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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


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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


April 2009, Vol 17, No 4 243


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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



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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 (


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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




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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


April 2009, Vol 17, No 4 247


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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




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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


April 2009, Vol 17, No 4 249


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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




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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


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




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.

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