Mayo Clinic investigators found shoulder function improved in older
children with obstetric
brachial plexus injury after undergoing
glenoid reconstruction, tendon transfers and other procedures,
according to a study presented at the
2011 Annual Meeting of the American Society for Surgery of the
To restore the rotator cuff or deltoid function of pediatric patients,
Bassem T. Elhassan, MD, released the patients’
internal rotation shoulder contractures, reduced the shoulder,
reconstructed the glenoid with
tricortical iliac crest bone grafting and performed tendon
“Good short-term outcome is expected after such a
reconstruction,” Elhassan said during his presentation.
Elhassan and his team performed the procedures on 13 boys and eight
girls with a mean age of 12 years who presented with limited range of motion
secondary to shoulder internal rotation contracture and had limited active and
passive external rotation. The patients also presented with
glenohumeral dysplasia with significant loss of the bony
posterior glenoid that was associated with posterior shoulder subluxation or
dislocation, according to the abstract.
Postoperatively, patients underwent CT scans at 8 weeks and 1 year. If
their shoulders were not functioning properly preoperatively, Elhassan
performed an anterior shoulder release with lengthening of the subscapularis
and performed posterior glenoid reconstruction with iliac crest tricortical
bone grafting. He also performed lower trapezius transfer to restore external
rotation in each patient.
preoperative CT scan shows a patient who underwent bony reconstruction of the
A postoperative CT scan of a patient who underwent bony
reconstruction of the glenoid is shown here.
Images: Elhassan BT
“Saving the subscapularis by lengthening it rather than releasing
it fully and lower trapezius transfer to the infraspinatus are essential to
restore the glenohumeral joint force couple and stabilize the shoulder,”
Also, “glenoid reconstruction is often needed in delayed
presentation of obstetric brachial plexus injury [OBPI],” Elhassan said.
Furthermore, Elhassan performed other transfers to restore rotator cuff
or deltoid function, including levator scapulae, teres major, upper/middle
trapezius, upper serratus or pedicled latissimus transfers.
Significant improvement seen
After surgery, shoulder spica casts in abduction-external rotation were
applied on patients who underwent such surgery for 8 weeks, after which the
patients began a rehabilitation program.
At the 2-year follow-up, each patient showed significant improvement of
external shoulder rotation improving from –60° preoperatively to
37° postoperatively. Shoulder flexion improved from 80° to 130°,
and shoulder abduction increased from 40° to 90°. No patient lost range
of motion, specifically internal rotation. Mean Mallet scores increased from
9.3 to 18.1 points. All patients who underwent bone grafting healed without
signs of resorption. Patients reported they were satisfied with the procedure.
“Long-term results are needed to better evaluate this surgical
approach,” Elh assan said. – by Renee Blisard
- Elhassan BT, Spinner RJ, Bishop AT, et al. Glenoid reconstruction,
lower trapezius transfer and other tendon transfers in older children with
obstetric brachial plexus palsy. Paper #54. Presented at the 2011 Annual
Meeting of the American Society for Surgery of the Hand. Sept. 8-10. Las Vegas.
- Bassem T. Elhassan, MD, can be reached at the Department of
Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905;
507-538-3270; email: firstname.lastname@example.org.
- Disclosure: Elhassan has no relevant financial
This study addresses a novel approach when addressing significant
glenohumeral dysplasia after obstetric brachial plexus palsy (OBPP). Typically,
derotational humeral osteotomy is performed once glenohumeral dysplasia is
present. The improvements in external rotation, shoulder flexion and abduction
are significant and likely will improve the child’s functional abilities
as demonstrated by the doubling of the aggregate Mallet scores.
However, I do have some cautions for the surgeon attempting this
reconstructive procedure. First, the procedure is technically demanding and
should be performed by individuals knowledgeable about normal glenoid anatomy
as well as tendon transfers about the shoulder to restore external rotation.
Second, the authors demonstrated improved range of motion and Mallet scores but
did not evaluate whether these children are experiencing painful motion. Third,
as the Mallet outcome measure is heavily weighted toward external rotation, we
do not know if these children lost significant internal rotation function
including their ability to reach midline. Lastly, we do not know the long-term
success rates with regard to maintenance of improved range of motion,
glenohumeral joint reduction, pain and function. In conclusion, this study
offers an alternative technique of shoulder reconstruction in older children
with OBPP to restore glenohumeral joint reduction and improve external
— Joshua M. Abzug, MD
University of Maryland School of Medicine
Disclosure: Abzug has no relevant financial disclosures.