Publications (3)0 Total impact
-
Article: Arm rotated medially with supination – the ARMS variant: description of its surgical correction
[show abstract] [hide abstract]
ABSTRACT: Abstract Background Patients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SHEAR deformity commonly occurs in conjunction with Medial Rotation Contracture (MRC) of the arm. OBPI also causes muscle imbalances at the level of the forearm, that lead to a fixed supination deformity (SD) in a small number of patients. Both MRC and SD will cause severe functional limitations without surgical intervention. Methods Fourteen OBPI patients were diagnosed with MRC of the shoulder and SD of the forearm along with SHEAR deformity during a 16 month study period, with eight patients available to long-term follow-up (age range 2.2 – 18 years). Surgical correction of the MRC was performed as a triangle tilt or humeral osteotomy depending on the age of the child, after which, the patients were treated with a radial osteotomy to correct the fixed supination deformity. Function was assessed using the modified Mallet scale, examination of apparent supination and appearance of the extremity at rest. Results Significant functional improvements were observed in patients with surgical reconstruction. Mallet score increased by an average of 5.2 (p < 0.05). Overall forearm position was not significantly changed from an average of 5° to an average of 34° maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries. Conclusion The simultaneous presence of two opposing deformities in the same limb will visually offset each other at the level of the wrist and hand, giving the false impression of neutral positioning of the limb. In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder. Both of these deformities require surgical attention, and the presence of concurrent MRC and SD should be monitored for in OBPI patients.BMC Musculoskeletal Disorders. 01/2009; -
Article: Rapid recovery of serratus anterior muscle function after microneurolysis of long thoracic nerve injury
[show abstract] [hide abstract]
ABSTRACT: Abstract Background Injury to the long thoracic nerve is a common cause of winging scapula. When the serratus anterior muscle is unable to function, patients often lose the ability to raise their arm overhead on the affected side. Methods Serratus anterior function was restored through decompression, neurolysis, and tetanic electrical stimulation of the long thoracic nerve. This included partial release of constricting middle scalene fibers and microneurolysis of epineurium and perineurium of the long thoracic nerve under magnification. Abduction angle was measured on the day before and the day following surgery. Results In this retrospective study of 13 neurolysis procedures of the long thoracic nerve, abduction is improved by 10% or greater within one day of surgery. The average improvement was 59° (p < 0.00005). Patients had been suffering from winging scapula for 2 months to 12 years. The improvement in abduction is maintained at last follow-up, and winging is also reduced. Conclusion In a notable number of cases, decompression and neurolysis of the long thoracic nerve leads to rapid improvements in winging scapula and the associated limitations on shoulder movement. The duration of the injury and the speed of improvement lead us to conclude that axonal channel defects can potentially exist that do not lead to Wallerian degeneration and yet cause a clear decrease in function.Journal of Brachial Plexus and Peripheral Nerve Injury. 01/2007; -
Article: Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: Evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture
[show abstract] [hide abstract]
ABSTRACT: Abstract Background The current method of treatment for persistent internal rotation due to the medial rotation contracture in patients with obstetric brachial plexus injury is humeral derotational osteotomy. While this procedure places the arm in a more functional position, it does not attend to the abnormal glenohumeral joint. Poor positioning of the humeral head secondary to elevation and rotation of the scapula and elongated acromion impingement causes functional limitations which are not addressed by derotation of the humerus. Progressive dislocation, caused by the abnormal positioning and shape of the scapula and clavicle, needs to be treated more directly. Methods Four patients with Scapular Hypoplasia, Elevation And Rotation (SHEAR) deformity who had undergone unsuccessful humeral osteotomies to treat internal rotation underwent acromion and clavicular osteotomy, ostectomy of the superomedial border of the scapula and posterior capsulorrhaphy in order to relieve the torsion developed in the acromio-clavicular triangle by persistent asymmetric muscle action and medial rotation contracture. Results Clinical examination shows significant improvement in the functional movement possible for these four children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy. Conclusion These results reveal the importance of recognizing the presence of scapular hypoplasia, elevation and rotation deformity before deciding on a treatment plan. The Triangle Tilt procedure aims to relieve the forces acting on the shoulder joint and improve the situation of the humeral head in the glenoid. Improvement in glenohumeral positioning should allow for better functional movements of the shoulder, which was seen in all four patients. These dramatic improvements were only possible once the glenohumeral deformity was directly addressed surgically.Journal of Brachial Plexus and Peripheral Nerve Injury. 01/2006;
