Clinical Diagnosis of the Infantile Shoulder Subluxation in Residual Brachial Plexus Birth Injury and Its Correlation With Ultrasound Diagnosis.

INTRODUCTION AND AIMS OF STUDY: Timely detection of shoulder subluxation in infants with brachial plexus birth injury (BPBI) is essential to prevent the progression of glenohumeral deformity. Shoulder ultrasonography (USG) is routinely used to detect an infantile subluxation/dislocation, but its use is limited because of the paucity of expert radiologists in developing countries. The aim of this study was to determine the clinical examination predictors to determine shoulder subluxation in patients with BPBI correlating with ultrasound confirmation. METHODS: We prospectively studied children who presented to our hospital between 2017 and 2021 diagnosed as brachial plexus birth injury. In patients developing internal rotation contracture of the shoulder, we looked for 3 standard clinical signs: reduced passive external rotation <60 degrees, deep anterior crease (DAC) and relatively short arm segment. Shoulder subluxation was defined as USG measurement of alpha angle>30 degrees and ossific nuclei of the humerus lying behind the dorsal scapular line. Sensitivity and specificity were used to assess their efficacy in clinical diagnosis of shoulder subluxation in different groups. The predicted probability of shoulder subluxation from each prediction rule was compared with actual distributions based on USG confirmation. RESULTS: Of the 58 BPBI infants who developed PER<60 degrees at the shoulder, 41 had USG confirmed shoulder subluxation. The 2 independent predictors of shoulder subluxation (PER<45 degrees and DAC) were identified in the current patient population based on data analysis. The presence of short arm segment is a very specific marker of shoulder subluxation but not sensitive. The predicted probability of shoulder subluxation from the prediction rule combining all the 3 markers were similar to the actual distributions in the current patient population. CONCLUSIONS: PER<45 degrees and presence of deep anterior crease are clinical markers indicating shoulder dislocation in patients with BPBI developing reduced external rotation at the shoulder. On the basis of the proposed clinical diagnosis algorithm, the above markers along with the selective use of USG can help in early detection and treatment of infantile shoulder dislocation.

Minimally Invasive Subscapularis Release: A Novel Technique and Results.

BACKGROUND: Shoulder imbalance secondary to residual brachial plexus birth palsy requires release of internal rotation contracture and tendon transfer. Subscapularis is considered as the prime element of internal rotation contracture and various methods have been described for subscapularis lengthening. It includes open subscapularis slide or lengthening and arthroscopic release. We hypothesized that subscapularis can be released through minimally invasive approach from the medial border of scapula and thus avoiding formal open procedures and risk of weakening the internal rotation strength. METHODS: Safety zones to avoid injury to important neurovascular structures while performing minimally invasive subscapularis release (MISR) were determined through cadaveric dissection. Between 2014 and 2016, 45 patients underwent MISR. A concomitant conjoined Latissimus Dorsi and Teres Major transfer was performed. Twenty patients with minimum 2-year follow-up were included in this study. Average age of patients was 6.4 years. A 5-point modified Mallet Score, degrees of active and passive rotations and abduction were used as outcome measures. Axial MRI imaging were available to classify the gleno-humeral deformity. RESULTS: Mean improvement in passive external rotation was 80 degrees and in active external rotation was 43 degrees (P <0.001) at 3 months, which was maintained at final follow-up. Average shoulder abduction improved from preoperative-101 degrees to postoperative-142 degrees. Aggregate 5-point Mallet Score improved from 12.8 points (range, 11 to 16) preoperatively to 18.5 points (range, 16 to 21) postoperatively. None of the patients developed external rotation contracture. The results were comparable with other existing techniques of subscapularis release with conjoint tendon transfer. CONCLUSIONS: MISR with conjoined tendon transfer is an effective way of treating internal rotation contracture in children with congruent glenohumeral joints. This procedure has shown beneficial outcomes even in patients with noncongruous glenohumeral joints, when performed in children younger than 4 years. Advantages of MISR include less risk to neurovascular structures, minimal soft tissue trauma, directly addressing the medial tight subscapularis fibers, significantly less surgical time and minimum learning curve. LEVELS OF EVIDENCE: Level III-retrospective comparative study.

Duplication of hemi mandible and oral cavity, presentation of an adult patient--a case report.

We are present a case of duplication of hemi mandible and oral cavity in an adult patient. This is a very rare condition and each and every case warrants publication. This patient is unique in that she would not have presented for surgery if she was married. She presented at 30 years of age. The patient underwent radiological investigations using CAT scan, orthopantogram and routine X-ray films. She was operated on with an elliptical incision around the swelling, excising the whole of the duplicated mandible along with other associated structures such as a salivary gland and the branchial cyst present along with it. Postoperatively the patient had mild marginal mandibular weakness which recovered with time.