes. By contrast, we show here that an OFC patient bears a single-nucleotide substitution in a splice site of EYA1. Our results indicate that not only major rearrangements, but also point mutations altering the EYA1 reading frame, can be found in patients with OFC syndrome.

Congenital anomalies of the ribs and chest wall associated with congenital deformities of the spine

BACKGROUND

Congenital anomalies of the ribs and chest wall as well as Sprengel deformity of the shoulder are often associated with congenital deformities of the spine. It has been suggested that rib anomalies may adversely affect the progression of the spinal deformity.

METHODS

We conducted a retrospective study of the medical records and spine radiographs of 620 consecutive patients with congenital deformities of the spine; 497 patients (80%) had scoliosis; eighty-eight patients (14%), kyphoscoliosis; and thirty-five patients (6%), kyphosis. The rib anomalies were classified into simple and complex, and the presence of a Sprengel deformity of the shoulder was recorded. The rate of scoliosis deterioration without treatment before the age of eleven years, as well as the patient age and curve size at the time of surgery, was compared for different types of vertebral abnormalities in patients with and without rib anomalies.

RESULTS

A total of 119 patients (19.2%) had rib anomalies, which were most commonly associated with congenital scoliosis (111 patients; 93%) and were much less frequently associated with congenital kyphoscoliosis or kyphosis (eight patients). The rib anomalies were simple in ninety-five patients and complex in twenty-four. Eighty-five patients (71%) with rib abnormalities had a scoliosis due to a unilateral failure of vertebral segmentation, and seven patients had mixed or unclassifiable vertebral anomalies. In contrast, only sixteen of 203 patients with a scoliosis due to a hemivertebra alone had rib anomalies. The rib anomalies were most frequently associated with a thoracic or thoracolumbar scoliosis (102 patients; 92%) and occurred on the concavity in eighty-two patients (74%), the convexity in twenty-two patients (20%), and were bilateral in seven patients. The Sprengel deformity occurred in forty-five patients and most frequently in association with a thoracic scoliosis due to a unilateral failure of vertebral segmentation (twenty-seven patients). No significant difference was detected in the rate of curve progression without treatment in patients with and without rib anomalies. The only exception was the mean age at the time of surgery, which was higher for patients with a unilateral unsegmented bar without rib anomalies (p = 0.005). In addition, no significant difference was found with regard to any tethering effect due to the site of the rib fusions on the concavity of the scoliosis, i.e., whether they were in close approximation to the spine or were more lateral (p > 0.05).

CONCLUSIONS

Congenital rib anomalies occur most commonly on the concavity of a thoracic or thoracolumbar congenital scoliosis that is due to a unilateral failure of vertebral segmentation, and they do not appear to have an adverse effect on curve size or rate of progression.

Oto-onycho-peroneal syndrome: further delineation and first fetal report

We report on the sixth case and first fetal description of oto-onycho-peroneal syndrome (MIM 259780). This entity consists in the association of ear anomalies (-oto), hypoplastic nails (-onycho), hypoplastic or absent fibulae (-peroneal), and shoulder anomalies. Described for the first time by Leiba et al. [1975: Birth Defects 11:67-73] in a male patient, coined by Pfeiffer [1982: Eur J Pediatr 138:317-320], and confirmed by Devriendt et al. [1998: J Med Genet 35:508-509] this condition is most likely autosomal recessive, given the occurrence in sibs of both sexes with normal parents.

Shoulder magnetic resonance imaging abnormalities, wheelchair propulsion, and gender

OBJECTIVE

To investigate the relationship between pushrim forces and the progression of shoulder injuries in manual wheelchair users.

DESIGN

Longitudinal case series.

SETTING

Biomechanics laboratory and magnetic resonance imaging (MRI) facility at a Veterans Health Administration medical center and university hospital, respectively.

PARTICIPANTS

Fourteen individuals with spinal cord injury (8 men, 6 women) who used manual wheelchairs.

INTERVENTION

Subjects propelled their own wheelchairs on a dynamometer at 0.9 and 1.8m/s. Bilateral biomechanical data were obtained by using force and moment sensing pushrims at time 1. Bilateral shoulder MR images were also completed on 2 occasions, at time 1 and, approximately 2 years later, at time 2.

MAIN OUTCOME MEASURES

The peak pushrim forces in a pushrim coordinate system were calculated, weight normalized and averaged over 5 strokes (presented as % body weight). MRI abnormalities were graded by using a summated scale. Differences between scores between times 1 and 2 were calculated.

RESULTS

Subjects were divided into 2 groups based on change in MRI score. Seven subjects were in the group with worsening scores (MRI+; mean, 8.14 points; range, 5-16), and 7 were in the group with improving or unchanging scores (MRI-; mean, -1.00 point; range, -5 to 1). There was no significant difference between groups with respect to age, body mass index, or years from injury. There were significantly more women in the MRI+ group (6 women, 1 man) than in the MRI- group (7 men) (P=.001). The MRI+ group used significantly greater weight-normalized radial force, or force directed toward the axle at time 1, to propel their wheelchairs at each speed (P<.01): MRI+ at 0.9m/s (mean radial force +/- standard deviation, 5.2%+/-1.0%) and MRI- at 0.9m/s (mean radial force, 3.2%+/-1.7%) (P=.028); and MRI+ at 1.8m/s (mean radial force, 6.6%+/-1.2%) (P=.023) and MRI- at 1.8m/s (mean radial force, 4.1%+/-2.2%). In a separate analysis, women were found to propel with a significantly higher radial force. A logistic regression found a significant relationship between radial force at time 1 and increased risk of progression of MRI findings over time.

CONCLUSION

Individuals who propel with a greater percentage of force directed toward the axle were at increased risk of progression of MRI findings over time. Most people in this group were women. Clinicians should instruct wheelchair users in effective propulsion techniques and should pay particular attention to women who use wheelchairs. Reducing forces during wheelchair propulsion may minimize the likelihood of developing shoulder injuries.

Clinically significant skeletal variations of the shoulder and the wrist: role of MR imaging

Several skeletal variations of the upper extremity may cause painful conditions or precipitate early degenerative changes, either spontaneously or in response to overuse and trauma. Magnetic resonance imaging has proved particularly useful for accurate interpretation of many of these clinically significant skeletal variations; however, the widespread use of MR imaging may have contributed to over-emphasizing their clinical importance, which is still controversial in many cases. We review, illustrate, and discuss clinically significant skeletal variations of the upper extremity as seen on MR images, particularly those involving the shoulder and the wrist. In the shoulder region, we evaluate variations of acromial and coracoid processes as well as variations and minor dysplastic deformities of the glenoid fossa. We also review different skeletal variations of the carpal region, including ulnar variance, ulnar styloid, lunate morphology, carpal coalition, and carpal accessory ossicles. The role of MR imaging in assessing the clinical importance of such conditions, whether potential, controversial, or well established, is emphasized in this review.

Shoulder deformities in obstetric brachial plexus paralysis: a computed tomography study

Obstetric brachial plexus palsy invariably involves the upper roots. If left untreated, characteristic deformities of the shoulder are common sequelae. The most objective way to investigate these shoulder deformities is computed tomographic (CT) scanning of bilateral upper limbs. In this study, specific measurements on CT scans of bilateral upper extremities were performed in a population of patients with obstetric brachial plexus palsy before and after reconstruction (nerve repairs and secondary procedures). The measurements showed that the restoration of external rotation and the scapula stabilization procedure correct the inclination of the humeral head, improve the joint congruency significantly, and decrease the winging of the scapula, thus improving the kinetics of the shoulder. Periodic CT measurement is an objective method of measuring the changes at the shoulder joint that occur over time during the natural evolution of the obstetric brachial plexus palsy lesion and of documenting the benefits of microsurgical intervention.

The OAR/aristaless domain of the homeodomain protein Cart1 has an attenuating role in vivo

Aristaless-related genes encode a structurally defined group of homeoproteins that share a C-terminal stretch of amino acids known as the OAR- or aristaless domain. Many aristaless-related genes have been linked to major developmental functions, but the function of the aristaless domain itself is poorly understood. Expression and functional studies have shown that a subgroup of these genes, including Prx1, Prx2, Alx3, Alx4 and Cart1, is essential for correct morphogenesis of the limbs and cranium. We now demonstrate the function of the aristaless domain in vivo by ectopically expressing normal and mutated forms of Cart1 and Alx3. Ectopic expression of Cart1 in transgenic mice does not disturb development, whereas expression of a Cart1 form from which the aristaless domain has been deleted results in severe cranial and vertebral malformations. The Alx3 protein contains a divergent aristaless domain that appears not to be functional, as ectopic expression of Alx3 results in an altered phenotype irrespective of the presence of this aristaless domain. Linking the Cart1 aristaless domain to Alx3 extinguishes teratogenicity. We show that, at the molecular level, the most important consequence of deleting the aristaless domain is increased DNA binding to its palindromic target sequence. This demonstrates that the aristaless domain functions as an intra-molecular switch to contain the activity of the transcription factor that it is part of.

Syndrome of coronal craniosynostosis, Klippel-Feil anomaly, and sprengel shoulder with and without Pro250Arg mutation in the FGFR3 gene

A unique Pro250Arg point mutation in fibroblast growth factor receptor 3 (FGFR3) was initially reported by Bellus et al. [1996: Nat Genet 14:174-176] and the phenotype subsequently by Muenke et al. [1997: Am J Hum Genet 60:555-564], Reardon et al. [1997: J Med Genet 34:632-636], and Graham et al. [1998: Am J Med Genet 77:322-329]. These authors emphasized the pleiotropic nature of this form of coronal craniosynostosis, including brachydactyly with carpal and/or tarsal coalitions, with other anomalies at lower frequency. We report on a family with autosomal dominant coronal synostosis, segmentation and fusion anomalies of the vertebra and ribs, and Sprengel shoulder due to the Pro250Arg mutation. We also report a single case with an identical phenotype without the mutation.

Scapuloiliac dysostosis (Kosenow syndrome, pelvis-shoulder dysplasia) spectrum: three additional cases

We report on 3 patients (2 sibs and an unrelated adult woman) with scapuloiliac dysostosis (Kosenow syndrome, Pelvis-Shoulder Dysplasia) each of whom has additional abnormalities not previously reported in the literature. The clinical spectrum of this entity is discussed along with possible inheritance patterns.

Augmentation of shoulder contour using a calf implant

Sprengel deformity is a rare orthopedic condition that is associated with functional and cosmetic impairment. Results of orthopedic procedures are usually inconsistent and cosmetic results are far from satisfactory in these patients. A silicone-gel-filled calf prosthesis was used to correct the shoulder contour in a patient with Sprengel deformity. Cosmetically the deformity can be restored by using a calf implant for patients in whom orthopedic procedures are not likely to yield a satisfactory outcome.

The Sprengel deformity. Morphometric analysis using 3D-CT and its clinical relevance

We evaluated scapular dysplasia and malposition in 15 patients with the Sprengel deformity using three-dimensional CT (3D-CT). The shape, height-to-width ratio, the areas of both scapulae, the anterior curvature of the supraspinous portion and glenoid version were assessed on scapular posterior, medial and inferior views. The degree of rotation and superior displacement were measured on the trunk posterior view. The omovertebral connection was also assessed and correlated with the operative findings. Most of the affected scapulae had a characteristic shape with a decrease in the height-to-width ratio and were larger than the contralateral scapulae. There was an inverse relationship between scapular rotation and superior displacement. The typical curve of the supraspinous portion of the scapula was seen in only three cases. There was no significant difference in glenoid version. The point of tethering of the omovertebral connection may determine the shape, rotation and superior displacement of the scapula. 3D-CT was helpful in delineating the deformity in detail, and in planning scapuloplasty.

Intracapsular origin of the long head of the biceps tendon

A developmental anomaly of the long head of the biceps tendon was found in a cadaveric shoulder. Findings on arthroscopy, routine MR imaging, and MR arthrography were compared and correlated with results of anatomic dissection. MR arthrography appears to be a very good diagnostic imaging method for depicting this anomaly prior to arthroscopy.

Nevoid basal cell carcinoma syndrome. Clinical findings in 37 Italian affected individuals

Nevoid basal cell carcinoma syndrome (NBCCS) is a hereditary condition transmitted as an autosomal dominant trait with complete penetrance and variable expressivity. The syndrome is characterised by numerous basal cell carcinomas (BCCs), odontogenic keratocysts of the jaws, palmar and/or plantar pits, skeletal abnormalities and intracranial calcifications. In this paper, the clinical features of 37 Italian patients are reviewed. Jaw cysts and calcification of falx cerebri were the most frequently observed anomalies, followed by BCCs and palmar/plantar pits. Similar to the case of African Americans, the relatively low frequency of BCCs in the Italian population is probably due to protective skin pigmentation. A future search based on mutation screening might establish a possible genotype phenotype correlation in Italian patients.

[Surgical treatment of children with brachial plexus paralysis]

OBJECTIVE AND METHODS

A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.

Disorders of the upper extremity in children

This article presents a brief overview of the indications of MR imaging in a variety of disorders of the upper extremity of the pediatric patient. This covers congenital anomalies: Sprengel shoulder, Poland sequence, arthrogryposis; posttraumatic lesions of cartilage, bone, tendon, muscle and nerve including the brachial plexus injury; inflammatory arthritis and synovitis; bone and joint infection; osteochondritis dissecans, bone necrosis and infarcts in sickle cell anemia and juvenile Gaucher disease, as well as tumors. In this last category, the authors briefly describe the appearances of cysts and tumors of bones and soft tissues of the upper extremity. Indications for the intravenous administration of Gadolinium are given throughout the article with emphasis on the synovial enhancement seen in active arthritis and synovitis.

[Congenital cervical deformities]

The paper deals with the survey of 66 congenital neck malformations (27 thyroglossal cysts and 32 branchial plus 7 lymphatic anomalies) surgically treated in the last 5 years term. Thyroglossal cysts presented in children and young people, in the middle line, and 92.6% of them were infrahyoid. Recidivation appeared in 7.4% of all cases, always in connection with previous infections. Branchial malformations presented on the neck's side of middle age persons were related to the 2nd. cleft (97%). Lymphatic anomalies presented in children under 3 years, in these instances the dissection sheaths were not spared and the neighboring structures altered.

A new strategy of muscle transposition for treatment of shoulder deformity caused by obstetric brachial plexus palsy

Cross-innervation (caused by misdirection of regenerated axons), muscular imbalance (caused by muscle paresis or earlier recovery), and growth are the three main causes of shoulder deformity due to obstetric brachial plexus palsy. If perioperative studies demonstrate the existence of muscle recovery by cross-innervation, a new strategy of muscle transposition to minimize the influence of cross-innervation is used. Release of antagonistic muscles (pectoralis major and teres major muscles) and augmentation of paretic muscles (transferring teres major to the infraspinatus muscle, reinserting both ends of the clavicular part of the pectoralis major muscle laterally) are performed for reconstruction. Since 1993, 29 patients having shoulder deformity caused by obstetric brachial plexus palsy underwent reconstruction utilizing this strategy of muscle transposition. The timing for the reconstruction was at an average of 8.5 years (range, 4 to 21 years). The average shoulder abduction following the muscle transposition was 151 degrees (i.e., average gain 104 percent, or 77 degrees) and that of external rotation was 72 degrees (average gain 200 percent, or 48 degrees). Compared with the patients who had no surgery for shoulder deformity caused by obstetric brachial plexus palsy and early nerve surgery for the infant obstetric brachial plexus palsy, the results of the strategy seem to be significantly impressive.

Prevalence and risk factors for asymmetric posture in preschool children aged 6-7 years

BACKGROUND

Adult scoliosis can be a severe disease. Not much is known about its determinants and the predictive value of early trunk asymmetries. In Vilnius, Lithuania, a cohort study has been started among 6-7 year old children in 1994. The purpose of the present report was to estimate the prevalence of trunk asymmetry in 6-7 year old children, and the association between previous rachitis, frequent illness during childhood and reduced physical activity and trunk asymmetry.

METHODS

The degree of asymmetry was established in 791 children in kindergartens by measuring with a ruler the distance from the seventh cervical vertebra to the lower angles of the left and the right scapulas. Rachitis and the number of illnesses were extracted from each child's medical card, whereas data on physical activity were based on questionnaires filled in by parents and kindergarten teachers.

RESULTS

In all, 46.9% of children were found to have trunk asymmetry. The odds ratio of asymmetric posture was 2.76 (95% confidence interval [CI]: 1.62-4.72) for children with rachitis degree II compared to non-rachitic children, 3.97 (95% CI: 2.48-6.36) for those who were ill 16-28 times (over the years) compared to those who reported fewer than nine illnesses and 2.44 (95% CI: 1.21-4.91) for children with low physical activity level (13-22 points) as compared to children with a high level (> 33 points).

CONCLUSION

These findings indicate the need for prophylactic measures to decrease the incidence of infantile rachitis, acute morbidity and to increase physical activity. The significance of the high frequency of asymmetric posture can only be assessed by a follow-up of this cohort.

Modified Woodward procedure for Sprengel deformity of the shoulder: long-term results

Sprengel deformity of the shoulder is characterized by elevation and medial rotation of the inferior pole of the scapula. Surgical treatment is recommended in significantly involved patients to improve cosmetic appearance and function of the involved shoulder. We report long-term results of a Woodward procedure modified by excision of the prominent superomedial border of the scapula for correction of this deformity in 15 patients. Preoperatively, the total abduction of the shoulder averaged 115 degrees, and on follow-up the abduction had improved to an average of 150 degrees. In all patients except one, there was marked improvement in appearance as assessed on Cavendish scale. All patients except two had achieved skeletal maturity at the last follow-up. Eighty-six percent of patients expressed satisfaction with operative results. Our data support the concept that correction achieved by a modified Woodward procedure is not altered by growth and is maintained beyond skeletal maturity.

Holt-Oram syndrome: a clinical genetic study

A clinical and genetic study of the Holt-Oram syndrome (HOS) has been carried out in the United Kingdom involving 55 cases designated Holt-Oram syndrome, together with their parents and sibs. Data from the clinical assessment of both familial and isolated cases were used to define the HOS phenotype and to outline the spectrum of abnormalities, especially factors affecting severity. Skeletal defects affected the upper limbs exclusively and were bilateral and asymmetrical. They ranged from minor signs such as clinodactyly, limited supination, and sloping shoulders to severe reduction deformities of the upper arm (4.5%). The radial ray was predominantly affected than the right. All affected cases showed evidence of upper limb involvement. Cardiac defects were seen in 95% of familial cases and included both atrial septal defect (ASD, 34%) and ventricular septal defect (VSD, 25%); 39% had only ECG changes. Cardiac involvement ranged from asymptomatic conduction disturbances to multiple structural defects requiring surgery in infancy. Sudden death could be caused by heart block. Inheritance was autosomal dominant with 100% penetrance and no evidence of reduced fitness. Increasing severity occurred in succeeding generations consistent with anticipation.

Otofaciocervical syndrome: a sporadic patient supports splitting from the branchio-oto-renal syndrome

A sporadic patient with OFC syndrome is described. Distinguishing features were a long face with narrow nose, high arched palate, prominent and dysmorphic ears, long neck, sloping shoulders and clavicles, winged, low, and laterally set scapulae, tetralogy of Fallot, and deafness secondary to cochlear malformation. Some features present in the original family, including lateral cervical fistulae, have suggested that OFC syndrome could be a variant of BOR syndrome. The absence of preauricular tags, lacrimal duct stenosis, and renal malformations, and the presence of distinct facial and radiographic findings and markedly downward sloping shoulders in the present patient support OFC syndrome being a unique, clinically recognisable entity.

The prevalence of cervical and thoracic congenital skeletal abnormalities in basal cell naevus syndrome; a review of cervical and chest radiographs in 80 patients with BCNS

The major clinical stigmata of basal cell naevus syndrome (BCNS) appear in adolescence and adult life but some occult skeletal abnormalities are congenital. BCNS is dominantly inherited and it would be useful to identify, as early in life as possible, which of the offspring of patients with BCNS are at risk of developing the syndrome. Radiographs of the neck and chest of 80 patients with BCNS diagnosed confidently on clinical criteria have been examined for abnormalities which were considered to be congenital skeletal anomalies. Congenital abnormalities of the cervical and thoracic spine, mainly spina bifida occulta, were found in 45%. Congenital abnormalities of ribs were found in 49% and of the shoulder(s) in 36%. Overall congenital abnormalities were shown on the neck or chest radiograph in 55 (69%) patients. The presence of one or more of these congenital abnormalities on the chest or neck radiograph of a child who is the offspring of a person with BCNS makes it extremely likely that the child also has BCNS. The absence of these features, and of any clinical features of BCNS, would suggest that the risk of the child developing BCNS has been reduced from the prior expectation of 50% to approximately half that (24%).

Genetic interaction between hoxb-5 and hoxb-6 is revealed by nonallelic noncomplementation

hoxb-5 and hoxb-6 are adjacent genes in the mouse HoxB locus and are members of the homeotic transcription factor complex that governs establishment of the mammalian body plan. To determine the roles of these genes during development, we generated mice with a targeted disruption in each gene. Three phenotypes affecting brachiocervicothoracic structures were found in the mutant mice. First, hoxb-5- homozygotes have a rostral shift of the shoulder girdle, analogous to what is seen in the human Sprengel anomaly. This suggests a role for hoxb-5 in specifying the position of limbs along the anteroposterior axis of the vertebrate body. Second, hoxb-6- homozygotes frequently have a missing first rib and a bifid second rib. The third phenotype, an anteriorizing homeotic transformation of the cervicothoracic vertebrae from C6 through T1, is common to both hoxb-5- and hoxb-6- homozygotes. Quite unexpectedly, hoxb-5, hoxb-6 transheterozygotes (hoxb-5-hoxb-6+/hoxb-5+ hoxb-6-) also show the third phenotype. By this classical genetic complementation test, these two mutations appear as alleles of the same gene. This phenomenon is termed nonallelic noncomplementation and suggests that these two genes function together to specify this region of the mammalian vertebral column.

Prevalence of trunk abnormalities in eleven-year-old schoolchildren in Rotterdam, The Netherlands

The prevalence of trunk abnormalities was studied in 4,915 children aged 11 years (2,528 boys, 2,387 girls); 33% of the children were of non-Dutch origin. The following measurements were recorded: height, weight, signs of puberty, and menarche. Trunk abnormality was assessed in the erect child (asymmetry of shoulders, waistline, imbalance of the trunk, scoliosis, lordosis, kyphosis, swayback, and flexibility) and by the forward bending test (rib hump or lumbar prominence, persistence of scoliosis, kyphosis, deviant lateral aspect); 85.9% of boys and 81.3% of girls were symmetric, and abnormal forward bending test was noted in 7.1% of boys and 10.6% of girls. In non-Dutch girls, trunk abnormalities were more prevalent.

Shoulder abnormalities in association with branchio-oto-renal dysplasia in a patient who also has familial joint laxity

A patient with branchio-oto-renal dysplasia and associated shoulder abnormalities is presented. The combination of features makes discrimination from the oto-facial-cervical syndrome difficult. Shoulder abnormalities should be regarded as a rare feature of the branchio-oto-renal syndrome.

Craniofrontonasal dysostosis with deafness and axillary pterygia

Craniofrontonasal dysostosis (CFND) is an inherited disorder previously referred to as craniofrontonasal dysplasia. However, there is no evidence of tissue dysplasia and, therefore, the term dysostosis has been substituted. The disorder is characterized by frontonasal dysostosis, coronal craniostenosis, and the variable presence of other skeletal defects, including short webbed neck, sloping shoulders, polydactyly, syndactyly, and broad first toes. Here we report an affected mother and daughter who also have limited hip abduction. In addition, the mother had an axillary pterygia, congenital footplate fixation of the left ear, and right sensorineural hearing loss; these manifestations have not been reported previously in CFND and expand the phenotype of this syndrome. Both patients had marked restriction of shoulder abduction, and the mother had limited forearm pronation; these manifestations have been reported in only one other patient with CFND. Awareness of the possibility of these abnormalities may allow for early intervention by physical therapy and hearing aides in infants and young children with these manifestations as a component of CFND.

Familial absence of the trapezius muscle with associated shoulder girdle abnormalities

Two brothers with congenital absence of the trapezius, pectoralis, supraspinatus and serratus anterior are reported and the relevant literature reviewed.

Ulnar deficiency

Twenty-nine patients with 34 ulnar deficient limbs were studied; the average follow-up was 7.7 years. To permit early determination of prognosis and decisions regarding treatment, four subtypes of this condition have been identified. Progressive ulnar deviation of the wrist was not observed in any case, and the fibrocartilaginous ulnar anlage was resected only to correct fixed deformities of the wrist. The most useful operation was humeral or radial osteotomy to correct the hand on flank deformity. A group of patients who were optimally treated with prosthetic fitting is discussed.

Familial absence of the pectoralis major, serratus anterior, and latissimus dorsi muscles

Congenital absence of shoulder girdle muscles is described in three generations of a family. The proband, a 3 year old boy, had absence of the sternocostal head of the right pectoralis major. His father had absence of the left serratus anterior and part of the left latissimus dorsi and his paternal grandfather had absence of the lower two-thirds of the left pectoralis major, with absence of the left serratus anterior and latissimus dorsi muscles. The condition is probably the result of a dominant gene. These observations show that absence of the pectoralis major is part of a wider spectrum of shoulder girdle defects. Where genetic advice is sought by persons with apparently sporadic absence of the pectoralis major, examination of the relatives is necessary.

Shoulder contour deformity after the Tikhoff-Linberg procedure: correction by silicone implant

A case of severe shoulder deformity after radical excision of soft tissue, proximal humerus, scapula, and clavicle is presented. Satisfactory restoration of the shoulder contour was accomplished by the use of a silicone implant.

Congenital and developmental anomalies of the shoulder girdle

An understanding of congenital and developmental anomalies of the shoulder girdle is facilitated by a knowledge of embryology, physeal appearance and closure, and phylogenetic changes. Scapular, clavicular, and proximal humeral anomalies are classified and discussed with reference to diagnosis and management. Finally anomalies of the shoulder girdle musculature are delineated.

The association of spinal retroflexion with limb anomalies

The spectrum of conditions in which retroflexion of the spine occurs includes anencephaly, iniencephaly, and Klippel-Feil syndrome. It was suggested by Gimour ('41) that a continuum may exist linking the latter two entities. The present paper attempts to reopen this question by reporting two specimens which have none of the above conditions, yet have spinal retroflexion and limb malformations. Combined with other isolated case reports, they show that spinal retroflexion can arise over a variable period of time.

Studies of malformation syndromes of man XXXXIIB: mother and son affected with the ulnar-mammary syndrome type Pallister

We report mother and son with the ulnar-mammary syndrome type Pallister: both had postaxial polydactyly in one upper limb and absence or hypoplasia of the axillary apocrine glands bilaterally. The mother had total lack of the mammary gland tissue and absence of one kidney. Her son also had unilateral oligodactyly, an absent ulna and hypoplasia of the ipsilateral shoulder girdle.