Tendon Transfer Around the Shoulder in Obstetric Brachial Plexus Paralysis: Clinical and Computed Tomographic Study

Author(s): El-Gammal TA, Saleh WR, El-Sayed A, Kotb MM, Imam HM, Fathi NA

Source: J Pediatr Orthop 26:641-646, 2006.

Summary:

The specific procedure to balance the shoulder following brachial plexus birth palsy remains controversial.  This retrospective study reports a specific surgical technique in children with brachial plexus birth palsy consisting of an anterior approach to lengthen the pectoralis major and subscapularis muscle/tendons.  Through a posterior approach, the teres major was transferred was to the infraspinatus.  Importantly, the joint was not opened in any case and latissimus dorsi muscle was left to maintain internal rotation.  A small subgroup of six patients underwent lateral transfer of the clavicular head of the pectoralis major to the deltoid.  This additional procedure was performed in children with shoulder abduction with less than 45 degrees.  A total of 109 children were included in this rather large cohort.

There was a large age range of surgery from 11 months to 192 months.  The average age was 67 months or approximately 5 ½ years.  Follow-up averaged about three years.  Thirty-nine cases underwent follow-up CT scans of both shoulders to detect bony changes.  The results show impressive improvement in range of motion.  The mean improvement in shoulder abduction was 64 degrees and improvement in external rotation was 50 degrees (measured at 90 degrees of abduction).  Twenty-eight cases lost 30 degrees of internal rotation.  Of the six patients that underwent concomitant pectoralis major transfer, the mean improvement in shoulder abduction and external rotation was 87 degrees and 57 degrees, respectively.  Postoperative CT scans did show glenoid retroversion and posterior subluxation of the humeral head.  This finding was more severe in children older than four year of age.

Further analysis of the results indicate superior outcome with regard to abduction and external rotation in children less than two years of age.  However, statistical improvement occurred up until the age of four years.  Children older than four years did not significantly increase motion.  This trend of earlier surgery about the shoulder is becoming accepted by surgeons that treat children with brachial plexus birth palsy.  The concept of leaving the latissimus dorsi for internal rotation is interesting especially in the face of subscapularis and pectoralis major muscle lengthenings.  One quarter of the patients still loss the last 30 degrees of internal rotation.  This highlights the difficulty in achieving “balance about the shoulder.”  Unfortunately, the 39 patients that underwent postoperative CT scans did not have preoperative imaging studies.  Therefore, little conclusion can be gleaned from this data. Lastly, only six patients underwent lateral transfer of the pectoralis major, a procedure still worth considering in the treatment of children with impaired abduction and flexion after brachial plexus birth palsy.
  
Shoulder, Brachial, Plexus, Palsy, Tendon, Transfer, Glenohumeral, Dysplasia


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