Pectoralis Major Release to Improve Shoulder Abduction in Children With Cerebral Palsy

Author(s): Domzalski M, Muharrem I, Littleton A, Miller F

Source:  J Pediatr Orthop 2007; 27:457-461.

Summary:

Summary:   Cerebral Palsy represents a wide spectrum of presentation with varied degrees of spasticity and contracture.  Muscle contractures about the shoulder are commonly found in patients with cerebral palsy, but the literature is scant regarding treatment.  Many children present with a dynamic deformity that becomes fixed over time.  This study evaluates surgical results to improve shoulder abduction in a relatively small cohort of children with cerebral palsy.

Twenty-one shoulders in 13 patients underwent pectoralis major release to improve shoulder abduction.  Additional soft tissue releases about the shoulder were performed according to the patient’s examination and primarily consisted of concomitant latissimus dorsi release.  Indications included contracture affecting routine hygiene, dressing difficulty for caretakers, and/ or skin breakdown.  The procedure is relatively straight forward with a deltopectoral approach and release of the tendons at their insertions into the humerus.  In severe cases, the latissimus dorsi tendon was also released.  Post-operative passive range of motion was instituted.  All but one child had quadriplegic type of cerebral palsy.  Because of the child’s impairment, the outcome involved a questionnaire evaluating both shoulder function and caregiver assessment.   In 17 limbs, only the pectoralis major was released and in four limbs the concomitant latissimus dorsi release was also performed.  No surgical complications were noted.   The passive range of abduction was maintained to at least 90 degrees in 10 of the 13 patients.  At follow-up, the authors noted five patients with internal rotation contracture up to 45 degrees.

Contractures about the shoulder are common in patients with involved cerebral palsy.  The exact treatment and timing of treatment remains controversial.   Passive range of motion remains the mainstay, but fixed contractures can develop over time. A common concern is the development of an adduction contracture that impairs routine hygiene and dressing, and also cause skin problems in the axilla.  These authors describe a relatively simple approach with release of the pectoralis major +/- latissimus dorsi to improve passive abduction.  This resulted in improved care in 12 out of the 13 patients.  However, 5 patients were noted to have a severe internal rotation contracture.  My critique of the article involves the lack of assessment of glenohumeral joint deformity.  Persistent internal rotation contracture can lead to glenohumeral dysplasia as seen in the plexus population.  Extra capsular releases of the pectoralis and latissimus dorsi will not improve joint position, and therefore persistent limited passive motion will remain.   The status of the glenohumeral joint must be considered during the decision making process.  Lastly, the role of shoulder surgery in the severely involved spastic cerebral palsy patient is limited to a small group of patients with hygiene, dressing, or skin difficulties.

 

Cerebral, Palsy, Dysplasia, Shoulder, Pectoralis, Major, Abduction


Related Links
J of Pediatric Orthop