Glenohumeral Deformity Research Articles

Role of computed tomography in glenohumeral joint deformity following obstetric brachial plexus injury: Proposed radiological classification

Objective: The study aimed to study the usefulness of computed tomography (CT) in the measurement of glenoid version angle, humeral head dislocation, or subluxation and to propose a grading system for the severity of glenohumeral deformity following OBPI. Material and Methods: A prospective study conducted over a period of 3 years. The study group includes 21 children below the age of 12 years presenting with posterior dislocation of the shoulder, with prior history of OBPI. CT of both shoulders was done using a 128-slice CT scanner. The children were assessed clinically by a Modified Mallet Scale and graded by Waters classification. Results: We graded the severity of deformity on the affected side according to Waters et al. The difference between affected and normal shoulder glenoscapular angle (GSA), percentage of humeral head anterior to the scapular line (PHH), scapular height, and scapular width was statistically significant (P < 0.05). We propose grading for severity and assessed joint stability based on the CT parameters. GSA and PHH show a statistically significant difference between the three grades (P < 0.05). We also confirm that the higher the grade of the deformity, the more difficult the shoulder movements leading to worse scores on the Modified Mallet Scale. Conclusion: CT scan identifies glenohumeral deformities such as increased glenoid retroversion, posterior dislocation of the humeral head, smaller humeral head size, and smaller size of the scapula as deviations from normal status and helps in radiological grading.

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

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. 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. 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. 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.

Clinical Diagnosis of the Infantile Shoulder Subluxation in Residual Brachial Plexus Birth Injury and Its Correlation With Ultrasound Diagnosis.

Timely detection of shoulder subluxation in infants with brachial plexus birth injury (BPBI) is essential to prevent the progression of glenohumeral deformity. Shoulder ultrasonography (USG) is routinely used to detect an infantile subluxation/dislocation, but its use is limited because of the paucity of expert radiologists in developing countries. The aim of this study was to determine the clinical examination predictors to determine shoulder subluxation in patients with BPBI correlating with ultrasound confirmation. We prospectively studied children who presented to our hospital between 2017 and 2021 diagnosed as brachial plexus birth injury. In patients developing internal rotation contracture of the shoulder, we looked for 3 standard clinical signs: reduced passive external rotation <60 degrees, deep anterior crease (DAC) and relatively short arm segment. Shoulder subluxation was defined as USG measurement of alpha angle>30 degrees and ossific nuclei of the humerus lying behind the dorsal scapular line. Sensitivity and specificity were used to assess their efficacy in clinical diagnosis of shoulder subluxation in different groups. The predicted probability of shoulder subluxation from each prediction rule was compared with actual distributions based on USG confirmation. Of the 58 BPBI infants who developed PER<60 degrees at the shoulder, 41 had USG confirmed shoulder subluxation. The 2 independent predictors of shoulder subluxation (PER<45 degrees and DAC) were identified in the current patient population based on data analysis. The presence of short arm segment is a very specific marker of shoulder subluxation but not sensitive. The predicted probability of shoulder subluxation from the prediction rule combining all the 3 markers were similar to the actual distributions in the current patient population. PER<45 degrees and presence of deep anterior crease are clinical markers indicating shoulder dislocation in patients with BPBI developing reduced external rotation at the shoulder. On the basis of the proposed clinical diagnosis algorithm, the above markers along with the selective use of USG can help in early detection and treatment of infantile shoulder dislocation.

THE RESULTS OF ARTHROSCOPIC RELEASE WITH TENDON TRANSFERS IN CASES OF B.P.B.P WITH GLENOHUMERAL DYSPLASIA

Background: Internal rotation deformity due to brachial plexus birth palsy frequently lead to glenohumeral deformity . Our surgical approach to treat these contractures relies on arthroscopic release and tendon transfer of latissimus dorsi muscle for young children . We report the results for twenty children followed for a minimum of two years after such treatment Patients and methods: This study was done in the Orthopedic department, Sohag University Hospitals including all patients with brachial plexus birth palsy with internal rotation contracure of the shoulder. Twenty children with a mean age of 4 years (between 2 and 6 years old) underwent arthroscopic contracture release and tendon transfer of latissimus dorsi muscle as a primary procedure.Passive and active external rotation, internal rotation, and elevation were measured for all patients pre and postoperatively. Modified mallet score and active movement score was measured pre and postoperatively. Magnetic resonance imaging was performed preoperatively and postoperatively to evaluate glenoid version and head sublaxation. Results: At the time of follow-up, the mean passive external rotation was increased by 67° (p &lt; 0.005) in the children with a successful arthroscopic release and tendon transfer. The mean active elevation increased by 12°. Internal rotation was not measured consistently preoperatively, but when it had been it was found to have decreased substantially postoperatively. Mean glenoid version improved from -33° to -7° following soft-tissue releases and The percentage of the humeral head anterior to the middle of the glenoid improved from 8% to 43%. While the average duration of clinical and radiographic follow-up was twenty-four months, improvements in both shoulder motion and glenohumeral joint morphology were seen early and were maintained during the follow up period. Conclusion: In children with internal rotation contracture, arthroscopic release and tendon transfer effectively restores nearly normal passive external rotation and a centered glenohumeral joint at the time of surgery. In most of these children, external rotation strength is sufficient to maintain this range of motion and to improve glenoid development when preoperative deformity was present. Improvement in active elevation was minimal. All children have a loss of internal rotation, which is moderate in most of them.

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

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. 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.

Influence of Brachial Plexus Birth Injury Location on Glenohumeral Joint Morphology

Patient presentation after brachial plexus birth injury (BPBI) is influenced by nerve injury location; more contracture and bone deformity occur at the shoulder in postganglionic injuries. Although bone deformity after postganglionic injury is well-characterized, the extent of glenohumeral deformity after preganglionic BPBI is unclear. Twenty Sprague-Dawley rat pups received preganglionic or postganglionic neurectomy on a single forelimb at postnatal days 3 to 4. Glenohumeral joints on affected and unaffected sides were analyzed using micro-computed tomography scans after death at 8 weeks after birth. Glenoid version, glenoid inclination, glenoid and humeral head radius of curvature, and humeral head thickness and width were measured bilaterally. The glenoid was significantly more declined in affected compared with unaffected shoulders after postganglionic (-17.7° ± 16.9°) but not preganglionic injury. Compared with the preganglionic group, the affected shoulder in the postganglionic group exhibited significantly greater declination and increased glenoid radius of curvature. In contrast, the humeral head was only affected after preganglionic but not postganglionic injury, with a significantly smaller humeral head radius of curvature (-0.2 ± 0.2 mm), thickness (-0.2 ± 0.3 mm), and width (-0.3 ± 0.4 mm) on the affected side compared with the unaffected side; changes in these metrics were significantly associated with each other. These findings suggest that glenoid deformities occur after postganglionic BPBI but not after preganglionic BPBI, whereas the humeral head is smaller after preganglionic injury, possibly suggesting an overall decreased biological growth rate in this group. This study expands understanding of the altered glenoid and humeral head morphologies after preganglionic BPBI and its comparisons with morphologies after postganglionic BPBI.

Minimally Invasive Subscapularis Release: A Novel Technique and Results.

Shoulder imbalance secondary to residual brachial plexus birth palsy requires release of internal rotation contracture and tendon transfer. Subscapularis is considered as the prime element of internal rotation contracture and various methods have been described for subscapularis lengthening. It includes open subscapularis slide or lengthening and arthroscopic release. We hypothesized that subscapularis can be released through minimally invasive approach from the medial border of scapula and thus avoiding formal open procedures and risk of weakening the internal rotation strength. Safety zones to avoid injury to important neurovascular structures while performing minimally invasive subscapularis release (MISR) were determined through cadaveric dissection. Between 2014 and 2016, 45 patients underwent MISR. A concomitant conjoined Latissimus Dorsi and Teres Major transfer was performed. Twenty patients with minimum 2-year follow-up were included in this study. Average age of patients was 6.4 years. A 5-point modified Mallet Score, degrees of active and passive rotations and abduction were used as outcome measures. Axial MRI imaging were available to classify the gleno-humeral deformity. Mean improvement in passive external rotation was 80 degrees and in active external rotation was 43 degrees (P <0.001) at 3 months, which was maintained at final follow-up. Average shoulder abduction improved from preoperative-101 degrees to postoperative-142 degrees. Aggregate 5-point Mallet Score improved from 12.8 points (range, 11 to 16) preoperatively to 18.5 points (range, 16 to 21) postoperatively. None of the patients developed external rotation contracture. The results were comparable with other existing techniques of subscapularis release with conjoint tendon transfer. MISR with conjoined tendon transfer is an effective way of treating internal rotation contracture in children with congruent glenohumeral joints. This procedure has shown beneficial outcomes even in patients with noncongruous glenohumeral joints, when performed in children younger than 4 years. Advantages of MISR include less risk to neurovascular structures, minimal soft tissue trauma, directly addressing the medial tight subscapularis fibers, significantly less surgical time and minimum learning curve. Level III-retrospective comparative study.

What Range of Motion is Achieved 5 Years After External Rotationplasty of the Shoulder in Infants with an Obstetric Brachial Plexus Injury?

Obstetric brachial plexus injuries result from traction injuries during delivery, and 30% of these children have persisting functional limitations related to an external rotation deficit of the shoulder. Little is known about the long-term effect of soft-tissue procedures of the shoulder in patients with obstetric brachial plexus injuries. (1) After soft-tissue release for patients with passive external rotation less than 20° and age younger than 2 years and for patients older than 2 years with good external rotation strength, what are the improvements in passive external rotation and abduction arcs at 1 and 5 years? (2) For patients who underwent staged tendon transfer after soft-tissue release, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? (3) For patients with passive external rotation less than 20° and no active external rotation, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? This was a retrospective analysis of a longitudinally maintained institutional database. Between 1996 and 2009, 149 children underwent a soft-tissue procedure of the shoulder for an internal rotation contracture. The inclusion criteria were treatment with an internal contracture release and/or tendon transfer, a maximum age of 18 years at the time of surgery, and a minimum follow-up period of 2 years. Six patients were older than 18 years at the time of surgery and 31 children were seen at our clinic until 1 year postoperatively, but because they had good clinical results and lived far away from our center, these children were discharged to physical therapists in their hometown for annual follow-up. Thus, 112 children (59 boys) were available for analysis. Patients with passive external rotation less than 20° and age younger than 2 years and patients older than 2 years with good external rotation strength received soft-tissue release only (n = 37). Of these patients, 17 children did not have adequate active external rotation, and second-stage tendon transfer surgery was performed. For patients with passive external rotation less than 20° with no active external rotation, single-stage contracture release with tendon transfer was performed (n = 68). When no contracture was present (greater than 20° of external rotation) but the patient had an active deficit (n = 7), tendon transfer alone was performed; this group was not analyzed. A functional assessment of the shoulder was performed preoperatively and postoperatively at 6 weeks, 3 months, and annually thereafter and included abduction, external rotation in adduction and abduction, and the Mallet scale. Internal contracture release resulted in an improvement in passive external rotation in adduction and abduction of 29° (95% confidence interval, 21 to 38; p < 0.001) and 17° (95% CI, 10 to 24; p < 0.001) at 1 year of follow-up and 25° (95% CI, 15-35; p < 0.001) and 15° (95% CI, 7 to 24; p = 0.001) at 5 years. Because of insufficient strength of the external rotators after release, 46% of the children (17 of 37) underwent an additional tendon transfer for active external rotation, resulting in an improvement in active external rotation in adduction and abduction at each successive follow-up visit. Patients with staged transfers had improved active function; improvements in active external rotation in adduction and abduction were 49° (95% CI, 28 to 69; p < 0.05) and 45° (95% CI, 11 to 79; p < 0.001) at 1 year of follow-up and 38° (95% CI, 19 to 58; p < 0.05) and 23° (95% CI, -8 to 55; p < 0.001) at 5 years. In patients starting with less than 20° of passive external rotation and no active external rotation, after single-stage contracture release and tendon transfer, active ROM was improved. Active external rotation in adduction and abduction were 75° (95% CI, 66 to 84; p < 0.001) and 50° (95% CI, 43 to 57; p < 0.001) at 1 year of follow-up and 65° (95% CI, 50 to 79; p < 0.001) and 40° (95% CI, 28 to 52; p < 0.001) at 5 years. Young children with obstetric brachial plexus injuries who have internal rotation contractures may benefit from soft-tissue release. When active external rotation is lacking, soft-tissue release combined with tendon transfer improved active external rotation in this small series. Future studies on the degree of glenohumeral deformities and functional outcome might give more insight into the level of increase in external rotation. Level III, therapeutic study.

Isolated open anterior shoulder release in brachial plexus birth palsy

In children with brachial plexus birth palsy (BPBP), a shoulder joint internal contracture is commonly observed, which may result in glenohumeral osseous deformities and posterior joint subluxation. The purpose of this retrospective study was to evaluate the impact of an isolated anterior shoulder release on osteoarticular disorders and assess the subsequent clinical improvements. Forty consecutive BPBP patients with glenohumeral dysplasia underwent an open anterior shoulder release. Shoulder scans (ie, magnetic resonance imaging preoperatively and computed tomography postoperatively) were conducted to assess glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa. Clinical dataincluding analytical shoulder rangeof motion and modified Mallet scores were collected. After a mean follow-up period of 23 months, glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa significantly improved from -32° and 18%, respectively, to mean postoperative values of -12° (P < .001) and 45% (P < .001), respectively. Passive and active external rotation increased from -2° and -43°, respectively, to 76° (P < .001) and 54° (P < .001), respectively. The mean modified Mallet score significantly improved from 14.2 to 21.4 points (P < .001). In 8 children with satisfactory passive motion, a latissimus dorsi transfer was performed secondarily to obtain satisfactory active motion. In BPBP patients with glenohumeral deformities, isolated open anterior release of the shoulder induces significant remodeling of the joint, reducing posterior joint subluxation and improving both passive and active shoulder ranges of motion. Additional latissimus transfer remains mandatory in selected cases to achieve satisfactory function.

Computational analysis of glenohumeral joint growth and morphology following a brachial plexus birth injury

Children affected with brachial plexus birth injury (BPBI) undergo muscle paralysis. About 33% of affected children experience permanent osseous deformities of the glenohumeral joint. Recent evidence suggests that some cases experience restricted muscle longitudinal growth in addition to paralysis and reduced range of motion at the shoulder and elbow. It is unknown whether altered loading due to paralysis, muscle growth restriction and contracture, or static loading due to disuse is the primary driver of joint deformity after BPBI. This study uses a computational framework integrating finite element analysis and musculoskeletal modeling to examine the mechanical factors contributing to changes in bone growth and morphometry following BPBI. Simulations of 8 weeks of glenohumeral growth in a rat model of BPBI predicted that static loading of the joint is primarily responsible for joint deformation consistent with experimental measures of bone morphology, whereas dynamic loads resulted in normal bone growth. Under dynamic loading, glenoid version angle (GVA), glenoid inclination angle (GIA), and glenoid radius of curvature (GRC) (−1.3°, 38.2°, 2.5 mm respectively) were similar to the baseline values (−1.8°, −38°, 2.1 mm respectively). In the static case with unrestricted muscle growth, these measures increased in magnitude (5.2°, −48°, 3.5 mm respectively). More severe joint deformations were observed in GIA and GRC when muscle growth was restricted (GVA: 3.6°, GIA: −55°, GRC: 4.0 mm). Predicted morphology was consistent with literature reports of in vivo glenoid morphology following postganglionic BPBI. This growth model provides a framework for understanding the most influential mechanical factors driving glenohumeral deformity following BPBI.

The Pathogenesis of Glenohumeral Deformity and Contracture Formation in Obstetric Brachial Plexus Palsy-A Review.

Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.

Application of three-dimensional prototyping in planning the treatment of proximal humerus bone deformities

ObjectiveTo describe the use of three-dimensional prototyping or rapid prototyping in acrylic resin to create synthetic three-dimensional models in order to promote the understanding of bone deformities of the shoulder. MethodsFive patients were analyzed between ages of 11 and 73 years old, treated between 2008 and 2013 with glenohumeral deformities that required a more thorough review of the anatomical alterations, for whom three-dimensional prototyping was performed. ResultsPatient 1 was treated conservatively and is awaiting humeral head arthroplasty if symptoms get worse. Patient 2 underwent a valgus proximal humerus osteotomy secured with pediatric locked hip plate according to a prior assessment with prototyping. Patient 3 underwent a disinsertion of the rotator cuff, tubercleplasty and posterior reinsertion of the rotator cuff. Patient 4 underwent an arthroscopic step-off resection, 360-degree capsulotomy, and tenolysis of the subscapularis. Patient 5 underwent a reverse shoulder arthroplasty with an L-shaped bone graft on the posterior glenoid. ConclusionsRapid prototyping in acrylic resin allows a better preoperative planning in treatment of bone deformities in the shoulder, minimizing the risk of intraoperative complications in an attempt to improve the results.

O uso da prototipagem tridimensional para o planejamento do tratamento das deformidades ósseas do úmero proximal

ObjectiveTo describe the use of three‐dimensional prototyping or rapid prototyping in acrylic resin to create synthetic three‐dimensional models in order to promote the understanding of bone deformities of the shoulder. MethodsFive patients were analyzed between ages of 11 and 73 years old, treated between 2008 and 2013 with glenohumeral deformities that required a more thorough review of the anatomical alterations, for whom three‐dimensional prototyping was performed. ResultsPatient 1 was treated conservatively and is awaiting humeral head arthroplasty if symptoms get worse. Patient 2 underwent a valgus proximal humerus osteotomy secured with pediatric locked hip plate according to a prior assessment with prototyping. Patient 3 underwent a disinsertion of the rotator cuff, tubercleplasty and posterior reinsertion of the rotator cuff. Patient 4 underwent an arthroscopic step‐off resection, 360‐degree capsulotomy, and tenolysis of the subscapularis. Patient 5 underwent a reverse shoulder arthroplasty with an L‐shaped bone graft on the posterior glenoid. ConclusionsRapid prototyping in acrylic resin allows a better preoperative planning in treatment of bone deformities in the shoulder, minimizing the risk of intraoperative complications in an attempt to improve the results.

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.

Measurement of external rotation of the shoulder in patients with obstetric brachial plexus palsy

A discussion is presented concerning scoring while assessing shoulder function. Divergence in observation and in interpretation of what is observed may give rise to serious disagreement about indications for surgery. Agreement regarding starting points of measurement is essential. One must realize that the number of degrees, obtained using a scoring system, may not reflect the real amount of motion per se, it may solely indicate the limit of the motion in relation to the neutral zero point of the measurement. This realization may improve the justification of and the indication for surgical treatment.It is worthy of mention that this paper deals in particular with active external rotation. Indications for secondary surgery to prevent gleno-humeral deformation if passive external rotation is diminishing progressively, is a separate topic. We wish to point out that the insidious problem of fixed deformity, even to a minor degree, will contribute to the problem of loss of active functional movement.

An MRI study on the relations between muscle atrophy, shoulder function and glenohumeral deformity in shoulders of children with obstetric brachial plexus injury

BackgroundA substantial number of children with an obstetric brachial plexus lesion (OBPL) will develop internal rotation adduction contractures of the shoulder, posterior humeral head subluxations and glenohumeral deformities. Their active shoulder function is generally limited and a recent study showed that their shoulder muscles were atrophic. This study focuses on the role of shoulder muscles in glenohumeral deformation and function.MethodsThis is a prospective study on 24 children with unilateral OBPL, who had internal rotation contractures of the shoulder (mean age 3.3 years, range 14.7 months to 7.3 years). Using MR imaging from both shoulders the following parameters were assessed: glenoid form, glenoscapular angle, subluxation of the humeral head, thickness and segmental volume of the subscapularis, infraspinatus and deltoid muscles. Shoulder function was assessed measuring passive external rotation of the shoulder and using the Mallet score for active function. Statistical tests used are t-tests, Spearman's rho, Pearsons r and logistic regression.ResultsThe affected shoulders showed significantly reduced muscle sizes, increased glenoid retroversion and posterior subluxation. Mean muscle size compared to the normal side was: subscapularis 51%, infraspinatus 61% and deltoid 76%. Glenoid form was related to infraspinatus muscle atrophy. Subluxation was related to both infraspinatus and subscapularis atrophy. There was no relation between atrophy of muscles and passive external rotation. Muscle atrophy was not related to the Mallet score or its dimensions.ConclusionMuscle atrophy was more severe in the subscapularis muscle than in infraspinatus and deltoid. As the muscle ratios are not related to passive external rotation nor to active function of the shoulder, there must be other muscle properties influencing shoulder function.

An MRI study on the relations between muscle atrophy, shoulder function and glenohumeral deformity in shoulders of children with obstetric brachial plexus injury

An MRI study on the relations between muscle atrophy, shoulder function and glenohumeral deformity in shoulders of children with obstetric brachial plexus injury

Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: Evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture

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.

Three dimensional gleno-humeral deformities in obstetric brachial plexus palsy

Three dimensional gleno-humeral deformities in obstetric brachial plexus palsy

Operative reduction and tendon transfer for treatment of posterior dislocation of the glenohumeral joint secondary to obstetric brachial plexus palsy in young children

Background The incidence of posterior subluxation/dislocation of the shoulder secondary to obstetric brachial plexus palsy is found to be relatively high with increasing awareness of the condition and advances in radiological imaging. Left untreated, glenohumeral deformation and functional impairment are progressive with increasing age. Patients and methods Twelve patients with posterior subluxation (five patients)/dislocation (seven patients) of the shoulder secondary to obstetric brachial plexus palsy were treated by operative reduction with concomitant anterior soft-tissue release and latissimus dorsi and teres major tendon transfers to the rotator cuff. The mean age at surgery was 3 years. Results After a mean follow-up of 3 years, the mean aggregate Mallet score improved from 9.5 points preoperatively to 14.4 points postoperatively (increased by 51.6%). Abduction and external rotation improved significantly. Radiologically, the mean percentage of humeral head anterior to the midscapular line improved from 9% preoperatively to 42% postoperatively. All patients except one showed restoration of the dislocation, which was maintained until final follow-up. The mean glenoid version improved from −45.8° preoperatively to −8° at the latest follow-up. Conclusion The procedure used results in improved shoulder function and glenohumeral joint remodeling. Postoperative care and rehabilitation programs are mandatory for satisfactory outcome.