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Russo SA, Nice EM, Chafetz RS, Richards JG, Zlotolow DA, Kozin SH. Impact of tendon transfer on scapulothoracic and glenohumeral motion in children with brachial plexus birth injuries. J Shoulder Elbow Surg 2025; 34:e227-e238. [PMID: 39151671 DOI: 10.1016/j.jse.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 06/22/2024] [Accepted: 06/27/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Tendon transfers are often utilized to improve shoulder external rotation and abduction in children with brachial plexus birth injuries and are designed to improve glenohumeral (GH) joint motion. However, changes in scapulothoracic (ST) and GH joint function after tendon transfer are not well defined. The purpose of this study was to quantify changes in GH, ST, and humerothoracic (HT) joint function before and after tendon transfer, and we hypothesized that tendon transfers would reorient the arc of motion into more external rotation and abduction, but not increase GH motion. METHODS Motion analysis was performed in 15 children (ages 3-16) before and after transfer of teres major and/or latissimus dorsi. ST, GH, and HT joint angles were measured in a neutral, resting position and each of the modified Mallet positions. Joint angular displacements from the neutral position and the total arc of internal-external rotation for each joint were also calculated. Relevant joint angles, joint angular displacements, and internal-external rotation arcs were compared using multivariate analyses of variance with repeated measures and univariate posthoc analyses. RESULTS Glenohumeral and HT external rotation were significantly increased in all positions postoperatively. The arc of GH internal-external rotation was unchanged, but oriented in more external rotation after surgery. Only 6 patients gained active external rotation. Glenohumeral and HT internal rotation were significantly decreased after surgery, but ST internal rotation was significantly increased. Two patients had loss of midline function. In the abduction position, GH elevation joint angles were unchanged, but ST and HT elevation increased. DISCUSSION Only 4 patients gained active GH external rotation and maintained their internal rotation. Each of those patients underwent isolated tendon transfer without concomitant joint release. Seven patients maintained their preoperative internal rotation, which was attributed to increased ST internal rotation. The other half of patients lost internal rotation and gained external rotation through reorientation of the arc of rotation. Nine patients gained HT elevation, with 3 attributed to increased ST upward rotation, 5 attributed to a combination of increased ST upward rotation, and increased GH elevation, and 1 attributed to increased GH abduction contracture. These findings challenge the dogma that teres major/latissimus dorsi tendon transfers augment GH motion and highlight the importance of ST function for outcome determination.
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Affiliation(s)
- Stephanie A Russo
- Department of Orthopedic Surgery, Akron Children's Hospital, Akron, OH, USA.
| | - Emily M Nice
- Department of Research, Shriners Children's, Philadelphia, PA, USA
| | - Ross S Chafetz
- Motion Analysis Laboratory, Shriners Children's, Philadelphia, PA, USA
| | - James G Richards
- Department of Kinesiology and Applied Anatomy, University of Delaware, Newark, DE, USA
| | - Dan A Zlotolow
- Department of Orthopedic Surgery, Shriners Children's, Philadelphia, PA, USA
| | - Scott H Kozin
- Department of Orthopedic Surgery, Shriners Children's, Philadelphia, PA, USA
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Manske MC, Wilson MD, Wise BL, Hedriana HL, Melnikow J, Tancredi DJ. Are racial and ethnic disparities in brachial plexus birth injuries explained by known risk factors? J Perinatol 2025:10.1038/s41372-025-02239-8. [PMID: 40089579 DOI: 10.1038/s41372-025-02239-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2024] [Revised: 01/29/2025] [Accepted: 02/11/2025] [Indexed: 03/17/2025]
Abstract
OBJECTIVE To investigate the association of maternal race/ethnicity with risk factors for brachial plexus birth injury (BPBI) and quantify the proportion of excess BPBI risk due to these factors. STUDY DESIGN This retrospective cohort study of all livebirths occurring in California-licensed hospitals from 1996-2012 included 6,278,562 maternal-livebirth infant pairs with 7762 BPBI diagnoses. Multiple logistic regression and causal mediation analyses were used to evaluate the relationship of race/ethnicity and BPBI risk factors. RESULTS Black and Hispanic birthing-individuals were at increased risk of obesity, diabetes, and limited prenatal care utilization but decreased risk of many BPBI risk factors (shoulder dystocia, macrosomia, prolonged second stage of labor, and vaginal delivery). CONCLUSIONS Black and Hispanic birthing-individuals were at lower risk of many strongly associated risk factors for BPBI, and these factors mediate only a small proportion of their excess BPBI risk, underscoring the importance of identifying alternative risk factors, especially drivers of demographic disparities.
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Affiliation(s)
- M Claire Manske
- Associate Professor, Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA.
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Northern California, Sacramento, CA, USA.
| | - Machelle D Wilson
- Principal Biostatistician, Clinical and Translational Science Center, Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, CA, USA
| | - Barton L Wise
- Professor, Department of Internal Medicine, University of California Davis, Sacramento, CA, USA
| | - Herman L Hedriana
- Professor and Chief, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine University of California Davis, Sacramento, CA, USA
| | - Joy Melnikow
- Professor Emeritus, Department of Family and Community Medicine, University of California Davis, Sacramento, CA, USA
| | - Daniel J Tancredi
- Professor in Residence, Department of Pediatrics, University of California Davis, Sacramento, CA, USA
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Khabyeh-Hasbani N, Hoffman AF, Meisel E, Behbahani M, Koehler SM. Glenohumeral Dysplasia Following Brachial Plexus Birth Injuries: A Review. Neurosurgery 2025; 96:259-268. [PMID: 38916346 DOI: 10.1227/neu.0000000000003062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 05/01/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the high morbidity associated with glenohumeral dysplasia (GHD) in children with brachial plexus birth injuries, the progression of this condition often remains unnoticed, even after correcting for the underlying brachial plexus birth injuries. GHD, driven by a multifactorial process involving disruptions in both direct and indirect neural regulation of bony and muscular structures, can lead to intermittent or permanent shoulder mobility imbalances, significantly impacting the quality of life of those affected. Recent research efforts are increasingly directed toward identifying the root causes, managing the deformity, and determining effective treatment options for correcting GHD. METHODS A comprehensive search strategy was used by the authors to identify relevant literature relating to the progression, pathoanatomy, clinical presentation, and management of GHD following brachial plexus birth injuries across various search engines, such as PubMed, Scopus, and Embase. Considering the topic's interdisciplinary nature, articles were retrieved from both neurosurgical and orthopaedic journals to enrich the review. RESULTS Given the challenges in managing patients with brachial plexus birth injuries, a multidisciplinary care team consisting of certified occupational hand therapists, neurosurgeons, plastic surgeons, and orthopedic surgeons, specializing in brachial plexus injuries should be advocated for. The aim of this collaborative effort is to correct brachial plexus birth injuries and prevent the persistence of GHD. CONCLUSION As research continues to focus on understanding the complexities of this condition, the aim of this review article is to summarize the current literature on the course of brachial plexus birth injury and the development of GHD. By doing so, we hope to provide neurosurgeons with the necessary knowledge and essential tools needed to identify and effectively treat GHD during management of brachial plexus birth injuries.
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Affiliation(s)
| | - Alexandra F Hoffman
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx , New York , USA
| | - Erin Meisel
- Department of Orthopaedic Surgery, Children's Hospital Los Angeles, Los Angeles , California , USA
| | - Mandana Behbahani
- Department of Neurological Surgery, Montefiore Medical Center, Bronx , New York , USA
| | - Steven M Koehler
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx , New York , USA
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Manske MC, Wilson M, Wise B, Hedriana H, Melnikow J, Tancredi D. Are Racial and Ethnic Disparities in Brachial Plexus Birth Injuries Explained by Known Risk Factors? RESEARCH SQUARE 2024:rs.3.rs-5363261. [PMID: 39606470 PMCID: PMC11601867 DOI: 10.21203/rs.3.rs-5363261/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2024]
Abstract
Objective To investigate the association of maternal race/ethnicity with risk factors for brachial plexus birth injury (BPBI) and quantify the proportion of excess BPBI risk due to these factors. Study design This retrospective cohort study of all livebirths occurring in California-licensed hospitals from 1996-2012 included 6,278,562 maternal-livebirth infant pairs with 7,762 BPBI diagnoses. Multiple logistic regression and causal mediation analyses were used to evaluate the relationship of race/ethnicity and BPBI risk factors. Results Black and Hispanic birthing-individuals were at increased risk of obesity, diabetes, and limited prenatal care utilization but decreased risk of many BPBI risk factors (shoulder dystocia, macrosomia, prolonged second stage of labor, and vaginal delivery). Conclusions Black and Hispanic birthing-individuals were at lower risk of many strongly associated risk factors for BPBI, and these factors mediate only a small proportion of their excess BPBI risk, underscoring the importance of identifying alternative risk factors, especially drivers of demographic disparities.
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Balloufaud M, Hosni S, Bolivar J, Saguintaah M, Virassamy M, Laffont I, Coulet B, Lambert K, Delpont M. Subscapularis impairment on magnetic resonance imaging is correlated with functional limitations in neonatal brachial plexus palsy. INTERNATIONAL ORTHOPAEDICS 2024; 48:1635-1643. [PMID: 38167960 DOI: 10.1007/s00264-023-06081-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE The relationship between functional shoulder deficits in children with neonatal brachial plexus palsy (NBPP) and magnetic resonance imaging (MRI) shoulder abnormalities was evaluated. METHODS Shoulder function was assessed in 16 children (mean age: 5.8 years; range: 3-12 years) with NBPP based on shoulder rotator muscle strength, as measured using an isokinetic dynamometer and the modified Mallet score. The thickness and fatty infiltration of the subscapularis and infraspinatus muscles, and the morphology of the glenoid on MRI, were also determined. RESULTS The highest subscapularis fatty infiltration subgroup of NBPP patients promoted the highest alteration muscle thickness and modified Mallet score. CONCLUSIONS In NBPP children, subscapularis impairments play a major role in the functional limitations. This study of pediatric NBPP patients highlighted the value of adding an examination of the muscles to routine MRI assessment of bone parameters in the shoulders of NBPP children. TRIAL REGISTRATION NCT03440658.
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Affiliation(s)
- Maxime Balloufaud
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France
| | - Sarah Hosni
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - Julie Bolivar
- Pediatric Radiology, Arnaud De Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Magali Saguintaah
- Pediatric Radiology, Arnaud De Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Maxime Virassamy
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - Isabelle Laffont
- Physical Medicine and Rehabilitation Department, CHU Montpellier, University of Montpellier, Montpellier, France
- Euromov, UFR STAPS, University of Montpellier, Montpellier, France
| | - Bertrand Coulet
- Euromov, UFR STAPS, University of Montpellier, Montpellier, France
- Orthopedic Surgery, Upper Extremity, Hand and Peripheral Nerve Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Karen Lambert
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France
| | - Marion Delpont
- PhyMedExp, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France.
- Orthopedic Pediatric Surgery Department, Lapeyronie Hospital, CHU Montpellier, University of Montpellier, 191 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France.
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Manske MCB, Wilson MD, Wise BL, Melnikow J, Hedriana HL, James MA, Tancredi DJ. Maternal Epidemiology of Brachial Plexus Birth Injuries in California: 1996 to 2012. Am J Perinatol 2024; 41:e2106-e2114. [PMID: 37216973 DOI: 10.1055/a-2097-1358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE This study aimed to evaluate the incidence of brachial plexus birth injury (BPBI) and its associations with maternal demographic factors. Additionally, we sought to determine whether longitudinal changes in BPBI incidence differed by maternal demographics. STUDY DESIGN We conducted a retrospective cohort study of over 8 million maternal-infant pairs using California's Office of Statewide Health Planning and Development Linked Birth Files from 1991 to 2012. Descriptive statistics were used to determine BPBI incidence and the prevalence of maternal demographic factors (race, ethnicity, age). Multivariable logistic regression was used to determine associations of year, maternal race, ethnicity, and age with BPBI. Excess population-level risk associated with these characteristics was determined by calculating population attributable fractions. RESULTS The incidence of BPBI between 1991 and 2012 was 1.28 per 1,000 live births, with peak incidence of 1.84 per 1,000 in 1998 and low of 0.9 per 1,000 in 2008. Incidence varied by demographic group, with infants of Black (1.78 per 1,000) and Hispanic (1.34 per 1,000) mothers having higher incidences compared with White (1.25 per 1,000), Asian (0.8 per 1,000), Native American (1.29 per 1,000), other race (1.35 per 1,000), and non-Hispanic (1.15 per 1,000) mothers. After controlling for delivery method, macrosomia, shoulder dystocia, and year, infants of Black (adjusted odds ratio [AOR] = 1.88, 95% confidence interval [CI] = 1.70, 2.08), Hispanic (AOR = 1.25, 95% CI = 1.18, 1.32), and advanced-age mothers (AOR = 1.16, 95% CI = 1.09, 1.25) were at increased risk. Disparities in risk experienced by Black, Hispanic, and advanced-age mothers contributed to a 5, 10, and 2% excess risk at the population level, respectively. Longitudinal trends in incidence did not vary among demographic groups. Population-level changes in maternal demographics did not explain changes in incidence over time. CONCLUSION Although BPBI incidence has decreased in California, demographic disparities exist. Infants of Black, Hispanic, and advanced-age mothers are at increased BPBI risk compared with White, non-Hispanic, and younger mothers. KEY POINTS · The incidence of BPBI has decreased over time.. · Demographic disparities in BPBI incidence and risk exist.. · Infants of Black, Hispanic, and advanced age mothers are at greatest risk of BPBI..
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Affiliation(s)
- Mary Claire B Manske
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Northern California, Sacramento, California
| | - Machelle D Wilson
- Department of Public Health Sciences, Division of Biostatistics, Clinical and Translational Science Center, University of California Davis, Sacramento, California
| | - Barton L Wise
- Department of Internal Medicine, University of California Davis, Sacramento, California
| | - Joy Melnikow
- Department of Family and Community Medicine, University of California Davis, Sacramento, California
| | - Herman L Hedriana
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine University of California Davis, Sacramento, California
| | - Michelle A James
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Northern California, Sacramento, California
| | - Daniel J Tancredi
- Department of Pediatrics, University of California Davis, Sacramento, California
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Cho KH, Kim JH, Yamamoto M, Hayashi S, Murakami G, Rodríguez-Vázquez JF. Growth of the brachial nerve plexus with reference to topographical relation of the medianus nerve ansa with the thoracic wall and shoulder: a histologic study using human embryos and fetuses. Surg Radiol Anat 2024; 46:443-449. [PMID: 38431890 DOI: 10.1007/s00276-024-03317-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND There is currently no information on positional changes in the brachial nerve plexus during prenatal growth. The subclavian-axillary artery passing through the medianus nerve ansa is considered a good landmark for evaluating the height of the plexus. MATERIALS AND METHODS We used histologic sections from 9 embryos and 17 fetuses (approximately 6-15 weeks of gestational age) to identify the height of the ansa by referring to the level of the rib and the glenohumeral joint. RESULTS The nerve ansa was usually (23 plexuses) observed at the level of the first and/or second ribs. However, it was sometimes observed above the first rib, at a distance equal to or more than an intercostal width (7 plexuses). In the latter group, the ansa was usually located below the glenohumeral joint. Thus, the joint was located higher than the first rib, although the upper extremities were in the anatomic position for all specimens. The left-right difference in the height of the plexus corresponded to or was less than the width of the first intercostal space. Despite the synchronized growth between the thorax and shoulder girdle, the brachial plexus showed a considerable variation in comparative height; the range corresponded to twice of an intercostal width. Whether the nerve plexus is located high or low is determined at an early developmental stage and is maintained during the later growth stages. CONCLUSION The high-positioned plexus might cause nerve injury at delivery, followed by a glenohumeral joint deformity because of the fragility without fixation in the thorax.
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Affiliation(s)
- Kwang Ho Cho
- Department of Neurology, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine and Hospital, 895, Muwang-ro, Iksan-si, Jeollabuk-do, 54538, Republic of Korea.
| | - Ji Hyun Kim
- Department of Anatomy, Jeonbuk National University Medical School, Jeonju, Korea
| | - Masahito Yamamoto
- Department of Anatomy, Division of Basic Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Shogo Hayashi
- Department of Anatomy, Division of Basic Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Gen Murakami
- Division of Internal Medicine, Cupid Clinic, Iwamizawa, Japan
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Manske MC, Wilson MD, Wise BL, James MA, Melnikow J, Hedriana HL, Tancredi DJ. Association of Parity and Previous Birth Outcome With Brachial Plexus Birth Injury Risk. Obstet Gynecol 2023; 142:1217-1225. [PMID: 37797333 PMCID: PMC10592124 DOI: 10.1097/aog.0000000000005394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/20/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To evaluate the association of maternal delivery history with a brachial plexus birth injury risk in subsequent deliveries and to estimate the effect of subsequent delivery method on brachial plexus birth injury risk. METHODS We conducted a retrospective cohort study of all live-birth deliveries occurring in California-licensed hospitals from 1996 to 2012. The primary outcome was recurrent brachial plexus birth injury in a subsequent pregnancy. The exposure was delivery history (parity, shoulder dystocia in a previous delivery, or previously delivering a neonate with brachial plexus birth injury). Multiple logistic regression was used to model adjusted associations of delivery history with brachial plexus birth injury in a subsequent pregnancy. The adjusted risk and adjusted risk difference for brachial plexus birth injury between vaginal and cesarean deliveries in subsequent pregnancies were determined, stratified by delivery history, and the number of cesarean deliveries needed to prevent one brachial plexus birth injury was determined. RESULTS Of 6,286,324 neonates delivered by 4,104,825 individuals, 7,762 (0.12%) were diagnosed with a brachial plexus birth injury. Higher parity was associated with a 5.7% decrease in brachial plexus birth injury risk with each subsequent delivery (adjusted odds ratio [aOR] 0.94, 95% CI 0.92-0.97). Shoulder dystocia or brachial plexus birth injury in a previous delivery was associated with fivefold (0.58% vs 0.11%, aOR 5.39, 95% CI 4.10-7.08) and 17-fold (1.58% vs 0.11%, aOR 17.22, 95% CI 13.31-22.27) increases in brachial plexus birth injury risk, respectively. Among individuals with a history of delivering a neonate with a brachial plexus birth injury, cesarean delivery was associated with a 73.0% decrease in brachial plexus birth injury risk (0.60% vs 2.21%, aOR 0.27, 95% CI 0.13-0.55) compared with an 87.9% decrease in brachial plexus birth injury risk (0.02% vs 0.15%, aOR 0.12, 95% CI 0.10-0.15) in individuals without this history. Among individuals with a history of brachial plexus birth injury, 48.1 cesarean deliveries are needed to prevent one brachial plexus birth injury. CONCLUSIONS Parity, previous shoulder dystocia, and previously delivering a neonate with brachial plexus birth injury are associated with future brachial plexus birth injury risk. These factors are identifiable prenatally and can inform discussions with pregnant individuals regarding brachial plexus birth injury risk and planned mode of delivery.
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Affiliation(s)
- M. Claire Manske
- Assistant Professor, Department of Orthopaedic Surgery, University of California Davis, Sacramento, California, United States
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Northern California, Sacramento, California, United States
| | - Machelle D. Wilson
- Principal Biostatistician, Clinical and Translational Science Center, Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Sacramento, California, United States
| | - Barton L. Wise
- Professor, Department of Internal Medicine, University of California Davis, Sacramento, California, United States
| | - Michelle A. James
- Assistant Professor, Department of Orthopaedic Surgery, University of California Davis, Sacramento, California, United States
- Department of Orthopaedic Surgery, Shriners Hospitals for Children Northern California, Sacramento, California, United States
| | - Joy Melnikow
- Professor Emeritus, Department of Family and Community Medicine, University of California Davis, Sacramento, California, United States
| | - Herman L. Hedriana
- Professor and Chief, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of California Davis, Sacramento, California, United States
| | - Daniel J. Tancredi
- Professor in Residence, Department of Pediatrics, University of California Davis, Sacramento, California, United States
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Manske MC, Pham C, Taylor SL, James MA. Long-Term Outcomes of Biceps Rerouting for Flexible Supination Contractures in Children With Brachial Plexus Birth Injuries. J Hand Surg Am 2023; 48:37-45. [PMID: 34953599 DOI: 10.1016/j.jhsa.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/14/2021] [Accepted: 10/13/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Forearm supination contractures occur in 7% of children with brachial plexus birth injuries (BPBI). Biceps rerouting is proposed when pronation has deteriorated but is passively correctable to at least 0° (neutral). The purpose of this investigation was to evaluate long-term outcomes of biceps rerouting for this indication, including magnitude and maintenance of correction, complications, and subsequent osteotomy. METHODS We conducted a retrospective review of all children with BPBI and forearm supination contractures treated with biceps rerouting alone, for the above indications, from 1993 to 2017 with at least 2 years follow-up. Demographic information, BPBI characteristics, surgical details, and ranges of motion were obtained from medical records. Pre- and postoperative active pronation (AP) and supination (AS), elbow flexion contracture, and arc of forearm rotation (Arc) were analyzed using linear mixed-effect models. RESULTS Twenty-five children (13 females; 13 left forearms; 15 global BPBI) underwent biceps rerouting at age 7 ± 3 years and were followed for 6 ± 3 years. Before surgery, the mean AP and AS were 6° ± 29° and 62° ± 27°, respectively. At the final follow-up, the mean AP, AS, and Arc were 39° ± 36°, 18° ± 34°, and 57° ± 42°, respectively. AP was significantly improved and AS was significantly decreased by 2 years after surgery and at the final follow-up. Neither Arc nor elbow flexion contracture changed significantly. Two of 25 (8%) children underwent subsequent forearm osteotomy. CONCLUSIONS Biceps rerouting in children with BPBI improves the forearm position when pronation is deteriorating by shifting the arc from supination to pronation without decreasing the arc of motion or worsening elbow flexion contractures. There is a low risk of complications and a limited need for subsequent forearm osteotomy. These results are maintained over time. When performed before passive pronation is reduced beyond neutral, this procedure may prevent severe supination contractures and reduce the need for forearm osteotomy. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- M Claire Manske
- Department of Orthopedic Surgery, Shriners Hospital for Children Northern California, Sacramento, CA; Department of Orthopedic Surgery, University of California Davis Sacramento, CA.
| | - Cory Pham
- San Francisco Orthopaedic Residency Program, St. Mary's Medical Center, San Francisco, CA
| | - Sandra L Taylor
- Department of Public Health Sciences, University of California Davis, Sacramento, CA
| | - Michelle A James
- Department of Orthopedic Surgery, Shriners Hospital for Children Northern California, Sacramento, CA; Department of Orthopedic Surgery, University of California Davis Sacramento, CA
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Prevalence of perinatal factors in infants with brachial plexus birth injuries and their association with injury severity. J Perinatol 2022; 43:578-583. [PMID: 36585508 DOI: 10.1038/s41372-022-01594-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine the prevalence of perinatal factors associated with brachial plexus birth injury (BPBI) in affected infants and their relationship with BPBI severity. STUDY DESIGN Retrospective study of BPBI infants prospectively enrolled in a multicenter registry. The prevalence of perinatal factors was calculated. Infants were stratified by injury severity and groups were compared to determine the association of severity and perinatal factors. RESULTS Seven-hundred-ninety-six BPBI infants had a mean 4.2 ± 1.6 perinatal factors. Nearly all (795/796) reported at least one factor, including shoulder dystocia(96%), no clavicle fracture (91%), difficult delivery(84%), parity >1(61%) and birthweight >4000 g(55%). Ten-percent (74/778) had Horner's syndrome and 28%(222/796) underwent nerve surgery. Birth asphyxia and NICU admission were significantly associated with injury severity. CONCLUSIONS NICU admission and asphyxia were associated with BPBI severity. An improved understanding of the relationship between perinatal factors and BPBI severity may be used to guide early referral to BPBI providers and support prevention efforts.
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Abstract
BACKGROUND Brachial plexus birth injuries (BPBI) can result in lasting impairments of external rotation and cross-body adduction (CBA) that disrupt functional activities such as dressing, grooming, or throwing a ball. The purpose of this study was to compare the quantification of shoulder humerothoracic (HT) external rotation (ER), and glenohumeral (GH) CBA by 3 methods - physician visual estimate, goniometer measurement by an occupational therapist, and motion capture. METHODS Twenty-six patients with BPBI (average age of 9.9±3.2 y) participated in this study. Mallet scores and visual estimates of passive HT ER and GH CBA were recorded by a physician. The passive measures were repeated by an occupational therapist using a goniometer while motion capture measures were simultaneously collected. Active HT ER was also measured by motion capture. The passive measures were compared with analyses of variance with repeated measures, intraclass correlations, and Bland-Altman plots. External rotation Mallet scores determined by motion capture and by the physician were compared. RESULTS The measures of GH CBA were not statistically different and demonstrated good agreement, but substantial variation. For HT ER, all measures were significantly different and demonstrated poor agreement and substantial variation. When the joint angles measured by motion capture were used to determine the Mallet score, 79% of external rotation Mallet scores assigned by the physician were incorrectly categorized, with the physician always scoring the participant higher than predicted motion capture Mallet score. CONCLUSIONS Both GH CBA and HT ER measures demonstrated substantial variability between measurement types, but only HT ER joint angles were significantly different. In addition, more than three-quarters of external rotation Mallet scores were misclassified by the physician. Motion capture measurements offer the benefit of less susceptibility to patients' compensatory and/or out-of-plane movements and should be considered for clinical assessment of shoulder range of motion in children with BPBI. If motion capture is unavailable, the use of a goniometer provides more accurate clinical measures of shoulder motion than visual estimates and care should be taken to minimize and account for compensatory movement strategies. LEVEL OF EVIDENCE Level IV Case series.
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12
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Delioğlu K, Uzumcugil A, Gunel M. Activity-based hand-function profile in preschool children with obstetric brachial plexus palsy. HAND SURGERY & REHABILITATION 2022; 41:487-493. [DOI: 10.1016/j.hansur.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/03/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
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13
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Quantifying
Real‐World
Upper Limb Activity Via
Patient‐Initiated
Spontaneous Movement in Neonatal Brachial Plexus Palsy. PM R 2022; 15:604-612. [DOI: 10.1002/pmrj.12780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 12/22/2021] [Accepted: 01/17/2022] [Indexed: 11/07/2022]
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14
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Yoon JP, Cederna PS, Dehdashtian A, Min S, Kim KR, Chung KC, Kemp SWP. Comparison of Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Versus Nerve Grafting for Neonatal Brachial Plexus Injury. Orthopedics 2022; 45:7-12. [PMID: 34734774 DOI: 10.3928/01477447-20211101-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Neonatal brachial plexus injuries may cause critical limitations of upper extremity function. The optimal surgical approach to address neonatal brachial plexus injuries has not been defined. In this systematic review, we compare clinical results after spinal accessory to suprascapular nerve transfer and nerve graft techniques among patients with neonatal brachial plexus injury. [Orthopedics. 2022;45(1):7-12.].
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15
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Delpont M, Coulet B, Cottalorda J, Ramdani S, Lagacé JC, Mercier J, Laffont I, Bernard PL, Lambert K. Weakness of shoulder rotator muscles in children with brachial plexus palsy under age 5 years: not only in lateral rotation. Ann Phys Rehabil Med 2021; 65:101572. [PMID: 34530153 DOI: 10.1016/j.rehab.2021.101572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/07/2021] [Accepted: 06/12/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Marion Delpont
- Chirurgie infantile, Hôpital Lapeyronie, CHU Montpellier, Université de Montpellier, Montpellier, France.
| | - Bertrand Coulet
- Chirurgie orthopédique, unité de chirurgie du membre supérieur, de la main et des nerfs périphériques, Hôpital Lapeyronie, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Jérôme Cottalorda
- Chirurgie infantile, Hôpital Lapeyronie, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Sofiane Ramdani
- Euromov, UFR STAPS, Université de Montpellier, Montpellier, France
| | - Jean-Christophe Lagacé
- Research Centre on Aging, affiliated with CIUSS de l'Estrie-CHUC, 1036 rue Belvédère sud, Université de Sherbrooke, Sherbrooke, PQ, Canada
| | - Jacques Mercier
- PhyMedExp, CNRS UMR 9214, INSERM U1046, Université de Montpellier, Montpellier, France
| | - Isabelle Laffont
- Service de Médecine Physique et de Réadaptation, CHU Montpellier, Université de Montpellier, Montpellier, France
| | | | - Karen Lambert
- PhyMedExp, CNRS UMR 9214, INSERM U1046, Université de Montpellier, Montpellier, France
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16
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The outcome of soft-tissue release and tendon transfer in shoulders with brachial plexus birth palsy. JSES Int 2021; 5:905-911. [PMID: 34505104 PMCID: PMC8411056 DOI: 10.1016/j.jseint.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Shoulder involvement in brachial plexus birth palsy is common, and the adduction, internal rotation contracture deformity often requires some form of surgical treatment. There are very few long-term reports on release of contracted muscles and tendon transfers, especially in older children. We are reporting the single-center results of such a surgery with detailed outcome analysis. Methods The prospectively collected data from brachial plexus birth palsy cases who had undergone contracture release and tendon transfer were retrospectively studied and examined. The new Mallet and functional scores were compared with the original data forms and then analyzed. The radiographic evidence of glenoid dysplasia and its correlation with age and functional outcome was assessed. Results A total of 82 cases with surgery at mean age of 9.5 ± 5.09 years and a follow-up of 8 ± 3.8 (3-20) years entered the study. Of these, 56% of cases had 7 to 20 years of age at surgery. Fifty-four (66%) patients had only shoulder surgery, and 28 (34%) required additional reconstructive surgeries for hand and wrist. Moderate to severe glenohumeral dysplasia was present in 38%. The preoperative Mallet score of 10.6 ± 2.97 improved to 19.3 ± 3.39 (P < .001). Eighty-one percent of patients showed improvement in “reaching face” functions, 71% in “above head” functions, and 74% in “midline functions.” The cases with lack of improvement in midline function mostly belonged to pan-plexus injuries. Noticeable subjective and objective improvement was also observed in cases with glenohumeral dysplasia in their Mallet and functional scores (P < .001). The improvement in function and subjective satisfaction of 92% was observed irrespective of age at surgery. Conclusion Soft-tissue release and tendon transfer for brachial plexus birth palsy shoulder can improve function and limb appearance even in older children and young adults and even in the presence of glenohumeral dysplasia.
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17
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Dixit NN, McCormick CM, Cole JH, Saul KR. Influence of Brachial Plexus Birth Injury Location on Glenohumeral Joint Morphology. J Hand Surg Am 2021; 46:512.e1-512.e9. [PMID: 33358583 PMCID: PMC8180483 DOI: 10.1016/j.jhsa.2020.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/12/2020] [Accepted: 10/20/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Patient presentation after brachial plexus birth injury (BPBI) is influenced by nerve injury location; more contracture and bone deformity occur at the shoulder in postganglionic injuries. Although bone deformity after postganglionic injury is well-characterized, the extent of glenohumeral deformity after preganglionic BPBI is unclear. METHODS Twenty Sprague-Dawley rat pups received preganglionic or postganglionic neurectomy on a single forelimb at postnatal days 3 to 4. Glenohumeral joints on affected and unaffected sides were analyzed using micro-computed tomography scans after death at 8 weeks after birth. Glenoid version, glenoid inclination, glenoid and humeral head radius of curvature, and humeral head thickness and width were measured bilaterally. RESULTS The glenoid was significantly more declined in affected compared with unaffected shoulders after postganglionic (-17.7° ± 16.9°) but not preganglionic injury. Compared with the preganglionic group, the affected shoulder in the postganglionic group exhibited significantly greater declination and increased glenoid radius of curvature. In contrast, the humeral head was only affected after preganglionic but not postganglionic injury, with a significantly smaller humeral head radius of curvature (-0.2 ± 0.2 mm), thickness (-0.2 ± 0.3 mm), and width (-0.3 ± 0.4 mm) on the affected side compared with the unaffected side; changes in these metrics were significantly associated with each other. CONCLUSIONS These findings suggest that glenoid deformities occur after postganglionic BPBI but not after preganglionic BPBI, whereas the humeral head is smaller after preganglionic injury, possibly suggesting an overall decreased biological growth rate in this group. CLINICAL RELEVANCE This study expands understanding of the altered glenoid and humeral head morphologies after preganglionic BPBI and its comparisons with morphologies after postganglionic BPBI.
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Affiliation(s)
| | - Carolyn M. McCormick
- North Carolina State University, Raleigh, NC,University of North Carolina, Chapel Hill, NC
| | - Jacqueline H. Cole
- North Carolina State University, Raleigh, NC,University of North Carolina, Chapel Hill, NC
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18
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Sénès FM, Nucci AM, Valore A, Catena N. Corrective Procedure for Flexion Contracture of the Elbow in Neonatal Palsy Sequelae: Long-term Follow-up. Indian J Orthop 2021; 55:452-459. [PMID: 34306560 PMCID: PMC8275703 DOI: 10.1007/s43465-020-00316-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/16/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Aim of this paper is to validate a procedure for correcting elbow flexion contracture in patients suffering from brachial plexus neonatal palsy sequelae during their teens. Elbow flexion contracture represents an unsolved problem in the natural history of obstetric brachial plexus palsy (OBPP) because of the consistent deformity recurrence. Following a previous paper, in which an original technique was proposed in a small sample of patients, the authors show the possible correction of the deformity in a larger group of patients. METHODS The procedure includes a combination of a posterior approach to the elbow with olecranon tip section and an anterior one with capsulotomy and soft tissue release to improve elbow range of motion. A series of 26 patients, who underwent the procedure, were checked out in medium and long term. Collected data were age, type of brachial plexus palsy, length of hospitalization, duration of surgery, preoperative and postoperative elbow range of motion, preoperative and postoperative DASH scores and satisfaction scores. Explaining further details about the procedure, the Authors report their results, including a statistical analysis. RESULTS At the final follow-up, the mean increase of elbow extension was about 22°. Functional outcomes were successful as well, with a mean increase of 10 points of DASH score. Over 75% of patients were fully satisfied with their outcome. CONCLUSIONS The outcome has confirmed the good efficacy of the procedure in increasing elbow extension but also in improving cosmetic appearance in adolescents suffering from flexed elbow in OBPP sequelae.
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Affiliation(s)
- Filippo Maria Sénès
- grid.419504.d0000 0004 1760 0109Hand Surgery and Reconstructive Microsurgery Unit, IRCSS Giannina Gaslini Institute, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Anna Maria Nucci
- Traumatology and Orthopedics Unit, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa 2, 56125 Pisa, Italy
| | - Annalisa Valore
- grid.419504.d0000 0004 1760 0109Hand Surgery and Reconstructive Microsurgery Unit, IRCSS Giannina Gaslini Institute, Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Nunzio Catena
- Pediatric Orthopedic and Traumatology Unit, Children’s Hospital, AON SS Antonio E Biagio E Cesare Arrigo, Spalto Marengo 46, 15121 Alessandria, Italy
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19
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Delioğlu K, Uzumcugil A, Öztürk E, Kerem Gunel M. Relative importance of factors affecting activity and upper extremity function in children with Narakas Group 2 brachial plexus birth palsy. J Hand Surg Eur Vol 2021; 46:239-246. [PMID: 33092449 DOI: 10.1177/1753193420964768] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of the study was to determine the differences in upper limb function and activity/participation levels between preschool children with Narakas Groups 2a and 2b obstetric brachial plexus injury; and to determine the significance level of the factors affecting upper limb functions in these patients. Sixty-seven children, aged 3 to 7, who had not had surgical intervention, were evaluated in terms of joint movements, modified Mallet classification, Raimondi hand classification, brachial plexus outcome measure, paediatric outcome data collection instrument and stereognosis. There were significant functional differences between the groups, in favour of Group 2a. The movements affecting total function of the upper limb were: hand to spine (p < 0.001), global abduction (p < 0.001) and hand to mouth (p < 0.001), in descending order of significance. Passive internal rotation was the most important passive joint movement affecting shoulder function (p < 0.001). The results of this study suggest that more emphasis should be placed on the shoulder internal rotation in treatment strategies.Level of evidence: III.
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Affiliation(s)
- Kıvanç Delioğlu
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
| | - Akin Uzumcugil
- Department of Orthopedics and Traumatology, Hacettepe University, Ankara, Turkey
| | - Ebru Öztürk
- Department of Biostatistics, Hacettepe University, Ankara, Turkey
| | - Mintaze Kerem Gunel
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey
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20
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Radiographic and Clinical Outcomes of the Shoulder in Long-Term Follow-Up of Brachial Plexus Birth Injury. J Hand Surg Am 2020; 45:1115-1122. [PMID: 33289634 DOI: 10.1016/j.jhsa.2020.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 07/07/2020] [Accepted: 09/11/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to examine radiographic and functional outcomes of the shoulder in brachial plexus birth injury (BPBI) patients at long-term follow-up. METHODS Medical records were reviewed at the Shriners Hospital in St. Louis to identify patients older than 18 years with a diagnosis of BPBI. Twenty-five patients were included in this study. Evaluations included radiographic examination, clinical examination, and outcome measures including the Mallet classification, visual analog scale (VAS) for shoulder pain, American Shoulder and Elbow Shoulder score (ASES), quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Simple Shoulder Test (SST), and Patient-Reported Outcomes Measurement Information System (PROMIS) domain measures. RESULTS The mean age of the patients included was 44 years. Average follow-up was 37 years. No patient had primary nerve reconstruction surgery. Thirteen patients had a history of shoulder surgery at an average age of 6 years. There was a wide spectrum of deformity seen radiographically. Fifty-five percent of patients had evidence of glenoid retroversion, posterior humeral translation, or a biconcave glenoid. An additional 20% of patients had complete posterior dislocation of the humeral head. Despite the degenerative changes seen on radiographs, the mean VAS for pain was low, at 2. The mean ASES shoulder score was 54. The mean QuickDASH score was 30. Mean PROMIS Physical Function, Pain Interference, Depression, and Anxiety scores were near the means for the general population, with similar outcomes in patients treated with shoulder surgery compared with those treated without surgery. CONCLUSIONS Adult BPBI patients experience minimal shoulder pain despite deformity and degenerative changes on shoulder radiographs. Whereas there are significant deficits in range of motion and function, PROMIS scores in adult BPBI patients are normal. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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21
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Vuillermin C, Bauer AS, Kalish LA, Lewine EB, Bae DS, Waters PM. Follow-up Study on the Effects of Tendon Transfers and Open Reduction on Moderate Glenohumeral Joint Deformity in Brachial Plexus Birth Injury. J Bone Joint Surg Am 2020; 102:1260-1268. [PMID: 32675676 DOI: 10.2106/jbjs.19.00685] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Soft-tissue contractures about the shoulder in patients with brachial plexus birth injury are common and can lead to progressive shoulder displacement and glenohumeral dysplasia. Open or arthroscopic reduction with musculotendinous lengthening and tendon transfers have become the standard of care. The clinical function and radiographic joint remodeling beyond the first 2 years after surgery are not well understood. METHODS We performed a follow-up study of 20 patients with preexisting mild to moderate glenohumeral joint deformity who had undergone open glenohumeral joint reduction with latissimus dorsi and teres major tendon transfers and concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis. Prospective collection of Modified Mallet and Active Movement Scale (AMS) scores and radiographic analysis of cross-sectional imaging for glenoid version, humeral head subluxation, and glenohumeral joint deformity classification were analyzed for changes over time. RESULTS The average duration of radiographic follow-up was 4.2 years (range, 2 to 6 years). The mean glenoid version improved from -31.8° to -15.4° (p < 0.0001). The mean percentage of the humeral head anterior to the middle of the glenoid (PHHA) improved from 9.6% to 30.4% (p < 0.0001). The mean glenohumeral joint deformity score improved from 3.7 to 2.1 (p < 0.0001). CONCLUSIONS All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. There were no significant changes beyond the 1-year time point in the Mallet scores, AMS scores, or radiographic outcome measures, possibly because of insufficient power, although trends of improvement were noted for some outcomes. No decline in outcome measures was found during the study period. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Carley Vuillermin
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Andrea S Bauer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Leslie A Kalish
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | | | - Donald S Bae
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Peter M Waters
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
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22
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Dixit NN, McFarland DC, Fisher MB, Cole JH, Saul KR. Integrated iterative musculoskeletal modeling predicts bone morphology following brachial plexus birth injury (BPBI). J Biomech 2020; 103:109658. [PMID: 32089271 PMCID: PMC7141945 DOI: 10.1016/j.jbiomech.2020.109658] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 01/05/2023]
Abstract
Brachial plexus birth injury (BPBI) is the most common nerve injury among children. The glenohumeral joint of affected children can undergo severe osseous deformation and altered muscle properties, depending on location of the injury relative to the dorsal root ganglion (preganglionic or postganglionic). Preganglionic injury results in lower muscle mass and shorter optimal muscle length compared to postganglionic injury. We investigated whether these changes to muscle properties over time following BPBI provide a mechanically-driven explanation for observed differences in bone deformity between preganglionic and postganglionic BPBI. We developed a computational framework integrating musculoskeletal modeling to represent muscle changes over time and finite element modeling to simulate bone growth in response to mechanical and biological stimuli. The simulations predicted that the net glenohumeral joint loads in the postganglionic injury case were nearly 10.5% greater than in preganglionic. Predicted bone deformations were more severe in the postganglionic case, with the glenoid more declined (pre: -43.8°, post: -51.0°), flatter with higher radius of curvature (pre: 3.0 mm, post: 3.7 mm), and anteverted (pre: 2.53°, post: 4.93°) than in the preganglionic case. These simulated glenoid deformations were consistent with previous experimental studies. Thus, we concluded that the differences in muscle mass and length between the preganglionic and postganglionic injuries are critical mechanical drivers of the altered glenohumeral joint shape.
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Affiliation(s)
- Nikhil N Dixit
- North Carolina State University, Raleigh, NC, United States
| | | | - Matthew B Fisher
- North Carolina State University, Raleigh, NC, United States; University of North Carolina, Chapel Hill, NC, United States
| | - Jacqueline H Cole
- North Carolina State University, Raleigh, NC, United States; University of North Carolina, Chapel Hill, NC, United States
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23
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Manske MC, Kalish LA, Cornwall R, Peljovich AE, Bauer AS. Reconstruction of the Suprascapular Nerve in Brachial Plexus Birth Injury: A Comparison of Nerve Grafting and Nerve Transfers. J Bone Joint Surg Am 2020; 102:298-308. [PMID: 31725125 DOI: 10.2106/jbjs.19.00627] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder external rotation recovery in brachial plexus birth injury is often limited. Nerve grafting to the suprascapular nerve and transfer of the spinal accessory nerve to the suprascapular nerve are commonly performed to restore shoulder external rotation, but the optimal surgical technique has not been clearly demonstrated. We investigated whether there was a difference between nerve grafting and nerve transfer in terms of shoulder external rotation recovery or secondary shoulder procedures. METHODS This is a multicenter, retrospective cohort study of 145 infants with brachial plexus birth injury who underwent reconstruction with nerve grafting to the suprascapular nerve (n = 59) or spinal accessory nerve to suprascapular nerve transfer (n = 86) with a minimum follow-up of 18 months (median, 25.7 months [interquartile range, 22.0, 31.2 months]). The primary outcome was the Active Movement Scale (AMS) score for shoulder external rotation at 18 to 36 months. The secondary outcome was secondary shoulder surgery. Two-sample Wilcoxon and t tests were used to analyze continuous variables, and the Fisher exact test was used to analyze categorical variables. The Kaplan-Meier method was used to estimate the cumulative risk of subsequent shoulder procedures, and the proportional hazards model was used to estimate hazard ratios (HRs). RESULTS The grafting and transfer groups were similar in Narakas type, preoperative AMS scores, and shoulder subluxation. The mean postoperative shoulder external rotation AMS scores were 2.70 in the grafting group and 3.21 in the transfer group, with no difference in shoulder external rotation recovery between the groups (difference, 0.51 [95% confidence interval (CI), -0.31 to 1.33]). A greater proportion of the transfer group (24%) achieved an AMS score of >5 for shoulder external rotation compared with the grafting group (5%) (odds ratio, 5.9 [95% CI, 1.3 to 27.4]). Forty percent of the transfer group underwent a secondary shoulder surgical procedure compared with 53% of the grafting group; this was a significantly lower subsequent surgery rate (HR, 0.58 [95% CI, 0.35 to 0.95]). CONCLUSIONS Shoulder external rotation recovery in brachial plexus birth injury remains disappointing regardless of surgical technique, with a mean postoperative AMS score of 3, 17% of infants achieving an AMS score of >5, and a high frequency of secondary shoulder procedures in this study. Spinal accessory nerve to suprascapular nerve transfers were associated with a higher proportion of infants achieving functional shoulder external rotation (AMS score of >5) and fewer secondary shoulder procedures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- M Claire Manske
- Department of Orthopedic Surgery, Shriners Hospital for Children-Northern California, Sacramento, California.,Department of Orthopedic Surgery, University of California, Davis, Sacramento, California
| | - Leslie A Kalish
- Boston Children's Hospital Institutional Centers for Clinical and Translational Research, Boston, Massachusetts
| | - Roger Cornwall
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Allan E Peljovich
- Department of Orthopaedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia.,The Hand and Upper Extremity Center of Georgia, Atlanta, Georgia
| | - Andrea S Bauer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts
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What Range of Motion is Achieved 5 Years After External Rotationplasty of the Shoulder in Infants with an Obstetric Brachial Plexus Injury? Clin Orthop Relat Res 2020; 478:114-123. [PMID: 31651590 PMCID: PMC7000049 DOI: 10.1097/corr.0000000000000996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Obstetric brachial plexus injuries result from traction injuries during delivery, and 30% of these children have persisting functional limitations related to an external rotation deficit of the shoulder. Little is known about the long-term effect of soft-tissue procedures of the shoulder in patients with obstetric brachial plexus injuries. QUESTIONS/PURPOSES (1) After soft-tissue release for patients with passive external rotation less than 20° and age younger than 2 years and for patients older than 2 years with good external rotation strength, what are the improvements in passive external rotation and abduction arcs at 1 and 5 years? (2) For patients who underwent staged tendon transfer after soft-tissue release, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? (3) For patients with passive external rotation less than 20° and no active external rotation, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? METHODS This was a retrospective analysis of a longitudinally maintained institutional database. Between 1996 and 2009, 149 children underwent a soft-tissue procedure of the shoulder for an internal rotation contracture. The inclusion criteria were treatment with an internal contracture release and/or tendon transfer, a maximum age of 18 years at the time of surgery, and a minimum follow-up period of 2 years. Six patients were older than 18 years at the time of surgery and 31 children were seen at our clinic until 1 year postoperatively, but because they had good clinical results and lived far away from our center, these children were discharged to physical therapists in their hometown for annual follow-up. Thus, 112 children (59 boys) were available for analysis. Patients with passive external rotation less than 20° and age younger than 2 years and patients older than 2 years with good external rotation strength received soft-tissue release only (n = 37). Of these patients, 17 children did not have adequate active external rotation, and second-stage tendon transfer surgery was performed. For patients with passive external rotation less than 20° with no active external rotation, single-stage contracture release with tendon transfer was performed (n = 68). When no contracture was present (greater than 20° of external rotation) but the patient had an active deficit (n = 7), tendon transfer alone was performed; this group was not analyzed. A functional assessment of the shoulder was performed preoperatively and postoperatively at 6 weeks, 3 months, and annually thereafter and included abduction, external rotation in adduction and abduction, and the Mallet scale. RESULTS Internal contracture release resulted in an improvement in passive external rotation in adduction and abduction of 29° (95% confidence interval, 21 to 38; p < 0.001) and 17° (95% CI, 10 to 24; p < 0.001) at 1 year of follow-up and 25° (95% CI, 15-35; p < 0.001) and 15° (95% CI, 7 to 24; p = 0.001) at 5 years. Because of insufficient strength of the external rotators after release, 46% of the children (17 of 37) underwent an additional tendon transfer for active external rotation, resulting in an improvement in active external rotation in adduction and abduction at each successive follow-up visit. Patients with staged transfers had improved active function; improvements in active external rotation in adduction and abduction were 49° (95% CI, 28 to 69; p < 0.05) and 45° (95% CI, 11 to 79; p < 0.001) at 1 year of follow-up and 38° (95% CI, 19 to 58; p < 0.05) and 23° (95% CI, -8 to 55; p < 0.001) at 5 years. In patients starting with less than 20° of passive external rotation and no active external rotation, after single-stage contracture release and tendon transfer, active ROM was improved. Active external rotation in adduction and abduction were 75° (95% CI, 66 to 84; p < 0.001) and 50° (95% CI, 43 to 57; p < 0.001) at 1 year of follow-up and 65° (95% CI, 50 to 79; p < 0.001) and 40° (95% CI, 28 to 52; p < 0.001) at 5 years. CONCLUSION Young children with obstetric brachial plexus injuries who have internal rotation contractures may benefit from soft-tissue release. When active external rotation is lacking, soft-tissue release combined with tendon transfer improved active external rotation in this small series. Future studies on the degree of glenohumeral deformities and functional outcome might give more insight into the level of increase in external rotation. LEVEL OF EVIDENCE Level III, therapeutic study.
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CORR Insights®: What Range of Motion is Achieved Five Years After an External Rotationplasty of the Shoulder in Infants with Obstetric Brachial Plexus Injury? Clin Orthop Relat Res 2020; 478:124-126. [PMID: 31764318 PMCID: PMC7000053 DOI: 10.1097/corr.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Nikolaou S, Cramer AA, Hu L, Goh Q, Millay DP, Cornwall R. Proteasome inhibition preserves longitudinal growth of denervated muscle and prevents neonatal neuromuscular contractures. JCI Insight 2019; 4:128454. [PMID: 31661460 DOI: 10.1172/jci.insight.128454] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 10/16/2019] [Indexed: 12/14/2022] Open
Abstract
Muscle contractures are a prominent and disabling feature of many neuromuscular disorders, including the 2 most common forms of childhood neurologic dysfunction: neonatal brachial plexus injury (NBPI) and cerebral palsy. There are currently no treatment strategies to directly alter the contracture pathology, as the pathogenesis of these contractures is unknown. We previously showed in a mouse model of NBPI that contractures result from impaired longitudinal muscle growth. Current presumed explanations for growth impairment in contractures focus on the dysregulation of muscle stem cells, which differentiate and fuse to existing myofibers during growth, as this process has classically been thought to control muscle growth during the neonatal period. Here, we demonstrate in a mouse model of NBPI that denervation does not prevent myonuclear accretion and that reduction in myonuclear number has no effect on functional muscle length or contracture development, providing definitive evidence that altered myonuclear accretion is not a driver of neuromuscular contractures. In contrast, we observed elevated levels of protein degradation in NBPI muscle, and we demonstrate that contractures can be pharmacologically prevented with the proteasome inhibitor bortezomib. These studies provide what we believe is the first strategy to prevent neuromuscular contractures by correcting the underlying deficit in longitudinal muscle growth.
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Affiliation(s)
| | - Alyssa Aw Cramer
- Division of Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | - Douglas P Millay
- Division of Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Roger Cornwall
- Division of Orthopaedic Surgery, and.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Russo SA, Zlotolow DA, Chafetz RS, Rodriguez LM, Kelly D, Linamen H, Richards JG, Lubahn JD, Kozin SH. Efficacy of 3 therapeutic taping configurations for children with brachial plexus birth palsy. J Hand Ther 2019; 31:357-370. [PMID: 28454773 DOI: 10.1016/j.jht.2017.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 12/10/2016] [Accepted: 03/20/2017] [Indexed: 02/09/2023]
Abstract
STUDY DESIGN Cross-sectional clinical measurement study. INTRODUCTION Scapular winging is a frequent complaint among children with brachial plexus birth palsy (BPBP). Therapeutic taping for scapular stabilization has been reported to decrease scapular winging. PURPOSE OF THE STUDY This study aimed to determine which therapeutic taping construct was most effective for children with BPBP. METHODS Twenty-eight children with BPBP participated in motion capture assessment with 4 taping conditions: (1) no tape, (2) facilitation of rhomboid major and rhomboid minor, (3) facilitation of middle and lower trapezius, and (4) facilitation of rhomboid major, rhomboid minor, and middle and lower trapezius (combination of both 2 and 3, referred to as combined taping). The participants held their arms in 4 positions: (1) neutral with arms by their sides, (2) hand to mouth, (3) hand to belly, and (4) maximum crossbody adduction (CBA). The scapulothoracic, glenohumeral and humerothoracic (HT) joint angles and joint angular displacements were compared using multivariate analyses of variance with Bonferroni corrections. RESULTS Scapular winging was significantly decreased in both the trapezius and combined taping conditions in all positions compared with no tape. Rhomboids taping had no effect. Combined taping reduced HT CBA in the CBA position. CONCLUSIONS Rhomboid taping cannot be recommended for treatment of children with BPBP. Both trapezius and combined taping approaches reduced scapular winging, but HT CBA was limited with combined taping. Therefore, therapeutic taping of middle and lower trapezius was the most effective configuration for scapular stabilization in children with BPBP. Resting posture improved, but performance of the positions was not significantly improved. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Stephanie A Russo
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center - Hamot, Erie, PA, USA.
| | - Dan A Zlotolow
- Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Ross S Chafetz
- Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Luisa M Rodriguez
- Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA
| | - Devin Kelly
- Movement Analysis Laboratory, Shriners Hospital for Children, Erie, PA, USA
| | - Holly Linamen
- Department of Physical and Occupational Therapy, Shriners Hospital for Children, Erie, PA, USA
| | - James G Richards
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, USA
| | - John D Lubahn
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center - Hamot, Erie, PA, USA
| | - Scott H Kozin
- Upper Extremity Center of Excellence, Shriners Hospital for Children, Philadelphia, PA, USA
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Jönsson K, Werner M, Roos F, Hultgren T. Development of the glenohumeral joint after subscapular release and open relocation in children with brachial plexus birth palsy: long-term results in 61 patients. J Shoulder Elbow Surg 2019; 28:1983-1990. [PMID: 31085034 DOI: 10.1016/j.jse.2019.02.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/19/2019] [Accepted: 02/27/2019] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Krister Jönsson
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Department of Hand Surgery, Södersjukhuset, Stockholm, Sweden.
| | - Michael Werner
- Department of Radiology, Södersjukhuset, Stockholm, Sweden
| | - Fredrik Roos
- Department of Hand Surgery, Södersjukhuset, Stockholm, Sweden
| | - Tomas Hultgren
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden; Department of Hand Surgery, Södersjukhuset, Stockholm, Sweden
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29
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Pons C, Eddi D, Le Gal G, Garetier M, Ben Salem D, Houx L, Fitoussi F, Quintero N, Brochard S. Effectiveness and safety of early intramuscular botulinum toxin injections to prevent shoulder deformity in babies with brachial plexus birth injury (POPB-TOX), a randomised controlled trial: study protocol. BMJ Open 2019; 9:e032901. [PMID: 31575585 PMCID: PMC6773354 DOI: 10.1136/bmjopen-2019-032901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION In children with brachial plexus birth injury (BPBI), denervation of the shoulder muscles leads to bony deformity in the first months of life, reducing active and passive range of motion (ROM) and causing activity limitation. The aim of this multicentre randomised controlled trial is to evaluate the effectiveness of botulinum toxin injections (BTI) in the shoulder internal rotator muscles of 12-month-old babies in limiting the progression of posterior subluxation of the glenohumeral joint, compared with a sham procedure mimicking BTI. The secondary aims are to evaluate the effectiveness of BTI in (1) limiting the progression of glenoid retroversion and three-dimensional (3D) deformity and (2) improving shoulder ROM and upper limb function, as well as to confirm the tolerance of BTI. METHODS AND ANALYSIS Sixty-two babies with unilateral BPBI and a risk of posterior humeral head subluxation will be included. Only those with at least 7% posterior subluxation of the humeral head compared with the contralateral shoulder on the MRI will be randomised to one of two groups: 'BTI' and 'Sham'. The BTI group will receive BOTOX injections at the age of 12 months in the internal shoulder rotator muscles (8 UI/kg). The sham group will undergo a sham BTI procedure. Both groups will undergo repeated shoulder MRI at 18 months of age to quantify changes in the percentage of posterior migration of the humeral head (primary outcome), glenoid version and 3D bone deformity. Clinical evaluations (passive shoulder ROM, active movement scale) will be carried out at baseline and 15 and 18 months of age. The mini-assisting hand assessment will be rated between 10 and 11 months and at 18 months of age. Adverse events will be recorded at least monthly for each child. ETHICS AND DISSEMINATION Full ethical approval for this study has been obtained. The findings will be disseminated in peer-reviewed publications. TRIAL REGISTRATION NUMBER EudraCT: 2015-001402-34 in European Clinical Trial database; NCT03198702 in Clinical Trial database; Pre-results.
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Affiliation(s)
- Christelle Pons
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
| | | | - Gregoire Le Gal
- Centre for Clinical Investigation INSERM CIC 1412, Brest CHRU, Brest, France
| | - Marc Garetier
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Radiology department, Hopital d'Instruction des Armees Clermont-Tonnerre, Brest, France
| | - Douraied Ben Salem
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Radiology department, Brest CHRU, Brest, France
- Medical School, Université de Bretagne Occidentale, Brest, France
| | - Laetitia Houx
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
| | - Franck Fitoussi
- CHU Paris Est - Hôpital d'Enfants Armand-Trousseau, Paris, France
| | - Nathaly Quintero
- Physical Medicine and Rehabilitation department, Hopitaux de Saint-Maurice, Saint Maurice, France
| | - Sylvain Brochard
- Pediatric rehabilitation department, Fondation ILDYS, Brest, France
- Laboratory of Medical Information Processing (LaTIM), INSERM UMR 1101, Brest, France
- Physical Medicine and Rehabilitation department, Brest CHRU, Brest, France
- Medical School, Université de Bretagne Occidentale, Brest, France
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Oka K, Murase T, Tanaka H, Kawabata H. The morphologic change of the elbow with flexion contracture in upper obstetric brachial plexus palsy. J Shoulder Elbow Surg 2019; 28:1764-1770. [PMID: 31043347 DOI: 10.1016/j.jse.2019.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/04/2019] [Accepted: 02/15/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Contracture of the elbow after obstetric brachial plexus palsy (OBPP) is well known; however, details of the 3-dimensional (3D) morphologic changes in the elbow joint in OBPP have not been clarified. This study aimed to clarify the 3D morphologic changes in the elbow joint by focusing on the distal humerus with flexion contracture in upper OBPP. We tested the hypothesis that the shape of the distal humerus with flexion contracture in upper OBPP is hypoplastic in the trochlea, capitellum, and olecranon fossa. METHODS We retrospectively studied 20 patients with elbow flexion contracture and residual OBPP. The approximate radius of the distal humerus, the shortest distance between the olecranon and coronoid fossa, and the size of the olecranon fossa were measured and compared between the affected and normal sides using 3D bone models to assess the distal humerus morphology. RESULTS The average radius of the distal humerus was smaller on the affected side than on the normal side. Furthermore, the average distance between the olecranon and coronoid fossa was greater and the average size of the olecranon fossa was smaller on the affected side than on the normal side. The size of the distal humerus was significantly smaller and the olecranon fossa was significantly shallower on the affected side. CONCLUSIONS Consistent with our original hypothesis, the distal humerus with flexion contracture in upper OBPP was hypoplastic. The shallow olecranon fossa might prevent full extension of the elbow even though soft tissue contracture release is performed. We recommend evaluation of the morphology of the olecranon fossa to determine the treatment plan for elbow flexion contracture with OBPP.
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Affiliation(s)
- Kunihiro Oka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan.
| | - Tsuyoshi Murase
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hiroyuki Tanaka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hidehiko Kawabata
- Department of Orthopaedic Surgery, Osaka Rehabilitation Hospital for Children, Osaka, Japan
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Sarac C, Hogendoorn S, Nelissen RGHH. A New Surgical Technique for Internal Shoulder Contractures Secondary to Obstetric Brachial Plexus Injury: An Anterior Coracohumeral Ligament Release. J Brachial Plex Peripher Nerve Inj 2019; 14:e35-e38. [PMID: 31413723 PMCID: PMC6692147 DOI: 10.1055/s-0039-1693746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/20/2019] [Indexed: 11/16/2022] Open
Abstract
Background
Obstetric brachial plexus injuries result from traction injury during delivery; 30% of these children sustain persisting functional limitations related to an external rotation deficit of the shoulder. The aim of this study was to compare the intraoperative gain in external rotation after a posterior subscapular release and an anterior coracohumeral ligament release.
Methods
This is a prospective study on 102 children with an internal rotation contracture of the shoulder who received either a posterior subscapular release (posterior skin incision along the medial border of the scapula of 3–5 cm) or an anterior (5-mm skin incision) coracohumeral ligament release between 1996 and 2010. After general anesthesia, internal and external rotations in both adduction and abduction were measured before and after the surgical release.
Results
After a posterior subscapular release, the intraoperative external rotation improved with a mean of 64 degrees (95% confidence interval [CI]: 54–74;
p
< 0.001) in adduction and with a mean of 41 degrees (95% CI: 32–49;
p
< 0.001) in abduction. After an anterior coracohumeral ligament release, external rotation increased with a mean of 61 degrees (95% CI: 56–66;
p
< 0.001) in adduction and a mean of 42 degrees in abduction (95%CI: 39–45,
p
< 0.001). Differences between these two groups were not statistically different.
Conclusion
The anterior release technique shows comparable results with the posterior subscapular release. And since it is performed through a smaller incision of 5 mm, this is our preferred method to increase passive external rotation.
Level of evidence
II.
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Affiliation(s)
- C Sarac
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - S Hogendoorn
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - R G H H Nelissen
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Olofsson PN, Chu A, McGrath AM. The Pathogenesis of Glenohumeral Deformity and Contracture Formation in Obstetric Brachial Plexus Palsy-A Review. J Brachial Plex Peripher Nerve Inj 2019; 14:e24-e34. [PMID: 31308856 PMCID: PMC6625958 DOI: 10.1055/s-0039-1692420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/05/2018] [Indexed: 01/25/2023] Open
Abstract
Contractures of the shoulder joint and glenohumeral joint dysplasia are well known complications to obstetrical brachial plexus palsy. Despite extensive description of these sequelae, the exact pathogenesis remains unknown. The prevailing theory to explain the contractures and glenohumeral joint dysplasia states that upper trunk injury leads to nonuniform muscle recovery and thus imbalance between internal and external rotators of the shoulder. More recently, another explanation has been proposed, hypothesizing that denervation leads to reduced growth of developing muscles and that reinnervation might suppress contracture formation. An understanding of the pathogenesis is desirable for development of effective prophylactic treatment. This article aims to describe the current state of knowledge regarding these important complications.
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Affiliation(s)
- Pontus N Olofsson
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Alice Chu
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, United States
| | - Aleksandra M McGrath
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.,Department of Clinical Science, Umeå University, Umeå, Sweden
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Dixit NN, McFarland DC, Saul KR. Computational analysis of glenohumeral joint growth and morphology following a brachial plexus birth injury. J Biomech 2019; 86:48-54. [PMID: 30797561 DOI: 10.1016/j.jbiomech.2019.01.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/29/2018] [Accepted: 01/21/2019] [Indexed: 02/02/2023]
Abstract
Children affected with brachial plexus birth injury (BPBI) undergo muscle paralysis. About 33% of affected children experience permanent osseous deformities of the glenohumeral joint. Recent evidence suggests that some cases experience restricted muscle longitudinal growth in addition to paralysis and reduced range of motion at the shoulder and elbow. It is unknown whether altered loading due to paralysis, muscle growth restriction and contracture, or static loading due to disuse is the primary driver of joint deformity after BPBI. This study uses a computational framework integrating finite element analysis and musculoskeletal modeling to examine the mechanical factors contributing to changes in bone growth and morphometry following BPBI. Simulations of 8 weeks of glenohumeral growth in a rat model of BPBI predicted that static loading of the joint is primarily responsible for joint deformation consistent with experimental measures of bone morphology, whereas dynamic loads resulted in normal bone growth. Under dynamic loading, glenoid version angle (GVA), glenoid inclination angle (GIA), and glenoid radius of curvature (GRC) (-1.3°, 38.2°, 2.5 mm respectively) were similar to the baseline values (-1.8°, -38°, 2.1 mm respectively). In the static case with unrestricted muscle growth, these measures increased in magnitude (5.2°, -48°, 3.5 mm respectively). More severe joint deformations were observed in GIA and GRC when muscle growth was restricted (GVA: 3.6°, GIA: -55°, GRC: 4.0 mm). Predicted morphology was consistent with literature reports of in vivo glenoid morphology following postganglionic BPBI. This growth model provides a framework for understanding the most influential mechanical factors driving glenohumeral deformity following BPBI.
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Affiliation(s)
- Nikhil N Dixit
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, United States
| | - Daniel C McFarland
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, United States
| | - Katherine R Saul
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, United States.
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Scapular Stabilization Limits Glenohumeral Stretching in Children With Brachial Plexus Injuries. J Hand Surg Am 2019; 44:63.e1-63.e9. [PMID: 29934088 DOI: 10.1016/j.jhsa.2018.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 03/14/2018] [Accepted: 04/20/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify the effects of scapular stabilization on scapulothoracic and glenohumeral (GH) stretching. METHODS Motion capture data during external rotation and abduction with and without scapular stabilization were collected and analyzed for 26 children with brachial plexus birth palsy. These positions were performed by an experienced occupational therapist and by the child's caretaker. Scapulothoracic and GH joint angular displacements were compared between stretches with no stabilization, stabilization performed by the therapist, and stabilization performed by the caretaker. The relationship between the age and ability of the therapist and caretaker to perform the stretches with scapular stabilization was also assessed. RESULTS During external rotation there were no significant differences in either the scapulothoracic or GH joint during stabilization by either the therapist or the caretaker. During abduction, both scapulothoracic and GH joint angular displacements were statistically different. Scapulothoracic upward rotation angular displacement significantly decreased with scapular stabilization by the therapist and caretaker. Glenohumeral elevation angular displacement significantly decreased with scapular stabilization performed by the therapist and caretaker. There were only weak correlations between age and the differences in scapulothoracic and GH joint angular displacement performed by both the therapist and the caretaker. CONCLUSIONS The findings of this study indicate that scapular stabilization may be detrimental to passive stretching of the GH joint in children, as demonstrated by a reduced stretch. Based on the findings of this study, we have changed our practice to recommend passive stretches without scapular stabilization for children aged 5 years and older with brachial plexus birth palsy. In infants and children aged less than 5 years, we now recommend stretching with and without scapular stabilization until the effect of scapular stabilization is objectively assessed in these age groups. LEVEL OF EVIDENCE/TYPE OF STUDY Therapeutic IV.
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van de Bunt F, Pearl ML, van Essen T, van der Sluijs JA. Humeral retroversion and shoulder muscle changes in infants with internal rotation contractures following brachial plexus birth palsy. World J Orthop 2018; 9:292-299. [PMID: 30598873 PMCID: PMC6306517 DOI: 10.5312/wjo.v9.i12.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/16/2018] [Accepted: 11/15/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To examine humeral retroversion in infants who sustained brachial plexus birth palsy (BPBI) and suffered from an internal rotation contracture. Additionally, the role of the infraspinatus (IS) and subscapularis (SSc) muscles in the genesis of this bony deformation is explored.
METHODS Bilateral magnetic resonance imaging (MRI) scans of 35 infants (age range: 2-7 mo old) with BPBI were retrospectively analyzed. Retroversion was measured according to two proximal axes and one distal axis (transepicondylar axis). The proximal axes were: (1) the perpendicular line to the borders of the articular surface (humeral centerline); and (2) the longest diameter through the humeral head. Muscle cross-sectional areas of the IS and SSc muscles were measured on the MRI-slides representing the largest muscle belly. The difference in retroversion was correlated with the ratio of muscle-sizes and passive external rotation measurements.
RESULTS Retroversion on the involved side was significantly decreased, 1.0° vs 27.6° (1) and 8.5° vs 27.2° (2), (P < 0.01), as compared to the uninvolved side. The size of the SSc and IS muscles on the involved side was significantly decreased, 2.26 cm² vs 2.79 cm² and 1.53 cm² vs 2.19 cm², respectively (P < 0.05). Furthermore, the muscle ratio (SSc/IS) at the involved side was significantly smaller compared to the uninvolved side (P = 0.007).
CONCLUSION Even in our youngest patient population, humeral retroversion has a high likelihood of being decreased. Altered humeral retroversion warrants attention as a structural change in any child being evaluated for the treatment of an internal rotation contracture.
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Affiliation(s)
- Fabian van de Bunt
- Department of Orthopedics, Amsterdam UMC, VU University Medical Center, Amsterdam 1081 HV, Netherlands
| | - Michael L Pearl
- Department of Shoulder and Elbow Surgery, Kaiser Permanente Medical Center, Los Angeles, Ca 90027, United States
| | - Tom van Essen
- Department of Orthopedics, Amsterdam UMC, VU University Medical Center, Amsterdam 1081 HV, Netherlands
| | - Johannes A van der Sluijs
- Department of Orthopedics, Amsterdam UMC, VU University Medical Center, Amsterdam 1081 HV, Netherlands
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36
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Hodgson F, Alabau-Rodriguez S, Barrera-Ochoa S, Gharbaoui I, Knörr J, Soldado F. Clinical measurements for inferior, posterior, and superior glenohumeral joint contracture evaluation in children with brachial plexus birth palsy: intraobserver and interobserver reliability. J Shoulder Elbow Surg 2018; 27:1779-1784. [PMID: 29859662 DOI: 10.1016/j.jse.2018.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 04/16/2018] [Accepted: 04/18/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Glenohumeral (GH) contractures appear in most patients with incomplete motor recovery as a result of progressive development of periarticular muscle contractures. The objectives of this study were to describe a method to measure the passive range of motion of the glenohumeral joint (GHJ) in patients with brachial plexus birth palsy (BPBP) and to evaluate its intraobserver and interobserver reproducibility. METHODS Three orthopedic surgeons measured the passive GHJ mobility of 25 patients older than 4 years with unilateral BPBP. Measurements were performed twice on both shoulders. They comprised the spinohumeral abduction angle (SHABD), spinohumeral adduction angle (SHADD), GH cross-body adduction (CBADD), and GH internal rotation in abduction (IRABD). Anterior GH contracture was not evaluated. RESULTS Passive shoulder measurements obtained from the uninvolved and involved shoulders were as follows: SHABD, 42° and 18°, respectively; SHADD, 14° and -1°, respectively; CBADD, 71° and 41°, respectively; and IRABD, 54° and 37°, respectively. Contracture of the lower portion of the involved GHJ was observed in 18 of 25 patients (72%); the upper portion, in 16 of 25 (64%); and the posterior portion, in 22 of 25 (88%). Interobserver variation (intraclass correlation coefficient) was 0.91 (excellent) for SHABD, 0.63 (good) for SHADD, 0.86 (excellent) for CBADD, and 0.67 (good) for IRABD. Intraobserver variation (intraclass correlation coefficient) was 0.94 (excellent) for SHABD, 0.87 (excellent) for SHADD, 0.92 (excellent) for CBADD, and 0.89 (excellent) for IRABD. CONCLUSIONS Clinical measurements of passive GHJ range-of-motion analyzed in this study showed excellent or good intraobserver and interobserver variability. Our study showed that BPBP resulted in a multidirectional GH contracture in most patients. We have described a simple and reliable way to evaluate passive GH motion, providing reliable anatomic landmarks.
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Affiliation(s)
- Felipe Hodgson
- Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Sergi Alabau-Rodriguez
- Pediatric Orthopaedic Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Sergi Barrera-Ochoa
- Pediatric Hand Surgery and Microsurgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Idriss Gharbaoui
- Pediatric Orthopaedic Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Jorge Knörr
- Pediatric Orthopaedic Surgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
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37
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Hennen K, Crouch DL, Hutchinson ID, Li Z, Saul K. Relationship between glenoid deformity and gait characteristics in a rat model of neonatal brachial plexus injury. J Orthop Res 2018; 36:1991-1997. [PMID: 29244216 DOI: 10.1002/jor.23836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 12/04/2017] [Indexed: 02/04/2023]
Abstract
UNLABELLED Neonatal brachial plexus injury (NBPI) results in substantial postural and functional impairments associated with underlying muscular and osseous deformities. We examined the relationship between glenoid deformity severity and gait in a rat model of NBPI, an established model for studying the in vivo pathomechanics of NBPI. At 8 weeks post-operatively, we monitored the gait of 24 rat pups who exhibited varying degrees of glenoid deformity following unilateral brachial plexus neurectomy and chemodenervation interventions administered 5 days postnatal. Five basic stride and stance metrics were calculated for the impaired forelimbs over four consecutive gait cycles. Bilateral differences in glenoid version (ΔGAv ) and inclination (ΔGAi ) angles were computed from data for the same rats as reported in a previous study. A linear regression model was generated for each deformity-gait pair to identify significant relationships between the two. ΔGAv was not significantly correlated with any gait measurements, while ΔGAi significantly correlated with all five gait measurements. Specifically, ΔGAi was significantly positively correlated with stride length (R2 = 0.38, p = 0.001) and stance factor (R2 = 0.45, p < 0.001), and significantly negatively correlated with stance width (R2 = 0.24, p = 0.016), swing/stance ratio (R2 = 0.17, p = 0.046), and stride frequency (R2 = 0.33, p = 0.003). Rats with declined glenoids exhibited the most altered gait. CLINICAL SIGNIFICANCE Our findings link musculoskeletal changes and functional outcomes in an NBPI rat model. Thus, gait analysis is a potentially useful, non-invasive, quantitative way to investigate the effects of injury and deformity on limb function in the NBPI rat model. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1991-1997, 2018.
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Affiliation(s)
- Kelsey Hennen
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, North Carolina
| | - Dustin L Crouch
- Department of Mechanical, Aerospace, and Biomedical Engineering, The University of Tennessee, Knoxville, Tennessee
| | - Ian D Hutchinson
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Zhongyu Li
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Katherine Saul
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, North Carolina
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Stein J, Laor T, Carr P, Zbojniewicz A, Cornwall R. The Effect of Scapular Position on Magnetic Resonance Imaging Measurements of Glenohumeral Dysplasia Caused by Neonatal Brachial Plexus Palsy. J Hand Surg Am 2017; 42:1030.e1-1030.e11. [PMID: 28823534 DOI: 10.1016/j.jhsa.2017.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Neonatal brachial plexus palsy (NBPP) frequently causes glenohumeral dysplasia. Quantification of this dysplasia on magnetic resonance imaging can determine the need for and the success of nonsurgical or surgical intervention. However, we hypothesize that the variable position of the scapula on the thorax between affected and unaffected shoulders affects dysplasia measurements. METHODS Magnetic resonance imaging studies were analyzed from 19 NBPP patients (ages 0.8-18 years; median, 2.4 years) without prior shoulder surgery. Three reviewers measured the glenoid version angle (GVA) and percentage of humeral head anterior to the midscapular line (PHHA) on standard axial images ("thoracic axial") and on reformatted axial images aligned perpendicular to the scapular plane ("scapular axial"), which corrects for scapulothoracic position. Scapular tilt and protraction were measured to assess their impact on the difference between thoracic and scapular GVA and PHHA measurements. Intra- and interrater reliability were calculated for GVA and PHHA on both views. RESULTS The GVA of the affected shoulder was significantly greater on thoracic than on scapular images, by an average of 5° and as much as 34°. The PHHA was significantly less in the affected shoulders on thoracic than on scapular images, by an average of 5% and as much as 33% of humeral head width. The difference in GVA, but not PHHA, between thoracic and scapular axial images in the affected shoulder correlated with scapular tilt. Unaffected shoulders showed no significant difference in GVA or PHHA between thoracic and scapular axial images. Interrater reliability ranged from fair to substantial and did not differ between thoracic and scapular images. CONCLUSIONS Thoracic axial images overestimate the severity of glenohumeral dysplasia in NBPP, owing at least in part to the variable position of the scapula on the thorax. This confounding effect must be considered in interpretation of axial quantitative measures of glenohumeral dysplasia in NBPP. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.
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Affiliation(s)
- Jill Stein
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tal Laor
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Preston Carr
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew Zbojniewicz
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Roger Cornwall
- Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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39
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Pons C, Sheehan FT, Im HS, Brochard S, Alter KE. Shoulder muscle atrophy and its relation to strength loss in obstetrical brachial plexus palsy. Clin Biomech (Bristol, Avon) 2017; 48:80-87. [PMID: 28783492 PMCID: PMC5628613 DOI: 10.1016/j.clinbiomech.2017.07.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 07/11/2017] [Accepted: 07/26/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment/prevention of shoulder muscle strength imbalances are major therapeutic goals for children with obstetrical brachial plexus palsy. The study aims were to characterize muscle atrophy in children/adolescents with unilateral obstetrical brachial plexus palsy, to quantify the agonist-antagonist muscle volume balance and the association between muscle volume and strength. METHODS Eight boys and four girls (age=12.1, standard deviation=3.3) participated in this case-control study. Three-dimensional magnetic resonance images of both shoulders were acquired. The unimpaired shoulder served as a reference. Volumes of deltoid, pectoralis major, supraspinatus, infraspinatus, teres major, subscapularis were calculated based on 3D models, derived through image segmentation. Maximal isometric torques were collected in six directions. FINDINGS All the major muscles studied were significantly atrophied. The teres major demonstrated the biggest difference in atrophy between groups (51 percentage points), the pectoralis major was the least atrophied (23 percentage points). The muscle volume distribution was significantly different between shoulders. Muscle volume could predict maximal voluntary isometric torques, but the regression coefficients were weaker on the impaired side (72% to 91% of the strength could be predicted in the uninvolved side and 24% to 90% in the involved side and external rotation strength could not be predicted). INTERPRETATION This study demonstrates muscle atrophy varied across all the main shoulder muscles of the glenohumeral joint, leading to significant muscle volume imbalances. The weaker coefficients of determination on the impaired side suggest that other variables may contribute to the loss of strength in addition to atrophy.
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Affiliation(s)
- Christelle Pons
- Rehabilitation Medicine Department, University Hospital of Brest, 2 avenue Foch, 29609 Brest cedex, France
| | - Frances T Sheehan
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, 9000 Rockville Pike Bethesda, Maryland 20892, USA
| | - Hyun Soo Im
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, 9000 Rockville Pike Bethesda, Maryland 20892, USA
| | | | - Katharine E Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, 9000 Rockville Pike Bethesda, Maryland 20892, USA
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Shen H, Lim C, Schwartz AG, Andreev-Andrievskiy A, Deymier AC, Thomopoulos S. Effects of spaceflight on the muscles of the murine shoulder. FASEB J 2017; 31:5466-5477. [PMID: 28821629 DOI: 10.1096/fj.201700320r] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 07/31/2017] [Indexed: 12/31/2022]
Abstract
Mechanical loading is necessary for the development and maintenance of the musculoskeletal system. Removal of loading via microgravity, paralysis, or bed rest leads to rapid loss of muscle mass and function; however, the molecular mechanisms that lead to these changes are largely unknown, particularly for the spaceflight (SF) microgravity environment. Furthermore, few studies have explored these effects on the shoulder, a dynamically stabilized joint with a large range of motion; therefore, we examined the effects of microgravity on mouse shoulder muscles for the 15-d Space Transportation System (STS)-131, 13-d STS-135, and 30-d Bion-M1 missions. Mice from STS missions were euthanized within 4 h after landing, whereas mice from the Bion-M1 mission were euthanized within 14 h after landing. The motion-generating deltoid muscle was more sensitive to microgravity than the joint-stabilizing rotator cuff muscles. Mice from the STS-131 mission exhibited reduced myogenic (Myf5 and -6) and adipogenic (Pparg, Cebpa, and Lep) gene expression, whereas either no change or an increased expression of these genes was observed in mice from the Bion-M1 mission. In summary, muscle responses to microgravity were muscle-type specific, short-duration SF caused dramatic molecular changes to shoulder muscles and responses to reloading upon landing were rapid.-Shen, H., Lim, C., Schwartz, A. G., Andreev-Andrievskiy, A., Deymier, A. C., Thomopoulos, S. Effects of spaceflight on the muscles of the murine shoulder.
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Affiliation(s)
- Hua Shen
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
| | - Chanteak Lim
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
| | - Andrea G Schwartz
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
| | - Alexander Andreev-Andrievskiy
- Institute for Biomedical Problems, Russian Academy of Sciences, Moscow, Russia.,Biology Faculty, M.V. Lomonosov Moscow State University, Moscow, Russia
| | - Alix C Deymier
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Columbia University, New York, New York, USA; .,Department of Biomedical Engineering, Columbia University, New York, New York, USA
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Kalia V, Leung DG, Sneag DB, Del Grande F, Carrino JA. Advanced MRI Techniques for Muscle Imaging. Semin Musculoskelet Radiol 2017; 21:459-469. [PMID: 28772322 DOI: 10.1055/s-0037-1604007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AbstractAdvanced magnetic resonance imaging (MRI) techniques can evaluate a wide array of muscle pathologies including acute or chronic muscle injury, musculotendinous response to injury, intramuscular collections and soft tissue masses, and others. In recent years, MRI has played a more important role in muscle disease diagnosis and monitoring. MRI provides excellent spatial and contrast resolution and helps direct optimal sites for muscle biopsy. Whole-body MRI now helps identify signature patterns of muscular involvement in large anatomical regions with relative ease. Quantitative MRI has advanced the evaluation and disease tracking of muscle atrophy and fatty infiltration in entities such as muscular dystrophies. Multivoxel magnetic resonance spectroscopy (MRS) now allows a more thorough, complete evaluation of a muscle of interest without the inherent sampling bias of single-voxel MRS or biopsy. Diffusion MRI allows quantification of muscle inflammation and capillary perfusion as well as muscle fiber tracking.
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Affiliation(s)
- Vivek Kalia
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
| | - Doris G Leung
- The Center for Genetic Muscle Disorders, Kennedy Krieger Institute, Baltimore, Maryland
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
| | - Filippo Del Grande
- Servizio si Radiologia del Sottoceneri, Ospedale Regionale di Lugano, Lugano, Ticino, Switzerland
| | - John A Carrino
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
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42
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Botulinum Toxin Injection for Internal Rotation Contractures in Brachial Plexus Birth Palsy. A Minimum 5-Year Prospective Observational Study. J Pediatr Orthop 2017; 37:e209-e215. [PMID: 27280900 DOI: 10.1097/bpo.0000000000000808] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Brachial plexus birth palsy is frequently associated with internal rotation contractures of the shoulder as a result of muscle imbalance. The purpose of this study is to assess the effect of botulinum toxin A (BTX-A) injection in the subscapular (SC) muscle on external rotation and the need for tendon transfer for external rotation of the shoulder. METHODS A prospective comparative study was performed including 15 consecutive patients treated with BTX-A and a historic control group of 67 patients with mean age 30 months (SD 10). The BTX-A injection (2 IU/kg body weight) was performed immediately following MRI under general anesthesia in the SC muscle. Passive external rotation, the need for tendon transfer surgery, glenohumeral deformity, and muscle degeneration were evaluated. The hazard ratio for no relapse of internal rotation contracture after BTX-A injection compared with no BTX-A injection was calculated. RESULTS In the BTX-A group, the passive external rotation in adduction increased from -1 degree (95% CI, -10 to 8) to 32 degrees (95% CI, 17-46) at 3 months and 6 patients were indicated for surgery compared with a decline from -2 degrees (95% CI, -7 to 3) to -11 degrees (95% CI, -17 to -6) in the control group with 66 indications for surgery. At 5 years of follow-up, 10 patients in the BTX-A group were indicated for surgery with a hazard ratio of 4.0 (95% CI, 1.9 to 8.4). CONCLUSIONS BTX-A injection in the SC muscle of brachial plexus birth palsy patients can reduce internal rotation contractures and subsequently the need for tendon transfer surgery. At 5 years of follow-up a relapse was seen in 67% of the patients treated with BTX-A. Because at MRI less SC degeneration was found in the good responders on BTX-A treatment, this group seems to be the best target group. Further research is needed on patient selection for BTX-A injection including glenohumeral deformity, SC degeneration, as well as doses of BTX-A to be used. LEVEL OF EVIDENCE Level II-prospective comparative study.
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van de Bunt F, Pearl ML, Lee EK, Peng L, Didomenico P. Analysis of normal and dysplastic glenohumeral morphology at magnetic resonance imaging in children with neonatal brachial plexus palsy. Pediatr Radiol 2017; 47:1337-1344. [PMID: 28676895 PMCID: PMC5574959 DOI: 10.1007/s00247-017-3882-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/28/2017] [Accepted: 04/27/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Glenoid version and percentage of the humeral head anterior to the scapular line are commonly used 2-D measures to assess deformity of the glenohumeral joint of children with neonatal brachial plexus palsy. OBJECTIVE To assess whether glenoid version and percentage of the humeral head anterior to the scapular line would be altered by standardizing the measurements to the orientation of the scapula. MATERIALS AND METHODS Twenty-one bilateral magnetic resonance imaging (MRI) scans were evaluated by four reviewers. Measurements were performed on the axial image slices and again after applying 3-D reformatting. RESULTS Three-dimensional reformatting led to intrapatient corrections up to 25° for version and -30% for percentage of the humeral head anterior to the scapular line. The mean difference on the involved side between clinical and anatomical version across all subjects from all reviewers was 2.2° ± 3.9° (range: -4.5° to 11.5°). The mean difference in the percentage of the humeral head anterior to the scapular line after reformatting was -1.8% (range: -15.9% to 5.2%). CONCLUSION Measurements can differ greatly for the same child depending on technical factors of image acquisition and presentation in the clinical setting. With this study, we present a clinically accessible protocol to correct for scapular orientation from MRI data of children with neonatal brachial plexus palsy.
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Affiliation(s)
- Fabian van de Bunt
- VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Michael L Pearl
- Kaiser Permanente, 4760 Sunset Blvd Ste. 1213, Los Angeles, CA, 90027, USA
| | - Eric K Lee
- Kaiser Permanente, 4760 Sunset Blvd Ste. 1213, Los Angeles, CA, 90027, USA
| | - Lauren Peng
- Kaiser Permanente, 4760 Sunset Blvd Ste. 1213, Los Angeles, CA, 90027, USA
| | - Paul Didomenico
- Kaiser Permanente, 4760 Sunset Blvd Ste. 1213, Los Angeles, CA, 90027, USA
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Duijnisveld BJ, Henseler JF, Reijnierse M, Fiocco M, Kan HE, Nelissen RGHH. Quantitative Dixon MRI sequences to relate muscle atrophy and fatty degeneration with range of motion and muscle force in brachial plexus injury. Magn Reson Imaging 2016; 36:98-104. [PMID: 27989913 DOI: 10.1016/j.mri.2016.10.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/14/2016] [Accepted: 10/26/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Assessment of muscle atrophy and fatty degeneration in brachial plexus injury (BPI) could yield valuable insight into pathophysiology and could be used to predict clinical outcome. The objective of this study was to quantify and relate fat percentage and cross-sectional area (CSA) of the biceps to range of motion and muscle force of traumatic brachial plexus injury (BPI) patients. METHODS T1-weighted TSE sequence and three-point Dixon images of the affected and non-affected biceps brachii were acquired on a 3 Tesla magnetic resonance scanner to determine the fat percentage, total and contractile CSA of 20 adult BPI patients. Regions of interest were drawn by two independent investigators to determine the inter-observer reliability. Paired Students' t-test and multivariate analysis were used to relate fat percentage, total and contractile CSA to active flexion and biceps muscle force. RESULTS The mean fat percentage 12±5.1% of affected biceps was higher than 6±1.0% of the non-affected biceps (p<0.001). The mean contractile CSA 8.1±5.1cm2 of the affected biceps was lower than 19.4±4.9cm2 of the non-affected biceps (p<0.001). The inter-observer reliability was excellent (ICC 0.82 to 0.96). The contractile CSA contributed most to the reduction in active flexion and muscle force. CONCLUSION Quantitative measurement of fat percentage, total and contractile CSA using three-point Dixon sequences provides an excellent reliability and relates with active flexion and muscle force in BPI.
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Affiliation(s)
- Bouke J Duijnisveld
- Department of Orthopaedics, Leiden University Medical Center, The Netherlands.
| | | | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, The Netherlands
| | - Marta Fiocco
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, The Netherlands; Mathematica institute Leiden University, Leiden University Medical Center, The Netherlands
| | - Hermien E Kan
- C.J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, The Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, The Netherlands
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Russo SA, Rodriguez LM, Kozin SH, Zlotolow DA, Chafetz RS, Killelea CM, Nicholson KF, Richards JG. Therapeutic Taping for Scapular Stabilization in Children With Brachial Plexus Birth Palsy. Am J Occup Ther 2016; 70:7005220030p1-7005220030p11. [DOI: 10.5014/ajot.2016.018903] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abstract
OBJECTIVE. In this study, we aimed to assess whether therapeutic taping for scapular stabilization affected scapulothoracic, glenohumeral, and humerothoracic joint function in children with brachial plexus birth palsy and scapular winging.
METHOD. Motion capture data were collected with and without therapeutic taping to assist the middle and lower trapezius in seven positions for 26 children. Data were compared with one-way multivariate analyses of variance.
RESULTS. With therapeutic taping, scapular winging decreased considerably in all positions except abduction. Additionally, there were increased glenohumeral cross-body adduction and internal rotation angles in four positions. The only change in humerothoracic function was an increase of 3° of external rotation in the external rotation position.
CONCLUSION. Therapeutic taping for scapular stabilization resulted in a small but statistically significant decrease in scapular winging. Overall performance of positions was largely unchanged. The increased glenohumeral joint angles with therapeutic taping may be beneficial for joint development; however, the long-term impact remains unknown.
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Affiliation(s)
- Stephanie A. Russo
- Stephanie A. Russo, MD, PhD, is Resident Physician, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center—Hamot, Erie, PA;
| | - Luisa M. Rodriguez
- Luisa M. Rodriguez, OTR/L, is Occupational Therapist, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA
| | - Scott H. Kozin
- Scott H. Kozin, MD, is Chief of Staff and Hand Surgeon, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA, and Department of Orthopaedic Surgery, Temple University, Philadelphia, PA
| | - Dan A. Zlotolow
- Dan A. Zlotolow, MD, is Hand Surgeon, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA, and Department of Orthopaedic Surgery, Temple University, Philadelphia, PA
| | - Ross S. Chafetz
- Ross S. Chafetz, DPT, PhD, is Motion Analysis Laboratory Physical Therapist, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA
| | - Carolyn M. Killelea
- Carolyn M. Killelea, PhD, is Motion Analysis Laboratory Engineer, Upper Extremity Center of Excellence, Shriners Hospitals for Children, Philadelphia, PA
| | - Kristen F. Nicholson
- Kristen F. Nicholson, PhD, is Motion Analysis Laboratory Biomechanist, Gait Analysis Laboratory, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
| | - James G. Richards
- James G. Richards, PhD, is Distinguished Professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark
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Abstract
The treatment of infants with brachial plexus birth palsy (BPBP) continues to be a focus at Boston Children's Hospital. Over the last 15 years, there have been many developments in the treatment of infants with BPBP. Some of the greatest changes have emerged through technical advances such as the advent of distal nerve transfers to allow targeted reinnervation as well as through research to understand the pathoanatomical changes that lead to glenohumeral dysplasia and how this dysplasia can be remodeled. This review will discuss our current practice of evaluation of the infant with BPBP, techniques for microsurgical reconstruction, and prevention and treatment of secondary glenohumeral dysplasia.
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Brochard S, Mozingo JD, Alter KE, Sheehan FT. Three dimensionality of gleno-humeral deformities in obstetrical brachial plexus palsy. J Orthop Res 2016; 34:675-82. [PMID: 26363273 PMCID: PMC5537731 DOI: 10.1002/jor.23049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/09/2015] [Indexed: 02/04/2023]
Abstract
The primary objective of this study was to test the hypothesis that gleno-humeral deformity in children and adolescent with obstetrical brachial plexus palsy is three-dimensional (3D). The study also compared the metrological properties of typical two-dimensional gleno-humeral measures to the newly developed 3D measures. Thirteen individuals (age = 11.8 ± 3.3 years) with obstetrical brachial plexus palsy participated in this IRB-approved study. 3D axial magnetic resonance images were acquired for both shoulders. Glenoid and humeral models were created in order to quantify 3D glenoid version, humeral head migration, and glenoid concavity. Two-dimensional (2D) measures were acquired as recommended in the literature. All measures were completed by two observers in this observer-blind study. Compared to the non-involved side, the glenoid was more retroverted (7.91°, p = 0.003) and inferiorly oriented (7.28°, p = 0.009). The humeral head was migrated more posteriorly (5.54 mm, p = 0.007), inferiorly (-3.96 mm, p = 0.013), and medially (-3.63 mm,p = 0.002). Eleven of the 13 glenoids were concave, based on the 3D glenoid models. The concurrent validity between three- and 2D measures were highly dependent of the parameter measured, the slice level used for the 2D analysis, and the presence/absence of pathology (0.63 < r < 0.91). The standard error of measurement for the 2D anterior-posterior version (>3°) was larger than that for the 3D measure of version (<1°) on the involved side. This study clearly demonstrated that the gleno-humeral deformation in obstetrical brachial plexus palsy is 3D, emphasizing the need for 3D subject specific gleno-humeral shape analysis for follow-up and treatment plans in children with obstetrical brachial plexus palsy.
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Affiliation(s)
- Sylvain Brochard
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland,Rehabilitation Medicine Department, University Hospital of Brest, Brest, France,LaTIM, INSERM U1101 Brest, France
| | - Joseph D. Mozingo
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland,Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota 55905
| | - Katharine E. Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland,Mt Washington Pediatric Hospital, Baltimore, Maryland
| | - Frances T. Sheehan
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, Maryland
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48
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Eismann EA, Laor T, Cornwall R. Three-Dimensional Magnetic Resonance Imaging of Glenohumeral Dysplasia in Neonatal Brachial Plexus Palsy. J Bone Joint Surg Am 2016; 98:142-51. [PMID: 26791035 DOI: 10.2106/jbjs.o.00435] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Existing quantitative measurements of glenohumeral dysplasia in children with unresolved neonatal brachial plexus palsy (NBPP) have been mostly limited to the axial plane. The purpose of this study was to describe the three-dimensional (3D) pathoanatomy of glenohumeral dysplasia using 3D magnetic resonance imaging (MRI) reformations. METHODS 3D MRI reformations of the scapula, glenoid labrum, and proximal part of the humerus were created from a volume-acquisition proton-density-weighted MRI sequence of both the affected and the unaffected shoulder of seventeen children less than six years of age with unresolved NBPP who had not undergone shoulder surgery. Glenoid retroversion and posterior humeral head displacement were measured on axial 2D images. Humeral head displacement in all planes, labral circumference, glenoid retroversion, glenoid declination, and scapular morphometric values were measured on 3D reformations. Contiguity of the humeral head with the labrum and the shape of the glenoid were classified. Measurements were compared between the affected and unaffected sides. RESULTS On 3D evaluation, the humeral head was completely posteriorly translated in ten patients but was never outside the glenoid labrum. Instead, in these patients, the humeral head was eccentrically articulating with the dysplastic glenoid and was contained by a posteriorly elongated labrum. Glenoid dysplasia was not limited to the axial plane. Less declination of the glenoid in the coronal plane correlated with greater 3D glenoid retroversion. Glenoid retroversion resulted from underdevelopment of the posterior aspect of the glenoid rather than overdevelopment of the anterior aspect of the glenoid. 3D measurements of greater glenoid retroversion and less declination correlated with 2D measurements of glenoid retroversion and posterior humeral head displacement. CONCLUSIONS Posterior humeral head displacement in NBPP should not be considered a simple "dislocation." Glenohumeral dysplasia is not limited to the axial plane. Abnormal glenoid declination may have potential implications for the evaluation and treatment of shoulder weakness and contractures.
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Affiliation(s)
- Emily A Eismann
- Division of Orthopaedic Surgery (E.A.E. and R.C.) and Department of Radiology (T.L.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tal Laor
- Division of Orthopaedic Surgery (E.A.E. and R.C.) and Department of Radiology (T.L.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Roger Cornwall
- Division of Orthopaedic Surgery (E.A.E. and R.C.) and Department of Radiology (T.L.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Limited glenohumeral cross-body adduction in children with brachial plexus birth palsy: a contributor to scapular winging. J Pediatr Orthop 2015; 35:240-5. [PMID: 24992351 DOI: 10.1097/bpo.0000000000000242] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Approximately 1 of every 1000 live births results in life-long impairments because of a brachial plexus injury. The long-term sequelae of persistent injuries include glenohumeral joint dysplasia and glenohumeral internal rotation and adduction contractures. Scapular winging is also common, and patients and their families often express concern regarding this observed scapular winging. It is difficult for clinicians to adequately address these concerns without a satisfying explanation for why scapular winging occurs in children with brachial plexus birth palsy. This study examined our proposed theory that a glenohumeral cross-body abduction contracture leads to the appearance of scapular winging in children with residual brachial plexus birth palsy. METHODS Sixteen children with brachial plexus injuries were enrolled in this study. Three-dimensional locations of markers placed on the thorax, scapula, and humerus were recorded in the hand to mouth Mallet position. The unaffected limbs served as a control. Scapulothoracic and glenohumeral cross-body adduction angles were compared between the affected and unaffected limbs. RESULTS The affected limbs demonstrated significantly greater scapulothoracic and significantly smaller glenohumeral cross-body adduction angles than the unaffected limbs. The affected limbs also exhibited a significantly lower glenohumeral cross-body adduction to scapulothoracic cross-body adduction ratio. CONCLUSIONS The results of this study support the theory that brachial plexus injuries can lead to a glenohumeral cross-body abduction contracture. Affected children demonstrated increased scapulothoracic cross-body adduction that is likely a compensatory mechanism because of decreased glenohumeral cross-body adduction. These findings are unique and better define the etiology of scapular winging in children with brachial plexus injuries. This information can be relayed to patients and their families when explaining the appearance of scapular winging. LEVEL OF EVIDENCE Level II.
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50
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van Gelein Vitringa VM, van Noort A, Ritt MJPF, van Royen BJ, van der Sluijs JA. Degree of Contracture Related to Residual Muscle Shoulder Strength in Children with Obstetric Brachial Plexus Lesions. J Brachial Plex Peripher Nerve Inj 2015; 10:e23-e29. [PMID: 27917235 DOI: 10.1055/s-0035-1558425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 06/03/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known about the relation between residual muscle strength and joint contracture formation in neuromuscular disorders. This study aimed to investigate the relation between residual muscle strength and shoulder joint contractures in children with sequelae of obstetric brachial plexus lesion (OBPL). In OBPL a shoulder joint contracture is a frequent finding. We hypothesize that residual internal and external rotator strength and their balance are related to the extent of shoulder joint contracture. METHODS Clinical assessment was performed in 34 children (mean 10.0 years) with unilateral OBPL and Narakas classes I-III. External and internal rotation strengths were measured with the shoulder in neutral position using a handheld dynamometer. Strength on the affected side was given as percentage of the normal side. Contracture was assessed by passive internal and external rotations in degrees (in 0° abduction). Mallet classification was used for active shoulder function. RESULTS External and internal rotation strengths on the affected side were approximately 50% of the normal side and on average both equally affected: 56% (SD 18%) respectively 51% (SD 27%); r = 0.600, p = 0.000. Residual strengths were not related to passive internal or external rotation (p > 0.200). Internal rotation strength (r = - 0.425, p <0.05) was related to Narakas class. Mallet score was related to external and internal rotation strengths (r = 0.451 and r = 0.515, respectively; p < 0.01). CONCLUSION The intuitive notion that imbalances in residual muscle strength influence contracture formation cannot be confirmed in this study. Our results are of interest for the understanding of contracture formation in OBPL.
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Affiliation(s)
| | - Arthur van Noort
- Department of Orthopaedic Surgery, Spaarne Ziekenhuis, Hoofddorp, The Netherlands
| | - Marco J P F Ritt
- Department of Plastic Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - Barend J van Royen
- Department of Orthopaedic Surgery, VU Medical Center, Amsterdam, The Netherlands
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