Development of the glenohumeral joint after subscapular release and open relocation in children with brachial plexus birth palsy: long-term results in 61 patients.

BACKGROUND: We present the long-term results of remodeling of the glenohumeral joint after open subscapularis elongation and relocation of the humeral head in patients with an internal rotation contracture and joint incongruity due to brachial plexus birth palsy. METHODS: In this before-and-after study, 61 patients who underwent open subscapularis elongation and reduction of the glenohumeral joint were evaluated with respect to joint remodeling, with a mean follow-up period of 10.2 years (range, 7-16 years). The mean age at operation was 3.2 years (range, 8 months to 15 years). Measurements of the percentage of the humeral head anterior to the midscapular line (PHHA), glenoid version, and diameter of the humeral head were recorded using magnetic resonance imaging, comparing the affected joints preoperatively vs. postoperatively (n = 31) and comparing the operated vs. unaffected sides postoperatively (n = 61). RESULTS: The mean increase in PHHA was 27.6 percentage points (95% confidence interval, 22.4-32.7 percentage points; P < .01), from 13.2% to 40.8%. The glenoid retroversion changed by 14.8° (95% confidence interval, 11.1°-18.4°; P < .01), from 25.4° to 10.6°, approaching a normal value. All patients, even those older than 5 years, showed a clear benefit from surgery. CONCLUSIONS: Our study confirms that open subscapularis lengthening with joint repositioning, up to the age of 5 years, gives consistent remodeling of incongruent shoulders with surprisingly small differences between the operated and unaffected shoulders at long-term follow-up. The findings indicate that open reduction is useful also in adolescents and challenges the notion that older children should be treated with derotational humeral osteotomy.

Pediatric and adolescent anterior shoulder instability: clinical management of first-time dislocators.

PURPOSE OF REVIEW: The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and clinical management of pediatric and adolescent patients following a first-time shoulder dislocation. RECENT FINDINGS: Shoulder instability is becoming increasingly common as pediatric and adolescent patients engage in earlier organized sports competition. Recommended treatment following a first-time glenohumeral dislocation event in adolescents depends on several factors, but surgical stabilization is becoming more frequently performed. Surgical indications include bony Bankart lesion, ALPSA lesion, bipolar injury (e.g. Hill-Sachs humeral head depression fracture) or off-season injury in an overhead or throwing athlete. Complications following surgical treatment are rare but most commonly are associated with recurrent instability. Young children (eg. open proximal humerus growth plate), individuals averse to surgery, or in-season athletes who accept the risk of redislocation may complete an accelerated rehabilitation program for expedited return to play in the absence of the structural abnormalities listed above. SUMMARY: Following a first-time dislocation event in pediatric and adolescent patients, a detailed discussion of the risks and benefits of nonoperative versus operative management is critical to match the recommended treatment with the patient's injury pattern, risk factors, and activity goals.

Recovery potential after postnatal shoulder paralysis. An animal model of neonatal brachial plexus palsy.

BACKGROUND: Injury to the brachial plexus during birth results in paralysis of the upper extremity in as many as one in 250 births and can lead to substantial functional deficits in the shoulder. The goal of this study was to characterize the development of bone and joint deformities in paralyzed neonatal shoulders and to assess the improvement of these deformities after muscle function recovery with use of an animal model. METHODS: Intramuscular injections of botulinum toxin were used to paralyze the supraspinatus, infraspinatus, and posterior deltoid of the left shoulders of mice at birth. Seventy mice were divided into three groups: Botox, recovery, and normal. The twenty-five mice in the Botox group received botulinum toxin injections until they were killed. The twenty mice in the recovery group received botulinum toxin injections for different durations and then were allowed injection-free recovery periods until they were killed. The twenty-five mice in the normal group received saline solution injections until they were killed. Radiographs were used to measure shoulder and elbow contractures. Microcomputed tomography was used to examine anatomical parameters of the supraspinatus muscle, humerus, and scapula. RESULTS: The Botox group showed bone and joint deformities including delayed mineralization and flattening of the humeral head, hypoplasia, and introversion (i.e., anteversion) of the humerus, contractures of the shoulder and elbow, hypoplasia of shoulder muscles, hypoplasia of the scapula, and hypoplasia and retroversion of the glenoid. In the recovery group, a significant trend toward normal properties was observed with longer recovery periods (p<0.05). However, only soft-tissue contractures of the shoulder and elbow were resolved completely with the longest recovery period. CONCLUSIONS: This mouse model successfully simulates human neonatal brachial plexus palsy, reproducing most of the bone and joint deformities found in the human condition. The deformities started to develop early in the postnatal period in the paralyzed shoulders and progressed with longer durations of paralysis. Early restoration of muscle function completely resolved the soft-tissue contractures of the shoulder and elbow. However, osseous deformities of the humerus and scapula were never resolved completely. These findings demonstrate the time-dependence of reversibility of musculoskeletal deformities in developing shoulders with neurological deficits.

Evaluation of shoulder balance in the normal adolescent population and its correlation with radiological parameters.

A descriptive clinical study in healthy adolescents was done to evaluate the clinical shoulder balance and analyze the correlation between clinical and radiological parameters which are currently used to evaluate shoulder balance. In addition to trunk shift and rib hump, shoulder balance is one of the criteria that are used to evaluate the outcomes in spinal deformity surgery. Several methods have been proposed to evaluate the shoulder balance in scoliotic patients; however, there is no uniformity to these methods in the current literature. Patients who applied to pediatric clinic without musculoskeletal pathology formed the patient population. Volunteers were asked to fill out a questionnaire assessing shoulder balance perception and had their clinical photograph taken simultaneously with a P-A chest X-ray. The clinical shoulder balance was evaluated through analysis of the clinical photograph. The X-rays were used to evaluate the radiological shoulder balance. The evaluated parameters included coracoid height difference (CHD), clavicular angle (CA), the clavicle-rib cage intersection difference (CRID), clavicular tilt angle difference (CTAD), and T1-tilt. The study group was composed of 48 male and 43 female patients with an average age of 13.6 +/- 2.1 (10-18) years. In the questionnaire, all patients stated that their shoulders were level. The digital photographs revealed that only 17(18.7%) adolescents had absolutely level shoulders. The average height difference between shoulders was 7.5 +/- 5.8 mm. The average CHD was 6.9 +/- 5.8 mm, average CA was 2.2 +/- 1.7 degrees , average CRID was 4.8 +/- 3.6 mm, average CTAD was 4 +/- 3.2 degrees , and average T1-tilt was 1.3 +/- 1.4 degrees . CHD, CA, and CRID demonstrated high correlation with clinical pictures, whereas CTAD demonstrated moderate and T1-tilt demonstrated only mild correlation. The radiological parameters used to evaluate the shoulder balance correlate with the clinical appearance. Contrary to popular belief, shoulder balance in healthy adolescents often does not exist.

Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy.

BACKGROUND: Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint deformity in patients with brachial plexus birth palsy. The objective of this investigation was to determine the effects of correction of external rotation weakness and internal rotation contractures with tendon transfers and extra-articular soft-tissue releases on glenohumeral development in patients with brachial plexus birth palsy. METHODS: Twenty-five patients with brachial plexus birth palsy who underwent latissimus dorsi and teres major tendon transfers to the rotator cuff-with or without concomitant musculotendinous lengthenings-were evaluated clinically and radiographically before the operation and at a minimum of two years (average, forty-three months) postoperatively. Shoulder function was prospectively assessed with use of the modified Mallet classification system, in which aggregate shoulder function is assigned a score of 5 to 25 points. Glenoid version and humeral head subluxation were quantified with magnetic resonance imaging or computed tomography, and glenohumeral deformity was graded. RESULTS: Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 13 points preoperatively to 18 points postoperatively (p < 0.01). As seen radiographically, the mean glenoid retroversion improved from 22 degrees preoperatively to 16.5 degrees postoperatively (p = 0.012). The mean posterior humeral head subluxation improved from 30% to 37% (p = 0.03). No patient had progressive worsening of the glenohumeral deformity. CONCLUSIONS: Latissimus dorsi and teres major tendon transfers to the rotator cuff, combined with appropriate extraarticular musculotendinous lengthenings, significantly improved global shoulder function but led to only modest improvements in glenoid retroversion and humeral head subluxation. No profound glenohumeral remodeling occurs after these extra-articular rebalancing procedures, even when they are performed in patients of a young age. While the long-term clinical and radiographically apparent effects at skeletal maturity are uncertain, soft-tissue rebalancing procedures alone were found to have halted the progression of, but not to have markedly decreased, glenohumeral dysplasia at the time of a two to five-year follow-up.

The development of humeral head retroversion.

Humeral head retroversion is important in a variety of clinical situations, but it is not known when retroversion actually develops to adult values. In utero and at birth, the humeral head is known to be in marked retroversion. It derotates sometime thereafter to assume the more standard value with which orthopedic surgeons are familiar. By studying a unique collection of children's bones (180 humeri), I have been able to determine that the greater part of this process takes place, on average, by the age of 8 years (SD +/- 2.12 years); from then on, however, the development continues more slowly until the final adult dimensions are reached, as heralded by the appearance of the radial groove at approximately 16 years of age. This process, along with its timing, appears to be similar, but opposite in direction to, the derotation process that is known to take place in the hip. It has not previously been documented in the shoulder.

The shoulder and elbow in Apert's syndrome.

Nine children with Apert's syndrome were studied and found to have progressive bony dysplasia in the shoulder and elbow. The children showed loss of joint motion and radiographic abnormalities including subluxation and flattening of the humeral head with irregularities of the glenoid. The elbow showed flattening and subluxation of the radial head in radiographs and a positive click on physical examination. The limitation of motion and the presence of bony defects were progressive, suggesting that Apert's syndrome is a progressive generalized dysplasia.