Assessment and treatment of glenohumeral joint deformities in children suffering from upper obstetric brachial plexus palsy

We present our approach to gleno-humeral joint deformities as sequelae from severe upper obstetric brachial plexus palsy. In 50 consecutive children with severe medial rotation contracture of the shoulder after obstetric brachial plexus palsy, we used magnetic resonance imaging to evaluate joint incongruence and dysplasia; showing frequently various deformities of the glenoid, the humeral head and pathologic changes in their relationship. The most severe deformity is true glenohumeral dysplasia. These diagnostic findings might influence our choice and technical details within surgical procedures. We actually evaluate image processing tools (segmentation software) for a better understanding of changes in anatomical structures responsible for this multifactorial joint deformity, limiting lateral and/or medial rotation of the glenohumeral joint in children with obstetric brachial plexus palsy.     

Operative treatment of medial rotation contracture of the shoulder caused by obstetric brachial plexus palsy

Objective:to introduce an operation of subscapularis slide from its origin and anterior release from its insertion for treatment of medial rkotation contracture,subluxation and dislocation of the shoulder caused by obstetric brachial plexus palsy(OBPP).Methods:Thirty-six cases with medial rotation contracture of the shoulder were diagnosed by measurement of the inferior glenohumeral angle,passive lateral rotation of the shoulder and plain radiographs.Subscakpularis slide was performed in 24 cases with simple medial rotation contracture,and anterior release in 12 cases with complex contracture-medial rotation contracture combined with subluxation,dislocationm,or other deformities of the shoulder joint.systems of Mallet scoring and Gilbert grading for the shoulder were used to evaluate the postoperative shoulder function.Results:with follow up for a minimum of six months,32 cases got apparent gains from operations,accounting for 88.8% of the total orerated on.The younger the child was,the better the result.Of 4 cases with no operative effects,3 has no flexion of the elbow preoperatively,suggesting a poor recovery of the upper trunk of the brachial plexus;the rest one had no repair of the severed subscapularis tendon.conclusions:subscapularis slide and anterior release of the shoulder are effective for treatment of medial rotation contracture as well as its consequence of subluxation and dislocation of the shoulder in OBPP.The operative effect is related to children‘s age and the recovery extent of the upper trunk of the brachial plexus.     

产瘫肩关节挛缩后遗症的诊断

目的：对产瘫患儿肩关节功能作定量和定性检查，以明确肩关节功能障碍是因主动肌的无力抑或是拮抗肌和关节囊的挛缩所致。方法：对４０例肩关节功能障碍而肱二头肌肌力达Ｍ３以上的产瘫患儿，采用Ｍａｌｅｔ评分，Ｇｉｌｂｅｒｔ分级，盂肱角测量，肩关节中立位被动外旋，翼状肩胛检查，肌电图及Ｘ线诊断等检查手段，综合评价其肩关节功能。结果：３８例肩关节功能障碍是由于拮抗肌或关节囊挛缩引起，其中内旋挛缩３５例（合并肩关节后关节囊挛缩１４例），肩关节下部挛缩３例。另２例肩外展不能是因主动肌无力所致。结论：产瘫患儿有较好的但不同步的神经恢复是产生各种肩关节挛缩后遗症的主要原因。早期诊断有助于及时治疗和预防肩关节继发性病变的发生     

Obstetric brachial plexus lesions: a study of 74 children registered with the British Paediatric Surveillance Unit (March 1998-March 1999)

Seventy-four children with obstetric brachial plexus palsy registered with the British Paediatric Surveillance Unit were prospectively followed for a minimum of 2 years. Thirty-nine (52.7%) spontaneously recovered to normal or nearly normal levels and a further 29 (39.3%) regained good function in the upper limb. The most important secondary deformity involved the gleno-humeral joint and 20 patients (27%) needed surgical correction. Two more children await operation for shoulder deformity. The brachial plexus was explored in nine patients (12.2%) and repaired in seven.     

产瘫后肩关节内旋挛缩畸形的手术治疗

目的：介绍用肩胛下肌起点剥离术及前路松解术，治疗产瘫后肩关节内旋挛缩后遗症的方法及疗效。方法：对３６例经盂肱角测定、肩关节中立位被动外旋及Ｘ线诊断为肩关节内旋挛缩的患儿，采用肩胛下肌起点剥离或止点延长、关节复位及继发性畸形纠正等手术进行治疗。用Ｍａｌｅｔ评分及Ｇｉｌｂｅｒｔ分级两项定量评价系统来评价术前、术后功能。结果：术后随访半年，３２例有效，有效率为８８．８％。年龄愈小疗效愈佳。４例无效者，３例术前无屈肘功能，提示臂丛上干恢复差；１例肩胛下肌止点切断后未作重建。结论：肩胛下肌起点剥离术或前路松解术，是治疗产瘫后肩内旋挛缩的有效方法，疗效与患儿年龄及臂丛上干的恢复程度密切相关     

Secondary reanimation procedures in late obstetrical brachial plexus palsy patients

The varying degrees of spontaneous reinnervation that occur in untreated obstetrical brachial plexus palsy leave characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Early microsurgical reconstruction of the affected plexus leads to a more rewarding overall function of the upper arm, but residual deformities might appear later which are similar, although less serious, than those observed in untreated cases. Secondary procedures of the shoulder, elbow, forearm, and hand will improve the appearance and function of the upper extremity in late cases of obstetrical brachial plexus. Careful preoperative planning is mandatory and a multistage approach should be applied, depending on the type of palsy and the age of the patient.     

带蒂大圆肌双极移位重建产瘫肩外展功能

目的评价带蒂大圆肌双板移位重建分娩性臂丛神经损伤（产瘫）后肩外展功能的疗效及临床应用前景。方法对9例产瘫后肩外展功能障碍的患儿行带血管神经蒂大圆肌双极移位术重建肩外展功能,并经术后1年以上的随访,观察其临床应用效果。结果9例患儿术前肩外展平均11．2°（0°-30°）,术后肩外展平均75．4°（45°～95°）。按照顾玉东的评定标准评价：优3例,良4例,可2例,优良率为77．8％。结论对于产瘫后肩外展功能障碍者,用带血管神经蒂大圆肌双极移位术重建其肩外展功能是有效而值得临床推广的治疗方法。     

Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results

We present 7 children with obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve. Three were male, and 4 were female. The left-side brachial plexus was affected in 4 patients, and the right side in 3 patients. All children had vaginal delivery; two of them presented with shoulder dystocia. The average birth weight was 4300 g (range, 3620-5500 g). Average age at time of operation was 16 months (range, 11-24 months). The indication for the operation was absent active elbow flexion with active shoulder abduction against gravity in 4 cases, and no biceps function and bad shoulder function in 3 cases. Oberlin's ulnar nerve transfer was done in 4 cases without brachial plexus exploration in those children with good shoulder function, and exploration of the brachial plexus was performed in the other 3 cases with bad shoulder function. The average follow-up was 19 months (range, 13-30 months). Five children had biceps muscle >or=M(3) with active elbow flexion against gravity, and 2 children had biceps muscle 相似文献   

Complete infraclavicular brachial plexus palsy with occlusion of axillary vessels following anterior dislocation of the shoulder joint

Two cases of complete infraclavicular brachial plexus palsy after anterior dislocation of the shoulder joint are reported. Both patients had transient motor brachial plexus paralysis and extensive anesthesia of the whole upper limb. Additionally, one of them had occlusion of the axillary vessels. Vascular recovery occurred immediately after manipulation and reduction of the affected shoulder joint. Neurological recovery occurred 9 to 12 months later in both cases without surgery, other than closed reductions. Such neurological and vascular complications after anterior dislocation of the shoulder joint are unique.     

Management of obstetrical brachial plexus palsy with early plexus microreconstruction and late muscle transfers

Birth brachial plexus injury usually affects the upper roots. In most cases, spontaneous reinnervation occurs in a variable degree. This aberrant reinnervation leaves characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are the internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Nowadays, the strategy in the management of obstetrical brachial plexus palsy focuses in close follow-up of the baby up to 3-6 months and if there are no signs of recovery, microsurgical repair is indicated. Nonetheless, palliative surgery consisting of an ensemble of secondary procedures is used to further improve the overall function of the upper extremity in patients who present late or fail to improve after primary management. These secondary procedures include transfers of free vascularized and neurotized muscles. We present and discuss our experience in treating early and/or late obstetrical palsies utilizing the above-mentioned microsurgical strategy and review the literature on the management of brachial plexus birth palsy.     

Morphometric analysis of the association of primary shoulder reconstruction procedures with scapular growth in obstetric brachial plexus paralysis patients

Background

Obstetric brachial plexus paralysis (OBPP) has been associated with shoulder deformities, scapular growth, and shoulder function impairment. The absence of balanced muscular forces acting on the scapula has been considered responsible for scapula dysplasia and impaired growth as compared with the normal side. Scapula growth impairment may also lead to shoulder and upper extremity dysfunction. This study aims at showing the association of primary nerve reconstruction with the restoration of scapular bone growth potential.

Methods

This is a retrospective review of 73 patients with OBPP who underwent primary shoulder reconstruction. Patients were categorized for assessment and analysis into group A, global paralysis; group B, Erb’s palsy; and group C, Erb’s palsy with C7 root involvement. Scapular posteroanterior and lateral X-rays were obtained in which four scapula dimensions were manually measured. The growth discrepancy depending on the applied treatment was investigated.

Results

The highest improvement was noted in scapular height in the Erb’s palsy group who underwent simultaneous neurotization of the suprascapular and axillary nerves. The oblique axis was more improved in the Erb’s palsy group while both big and small widths were more improved in the Erb’s palsy with C7 root involvement group in patients who underwent concomitant neurotization of the suprascapular and the axillary nerves. Functional improvement correlated positively with growth improvement in all groups and scapular dimensions.

Conclusion

Scapula growth and shoulder function improvement were higher in patients with Erb’s palsy. Simultaneous axillary and suprascapular nerve neurotization provided the best outcome in both functional and growth restoration.     

Glenoid version in children with obstetric brachial plexus palsy.

Glenoid version in a group of 29 children with obstetric brachial plexus paralysis and posterior dislocation of the shoulder was studied by using computed axial tomography (CT). The CT scan in most patients was done before an open release and reduction of the shoulder. A comparison was made between the normal and affected sides in regard to glenoid version and structure. In the study population, there were 16 girls and 13 boys with an average age at the time of initial CT of 2.8 years. Sixteen of the patients had posterior dislocations of the right shoulder, and none was bilateral. In 18 patients, the neurologic lesion was confined to the upper roots of the brachial plexus, with the remaining patients having whole plexus involvement. A significant difference in glenoid version between normal and affected sides was found in these patients. The mean glenoid version for the dislocated side was -29.5 +/- 2.5 degrees and that of the normal side was -6.9 +/- 2.4 degrees. Glenoid structure was different in dislocated shoulders. The glenoid articular surface was observed to be laterally convex in the majority of cases, and in these cases, the posterior rim of the glenoid was often hypoplastic and rounded.     

Operative aid to combined synchronous mastectomy and latissimus dorsi breast reconstruction

A special frame is described which has been designed to hold the upper trunk and arm of patients firmly in the lateral position during the operation of combined synchronous mastectomy and latissimus dorsi breast reconstruction. The frame has prevented movement at the shoulder joint and distraction on the brachial plexus which resulted in brachial plexus palsy in two out of 15 patients in whom the operation was performed with a conventional arm support.     

Intraobserver and interobserver reliability of two ultrasound measures of humeral head position in infants with neonatal brachial plexus palsy

BACKGROUND: Ultrasonographic evaluation of the hip in infants is considered both reliable and reproducible in the diagnosis of developmental dysplasia of the hip. Ultrasonographic evaluation of the shoulder in infants has been reported as a valuable diagnostic aid in dysplastic development following neonatal brachial plexus palsy. To our knowledge, there has been no study of the intraobserver reproducibility and interobserver reliability of sonography of the shoulder in infants with and without suspected posterior shoulder dislocation. METHODS: Two identical but randomly ordered sets of the same deidentified sonographic images of shoulders in infants were given to radiologists, pediatric orthopaedists and orthopaedic residents, and fellows with varying degrees of experience in the evaluation of shoulder pathology in infants, who measured the position of the humeral head relative to the axis of the scapula. Intraobserver reproducibility and interobserver reliability of the measurements were assessed. RESULTS: For the position of the humeral head with respect to the glenoid in both normal and abnormal conditions, the Pearson correlation coefficient for intraobserver reproducibility was 0.91 and the intraclass correlation coefficient for interobserver reliability was 0.875. For estimating the percentage of the humeral head posterior to the axis of the scapula, the Pearson correlation was 0.85 and the intraclass correlation coefficient was 0.77. CONCLUSIONS: Ultrasonographic examination of the shoulder in infants to assess for the position of the humeral head with respect to the scapula showed high intraobserver reproducibility and interobserver reliability. It is recommended as a reliable technique for evaluating shoulder position in infants with neonatal brachial plexus palsy.     

Bilateral elbow flexion reconstruction with functioning free muscle transfer for obstetric brachial plexus palsy

A child suffered a bilateral obstetric brachial plexus palsy involving the C5 and C6 nerve roots. Abduction of the shoulder joints had recovered by 1 year, but elbow flexion did not recover on either side. Free gracilis muscle transfers were performed on both sides, at an interval of 6 months, to achieve elbow flexion. The spinal accessory nerve was used as the donor nerve.     

Coracoid Abnormalities and Their Relationship with Glenohumeral Deformities in Children with Obstetric Brachial Plexus Injury

Background  

Patients with incomplete recovery from obstetric brachial plexus injury (OBPI) usually develop secondary muscle imbalances and bone deformities at the shoulder joint. Considerable efforts have been made to characterize and correct the glenohumeral deformities, and relatively less emphasis has been placed on the more subtle ones, such as those of the coracoid process. The purpose of this retrospective study is to determine the relationship between coracoid abnormalities and glenohumeral deformities in OBPI patients. We hypothesize that coracoscapular angles and distances, as well as coracohumeral distances, diminish with increasing glenohumeral deformity, whereas coracoid overlap will increase.     

Function of the upper limb after surgery for obstetric brachial plexus palsy

We reviewed a consecutive series of 33 infants who underwent surgery for obstetric brachial plexus palsy at a mean age of 4.7 months. Of these, 13 with an upper palsy and 20 with a total palsy were treated by nerve reconstruction. Ten were treated by muscle transfer to the shoulder or elbow, and 16 by tendon transfer to the hand. The mean postoperative follow-up was 4 years 8 months. Ten of the 13 children (70%) with an upper palsy regained useful shoulder function and 11 (75%) useful elbow function. Of the 20 children with a total palsy, four (20%) regained useful shoulder function and seven (35%) useful elbow function. Most patients with a total palsy had satisfactory sensation of the hand, but only those with some preoperative hand movement regained satisfactory grasp. The ability to incorporate the palsied arm and hand into a co-ordinated movement pattern correlated with the sensation and prehension of the hand, but not with shoulder and elbow function.     

Der Armplexusschaden

The treatment of traumatic brachial plexus lesions follows sequential steps. After acute therapy (phase I), neurological diagnostics (phase II), neurosurgery and postoperative treatment (phase III/IV), reconstructive operations (phase V) can be indicated and performed. In most cases an insufficient grade of muscle power remains. Within 6 months after injury, neurosurgery must be performed in patients with brachial plexus palsy. After malfunction of the muscles, taking into account the individual neuromuscular defects, passive joint function and bony deformities, different procedures such as muscle transposition, arthrodesis and corrective osteotomy can be performed to improve the function of the upper extremity. The treatment of patients suffering from brachial plexus lesion requires interdisciplinary teamwork.     

The brachial plexus lesion. Management, consequences of palsy and reconstructive operations

The treatment of traumatic brachial plexus lesions follows sequential steps. After acute therapy (phase I), neurological diagnostics (phase II), neurosurgery and postoperative treatment (phase III/IV), reconstructive operations (phase V) can be indicated and performed. In most cases an insufficient grade of muscle power remains. Within 6 months after injury, neurosurgery must be performed in patients with brachial plexus palsy. After malfunction of the muscles, taking into account the individual neuromuscular defects, passive joint function and bony deformities, different procedures such as muscle transposition, arthrodesis and corrective osteotomy can be performed to improve the function of the upper extremity. The treatment of patients suffering from brachial plexus lesion requires interdisciplinary teamwork.     

Surgical treatment of Sprengel's shoulder: experience at the Rizzoli Orthopaedic Institute 1975-2010

The outcome of 56 children (61 shoulders) treated surgically at the Rizzoli Institute between April 1975 and June 2010 for congenital elevation of the scapula is reported. There were 31?girls and 25 boys with a mean age at surgery of 6.4 years (2 to 15). The deformity involved the right shoulder in 20 cases, the left in 31 and was bilateral in five. The degree of the deformity was graded clinically and radiologically according to the classifications of Cavendish and Rigault, respectively. All patients underwent a modified Green procedure combined, in selected cases, with resection of the superomedial portion of the scapula and excision of any omovertebral connection. After a mean follow-up of 10.9 years (1 to 29.3), there was cosmetic improvement by at least one Cavendish grade in 54 shoulders (88.5%). The mean abduction of the shoulder improved from 92° (50° to 155°) to 112° (90° to 170°) and the mean flexion improved from 121° (80° to 160°) to 155° (120° to 175°). The unsatisfactory cosmetic result in seven shoulders was due to coexistent scoliosis in two cases and insufficient reduction of the scapular elevation in the other five. An incomplete upper brachial plexus palsy occurred post-operatively in three patients but resolved within seven months. We suggest that a modified Green procedure combined with resection of the superomedial portion of the scapula provides good cosmetic and functional results in patients with Sprengel's shoulder.