Closed Treatment of Shoulder Dislocation in Children With Birth Brachial Plexus Injuries

Abstract

There is no financial information to disclose. With earlier recognition of shoulder dysplasia, is there a role for intervention with closed shoulder reduction and botulinum toxin injections to improve shoulder dysplasia or prevent future open procedures? Early ultrasound identification and closed treatment of glenohumeral dysplasia in patients with birth brachial plexus injuries (BBPI) and shoulder subluxation can prevent worsening deformity and decrease the need for open shoulder reduction. 26 consecutive patients with BBPI who underwent closed shoulder reductions with or without botulinum toxin injections at a mean age of 6.5 months (range 3–19 months) were followed to failure of treatment (n = 18) or to an average follow-up of 40 months (range 12–66 months). All children included in the study were identified clinically by loss of passive external rotation (PER) with imaging confirming shoulder dislocation (Figure 23-1). All children were treated with closed reduction of the glenohumeral joint under general anesthesia and were casted in maximum shoulder external rotation (ER) (Figure 23-2). Treatment outcomes were assessed by changes in ER and ultrasound measurements of humeral head coverage (HHC) and alpha angle. Descriptive and comparative statistics were performed for all patients with available follow-up for preoperative versus postoperative AMS shoulder ER, PER, ultrasound percent HHC, and alpha angle for initial postoperative values (average 11 weeks). For patients undergoing open reduction, subgroup analysis was performed. Final outcome measures for patients not requiring subsequent open reduction were compared with preoperative measures for AMS and shoulder position. Active Movement Scale shoulder external rotation score improved by 0.7 posttreatment. Passive external rotation increased by 42° (P < .001). Humeral head coverage improved by 39% (P < .001). Alpha angle improved by –41° (P < .001). 18 patients (69%) required an open reduction and tendon transfer of the affected shoulder at an average of 13.4 months (range 1–47 months) after the index procedure. 7 patients (27%) did not require further open shoulder reduction. Of these 7 patients, 2 needed repeated botulinum toxin injections, and 1 repeated closed reduction and nerve transfer. 1 patient was lost to follow -up. The age at the time of closed shoulder reduction was significantly lower in the 7 children who did not require subsequent open reduction. •Early closed reduction of shoulder dislocation in patients with birth brachial plexus injuries improves PER, HHC, and alpha angle.•Early detection and closed treatment can prevent subsequent open reduction in 27% of children.•The authors recommend ultrasound screening of all children with BBPI and loss of PER.Figure 23-2All patients were immobilized for 4–6 weeks with the arm in 30° abduction and maximum external rotation with intraoperative ultrasound confirmation of shoulder reduction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)