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     

肩关节前、后路手术治疗产瘫肩关节内旋挛缩伴盂肱关节后脱位

目的 观察肩关节前路松解复位、后路关节囊紧缩治疗产瘫肩关节内旋挛缩畸形伴肩关节后脱位的临床效果. 方法 19例产瘫并发肩关节内旋挛缩畸形患者,经X线和CT检查确诊为盂肱关节半脱位伴假盂形成或完全脱位.男14例,女5例,年龄2.5 ～ 8.5岁,平均5岁.盂肱关节畸形按照改良的Water的标准进行分型,Ⅳ型15例,Ⅴ型4例.19例均行肩关节前路挛缩软组织松解、复位,同时行后路剥离关节囊与假盂的粘连并紧缩后下方关节囊,肩关节外旋0°位石膏固定4周. 结果 术后随访12 ～ 36个月,平均20个月.肩关节Mallet评分由术前平均(11.4±1.7)(7～16)分至术后(15.5±1.8)(13～19)分,两者差异有统计学意义(P＜0.05);术后盂肱关节达到中心性复位的有16例;3例肱骨头仍向后脱位. 结论 对于产瘫肩关节内旋挛缩导致的肩关节脱位,前路松解复位、后路剥离关节囊与假盂粘连、紧缩后下侧关节囊,不但使脱位的盂肱关节达到中心复位,同时明显改善其肩关节的功能.     

分娩性臂丛神经麻痹后遗肩关节内旋挛缩致盂肱关节畸形的Waters分型

目的对分娩性臂丛神经麻痹(产瘫)后遗肩关节内旋挛缩导致的盂肱关节畸形进行CT或MR检查并按照Waters进行分型,探讨Waters分型与术前肩关节被动外旋角度的相关性。方法33例产瘫后遗肩关节内旋挛缩患儿,男12例,女21例;年龄10个月￣16岁,平均4.5岁。产瘫类型:TassinⅡ型19例,Ⅲ型13例,Ⅳ型1例。在肩关节横断面CT或MRI扫描图像上,按照Friedman的标准测量关节盂的后倾角及肱骨头向后脱位的比率。按照Waters分型标准对盂肱关节的畸形进行分型,同时测量患侧肩关节中立位被动外旋角度,对二者之间的相关性进行统计学分析。结果按照Waters分型标准,33例患儿中Ⅰ型4例,Ⅱ型4例,Ⅲ型7例,Ⅳ型6例,Ⅴ型5例,Ⅵ型7例。Ⅰ、Ⅱ型患儿肩关被动外旋多能超过中立位;Ⅲ、Ⅳ型患儿肩关节多不固定在内旋位,但被动外旋很难超过中立位;Ⅴ、Ⅵ型患儿肩关节多固定在内旋位,被动外旋角度平均>-30°。盂肱关节畸形的程度与肩关节被动外旋受限的角度呈直线正相关。结论Waters分型较准确地提示盂肱关节的畸形程度,盂肱关节畸形越严重其肩关节被动外旋受限越明显。     

大龄产瘫肩关节功能重建术

目的 介绍大龄产瘫后遗肩关节内旋挛缩畸形矫正及外展、外旋功能重建的方法和疗效,方法 １９９６年４月￣１９９９年７月,对７例大龄产瘫后遗肩关节内旋挛缩畸形和外展、外旋功能障碍的患者,采用肩胛下肌止点部Ｚ形延长和背阔肌、大圆肌止点上移至冈上肌、冈下肌腱部进行矫治。结果 术后随访６￣４４个月,平均１９个月,Ｇｉｌｂｅｒｔ分级和Ｍａｌｌｅｔ评分：术前分别为１．５７、７．５７;术后分别为３．４５,１０．８６     

手术复位治疗产瘫肩关节内旋挛缩伴盂肱关节后脱位存在的问题及改进

目的观察肩关节前路松解复位、后路关节囊紧缩及关节孟后路截骨治疗产瘫肩关节内旋挛缩畸形伴肩关节后脱位的临床效果。方法经CT或MRI检查确诊为孟肱关节脱位的7例产瘫并发肩关节内旋挛缩畸形患者，男2例，女5例，年龄1．4～4岁，平均2岁2个月。孟肱关节畸形按照Water的标准进行分型，Ⅳ型5例，Ⅴ型2例。2例行肩关节前路松解复位，肩关节最大外旋位固定6周；5例同时行后路关节囊松解、紧缩及关节孟截骨，将后倾的关节孟向前掀起，取三角形髂骨块植骨，术后行石膏固定4周。结果2例单纯行前路松解复位者术后分别随访48，60个月，Mallent评分分别由术前6分至术后10分；CT及X线平片复查示，肱骨头前脱位，关节孟后侧部分仍后倾。5例同时后路行关节孟截骨，术后随访36～49个月，平均3年4个月，Mallant评分由术前平均5。4分至术后8．6分；经CT及X线平片复查，孟肱关节复位良好，关节孟包容良好，关节孟后倾纠正。结论对于产瘫肩关节内旋挛缩导致的肩关节脱位，前路松解复位、后路关节囊松解、紧缩及关节孟后路截骨，可使脱位的孟肱关节复位并恢复关节孟的包容同时改善其肩关节功能。     

大圆肌转位修复重建大龄产瘫肩外展功能

目的探讨大圆肌转位修复重建大龄产瘫患者肩外展功能的临床疗效。方法采用大圆肌转位修复重建术治疗17例大龄产瘫后遗肩外展功能障碍的患者。结果 17例均获得随访,时间10~62个月。术后6个月,Gilbert分级1级2例,2级3例,3级5例,4级7例;Mallet评分7~8分3例,9~10分4例,11~14分10例;肩关节外展活动度30°~90°。结论大圆肌转位是治疗大龄产瘫后遗肩关节内旋挛缩畸形和外展功能障碍的有效方法。     

臂丛神经产瘫的自然病程、显微外科修复与手术重建结果的比较

<正> 目的:本研究的目的是观察臂丛神经产瘫(BPBP)的自然病程(出生后6个月肱二头肌功能恢复的情况),评估6个月肱二头肌功能无恢复患儿行显微修复术的结果,比较后锯肌、大圆肌肌腱移位与肱骨旋转截骨的结果,并将肌腱移位术及截骨术与本病自然病程作比较。方法:观察66例(67侧)3月龄以内BPBP患儿肱二头肌功能恢复的时间及程度,每月记录一次。按肱二头肌恢复时的患儿月龄数分组。每月进行体格检查,并用Mallet功能标准进行评估,对6例出生后6个月肱二头肌功能无恢复的患儿行臂丛神经显微外科修复术。另一组27例患儿在他们6个月时被认为慢性神经病损,肩关节内旋挛缩或外旋功能差,其中9例行后锯肌和大     

产瘫早期显微外科修复的几点评估

1980年以来，我们围绕产瘫早期显微外科修复的临床、教学及科研方面作了一些工作，取得了有成效的经验，成功地对产瘫进行了新的分类畸，促进了产瘫的广泛交流。看到《实用手外科杂志》奥运年发表王树锋关于“治疗产瘫肩关节内旋挛缩畸形伴肩关节后脱位的临床效果”论著及影像资料，使我眼前一亮的是治疗产瘫肩关节后遗症在原基础上迈出了可喜的一步，改变了原来圈子。使患者真正获得了肩肱关节有效功能的恢复，走出一条为产瘫病人着想的研究之路。     

产瘫患儿肩外展受限的病理类型及其临床意义

目的探讨产瘫患儿肩外展受限的病理基础，提出新的分型并分析其临床意义。方法按住院日期先后随机选择１９９７年８月至１９９８年７月住院的肩外展受限的产瘫２５例，按肩部肌肉功能状态、肌电图表现和肩关节Ｘ线片发现，对其进行分析和归纳。根据临床检测结果，将其分为动力型、阻力型及混合型三型肩外展受限。结果（１）动力型肩外展受限：５例，以三角肌，冈上、下肌麻痹为主；（２）阻力型肩外展受限：１５例，以肩胛下肌挛缩，肌电图检测示大圆肌、背阔肌有同步放电现象，肩关节出现继发性骨关节病变者为主；（３）混合型：５例，具有上述两型的病理改变。结论产瘫患儿肩外展受限系多种因素引起，故进行正确的分型有助于选择正确的治疗方案。     

肱骨旋转截骨治疗大龄产瘫后肩关节内旋挛缩畸形

目的初步探讨肱骨旋转截骨治疗大龄产瘫后肩关节内旋挛缩畸形的疗效。方法2000年10月起，对17例肩胛下肌挛缩型大龄产瘫后肩关节内旋挛缩畸形的患者，采用肱骨旋转截骨术进行治疗。并用Mallet评分及Gilbert分级两项评价系统来评价术前、术后的功能。结果术后17例获得1年以上的随访。按改良Mallet评分法评分：7～8分3例，9～10分4例，11～14分10例；平均得分从术前的8．5分上升到11．0分。术后按Gilbert分级：1级1例，2级2例，3级4例，4级10例；平均级别由术前的2级上升到术后的4级。结论肱骨旋转截骨术是治疗大龄产瘫后肩关节内旋挛缩畸形的有效方法。     

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.     

Forearm rotational profile in obstetric brachial plexus injury

Children with obstetric brachial plexus palsy (OBPP) most commonly have weakness of supination. There is little previous information on later progress of forearm rotation movements, although severe supination contracture has been reported in a small proportion of children. The aims of this study were to evaluate forearm rotation after initial recovery from OBPP, to define the relationship with the severity of disease, and to assess which factors might limit rotation. Measurements of active and passive pronation and supination were recorded in 56 children (37 boys and 19 girls) who had had OBPP and did not have full recovery. The mean age was 8 years (minimum, 2.5 years). Care was taken to measure forearm rotation in isolation from shoulder movements. According to the Narakas classification for severity of the original brachial plexus lesion, there were 23 group I cases, 16 group II cases, 11 group III cases, and 6 group IV cases. Twenty-one children underwent reconstructive procedures for shoulder deformity. Mallet scores for shoulder function were available for all patients. Overall pronation was more limited than supination. Active movements were more limited than passive movements. Active pronation was less than normal in 48 children, active supination was less than normal in 36, passive pronation was less than normal in 22, and passive supination was less than normal in 9. Active pronation and active and passive supination were significantly limited in children with worse Mallet scores and in Narakas group IV children. Both active supination and passive supination were decreased in children with more severe elbow flexion contractures. No significant relationship was found between forearm rotation movements and the time of biceps recovery. Many children have persisting limitation of forearm rotation after OBPP. Despite the initial weakness of supination, pronation is more often reduced in the longer term. Patients with more severe OBPP and poorer recovery of shoulder function have greater limitation of forearm rotation.     

旋转截骨矫形手术在分娩性臂丛损伤治疗中的应用

目的　评价肱骨及桡骨旋转截骨术治疗分娩性臂丛损伤(产瘫)肩肘后遗症的价值。方法　1999年8月至2000年12月,对8例产瘫肩肘后遗症患儿（肩关节外旋挛缩2例,内旋挛缩1例,前臂旋后挛缩并发桡骨小头脱位5例）施行肱骨内旋截骨、外旋截骨、及前臂旋前截骨等手术,并经术后3～16个月(平均8个月)的随访。术后肩关节功能采用Mallet评分、前臂功能采用旋前位置角度的改善作为评价标准。结果　2例行肱骨内旋截骨者,1例按Mallet评分,术前术后的改变为肩外展3→3,外旋4→4,手到颈后4→3,手到背2→4,手到嘴2→4;另1例因感染及螺钉断裂致骨不连行内固定手术后尚在康复中。1例行肱骨外旋截骨者,按Mallet评分,术前术后改变为肩外展2→3,外旋2→4,手到颈后2→3,手到背4→3,手到嘴2→3。5例行桡骨旋前截骨者,术后前臂均处于旋前30°位置,功能及外观均获得改善。结论　肱骨及桡骨旋转截骨矫形手术在产瘫肩肘挛缩后遗症的治疗中具有一定的应用价值。     

大龄产瘫肩关节内旋挛缩畸形的两种术式比较

目的 初步探讨前路软组织松解加肱骨旋转截骨术和单纯肩关节前路松解术治疗大龄产瘫后肩关节内旋挛缩畸形的疗效.方法 1999年8月～2007年1月,对32例大龄产瘫后肩关节内旋挛缩畸形的患者,其中17例采用前路软组织松解加肱骨旋转截骨术,另15例采用单纯肩关节前路松解术.结果 术后随访1～9年,按Mallet评分方法评定:前路软组织松解+肱骨旋转截骨(A组)术后平均得分从术前的8.5分上升到1 1.0分;单纯肩关节前路松解(B组)术后平均得分从术前的7.7分上升到8.7分.按Gilbert分级方法评定:A组术后平均级别由术前的2.0级上升到术后的4.0级;B组术后平均级别由术前的2.0级上升到术后的2.8级.结论 肱骨旋转截骨是治疗大龄产瘫后肩关节内旋挛缩畸形的有效方法.     

Classification of impairment of shoulder abduction in obstetric brachial plexus palsy and its clinical significance

Shoulder abduction was studied in 25 cases of obstetric brachial plexus palsy (OBPP). According to muscle function, electromyographic features and X-ray examination, impairment of shoulder abduction could be classified into dynamic, resistant or combined types. Five cases were the dynamic type, which was characterized by paralysis of the shoulder abductors. Fifteen cases were categorized as the resistant type, with contracture of the subscapularis muscle, co-contraction of latissimus dorsi and teres major muscles and secondary disorders of the shoulder joint. Five cases were classified as the combined type in which there were both dynamic and resistant factors. Appropriate management and surgical procedures in the shoulder affected by OBPP depend on the pathological classification.     

The effect of derotational humeral osteotomy on global shoulder function in brachial plexus birth palsy

BACKGROUND: Derotational humeral osteotomies have been used in older children with brachial plexus birth palsy and glenohumeral joint deformity to place the upper extremity in a more functional position. The purpose of this study was to determine the effects of these procedures on shoulder function and joint morphology. METHODS: Forty-three patients underwent a derotational humeral osteotomy for functional impairment in the setting of internal rotation contracture and/or glenohumeral joint deformity at our institution from 1996 to 2004. Osteotomies were performed proximal to the deltoid insertion and were stabilized with plate-and-screw fixation. The average age of the patients at the time of surgery was 7.6 years (range, 2.3 to 17.0 years). Shoulder function was graded according to the modified Mallet classification system. Glenohumeral deformity was graded according to the classification scheme of Waters et al. The results for twenty-seven patients who were followed for a minimum of two years (average, 3.7 years) are reported. RESULTS: The average amount of external rotation achieved with osteotomy was 64 degrees (range, 35 degrees to 90 degrees). The mean aggregate Mallet classification score improved from 13 to 18 points (p < 0.01). The mean Mallet classification scores for the individual elements similarly demonstrated improvement following osteotomy, with the greatest gains in hand-to-mouth, hand-to-neck, and external rotation motions. The mean classification of the glenohumeral deformity was type IV preoperatively and postoperatively, signifying the persistence of glenohumeral dysplasia. There were no nonunions. One patient required a revision osteotomy for inadequate initial correction. One patient sustained a humeral fracture distal to the plate fixation because of sports-related trauma. CONCLUSIONS: Derotational humeral osteotomy improves shoulder function in patients with brachial plexus birth palsy, internal rotation contracture, and/or advanced glenohumeral joint deformity. This osteotomy provides an attractive treatment option for patients with brachial plexus birth palsy who have advanced glenohumeral dysplasia precluding soft-tissue releases and tendon transfers.     

Applying transfer of trapezius and/or latissimus dorsi with teres major for reconstruction of abduction and external rotation of the shoulder in obstetrical brachial plexus palsy

To evaluate the effects of transfer of the trapezius and/or latissimus dorsi with the teres major for treatment of dysfunction of the shoulder in obstetrical brachial plexus palsy (OBPP), 34 patients with paresis of the abductors and external rotators, as well as co-contraction of the adductors in abduction, who had undergone reconstructive operations, were followed-up for at least 1 year. Of these, transfer of the latissimus dorsi with attached teres major to the insertion of the infraspinatus (single procedure), was performed in 25 cases, and transfer of both latissimus dorsi with teres major and trapezius (to the humerus) in nine (combined procedure). Gilbert's grading system was used for evaluation. The results showed that in spite of improvement of external rotation in most of the cases, abduction was improved in only 13 of the 25 cases with a single procedure, and that eight of nine cases with a combined procedure gained improvement of both external rotation and abduction. These results indicated that, for improvement of both abduction and external rotation of the shoulder in OBPP, transfer of the latissimus dorsi with the teres major can be performed only when abduction is > or =90 degrees; otherwise, transfer of the trapezius should be added.