Clinical outcome of shoulder muscle transfer for shoulder deformities in obstetric brachial plexus palsy: A study of 150 cases.
ABSTRACT: BACKGROUND:Residual muscle weakness, cross-innervation (caused by misdirected regenerating axons), and muscular imbalance are the main causes of internal rotation contractures leading to limitation of shoulder joint movement, glenoid dysplasia, and deformity in obstetric brachial plexus palsy. Muscle transfers and release of antagonistic muscles improve range of motion as well as halt or reverse the deterioration in the bony architecture of the shoulder joint. The aim of our study was to evaluate the clinical outcome of shoulder muscle transfer for shoulder abnormalities in obstetric brachial plexus palsy. MATERIALS AND METHODS:One hundred and fifty patients of obstetric brachial plexus palsy with shoulder deformity underwent shoulder muscle transfer along with anterior shoulder release at our institutions from 1999 to 2007. Shoulder function was assessed both preoperatively and postoperatively using aggregate modified Mallet score and active and passive range of motion. The mean duration of follow-up was 4 years (2.5-8 years). RESULTS:The mean preoperative abduction was 45° ± 7.12, mean passive external rotation was 10° ± 6.79, the mean active external rotation was 0°, and the mean aggregate modified Mallet score was 11.2 ± 1.41. At a mean follow-up of 4 years (2.5-8 years), the mean active abduction was 120° ± 18.01, the mean passive external rotation was 80° ± 10.26, while the mean active external rotation was 45° ± 3.84. The mean aggregate modified Mallet score was 19.2 ± 1.66. CONCLUSIONS:This procedure can thus be seen as a very effective tool to treat internal rotation and adduction contractures, achieve functional active abduction and external rotation, as well as possibly prevent glenohumeral dysplasia, though the long-term effects of this procedure may still have to be studied in detail clinico-radiologically to confirm this hypothesis. LEVEL OF EVIDENCE:Therapeutic level IV.
Project description:BACKGROUND: Obstetric palsy is the injury of the brachial plexus during delivery. Although many infants with plexopathy recover with minor or no residual functional deficits, some children don't regain sufficient limb function because of functional limitations, bony deformities and joint contractures. Shoulder is the most frequently affected joint with internal rotation contracture causing limitation of abduction, external rotation. The treatment comprises muscle release procedures such as posterior subscapularis sliding or anterior subscapularis tendon lengthening and muscle transfers to restore the missing external rotation and abduction function. METHODS: We evaluated whether the preoperative abduction degree affects functional outcome. Between 1998 and 2002, 46 children were operated on to restore shoulder abduction and external rotation. The average age at surgery was 7.6 years and average follow up was 40.8 months. We compared the postoperative results of the patients who had preoperative abduction less than 90 degrees (Group I: n = 37) with the patients who had preoperative abduction greater than 90 degrees (Group II: n = 9), in terms of abduction and external rotation function with angle measurements and Mallet classification. We inquired whether patients in Group I needed another muscle transfer along with latissimus dorsi and teres major transfers. RESULTS: In Group I the average abduction improved from 62.5 degrees to 131.4 degrees (a 68.9 degrees +/- 22.9 degrees gain) and the average external rotation improved from 21.4 degrees to 82.6 degrees (a 61.1 degrees +/- 23 degrees gain). In Group II the average abduction improved from 99.4 degrees to 140 degrees (a 40.5 degrees +/- 16 degrees gain) and the average external rotation improved from 33.2 degrees to 82.7 degrees (a 49.5 degrees +/- 23.9 degrees gain). Although there was a significant difference between Group I and II for preoperative abduction (p = 0.000) and abduction gain in degrees (p = 0.001), the difference between postoperative values of both groups was not significant (p = 0.268). There was also no significant difference between the two groups in the preoperative external rotation, the external rotation gain and the postoperative external rotation (p = 0.163, p = 0.181 and p = 0.803, respectively). CONCLUSIONS: Obstetric palsy patients with shoulder sequela who had a preoperative abduction less than 90 degrees hadas good functional results using latissimus dorsi, teres major muscle transfer and subscapularis muscle release as the patients who hada preoperative abduction greater than 90 degrees.
Project description:BACKGROUND: The surgical management of obstetrical brachial plexus palsy can generally be divided into two groups; early reconstructions in which the plexus or affected nerves are addressed and late or palliative reconstructions in which the residual deformities are addressed. Tendon transfers are the mainstay of palliative surgery. Occasionally, surgeons are required to utilise already denervated and subsequently reinnervated muscles as motors. This study aimed to compare the outcomes of tendon transfers for residual shoulder dysfunction in patients who had undergone early nerve surgery to the outcomes in patients who had not. METHODS: A total of 91 patients with obstetric paralysis-related shoulder abduction and external rotation deficits who underwent a modified Hoffer transfer of the latissimus dorsi/teres major to the greater tubercle of the humerus tendon between 2002 and 2009 were retrospectively analysed. The patients who had undergone neural surgery during infancy were compared to those who had not in terms of their preoperative and postoperative shoulder abduction and external rotation active ranges of motion. RESULTS: In the early surgery groups, only the postoperative external rotation angles showed statistically significant differences (25 degrees and 75 degrees for total and upper type palsies, respectively). Within the palliative surgery-only groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. The significant differences between the early surgery groups and the palliative surgery groups with total palsy during the preoperative period diminished postoperatively (p < 0.05 and p > 0.05, respectively) for abduction but not for external rotation. Within the upper type palsy groups, there were no significant differences between the preoperative and postoperative abduction and external rotation angles. CONCLUSIONS: In this study, it was found that in patients with total paralysis, satisfactory shoulder abduction values can be achieved with tendon transfers regardless of a previous history of neural surgery even if the preoperative values differ.
Project description:A recent review by the International Federation of Societies for Surgery of the Hand showed no studies comparing the results of nerve grafting to distal nerve transfer for primary reconstruction of the brachial plexus in infants with obstetric brachial plexus palsy (OBBP). The aim of this retrospective study is to compare two surgical reconstructive strategies in primary reconstruction of the brachial plexus in extended Erb's obstetric palsy with double root avulsion: one with and one without distal nerve transfer for elbow flexion.Two groups of infants with extended Erb's palsy and double root avulsion were included in the study. Group I (n = 29) underwent reconstruction of the brachial plexus without distal nerve transfer. In group II (n = 26), the reconstruction included a distal nerve transfer for elbow flexion.Both groups had an excellent (over 96%) satisfactory outcome for elbow flexion. Group II has a significantly better outcome (P < 0.05) of shoulder abduction and wrist extension than group I.The use of a distant nerve transfer for bicep reconstruction in extended Erb's obstetric palsy with double root avulsion gives a better outcome for shoulder abduction and wrist extension; and this seems to be related to the availability of more cable grafts to reconstruct the posterior division of the upper trunk and the middle trunk. Level of Evidence: Level III, therapeutic study.
Project description:The outcome of primary brachial plexus reconstruction in extended Erb's obstetric palsy with single root avulsion has not been specifically documented in the literature.A series of 46 consecutive cases of extended Erb's obstetric palsy with single root avulsion was retrospectively reviewed. The upper and middle trunks were reconstructed with nerve grafts from the available two roots. No nerve transfers were used. The percentage of a satisfactory motor recovery was documented.The postoperative motor recovery was excellent (over 97%) satisfactory outcome for elbow flexion, elbow extension, and digital extension. A satisfactory wrist extension was noted in 84.8% of children. The lowest rates of satisfactory outcomes were for shoulder external rotation (65.2%) and shoulder abduction (56.5%).In extended Erb's obstetric palsy with single root avulsion, two ruptured roots are available for intraplexus neurotization of the upper and middle trunks. The surgeon gives a priority to elbow flexion and this is translated in an excellent outcome for elbow flexion. The triceps and digital extensors get a major contribution form the unaffected C8 root, and this is also translated in an excellent outcome for these two functions. Fewer cable grafts are available for reconstruction of the posterior division of upper trunk and the middle trunk, resulting in a lower rate of satisfactory outcomes at the shoulder for wrist extension. Level of Evidence: Level IV, therapeutic study.
Project description:While most obstetric brachial plexus palsy patients recover arm and hand function, the residual nerve weakness leads to muscle imbalances about the shoulder which may cause bony deformities. In this paper we describe abnormalities in the developing scapula and the glenohumeral joint. We introduce a classification for the deformity which we term Scapular Hypoplasia, Elevation and Rotation. Multiple anatomic parameters were measured in bilateral CT images and three-dimensional CT reconstruction of the shoulder girdle of 30 obstetric brachial plexus palsy patients (age range 10 months-10.6 years). The affected scapulae were found to be hypoplastic by an average of 14% while the ratio of the height to the width of the body of scapula (excluding acromion) were not significantly changed, the acromion was significantly elongated by an average of 19%. These parameters as well as subluxation of the humeral head (average 14%) and downward rotation in the scapular plane were found to correlate with the area of scapula visible over the clavicle. This finding provides a classification tool for diagnosis and objective evaluation of the bony deformity and its severity in obstetric brachial plexus palsy patients.
Project description:The purpose of this study was to evaluate shoulder function following minimally invasive subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release in children with Erb's palsy.A prospective study was conducted on 15 consecutive children who underwent subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release to treat internal rotation contracture of the shoulder joint after Erb's palsy. Age at surgery ranged from 24 to 38 months (average 28.3) (2.4 years). All of the patients were assessed clinically and radiologically preoperatively and postoperatively at regular intervals. The Mallet scoring system was used to analyze the results.The mean external rotation improved from -24° to +46° (p = 0.001) at the last follow-up. Active internal rotation was preserved in all cases. At the final follow-up, there had been no loss of the external rotation gained and no recurrence of internal rotation contracture of the shoulder, and the mean Mallet score (total) had improved from 11 to 17 points (p = 0.001).In children aged from 1 to 3 years, an arthroscopic release procedure alone may successfully restore function and yield a centered glenohumeral joint, which has a beneficial effect on glenoid remodeling.Level IV.
Project description:We describe the clinical outcome of a novel nerve transfer to restore active shoulder motion in upper brachial plexus injury. The thoracodorsal nerve (TDN) was successfully used as a vascularized donor nerve to neurotize to the suprascapular nerve (SSN) in a patient with limited donor nerve availability. At 4?years follow-up, he had regained useful external rotation of the injured limb, with no significant donor site morbidity. Shoulder abduction return was less impressive, however, and reasons for this are discussed. We provide a comprehensive review of the literature on this topic and a subsequent discussion on the details of this novel technique. This is the first reported case of TDN to SSN transfer, and also the first reported case of a vascularized TDN transfer in the English language literature. We advocate direct thoracodorsal to SSN transfer as a valid surgical option for the restoration of shoulder function in patients with partial brachial plexus avulsion, when conventional nerve donors are unavailable.
Project description:BACKGROUND: The superiority of a single stage combined anterior (first) posterior (second) approach and end-to-side side-to-side grafting neurorrhaphy in direct cord implantation was investigated as to providing adequate exposure to both the cervical cord and the brachial plexus, as to causing less tissue damage and as to being more extensible than current surgical approaches. METHODS: The front and back of the neck, the front and back of the chest up to the midline and the whole affected upper limb were sterilized while the patient was in the lateral position; the patient was next turned into the supine position, the plexus explored anteriorly and the grafts were placed; the patient was then turned again into the lateral position, and a posterior cervical laminectomy was done. The grafts were retrieved posteriorly and side grafted to the anterior cord. Using this approach, 5 patients suffering from complete traumatic brachial plexus palsy, 4 adults and 1 obstetric case were operated upon and followed up for 2 years. 2 were C5,6 ruptures and C7,8T1 avulsions. 3 were C5,6,7,8T1 avulsions. C5,6 ruptures were grafted and all avulsions were cord implanted. RESULTS: Surgery in complete avulsions led to Grade 4 improvement in shoulder abduction/flexion and elbow flexion. Cocontractions occurred between the lateral deltoid and biceps on active shoulder abduction. No cocontractions occurred after surgery in C5,6 ruptures and C7,8T1 avulsions, muscle power improvement extended into the forearm and hand; pain disappeared. LIMITATIONS INCLUDE: spontaneous recovery despite MRI appearance of avulsions, fallacies in determining intraoperative avulsions (wrong diagnosis, wrong level); small sample size; no controls rule out superiority of this technique versus other direct cord reimplantation techniques or other neurotization procedures; intra- and interobserver variability in testing muscle power and cocontractions. CONCLUSION: Through providing proper exposure to the brachial plexus and to the cervical cord, the single stage combined anterior (first) and posterior (second) approach might stimulate brachial plexus surgeons to go more for direct cord implantation. In this study, it allowed for placing side grafts along an extensive donor recipient area by end-to-side, side-to-side grafting neurorrhaphy and thus improved results. LEVEL OF EVIDENCE: Level IV, prospective case series.
Project description:Injuries causing fracture dislocation of shoulder and brachial plexus palsy are extremely rare. As per authors' knowledge, three part fracture of proximal humerus with shoulder dislocation and brachial plexus palsy has not been reported in the literature.A 53 year old female sustained a three part fracture of right proximal humerus along with dislocation of shoulder joint and brachial plexus palsy following a fall from a flight of stairs. Fracture was managed by plating of proximal humerus and brachial palsy was followed up with electrodiagnostic studies and regular physiotherapy. Fracture united by three months and patient had near complete recovery of brachial palsy. Authors have discussed diagnostic modalities and management options in the article.Clinician should always look for clinical evidence of brachial plexus injury in patients with anterior shoulder dislocation. Signs of nerve injury with shoulder fracture dislocation are easily overlooked or incorrectly attributed to pain due to bony injury. Subsequent loss of shoulder function in elderly is often thought to be due to immobilization and stiffness. Clinical suspicion can help in diagnosing the often missed neurological injuries and can help in improving outcomes.
Project description:OBJECTIVE: High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis. CLINICAL PRESENTATION: A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department. INTERVENTION: Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion. CONCLUSION: Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.