Download - Lattisimus Dorsi
-
7/29/2019 Lattisimus Dorsi
1/13
Shoulder Problems in ChildrenWith Brachial Plexus Birth Palsy:Evaluation and Management
Abstract
Traction injury to the brachial plexus sustained during the birth
process that results in impaired neuromuscular function of the
upper extremity continues to occur despite advances in modern
obstetric care. The most common pattern of injury usually results in
motor weakness of shoulder external rotation, leading to internal
rotation contractures and subsequent deformity of the skeletally
immature glenohumeral joint. Understanding of these deformities
and effective surgical intervention have advanced greatly over the
past decade. Restoration of balance between internal and external
rotation forces around the shoulder has great potential for
remodeling of the glenohumeral joint in the young child.
Arthroscopic-directed release of the contracture, with select use of
latissimus dorsi transfer to provide external rotation power, has
proved to be effective for many children with these contractures.
Epidemiologic studies show thatbrachial plexus palsy occurs in 1per 1,0001 to 4.6 per 1,000 births.2
Conventional thinking that 80% to
90% of children recover must be
tempered by the understanding that
there are differences in what is meant
by recovery. A completely normal
arm free of any sequelae is probably
less common than often realized. In
one study, persistent restriction in
passive range of shoulder motion
was observed in 54% of children
who did not demonstrate complete
neurologic recovery by 3 weeks, de-
spite many of them going on to a
good functional recovery.3 The
number of such children who will
have contractures requiring surgical
treatment also varies from center to
center, but in one cohort 20 of 74
children referred in early infancy
from an established registry were in
this category.4 Likely twice this many
have some degree of abnormal gleno-
humeral anatomy on magnetic reso-
nance imaging (MRI).5
Despite advances in obstetric care,the incidence of brachial plexus birth
palsy is increasing, speculated to be
the result of increasing birth
weights.1,2 The neurologic injury in
newborns may involve the entire
plexus but most often involves the
upper trunk, with varying degrees of
severity. Injuries may be transient,
with nearly complete neurologic re-
covery (ie, antigravity biceps and del-
toid function usually observed by age
2 months), or they may result in a
permanently flail arm (usually in as-
sociation with a complete plexus le-
sion and avulsion of the cervical spi-
nal nerve roots). For these two
extremes, there is little controversy
that the early-recovery group does
not need surgical intervention and
that the latter group will fare poorly
Michael L. Pearl, MD
Dr. Pearl is Shoulder and Elbow
Surgeon, Kaiser Permanente, Los
Angeles Medical Group, Los
Angeles, CA, and Assistant Clinical
Professor, Department of
Orthopaedic Surgery, University of
Southern California, Los Angeles.
Supported in part by research grants
from Kaiser Permanente Southern
California and American Shoulder
and Elbow Surgeons. Dr. Pearl or a
member of his immediate family has
received royalties from Zimmer.
Reprint requests: Dr. Pearl, Kaiser
Permanente, Los Angeles Medical
Center, 4760 Sunset Boulevard, Los
Angeles, CA 90027.
J Am Acad Orthop Surg 2009;17:
242-254
Copyright 2009 by the American
Academy of Orthopaedic Surgeons.
Review Article
242 Journal of the American Academy of Orthopaedic Surgeons
-
7/29/2019 Lattisimus Dorsi
2/13
without it. When the nerve roots are
avulsed, microsurgical options are
limited to nerve transfers from unin-
volved areas, such as the intercostal
and spinal accessory nerves. The in-
dications for neurosurgery on the
plexus for injuries that are intermedi-
ate to these two extremes remain
controversial. Depending on themedical center, recommendations
typically involve plexus exploration
and grafting from 3 to 9 months fol-
lowing birth.
With or without nerve repair or
transfer, internal rotation contrac-
ture of the shoulder is the most com-
mon problem requiring treatment in
children with incomplete recovery3-10
(Figure 1). This contracture results
from an imbalance between the
strength of the relatively unaffected
internal rotators and the paralytic
external rotators (primarily the in-
fraspinatus). Untreated, it usually
leads to progressive glenohumeral
deformity characterized by posterior
displacement of the humeral head on
an increasingly dysplastic and de-
formed glenoid. Treatment protocols
vary widely, making it challenging to
compare the literature and establish
definitive indications for both early
microsurgery and late secondary or-
thopaedic procedures.
Clinical Evaluation
Assessing the motor function of the
infant and young child is difficult.
Electromyography has not been reli-
able for most clinical investigations
in this patient population. As a re-
sult, the physical examination, with
all its inherent limitations, is the
mainstay of analysis. Fear of the ex-
amination, inability to comprehend
directions, and lack of coordination
from undeveloped motor function in
the very young patient all challenge
the examiner trying to assess active
range of motion (ROM) and
strength. The examiner must engage
the child in activities and then ob-
serve motor function. Young chil-
dren and especially infants can often
be prompted to reach for objects
overhead (eg, lollipop, shiny keys),
providing an indication of active ele-
vation (Figure 2). The effectiveness
of similar maneuvers in other direc-
tions is less predictable. By necessity,
therefore, the examination only ap-
proximates a complete motor exami-
nation, depending on the childs age
and ability to cooperate. Alternatives
to the muscle grading systems that
are commonly used for adults, such
as the British Medical Council5-point scale, are necessary.
The Hospital for Sick Children in To-
ronto, Canada, introduced an exami-
nation scale, the Active Movement Scale
(AMS), to address the limitations in the
British Medical Council system, specif-
ically that it is incongruous to grade the
strength of a weak muscle against grav-
ity if it is not clear that the muscle can
function with gravity eliminated.11
Thus, the first four grades of
strength in the AMS are devoted to
achieving full ROM with gravity
eliminated (Table 1). This system is
particularly useful for infants under
evaluation for potential neurologic
surgery, because they are especially
weak, rarely have contractures, and
have motor grades that must be
based on observation alone because
they cannot comply with commands.
Internal rotation contracture (20 of external rotation) in an 11-month-old child. A, Clinical photograph demonstratingthe degree of contracture with the arm at the side. B, Restriction of passive external rotation was confirmed underanesthesia at the time of surgery. (Reproduced with permission from Pearl ML, Edgerton BW, Kazimiroff PA, Burchette
RJ, Wong K: Arthroscopic release and latissimus dorsi transfer for shoulder internal rotation contractures andglenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 2006;86:564-574.)
Figure 1
Michael L. Pearl, MD
April 2009, Vol 17, No 4 243
-
7/29/2019 Lattisimus Dorsi
3/13
Conversely, this system is a limited
tool for measuring strength in the
context of marked limitations in pas-
sive ROM. When contractures are
present, they are not assessed in this
system, and grades of strength may
not sufficiently represent motor func-
tion. Furthermore, it is unclear that
the ability to achieve full ROM with
gravity eliminated is requisite for
generating appreciable quantities of
force in specific joint positions in all
circumstances. For example, a mus-
cle with a low score (ie, incomplete
ROM with gravity eliminated) may
be stronger in certain midrange posi-
tions than muscles graded higher
simply because they can achieve a
full range.
In an ongoing effort to standardize
evaluations, Bae et al12 performed a
reliability study of three major scor-
ing systems: Mallet classification,
Toronto Test Score, and Hospital for
Sick Children AMS. Two trained ex-
aminers twice evaluated 80 children
with brachial plexus birth palsy. Re-
sults were evaluated for intraob-
server and interobserver reliability as
well as test-retest reliability. Positive
intraobserver and interobserver cor-
relations were noted, and test-retestreliability was excellent. The authors
concluded that the modified Mallet
classification, Toronto Test Score,
and AMS are reliable instrument s
for assessing upper extremity func-
tion in patients with brachial plexus
birth palsy. It is not clear, however,
how the findings of two examiners
from the same institution translate to
the findings of multiple examiners
from different medical centers over
long time periods. More important,the effectiveness and extent to which
these scores reflect muscle function
and recovery of the limb is not ad-
dressed by measures of reliability.
No perfect scale or score exists that
is applicable to children of all ages un-
der consideration for neurosurgical or
orthopaedic intervention. Accordingly,
investigators and clinicians treating af-
fected children are limited to neurologic
examination tools in combination with
measures of passive and active ROM ofall upper extremity joints. With regard
to active ROM, the assessment is by ne-
cessity an approximation for young
children who cannot reliably follow
commands.
Imaging Studies
Ultrasonography,13,14 arthrography,6
and MRI5,7,15-19 have all been used to
study the morphology of the gleno-
humeral joint in children with bra-
chial plexus palsy. The exact role
and relative advantages of each of
these modalities is debatable, al-
though most centers now favor MRI.
Ultrasonography is real-time and
noninvasive, but the level of detail is
lower than that of other modalities.
Arthrography offers more detail than
Same child as in Figure 1 at the same presurgical consultationdemonstrating 120 of active elevation in reaching for her motherswristwatch. Note the effect of internal rotation contracture on the ability toreach.
Figure 2
Table 1
The Active Movement Scale11
Observation
Muscle
Grade
Gravity Eliminated*
No contraction 0
Contraction, nomotion
1
Motion range 2
Motion > range 3
Full motion 4
Against Gravity
Motion range 5
Motion > range 6
Full motion 7
* Active motion through a full range withgravity eliminated must be demonstratedbefore advancing to a score that denotesmotion through the range in the presenceof gravity.
Reproduced with permission from CurtisC, Stephens D, Clarke HM, Andrews D:The active movement scale: An evaluativetool for infants with obstetrical brachialplexus palsy. J Hand Surg [Am] 2002;27:470-478.
Shoulder Problems in Children With Brachial Plexus Birth Palsy
244 Journal of the American Academy of Orthopaedic Surgeons
-
7/29/2019 Lattisimus Dorsi
4/13
ultrasonography but is invasive;
however, it can be done at the time
of surgical intervention, under the
same anesthesia (Figure 3). MRI of-
fers the most detail and potential for
standardization but are costly and
often require general anesthesia inyoung children.
Regardless of the imaging modality
used, it is difficult to justify any clini-
cal study that does not assess the sta-
tus of glenohumeral development. It
is now evident that the internal rota-
tion contracture of the diseased
shoulder commonly leads to gleno-
humeral deformity. Posteriorly di-
rected forces displace the humeral
head in the same direction. In grow-
ing children, skeletal changes ensue.A false articulation often forms on
the posterior aspect of the glenoid
that becomes progressively retro-
verted, leading to a potential array of
deformities that have been described
as flat, biconcave, and convex (ie,
pseudoglenoid). Various classifica-
tion systems have been pro-
posed.3,7,14,20,21 They have in common
the fact that with increasing defor-
mity, there is increasing posterior
displacement of the glenohumeraljoint from its normally centered and
concentric position, and the normal
concave shape of the glenoid be-
comes increasingly convex. In ad-
vanced deformities, the humeral
head articulates with the posterior
aspect of the convex glenoid and be-
comes increasingly misshapen and
retroverted itself18 (Figure 4).
Surgical Management
A detailed review of the indications
and techniques for microscopic sur-
gical intervention for these injuries is
beyond the scope of this discussion,
but it is important to recognize that
microsurgical options are applicable
only to the most severe injuries; ap-
ply only to patients in the first year
of life, after which these options are
thought not to be effective; and
never result in complete neurologic
improvement, always leaving resid-
ual impairment. Thus, secondary or-
thopaedic procedures are a potential
consideration for all children with
incomplete recovery, regardless
whether they receive microsurgical
intervention. For avulsion injuries,
the prognosis for natural recovery is
so poor that early (
-
7/29/2019 Lattisimus Dorsi
5/13
and timing of microsurgical interven-
tion, with recommendations ranging
from age 3 to 9 months.24,25 There is
no doubt that with increasing delayin return of biceps function less
spontaneous recovery will occur. Wa-
ters26 has shown that children who
do not develop this ability by age 5
months do not do as well under con-
servative management as those who
receive microsurgical nerve interven-
tion (grafting or neurotization). Ef-
forts continue to refine surgical
indications, with some centers rec-
ommending a more comprehensive
evaluation that includes muscles
other than the biceps to predict re-
covery.27
Discerning which neurologic le-
sions will improve equally well with
late secondary orthopaedic interven-
tion and no early microsurgery, as
opposed to early microsurgery fol-
lowed later by secondary procedures,
is difficult. No study to date can de-
finitively claim that microsurgery in
combination with secondary ortho-
paedic procedures results in better
outcomes than secondary ortho-
paedic procedures alone, although
much of current practice is predi-
cated on this belief. Smith et al
24
pre-sented long-term follow-up of 22
children who had no brachial plexus
surgery and for whom biceps recov-
ery was delayed until age 3 to 6
months. These children demon-
strated comparable function to that
reported for children who had mi-
crosurgical repair or grafting to the
brachial plexus. Adding to the confu-
sion is the wide array of secondary
procedures that have been associated
in published accounts with clinicalsuccess.
Secondary Interventions
Internal RotationContracture Release
Internal rotation contractures and
the resultant glenohumeral deformity
have been documented in children as
young as age 5 months.5 Treatment
of the contracture can be undertakenat any time because it will not re-
cover spontaneously, although a pe-
riod of formal physical therapy may
be required for the parents to accept
this fact. Four soft-tissue procedures
and one bony procedure constitute
the majority of surgical experience
over the past two decades: (1) ante-
rior capsular release, Z-plasty
lengthening of the subscapularis ten-
don with or without transfer of mus-
cles for external rotation;28 (2) pecto-
ralis major release with transfer of
the latissimus and teres major as ad-
vocated by Hoffer and colleagues;29,30
(3) subscapularis slide with and
without a latissimus transfer as origi-
nally described by Carlioz and Brahi-
mi31 and recommended by Gilbert et
al;32 and (4) arthroscopic release of
the internal rotation contracture
with or without latissimus trans-
fer.10,33,34 These approaches variably
combine some form of contracture
release with or without a muscle
transfer to augment external rotation
power. For children with extensive
glenohumeral deformity, the prevail-ing recommendation is an external
rotational osteotomy of the humerus,
rotating the arm into a more func-
tional position of external rotation.35
How can these seemingly disparate
approaches be reconciled? One way
is to recognize that the internal rota-
tion contracture results from the loss
of the normal balance between exter-
nal rotation and internal rotation,
principally because of infraspinatus
weakness. Different types of proce-
dures that restore muscle balance
and stability by reducing internal ro-
tation strength and/or augmenting
external rotation strength may dem-
onstrate effectiveness. Similarly, a
bony procedure that increases exter-
nal rotation will improve function. It
is also likely that commonly used
clinical scoring systems, most nota-
bly the Mallet, are too crude to dis-
tinguish the outcomes among these
approaches.
Formal Anterior Approach
The first surgical releases described
in the early 20th century by Fair-
bank36 and later modified by Sever37
used a traditional anterior deltopec-
toral approach. To reduce the recur-
rence rate of the internal rotation
contracture and add external rota-
tion power, most centers added some
version of the LEpiscopo transfer of
the latissimus dorsi and teres major
tendons. Modified versions of these
approaches are still the preferred
method of treatment. Kirkos et al28
reported a 30-year mean follow-up
on 10 children who underwent a re-
lease of the upper half of the pecto-
ralis major and the entire subscapu-
laris and anterior capsule, along with
T2-weighted gradient-recalled echoMRI scan of the child in Figures 1and 3, demonstratingpseudoglenoid configuration. Theglenoid contour and scapularcenter line are enhanced with linetracing. (Reproduced withpermission from Pearl ML,Edgerton BW, Kazimiroff PA,
Burchette RJ, Wong K:Arthroscopic release and latissimusdorsi transfer for shoulder internalrotation contractures andglenohumeral deformity secondaryto brachial plexus birth palsy. JBone Joint Surg Am2006;86:564-574.)
Figure 4
Shoulder Problems in Children With Brachial Plexus Birth Palsy
246 Journal of the American Academy of Orthopaedic Surgeons
-
7/29/2019 Lattisimus Dorsi
6/13
rerouting (transfer) of the latissimus
dorsi and teres major tendons to the
pectoralis major stump. Gains in ex-
ternal rotation deteriorated over
time, and five patients had signifi-
cant degenerative changes of the gle-
nohumeral joint.
Among the concerns regarding theanterior approach were that it re-
sulted in poor cosmesis and poten-
tially led to anterior dislocation of
the glenohumeral joint and/or func-
tionally significant external rotation
contractures. Several authors have
modified this approach with an aim
to address some of these issues. Zan-
colli and Zancolli38,39 have long ad-
vocated an anterior approach. Their
clinical reports extensively describe
indications and surgical technique
but provide limited data analysis. To
minimize cosmetic concerns, these
surgeons use an incision in the skin
lines from the coracoid to the axilla
(Figure 5, A). The latissimus transfer
is done by performing a step cut of
the tendon insertion, rerouting the
released tendon posteriorly, and se-
curing it to the remaining latissimus
tendon anteriorly (Figure 5, B and
C). The subscapularis is released,
and sometimes the pectoralis and
teres major are released as well.
These authors warn against releasing
the anterior capsule. Satisfactory re-
sults have been reported with this
technique, with an increase of 50average abduction and 45 average
external rotation.39 In the presence of
an incongruent joint, which typically
is seen in children older than age 3
or 4 years, Zancolli and Zancolli39
recommend a rotational osteotomy
of the humerus and warn against any
attempt to reduce a posterior sub-
luxation surgically when the joints
surfaces are already deformed.
Recent reports by other authors
who use an anterior approach and
who warn against releasing the ante-
rior capsule have acknowledged that
despite their preoperative intentions,
at surgery it was not possible to re-
store external rotation and reduce
the glenohumeral joint without re-
leasing the capsule.40,41 In the series
of van der Sluijs et al,40 15 of 19 pa-
tients with internal rotation contrac-
tures required release of the anterior
capsule to achieve external rotation
and reduce the glenohumeral joint.
In addition to the presence of con-
tracted anterior soft tissues, these au-
thors postulate that in many cases
excessive retroversion of the hu-
merus obligates an external rotationcontracture once the glenohumeral
joint is reduced. In such cases as
these, Birch recommends an internal
rotational osteotomy as part of the
same surgery (70 of the 183 cases in
his series41).
Hoffer Modification of theLEpiscopo Procedure
A common surgical approach em-
ployed by many medical centers,
originally devised by Hoffer, uses a
cosmetic incision in the axillary
crease to release the pectoralis major
and transfer the combined tendons
of the latissimus dorsi and teres ma-
jor muscles to the posterior rotator
cuff29,30 (Figure 6). Hoffer et al29 first
reported on this technique in 11 pa-
tients, who achieved an average gain
Schematic illustration of anterior release, pectoralis transfer, and latissimus dorsi transfer as described by Zancolli and
Zancolli.
39
A, Incision. B, Detachment of the subscapularis, pectoralis major, and latissimus dorsi. C, Rerouting of thelatissimus tendon and reinsertion of the pectoralis into the subscapularis tendon. (Reproduced with permission fromZancolli EA, Zancolli ER III: Reconstructive surgery in brachial plexus sequelae, in Gupta A, Kay SPJ, Scheker LR[eds]: The Growing Hand. London, England: Mosby, 2000, pp 805-823.)
Figure 5
Michael L. Pearl, MD
April 2009, Vol 17, No 4 247
-
7/29/2019 Lattisimus Dorsi
7/13
of 64 of abduction and 45 of exter-
nal rotation at a minimum 2-year
follow-up. A subsequent report 20
years later presented similar success
in another eight children.30 A conten-
tion of these authors and others ad-
vocating this procedure is that one
should avoid releasing the anterior
capsule and even the subscapularis
for fear of anterior dislocation or
creation of an external rotation con-
tracture. However, recent reports
from different centers that used this
surgical approach have shown that
despite improvements in shoulder
function, this procedure did not im-
prove the glenohumeral deformity
present in many of the patients.9,42 It
is likely that this surgical approach is
most effective for external rotation
weakness in the absence of a severe,
firmly fixed internal rotation con-
tracture and glenohumeral defor-
mity.
Release of theSubscapularis Origin
Gilbert et al32 have long advocated
an approach originated by Carliozand Brahimi31 in which the subscap-
ularis origin is released and the mus-
cle reflected distally (Figure 7, A). In
a report on 65 patients followed
more than 5 years after this pro-
cedure, Gilbert et al32 noted an aver-
age gain in external rotation of 70
when children were operated on at
younger than age 2 years provided
that the joint was congruent and the
humeral head was round. Children
operated on after age 4 years did not
show similar improvement. For these
children, and those that failed an ear-
lier release, these authors recom-
mended transfer of the latissimus
dorsi tendon to the posterolateral ro-
tator cuff as well (Figure 7, B).
Among the stated principles of this
surgical approach is that it avoids re-
leasing the anterior capsule and only
Illustrations of partial pectoralis major release (A) and transfer of combined latissimus dorsi and teres major tendons tothe posterior rotator cuff (B) as described by Hoffer. (Reproduced with permission from Hoffer MM, Wickenden R,Roper B: Brachial plexus birth palsies: Results of tendon transfers to the rotator cuff. J Bone Joint Surg Am
1978;60:691-695.)
Figure 6
Illustrations demonstrating subscapularis release (A) and transfer of theisolated latissimus dorsi tendon (B) as described by Gilbert et al.32
(Reproduced with permission from Gilbert A: Obstetric brachial plexus palsy,in Tubiana R [ed]: The Hand. Philadelphia, PA: WB Saunders, 1993, vol 4,pp 592, 594.
Figure 7
Shoulder Problems in Children With Brachial Plexus Birth Palsy
248 Journal of the American Academy of Orthopaedic Surgeons
-
7/29/2019 Lattisimus Dorsi
8/13
partially weakens the subscapularis,
preserving some of its function. In so
doing, this technique clearly tips the
balance between internal and exter-
nal rotation strength in favor of the
weak external rotators. In one series,
however, there was inadequate re-lease of the capsular contracture in 5
of 25 children, requiring an anterior
approach at the same surgical set-
ting.6 A recent long-term follow-up
analysis noted that many of the func-
tional gains observed in the early
postoperative period deteriorated
with time, resulting in significant
functional limitations in adulthood,8
a seemingly consistent observation of
all reported methods in the few very
long-term studies available.28
Arthroscopic SubscapularisTenotomy and CapsularRelease
In 2003, Pearl33 first reported on ar-
throscopic release with promising
early results (Figure 8). A subsequent
report on 33 children confirmed the
utility of this procedure.10 The surgi-
cal protocol used in these studies fol-
lowed in part the recommendationsof Gilbert et al32 in that young children
(3 years) receive arthroscopic release
only and older children receive a simul-
taneous latissimus dorsi tendon trans-
fer. Nineteen children in this series re-
ceived a release only; 14 had a release
combined with a latissimus dorsi trans-
fer. At a minimum 2-year follow-up, the
mean passive external rotation in-
creased by 67 (P < 0.005) in the 15
children with a successful arthroscopic
release (Figure 9) and by 81 (P 3
years) treated with simultaneous release
and latissimus transfer maintained gains
in external rotation. At follow-up, the
four younger children who required de-
layed latissimus transfer had a mean
passive external rotation of 78 and
showed no ill effects of delayed trans-fer. This differential approach to man-
aging children younger than age 3 years
with an isolated arthroscopic release re-
mains the authors preferred method of
managing these contractures.
In the report by Pearl,33 arthro-
scopic release not only improved ex-
ternal rotation but also demon-
strated remarkable remodeling of
glenohumeral deformity when pres-
ent before surgery. Follow-up MRI
was available for 15 of 18 children
with advanced pseudoglenoid defor-
mities at the time of release or trans-
fer. All but the three most severe
deformities (12 of 15) showed nor-
malization of the glenohumeral joint
on follow-up MRI scan, as evidenced
by increased sphericity of the hu-
meral head, restoration of the gle-
noid concavity, and centralization of
the humeral head on the glenoid
fossa (Figure 10).
Normalization of glenohumeral
anatomy may result from a range of
surgical methods of contracture re-
lease as long as external rotation is
restored and preserved at follow-up.
Pedowitz et al
34
showed some im-provement of glenohumeral align-
ment on MRI immediately after
arthroscopic reduction with the
shoulder held in external rotation by
a spica cast. At our center, we have
observed remodeling of deformity by
a variety of surgical methods, open
anterior release, subscapularis slide
Figure 11), and now with our cur-
rent protocol of arthroscopic release
(Figure 10). Hui and Torode20 also
reported improved glenoid retrover-
sion for 23 children at an average
follow-up of 43 months after open
anterior release. Most recently, Wa-
ters and Bae43 reported on 23 chil-
dren with 83% showing remodeling
of deformity after open soft-tissue
procedures that included open gleno-
humeral joint reduction (ie, capsulor-
rhaphy). This was in contrast to their
Arthroscopic view of a rightshoulder from a posterior portaldemonstrating the level ofsubscapularis tenotomy with anelectrocautery device (arrow).BT = biceps tendon, HH = humeralhead. (Reproduced with permissionfrom Pearl ML: Arthroscopic
release of shoulder contracturesecondary to birth palsy: An earlyreport on findings and surgicaltechnique. Arthroscopy2003;19:577-582.)
Figure 8
Active external rotation 2 yearsafter arthroscopic release in thesame child as in Figures 1, 3, and4. (Reproduced with permissionfrom Pearl ML, Edgerton BW,Kazimiroff PA, Burchette RJ, WongK: Arthroscopic release andlatissimus dorsi transfer forshoulder internal rotationcontractures and glenohumeral
deformity secondary to brachialplexus birth palsy. J Bone JointSurg Am 2006;88:564-574.)
Figure 9
Michael L. Pearl, MD
April 2009, Vol 17, No 4 249
-
7/29/2019 Lattisimus Dorsi
9/13
earlier report on patients treated sim-
ilarly who did not receive a capsular
release and showed no improvement
in glenohumeral deformity.9
Procedures that tip the balance of
the shoulder rotators toward exter-nal rotation, either by sacrificing in-
ternal rotator strength or augment-
ing external rotator power, will
inevitably weaken internal rotation
or diminish internal rotation range.
A loss of internal rotation was ob-
served with the arthroscopic ap-
proach, as well.10 As reported,
The ability to reach up the
back was not measured preop-
eratively, but it was clearly re-stricted at the time of follow-
up, with the children only able
to reach between the sacrum
and L5 on the average.10
Earlier reports in the literature de-
scribing results from other tech-
niques have not addressed the result-
ant loss of internal rotation
sufficiently to allow for meaningful
comparison. The recent report by
Waters and Bae,43 describing internal
rotation using the Mallet scale hand
to spine score, described a mean im-
provement from a pre-operative 1 toa postoperative 2 (the ability to
reach S1 postoperatively). From
these two reports, it appears that
both surgical approaches (arthro-
scopic and open capsulorraphy) re-
sult in the same amount of internal
rotation.10,43 It is not clear why this
was observed as a decrease in func-
tion in the arthroscopic study and an
increase following capsulorraphy,
but the difficulties in examining mo-
tor function in young children may
play a role. One may conclude from
the literature on the various tech-
niques of contracture release and
tendon transfer, as just discussed,
that procedures that do not release
the anterior capsule will less consis-
tently restore external rotation and
improve glenohumeral deformity
than those that target the jointcapsule. Accordingly, historic con-
cerns regarding release of the sub-
scapularis and the anterior capsule
must be tempered by the evidence
that not doing so will not release allcontractures and will leave behind
many posteriorly displaced, de-
formed glenohumeral joints without
the possibility of remodeling. The ar-
throscopic release allows for select
attention to the subscapularis and
anterior capsule in contrast to the
earlier open procedures that required
release of multiple superficial struc-
tures as well.
Rotational Osteotomy
For older children or those with ad-
vanced glenohumeral deformity, the
prevailing recommendation has been
to avoid soft-tissue procedures at the
joint in favor of rotational osteot-
omy of the humerus. The utility of
this procedure was confirmed in a re-
cent report by Waters and Bae.35
These authors reported on 27 pa-
A, Preoperative T2-weighted gradient-recalled echo MRI scan of a 4.7-year-old patient revealing mild pseudoglenoid. B, T2-weighted gradient-recalledecho MRI scan of the same patient 2 years after arthroscopic release and
latissimus dorsi transfer, demonstrating remodeling to a concentric joint witha round humeral head well centered on the glenohumeral joint. (Reproducedwith permission from Pearl ML, Edgerton BW, Kazimiroff PA, Burchette RJ,Wong K: Arthroscopic release and latissimus dorsi transfer for shoulderinternal rotation contractures and glenohumeral deformity secondary tobrachial plexus birth palsy. J Bone Joint Surg Am 2006;86:564-574.)
Figure 10
T2-weighted gradient-recalled echoMRI scan taken 3.5 years
postoperatively of a child who hada pseudoglenoid prior to extra-articular subscapularis slide at age2 years. The scan shows a roundhumeral head well centered on aconcave glenoid.
Figure 11
Shoulder Problems in Children With Brachial Plexus Birth Palsy
250 Journal of the American Academy of Orthopaedic Surgeons
-
7/29/2019 Lattisimus Dorsi
10/13
tients who underwent rotational os-
teotomy with plate fixation and
achieved an average improvement of
64 in external rotation and im-
proved 5 points on a modified Mal-
let scale. No clear guidelines exist,
however, as to what age or degree ofdeformity should dictate this form of
surgical treatment. As it is now evi-
dent that many children younger
than age 6 years are capable of sub-
stantial remodeling, the decision to
perform an osteotomy is all the more
complex. Humeral osteotomy does
improve the functional position of
the hand, but it leaves the shoulder
in a posteriorly dislocated position
and eliminates all hope of remodel-
ing. At present, the surgeon mustmake a judgment call regarding the
growth potential of the child, the se-
verity of the deformity, and her or
his own surgical abilities in deciding
to perform a soft-tissue procedure
that recenters the humeral head on
the glenoid fossa (Figure 12).
Other Problems
Poor Active Elevation
Weakness of elevation is functionally
limiting when active elevation is
-
7/29/2019 Lattisimus Dorsi
11/13
Scapular dyskinesia may exist even
when the internal rotation contrac-
ture is not severe enough to compel
surgical treatment. Although some
weakness of the rhomboid and serra-
tus anterior muscles may contribute
to this scapular dyskinesia, these
muscles are usually functional. The
asymmetric scapular motion more
likely relates to persistent stiffness of
the glenohumeral joint and learned
patterns of movement. As with a fro-
zen shoulder, the ROM in these neu-
rologically damaged shoulders is glo-
bally restricted. Tightness in the
superior structures such as the su-
praspinatus will result in an abduc-
tion contracture of the humerus rela-
tive to the scapula. In severe cases, as
the child lowers the arm to the side,
the scapula will elevate. With move-
ment, as the child tries to position
the hand in space,38,39 the scapula
will be carried along in an asymmet-
ric manner. This abnormal scapular
movement does not represent a mo-tor problem of the scapular muscles,
but is secondary to changes at the
glenohumeral joint in the most ex-
treme cases.
The acronym SHEAR has been
used to refer to the deformity of
scapular hypoplasia, elevation, and
rotation.45,46 Nath and colleagues45,46
postulate that this deformity is the
cause, not the result, of the ensuing
medial rotation contractures and gle-
nohumeral deformity. They offer a sur-
gical protocol aimed at correcting this
root cause. Although this approach
does focus interest on a perhaps ne-
glected concern of the parent or guard-
ian (ie, unusual scapular motion), its
theoretical premise conflicts with much
of our current understanding of the
pathophysiology affecting the shoulder
in brachial plexus birth palsy. Brachial
plexus lesions have much less effect on
the muscles that move the scapula (and
none on the trapezius and levator scap-ulae) than on the muscles that exter-
nally rotate the shoulder. It is incongru-
ous to attribute an internal (medial)
rotation contracture to aberrant scap-
ular motion when the more proximate
cause is readily evident.
External RotationContractures
External rotation contractures pre-
sent a smaller subset of the problems
encountered from birth palsy than
internal rotation contractures, with
14% reported by Zancolli and Zan-
colli.38 This contracture does not re-
sult in posterior displacement of the
glenohumeral joint or in significant
deformity, but it can be functionally
disabling. External rotation contrac-
ture may also occur iatrogenically
following release of internal rotation
contractures. Surgical intervention is
indicated when functional limita-
tions in personal care are severe and
the child has great difficulty reaching
the midline. Zancolli and Zancolli39
described surgical release and length-ening of the posterior-superior rota-
tor cuff for this contracture. Few
others have experience with this ap-
proach, and caution is advised before
further weakening important motors
of external rotation and elevation in
affected children. However, internal
rotational osteotomy of the humerus
has been effective in helping appro-
priately selected children both cos-
metically and functionally in terms
of their ability to reach the midlineto perform activities of personal
care.10,41
Summary
Traction injuries to the brachial
plexus during the birth process result
in residual orthopaedic problems
that most commonly affect the
shoulder. Although the role of micro-
surgical intervention has become
clearer and the techniques refined,
complete restoration of neuromuscu-
lar function remains elusive. For
motor weakness that follows the
neurologic injury, internal rotation
contractures most commonly occur
as a result of external rotation weak-
ness. This leads to deformity of the
glenohumeral joint (ie, glenohumeral
dysplasia, posterior humeral head
subluxation). As a result, secondary
orthopaedic evaluation and correc-
tive procedures are an integral part
of the treatment of these children.
Internal rotation contractures must
be managed aggressively to avert and
even correct deformity of the gleno-
humeral joint. A variety of surgical
approaches to restore balance be-
tween external rotation and internal
rotation power has demonstrated
Postoperative active elevation of140 (20 gain from thepreoperative state) 2 years afterarthroscopic release in the samechild as shown in Figures 1, 3, 4,and 9. Note the improved ability toreach, with improved externalrotation.
Figure 13
Shoulder Problems in Children With Brachial Plexus Birth Palsy
252 Journal of the American Academy of Orthopaedic Surgeons
-
7/29/2019 Lattisimus Dorsi
12/13
clinical success. Currently, clinical
studies do not definitively favor one
approach, but existing evidence sup-
ports early correction of the internal
rotation contracture and reduction
of the glenohumeral joint by open or
arthroscopic means, even if it re-quires release of the anterior capsule.
Surgeons who have experience with
both open and arthroscopic methods
usually find that the arthroscopic-
guided release allows for equal if not
greater contracture release, with re-
duced morbidity. Regardless of the
method used for anterior capsule re-
lease, most surgeons who treat bra-
chial plexus birth palsy favor supple-
menting the release with a transfer of
the latissimus dorsi tendon, whetherin all children or in children older
than age 3 years.
Consideration of any of the proce-
dures to improve shoulder function
should include a realistic assessment
of the childs ability to use the hand
and of the limitations at the elbow. A
nonfunctional hand is unlikely to be
more useful even when it can be
placed in a functional position. Simi-
larly, an elbow that cannot extend
because of a persistent flexion con-tracture or an absent triceps may im-
pede a childs reach to a far greater
extent than limitation of shoulder
motion.
References
Evidence-based Medicine: The refer-
ences in this article are level IV case se-
ries or case-control studies.
Citation numbers printed inbold typeindicate references published within the
past 5 years.
1. Chauhan SP, Rose CH, Gherman RB,Magann EF, Holland MW, Morrison JC:Brachial plexus injury: A 23-yearexperience from a tertiary center. Am JObstet Gynecol2005;192:1795-1800.
2. Hoeksma AF, Wolf H, Oei SL:Obstetrical brachial plexus injuries:Incidence, natural course and shoulder
contracture. Clin Rehabil2000;14:523-
526.
3. Hoeksma AF, Ter Steeg AM, Dijkstra P,Nelissen RG, Beelen A, de Jong BA:Shoulder contracture and osseousdeformity in obstetrical brachial plexusinjuries. J Bone Joint Surg Am 2003;85:316-322.
4. Bisinella GL, Birch R: Obstetric brachialplexus lesions: A study of 74 childrenregistered with the British PaediatricSurveillance Unit (March 1998-March1999). J Hand Surg [Br] 2003;28:40-45.
5. van der Sluijs JA, van Ouwerkerk WJ, deGast A, Wuisman PI, Nollet F, ManoliuRA: Deformities of the shoulder ininfants younger than 12 months with anobstetric lesion of the brachial plexus.
J Bone Joint Surg Br 2001;83:551-555.
6. Pearl ML, Edgerton BW: Glenoiddeformity secondary to brachial plexusbirth palsy. J Bone Joint Surg Am 1998;80:659-667.
7. Kozin SH: Correlation between externalrotation of the glenohumeral joint anddeformity after brachial plexus birthpalsy. J Pediatr Orthop 2004;24:189-193.
8. Pagnotta A, Haerle M, Gilbert A: Long-term results on abduction and externalrotation of the shoulder after latissimusdorsi transfer for sequelae of obstetricpalsy. Clin Orthop Relat Res 2004;426:199-205.
9. Waters PM, Bae DS: Effect of tendontransfers and extra-articular soft-tissuebalancing on glenohumeral developmentin brachial plexus birth palsy. J Bone
Joint Surg Am 2005;87:320-325.
10. Pearl ML, Edgerton BW, Kazimiroff PA,Burchette RJ, Wong K: Arthroscopicrelease and latissimus dorsi transfer forshoulder internal rotation contracturesand glenohumeral deformity secondaryto brachial plexus birth palsy. J Bone
Joint Surg Am 2006;88:564-574.
11. Curtis C, Stephens D, Clarke HM,Andrews D: The active movement scale:An evaluative tool for infants withobstetrical brachial plexus palsy. J HandSurg [Am] 2002;27:470-478.
12. Bae DS, Waters PM, Zurakowski D:Reliability of three classification systems
measuring active motion in brachialplexus birth palsy. J Bone Joint Surg Am2003;85:1733-1738.
13. Saifuddin A, Heffernan G, Birch R:Ultrasound diagnosis of shouldercongruity in chronic obstetric brachialplexus palsy. J Bone Joint Surg Br 2002;84:100-103.
14. Moukoko D, Ezaki M, Wilkes D, CarterP: Posterior shoulder dislocation ininfants with neonatal brachial plexuspalsy. J Bone Joint Surg Am 2004;86:
787-793.
15. Pyhi TH, Nietosvaara YA, Remes VM,
Kirjavainen MO, Peltonen JI, Lamminen
AE: MRI of rotator cuff muscle atrophy
in relation to glenohumeral joint
incongruence in brachial plexus birth
injury. Pediatr Radiol2005;35:402-409.
16. Pearl ML, Edgerton BW, Kon DS, et al:Comparison of arthroscopic findings
with magnetic resonance imaging and
arthrography in children with
glenohumeral deformities secondary to
brachial plexus birth palsy. J Bone Joint
Surg Am 2003;85:890-898.
17. van der Sluijs JA, van Ouwerkerk WJ,Manoliu RA, Wuisman PI: Secondarydeformities of the shoulder in infantswith an obstetrical brachial plexuslesions considered for neurosurgicaltreatment. Neurosurg Focus 2004;16:E9.
18. van der Sluijs JA, van Ouwerkerk WJ, deGast A, Wuisman P, Nollet F, ManoliuRA: Retroversion of the humeral head inchildren with an obstetric brachialplexus lesion. J Bone Joint Surg Br 2002;84:583-587.
19. van der Sluijs JA, van der Meij M,Verbeke J, Manoliu RA, Wuisman PI:Measuring secondary deformities of theshoulder in children with obstetricbrachial plexus lesion: Reliability ofthree methods. J Pediatr Orthop B 2003;12:211-214.
20. Hui JH, Torode IP: Changing glenoidversion after open reduction of shouldersin children with obstetric brachial plexuspalsy. J Pediatr Orthop 2003;23:109-113.
21. Kon DS, Darakjian AB, Pearl ML, KoscoAE: Glenohumeral deformity in childrenwith internal rotation contracturessecondary to brachial plexus birth palsy:Intraoperative arthrographicclassification. Radiology 2004;231:791-795.
22. Chuang DC, Mardini S, Ma HS: Surgicalstrategy for infant obstetrical brachialplexus palsy: Experiences at Chang GungMemorial Hospital. Plast Reconstr Surg2005;116:132-142.
23. Noaman HH, Shiha AE, Bahm J:Oberlins ulnar nerve transfer to thebiceps motor nerve in obstetric brachial
plexus palsy: Indications, and good andbad results. Microsurgery 2004;24:182-187.
24. Smith NC, Rowan P, Benson LJ, EzakiM, Carter PR: Neonatal brachial plexuspalsy: Outcome of absent biceps functionat three months of age. J Bone Joint SurgAm 2004;86:2163-2170.
25. DiTaranto P, Campagna L, Price AE,Grossman JA: Outcome followingnonoperative treatment of brachialplexus birth injuries. J Child Neurol
Michael L. Pearl, MD
April 2009, Vol 17, No 4 253
-
7/29/2019 Lattisimus Dorsi
13/13
2004;19:87-90.
26. Waters PM: Comparison of the naturalhistory, the outcome of microsurgicalrepair, and the outcome of operativereconstruction in brachial plexus birthpalsy. J Bone Joint Surg Am 1999;81:649-659.
27. Nehme A, Kany J, Sales-De-Gauzy J,Charlet JP, Dautel G, Cahuzac JP:Obstetrical brachial plexus palsy:Prediction of outcome in upper rootinjuries. J Hand Surg [Br] 2002;27:9-12.
28. Kirkos JM, Kyrkos MJ, Kapetanos GA,Haritidis JH: Brachial plexus palsysecondary to birth injuries. J Bone JointSurg Br 2005;87:231-235.
29. Hoffer MM, Wickenden R, Roper B:Brachial plexus birth palsies: Results oftendon transfers to rotator cuff. J Bone
Joint Surg Am 1978;60:691-695.
30. Hoffer MM, Phipps GJ: Closedreduction and tendon transfer fortreatment of dislocation of theglenohumeral joint secondary to brachialplexus birth palsy. J Bone Joint Surg Am1998;80:997-1001.
31. Carlioz H, Brahimi L: Place of internaldisinsertion of the subscapularis musclein the treatment of obstetric paralysis ofthe upper limb in children [French]. AnnChir Infant1971;12:159-167.
32. Gilbert A, Brockman R, Carlioz H:Surgical treatment of brachial plexusbirth palsy. Clin Orthop Relat Res 1991;264:39-47.
33. Pearl ML: Arthroscopic release ofshoulder contracture secondary to birthpalsy: An early report on findings andsurgical technique. Arthroscopy 2003;19:577-582.
34. Pedowitz DI, Gibson B, Williams GR,Kozin SH: Arthroscopic treatment ofposterior glenohumeral joint subluxationresulting from brachial plexus birthpalsy. J Shoulder Elbow Surg2007;16:6-13.
35. Waters PM, Bae DS: The effect ofderotational humeral osteotomy on
global shoulder function in brachialplexus birth palsy. J Bone Joint Surg Am2006;88:1035-1042.
36. Fairbank HAT: Birth palsy: Subluxationof the shoulder joint in infants andyoung children. Lancet 1913;1:217-223.
37. Sever JW: Obstetrical paralysis. SurgObstet Gynecol1927;44:547-549.
38. Zancolli EA, Zancolli ER Jr: Palliativesurgical procedures in sequelae ofobstetric palsy. Hand Clin 1988;4:643-669.
39. Zancolli EA, Zancolli ER III: Recon-structive surgery in brachial plexus se-quelae, in Gupta A, Kay SPJ, Scheker LR(eds): The Growing Hand. London, En-gland: Mosby 2000, pp 805-823.
40. van der Sluijs JA, van Ouwerkerk WJ, deGast A, Nollet F, Winters H, WuismanPI: Treatment of internal rotationcontracture of the shoulder in obstetricbrachial plexus lesions by subscapulartendon lengthening and open reduction:Early results and complications. J PediatrOrthop B 2004;13:218-224.
41. Kambhampati SB, Birch R, Cobiella C,Chen L: Posterior subluxation anddislocation of the shoulder in obstetricbrachial plexus palsy. J Bone Joint SurgBr 2006;88:213-219.
42. Kozin SH, Chafetz RS, Barus D, FiliponeL: Magnetic resonance imaging andclinical findings before and after tendon
transfers about the shoulder in childrenwith residual brachial plexus birth palsy.J Shoulder Elbow Surg 2006;15:554-561.
43. Waters PM, Bae DS: The early effects oftendon transfers and opencapsulorrhaphy on glenohumeraldeformity in brachial plexus birth palsy.
J Bone Joint Surg Am 2008;90:2171-2179.
44. Nath RK, Paizi M: Improvement inabduction of the shoulder afterreconstructive soft-tissue procedures inobstetric brachial plexus palsy. J Bone
Joint Surg Br 2007;89:620-626.
45. Nath RK, Melcher SE, Paizi M: Surgicalcorrection of unsuccessful derotationalhumeral osteotomy in obstetric brachialplexus palsy: Evidence of the significanceof scapular deformity in thepathophysiology of the medial rotationcontracture. J Brachial Plex PeripherNerve Inj 2006;1:9.
46. Nath RK, Paizi M: Scapular deformity inobstetric brachial plexus palsy: A newfinding. Surg Radiol Anat2007;29:133-140.
Shoulder Problems in Children With Brachial Plexus Birth Palsy
254 Journal of the American Academy of Orthopaedic Surgeons