Abstract
BackgroundThe current method of treatment for persistent internal rotation due to the medial rotation contracture in patients with obstetric brachial plexus injury is humeral derotational osteotomy. While this procedure places the arm in a more functional position, it does not attend to the abnormal glenohumeral joint. Poor positioning of the humeral head secondary to elevation and rotation of the scapula and elongated acromion impingement causes functional limitations which are not addressed by derotation of the humerus. Progressive dislocation, caused by the abnormal positioning and shape of the scapula and clavicle, needs to be treated more directly.MethodsFour patients with Scapular Hypoplasia, Elevation And Rotation (SHEAR) deformity who had undergone unsuccessful humeral osteotomies to treat internal rotation underwent acromion and clavicular osteotomy, ostectomy of the superomedial border of the scapula and posterior capsulorrhaphy in order to relieve the torsion developed in the acromio-clavicular triangle by persistent asymmetric muscle action and medial rotation contracture.ResultsClinical examination shows significant improvement in the functional movement possible for these four children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy.ConclusionThese results reveal the importance of recognizing the presence of scapular hypoplasia, elevation and rotation deformity before deciding on a treatment plan. The Triangle Tilt procedure aims to relieve the forces acting on the shoulder joint and improve the situation of the humeral head in the glenoid. Improvement in glenohumeral positioning should allow for better functional movements of the shoulder, which was seen in all four patients. These dramatic improvements were only possible once the glenohumeral deformity was directly addressed surgically.
Highlights
The current method of treatment for persistent internal rotation due to the medial rotation contracture in patients with obstetric brachial plexus injury is humeral derotational osteotomy
The pathophysiology of the secondary deformities encountered in this population was described succinctly in 1905 by Whitman who wrote that the large majority of internal rotation and subluxation deformities of the shoulder in children with obstetric brachial plexus injuries were caused by fibrosis and contractures developed as a consequence of the neurological injury [2]
Humeral osteotomy attempts to improve the patient's passive range of external rotation, but ignores the bone deformity at the root of persistent medial rotation contracture (MRC), and does nothing to address the attendant subluxation of the humeral head within the glenoid fossa
Summary
The current method of treatment for persistent internal rotation due to the medial rotation contracture in patients with obstetric brachial plexus injury is humeral derotational osteotomy. While this procedure places the arm in a more functional position, it does not attend to the abnormal glenohumeral joint. The pathophysiology of the secondary deformities encountered in this population was described succinctly in 1905 by Whitman who wrote that the large majority of internal rotation and subluxation deformities of the shoulder in children with obstetric brachial plexus injuries were caused by fibrosis and contractures developed as a consequence of the neurological injury [2]. The current surgical approach to treating persistent MRC in OBPI patients is derotational humeral osteotomy [412] or anterior capsule release [13]. Anterior capsule release may result in excessive external rotation positioning of the humerus with attendant loss of internal rotation and midline functioning [13]
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