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The Importance of Shoulder External Rotation in Activities of Daily Living: Improving Outcomes in Traumatic Brachial Plexus Palsy
Abstract
To define the importance of shoulder external rotation in activities of daily living in normal individuals to better understand how restoration of shoulder external rotation in traumatic brachial plexus palsy could improve patient function.
Thirty-one normal individuals performed 12 common activities of daily living (ADLs) wearing a custom shoulder orthosis designed to selectively limit shoulder external rotation to 3 different settings, ranging from 0° (most restrictive) to 90° (least restrictive) of external rotation. Outcomes were measured with a visual analog scale of perceived difficulty in accomplishing the ADLs with each orthosis setting and the Disabilities of the Arm, Shoulder, and Hand questionnaire administered after each set of 12 ADLs was completed.
Subjects perceived increasing difficulty during all ADLs tested and registered higher disability scores with increasing restriction of shoulder external rotation. The ADLs requiring motions predominantly above the waist exhibited more marked and earlier changes in visual analog scale scores with increasing shoulder external rotation restriction.
Traditionally, surgeons have pursued restoration of shoulder abduction and forward elevation in secondary reconstruction of traumatic brachial plexus injuries. Recently, the concept of preferentially restoring shoulder external rotation has been proposed, without clear evidence in the literature of the role of shoulder external rotation in ADLs.
Our results support the notion that restoring shoulder external rotation in the treatment of traumatic brachial plexus palsy patients might improve outcomes by decreasing patient disability and increasing the ability to perform ADLs.
... rTSA provides good range of shoulder elevation; however, restoration of active rotational movements is less predictable and has been unreliable in past series. 1,44 Good rotational movements are obligatory for performance of activities of daily living (ADLs), internal rotation (IR) for activities regarding perineal and self-hygiene, 21,31,35 and external rotation (ER) for reaching with the hand to the mouth and head (for eating, drinking, and combing the hair). 21 The capability of performing these ADLs provides independence for many of these usually elderly patients. ...
... 1,44 Good rotational movements are obligatory for performance of activities of daily living (ADLs), internal rotation (IR) for activities regarding perineal and self-hygiene, 21,31,35 and external rotation (ER) for reaching with the hand to the mouth and head (for eating, drinking, and combing the hair). 21 The capability of performing these ADLs provides independence for many of these usually elderly patients. 45 Werner et al 45 found that active ER (AER) did not improve but actually decreased by a mean of 5°, particularly in elevation and abduction. ...
Background:
Reverse total shoulder arthroplasty (rTSA) has gained popularity in recent years, providing good shoulder elevation, yet less predictable rotations. Good rotations are crucial for performance of activities of daily living (ADLs), including personal hygiene. Concerns remain regarding bilateral rTSA over lack of rotations bilaterally and resultant difficulties with ADLs. This study examined the outcome of patients with bilateral rTSA in restoration of function and ADLs.
Methods:
Data were prospectively collected for 19 patients (15 women, 4 men; 38 shoulders), with a mean age of 74.5 years, who underwent staged bilateral rTSA between 2007 and 2013. Mean follow-up was 48.4 months (range, 24-75 months). Patients were evaluated clinically using the Constant score, patient's satisfaction, Subjective Shoulder Value, and the Activities of Daily Living External and Internal Rotations (ADLEIR) score. Video clips were also recorded for documentation at all visits.
Results:
Mean duration between staged operations was 18.2 months (range, 3-46 months). The Constant score improved from 18.7 to 65.1 points (age- and sex-adjusted, 100.2). Elevation improved from 57.5° to 143°, internal rotation (IR) from 9° to 81° (30 shoulders could reach above the sacroiliac joint), and external rotation (ER) from 20° to 32° (35 shoulders had >20° ER in adduction, 31 shoulders had full ER in elevation). The Subjective Shoulder Value improved from 2.1 of 10 to 9.2 of 10. Mean ADLEIR score was 33 of 36 (P < .001 for all). Most patients resumed their leisure and sport activities (gardening, golf, swimming, bowling).
Conclusion:
Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs and their leisure activities.
... Furthermore, restoration of internal and external rotation is particularly important for athletes participating in overhand throwing motions (Fleisig et al., 1996;Reinold et al., 2008;Dines et al., 2009) or patients recovering from total shoulder arthroplasty (Rhee et al., 2015;Oh et al., 2020;Ducharne et al., 2023). Shoulder pain can occur after trauma, repetitive use, or surgery, thereby impacting the ability to perform daily living tasks involving internal rotation (e.g., reaching behind the back to fasten a bra or retrieve items from a back pocket) or external rotation (e.g., reaching overhead to place an item on a high shelf or combing the hair) (Rundquist et al., 2009;Kim et al., 2020;Langer et al., 2012). ...
Internal and external rotation of the shoulder is often challenging to quantify in the clinic. Existing technologies, such as motion capture, can be expensive or require significant time to setup, collect data, and process and analyze the data. Other methods may rely on surveys or analog tools, which are subject to interpretation. The current study evaluates a novel, engineered, wearable sensor system for improved internal and external shoulder rotation monitoring, and applies it in healthy individuals. Using the design principles of the Japanese art of kirigami (folding and cutting of paper to design 3D shapes), the sensor platform conforms to the shape of the shoulder with four on-board strain gauges to measure movement. Our objective was to examine how well this kirigami-inspired shoulder patch could identify differences in shoulder kinematics between internal and external rotation as individuals moved their humerus through movement patterns defined by Codman’s paradox. Seventeen participants donned the sensor while the strain gauges measured skin deformation patterns during the participants’ movement. One-dimensional statistical parametric mapping explored differences in strain voltage between the rotations. The sensor detected distinct differences between the internal and external shoulder rotation movements. Three of the four strain gauges detected significant temporal differences between internal and external rotation (all p < .047), particularly for the strain gauges placed distal or posterior to the acromion. These results are clinically significant, as they suggest a new class of wearable sensors conforming to the shoulder can measure differences in skin surface deformation corresponding to the underlying humerus rotation.
... These functional goals align well with the most frequently reported ADL goals related to eating and drinking (ICF: d550 and d560, respectively), which require shoulder and elbow control. However, it is important to note that also shoulder external rotation has been shown to be critical in regaining ADL function in traumatic brachial plexus palsy [24]. Although the underlying mechanism of paralysis is different, the resulting limitations in ADL are likely to be comparable. ...
(1) Improving upper limb function is essential for people with tetraplegia. Although promising, technology-assisted upper limb training is understudied in this population. This article describes its implementation in a Swiss spinal cord injury rehabilitation centre and reports on the observed changes. (2) A retrospective evaluation of clinical data from January 2018 to June 2020 examined patient characteristics, training parameters, goal-setting practices, goal achievement, and changes in muscle strength over the course of technology-assisted upper limb training. (3) Data analysis included 61 individuals, 68.9% of whom had a spinal cord injury. The ArmeoSpring was the most frequently used device. The typical treatment regimen was three 25 min sessions per week, with evaluations approximately every six weeks. The 1:1 sessions, delivered by specialised staff, focused primarily on improving shoulder movement and the ability to eat and drink. Functional goals were set using a grid. Performance on selected goals in the areas of ‘body functions’ and ‘activities & participation’ as well as muscle strength, increased over the course of training. (4) The ArmeoSpring has broad applicability. Despite the observed improvements, the isolated effect of technology-assisted upper limb training cannot be concluded due to the lack of a control group and various concurrent interventions.
... Initial designs of RSA consistently improved forward elevation (FE) but were less effective at restoring external rotation (ER) 3,4 . Unfortunately, limitations in ER result in poorer patient-reported outcomes and functional status 5 . This is a particularly difficult problem in patients with cuff tear arthropathy and an absent posterior cuff (infraspinatus and teres minor) resulting in combined loss of active elevation and external rotation (CLEER), which Boileau et al. 6 defined as definitive loss of vertical and horizontal muscle balances. ...
Background:
Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied.
Methods:
A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed.
Results:
Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was -12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9).
Conclusions:
RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes.
Level of evidence:
Level IV. See Instructions for Authors for a complete description of levels of evidence.
... In the treatment of BPI, restoring shoulder external rotation may enhance outcomes by increasing their ability to perform activities of daily living. 7 If the extent of BPI permits dual nerve transfer for the shoulder, the spinal accessory to suprascapular and the triceps motor branch to the axillary nerve provides the best chance of restoring external rotation at the shoulder. However, the outcomes are variable. ...
Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexus injury (BPI). This internally rotated posture of the limb becomes more apparent and functionally limiting once the patient recovers elbow flexion resulting in the hand striking the abdomen on attempted flexion (‘tummy flexion’). This precludes hand-to-mouth reach, resulting in an inability to eat with the involved hand. The aim of this study is to present the outcomes of an external rotation osteotomy of the humerus in adult BPI.
Methods: All BPI patients who underwent an external rotation osteotomy of the humerus at our institution over a 5-year period from January 2015 to December 2020 were included in this study. Data with regard to the age, gender, type of BPI, time from injury to nerve surgery and from nerve surgery till external rotation osteotomy, degree of pre- and postoperative external rotation, time to union, patient satisfaction and complications were recorded.
Results: The study included 19 patients (18 men and one woman) with an average age of 30 years (range 20–58). The average time interval from the injury to the nerve surgery was 3.8 months, and between the nerve surgery and the external rotation osteotomy was 29.5 months. No patient had any preoperative external rotation and all attained a resting posture of 15°–20° of external rotation, were able to reach the mid-line of the body, and none complained of loss of internal rotation. There was an implant failure in one patient that was managed with splinting till union and removal of implants later.
Conclusions: External rotation osteotomy of the humerus is a simple and effective procedure to place the limb in a better aesthetic and functional position.
Level of Evidence: Level IV (Therapeutic)
... 1,15,21,41 For example, when performing forward elevation and abduction, both internal rotation (IR) and ER are critical movements. 23,33,38 Denard et al prospectively compared patients performing immediate or delayed ROM exercises following TSA and found that immediate ROM exercises and an earlier return to activity resulted in a more rapid return to function compared with a delayed approach to rehabilitation. 12 However, several studies have challenged this concept of early mobilization with ROM exercises and show that early gains in function with a rapid return to activity may come at the cost of appropriate healing, long-term instability, and functional decline. ...
Background
Maintaining subscapularis integrity may be a significant variable in optimizing patient outcomes following total shoulder arthroplasty. Multiple factors have been reported in orthopedic literature as a contributor to subscapularis failure. Most surgeons follow a protocol that calls for some period of immobilization. However, time of mobilization and rehabilitation is still a point of discussion, as no consensus currently exists. Our study aimed to compare postoperative outcomes of patients who followed a traditional immobilization protocol to those who underwent rapid mobilization.
Methods
A single-blinded, randomized controlled clinical trial was conducted between December 2015 and May 2018. Patients were prospectively enrolled and randomized using a 1:1 random allocation into two groups: Prolonged immobilization for 4 weeks or rapid mobilization at 1 week. All cases were performed by a single, fellowship-trained shoulder and elbow surgeon with standard pre- and intraoperative protocols. Metallic markers were used to mark the musculotendinous junction of the subscapularis tendon. Postoperatively, patients were notified of their randomization assignment and provided detailed instructions on when to begin mobilization. Patient-reported outcome measures, physical exam, and radiologic assessments were evaluated preoperatively and at 6 weeks, 3 months, 6 months, 12 months, and 32 months postoperatively. Our primary outcome was clinical and radiographic subscapularis failure.
Results
Forty-three patients consented with 40 procedures randomized to the two cohorts. Among these 40 procedures, there were up to 235 follow-up visits over 32 months. Of the 40 procedures, 2 (5.0%) were complicated with a postoperative tear, both associated with a weak belly test and radiographically confirmed with medialization of the surrogate markers on plain radiographs. No statistically significant difference was seen between the prolonged immobilization and rapid mobilization groups for American Shoulder and Elbow Surgeons Shoulder Score, Constant Shoulder Score, Visual Analog Scale Score, Simple Shoulder Test Score, and Short-Form Surveys at any follow-up point (all p > .05). Upon evaluating active forward flexion and external rotation, no statistically significant difference was also appreciated between the two groups at any time point (all p > .05).
Discussion
Our randomized control trial compared currently accepted protocols to immobilize for 4 weeks following total shoulder arthroplasty using a peel to early mobilization at 1 week and found no statistical and clinical difference in outcomes. However, further study is necessary before a consensus recommendation can be made.
... As it is well known, good rotational movements are obligatory for performing ADLs; IR for activities regarding perineal and selfhygiene, and ER for reaching the hand to the mouth and head (for eating, drinking, and combing). 20 However, the minimal functional range of movement necessary for performing ADLs remains undetermined. 8 Our systematic review illustrated that most patients noted no changes of their personal hygiene habits and ADLs after bilateral RTSA. ...
Purpose To answer the question whether bilateral reverse total shoulder arthroplasty (RTSA) is a safe and effective treatment which results in satisfactory clinical and functional outcomes with low complications rates. A second question to be answered was: what is the quality of the evidence of the already published studies which investigate the use of bilateral RTSA?
Methods Two reviewers independently conducted a systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms “reverse” AND “total” AND “shoulder” AND “arthroplasty” AND “clinical.” Descriptive statistics were used to summarize the data.
Results From the 394 initial studies we finally selected and assessed 6 clinical studies which were eligible to our inclusion–exclusion criteria. The aforementioned studies included in total 203 patients (69% females; mean age range: 67.1–75 years; mean follow-up range: 12–61 months). From those, 168 patients underwent staged bilateral RTSA (mean duration between first and second operation range: 8–21.6 months) and the rest of them a unilateral RTSA as controlled treatment. Almost all mean clinical and functional scores, which were used to assess the therapeutic value of bilateral RTSA, depicted significant postoperative improvement in comparison with the mean preoperative values. The modified Coleman methodology score, which was used to assess the quality of the studies, ranged from a minimum of 36/100 to a maximum of 55/100.
Conclusion Despite the lack of high-quality evidence, staged bilateral RTSA seems to be a safe and effective procedure for patients with cuff tear arthropathy, which results in significantly improved clinical and functional outcomes and low reoperations' rates.
Level of Evidence Systematic review of level III-IV therapeutic studies.
... These were selected since scapular plane abduction is the most commonly studied shoulder motion (Krishnan et al., 2019), and reaching behind the back (i.e. functional IR, a combination of extension and IR) plays a critical role in executing tasks of daily living (Langer et al., 2012). Neutral was used to quantify the resting pose of the scapula and humerus relative to the torso. ...
Age affects gross shoulder range of motion (ROM), but biomechanical changes over a lifetime are typically only characterized for the humerothoracic joint. Suitable age-related baselines for the scapulothoracic and glenohumeral contributions to humerothoracic motion are needed to advance understanding of shoulder injuries and pathology. Notably, biomechanical comparisons between younger or older populations may obscure detected differences in underlying shoulder motion. Herein, biplane fluoroscopy and skin-marker motion analysis quantified humerothoracic, scapulothoracic, and glenohumeral motion during 3 static poses (resting neutral, internal rotation to L4-L5, and internal rotation to maximum reach) and 2 dynamic activities (scapular plane abduction and external rotation in adduction). Orientations during static poses and rotations during active ROM were compared between subjects <35 years and >45 years of age (N=10 subjects per group). Numerous age-related kinematic differences were measured, ranging 5-25°, where variations in scapular orientation and motion were consistently observed. These disparities are on par with or exceed mean clinically important differences and standard error of measurement of clinical ROM, which indicates that high resolution techniques and appropriately matched controls are required to avoid confounding results of studies that investigate shoulder kinematics. Understanding these dissimilarities will help clinicians manage expectations and treatment protocols where indications and prevalence between age groups tend to differ. Where possible, it is advised to select age-matched control cohorts when studying the kinematics of shoulder injury, pathology, or surgical/physical therapy interventions to ensure clinically important differences are not overlooked.
... Patients without ERLS did show significant greater CS, ROM in all planes and strength (p < 0.05). This trend towards higher SSV when no ERLS is present (p = 0.06) is based on the fact that ER is essential for daily activities (combing hair, putting on clothes, washing, etc.) [44]. ...
Tuberosity healing and stem design can be outcome-dependent parameters in hemiarthroplasty for proximal humerus fractures (PHF). The relevance of fracture-specific stem design in reverse shoulder arthroplasty (RSA) is still a matter of debate. This retrospective study evaluates tuberosity healing and function for fracture specific stems (A) compared to conventional stems (B) in RSA for complex PHF in 26 patients (w = 21, mean age 73.5 years). Clinically, range of motion (ROM), Constant-Murley-Score (CS), Subjective Shoulder Value (SSV), and external rotation lag signs (ERLS) were evaluated. Healing of greater tuberosity (GT) and lesser tuberosity (LT), scapular notching, and loosening were examined radiologically. There were no statistical significant differences with regards to CS (A: 73 ± 11; B: 77 ± 9 points), SSV (A: 78% ± 11%; B: 84% ± 11%), external rotation (A: 18° ± 20°; B: 24° ± 19°), or internal rotation (A: 5.7 ± 2.2; B: 6.7 ± 2.8 CS-points) (p > 0.05). Mean forward flexion was superior for group A (p = 0.036). Consolidation of GT (82%) and LT (73%) was similar in both groups. Anatomical healing was slightly higher in group B (p > 0.05). Scapular notching was found in 27% (A) and 55% (B) (p > 0.05). RSA for PHF provides good to excellent clinical results. The quantitative and qualitative union rate for both cohorts was similar, indicating that fracture stems with open metaphyseal designs to allow for bone ingrowth do not improve tuberosity healing. ERLS correlates with a worse function in CS and ROM in all planes.
... In patients with injury to the upper brachial plexus, the suprascapular and axially nerves are typically targeted in the reconstruction of shoulder function, especially shoulder external rotation and abduction. Improving external rotation is necessary for the recovery of shoulder function in activities of daily living for patients with a suprascapular nerve palsy [5]. The surgical treatment of chronic suprascapular nerve injury in patients having the potential for recovery of rotator cuff function has not been previously reported. ...
Introduction:
Combined injuries to the suprascapular and axillary nerves can result in irreversible dysfunction of the shoulder joint, with reconstruction of shoulder external rotation being an essential component of an effective treatment. Transfer of the lower portion of the trapezius to the infraspinatus has been used, with success, to regain external rotation of the shoulder.
Case report:
We present the case of a 45-year-old man with a chronic traumatic injury of the suprascapular and axillary nerves. In addition to a surgical transfer of the lower trapezius to the infraspinatus, we included a transfer of the latissimus dorsi and teres major, with a tensor fasciaelatae graft to the supraspinatus tendon insertion, to improve the muscular strength of shoulder elevation and abduction, as well as to improve external rotation. At 24-month post-surgery, the patient had recovered 170° of shoulder elevation, 170° of abduction, and 60° of external rotation.
Conclusion:
Early recovery after surgery was achieved, with excellent improvement of the range of shoulder motion. We report the transfer of the lower trapezius to the infraspinatus might provide a useful salvage procedure for patients with poor functional prognosis of a chronic suprascapular nerve injury.
... Infraspinatus is the primary muscle for this movement and its paralysis, 1,2 results in major disability. Although some authors hold that restoring even small amounts of external rotation could improve function and decrease disability, 3 real functional recovery is seldom achieved through the usual reconstructive surgeries. The disappointing results that are usually obtained motivated us to attempt to transfer a branch of the radial nerve directly to the branch of the suprascapular nerve that goes to the infraspinatus muscle. ...
Background: Although reinnervation of the suprascapular nerve is frequently obtained through brachial plexus surgery, reestablishment of infraspinatus muscle function is rarely achieved.
Methods: The viability of transfer of the radial nerve to the nerve branch to the infraspinatus muscle was determined anatomically, including histomorphometrical analysis on 30 adult cadavers. Eleven adult patients were then treated using the proposed nerve transfer.
Results: The branch to the medial head was more suitable for the nerve transfer. In one cadaver, nerve transfer was impossible because there was no donor of sufficient length. According to axon counts, the branches to the lateral and medial heads had sufficient numbers of axons (means = 994.2 ± 447.6 and 1030.8 ± 258.5, respectively) for reinnervation of the branch to the infraspinatus (means = 830.2 ± 241.2 axons). In the surgical series, one patient was lost in the follow-up and only two patients achieved a good result from the transfer. Recovery of external shoulder rotation started 14 months after surgery in one patient and 8 months in the other. The first patient reached 90° of external rotation 6 months later and the second, achieved 120°of shoulder external rotation 6 months after surgery . Four other patients recovered small amounts of movement: 20, 35, 40 and 45°.
Conclusions: Although anatomically feasible, the proposed nerve transfer resulted in a small number of good clinical outcomes.
... This is important because ER has been shown to be essential for performing activities of daily living. 29 In fact, this study demonstrated a statistically significant difference in the ability to position the shoulder in a functional ER position and complete an ER-dependent task between those patients with greater tuberosity union compared with those patients who either did not have a greater tuberosity repair or developed a tuberosity nonunion. We recommend repair of the greater tuberosity for fracture RTSA whenever possible because of these findings. ...
... rate of eventual rotator cuff failure with increasing incidence of failure with time with revision to RSA. 16 Despite good outcomes for many indications, active internal and external rotation may not reliably improve after RSA. 4,5,17 Because suboptimal shoulder rotation may adversely affect many activities of daily living (ADLs), 18,19 surgeons may be opposed to performing bilateral RSA. Also, the increased constraint of the reverse arthroplasty design may lead surgeons to recommend low-to-medium demand activities to avoid subsequent implant loosening or mechanical complications. ...
Purpose:
Reverse shoulder arthroplasty (RSA) improves pain and function with very good satisfaction. Concerns exist about some activities of daily living (ADLs) involving internal rotation. The purpose of this study was to report how patients with bilateral RSA perform various ADLs.
Methods:
Thirty-one primary bilateral RSA patients (average age 76 years; 21 women and 10 men) completed a survey to assess various outcomes. The average time between the second arthroplasty and the survey was 2.7 years (range 1.0-7.8 years).
Results:
All clinical parameters were favorable. All patients reported being able to easily manage toileting and 87% reaching their back pocket. However, 29% found difficulty and 39% were unable to wash their back or put on bra. In comparison with various unilateral arthroplasty types, there was no statistical difference in overall activities ( p < 0.05).
Conclusion:
Bilateral RSA can provide good functional outcome and high satisfaction. Patients manage most ADLs easily with some limitations in activities requiring extreme internal rotation.
... Upper brachial plexus injuries can result in a variety of functional impairment patterns of the shoulder and elbow (Kostas-Agnantis et al., 2013). Shoulder lateral rotation is critical for attainment of most activities of daily living, enabling patients to bring their hand away from their torso when flexing the elbow or shoulder; however, failure to restore this motion is common in patients with brachial plexus injuries (Langer et al., 2012). Restoration of lateral rotation is most commonly performed using accessory nerve (AN) transfer to the suprascapular nerve (SSN). ...
Restoration of shoulder lateral rotation remains a significant challenge following brachial plexus injury. Transfer of the accessory nerve to suprascapular nerve (SSN) has been widely performed, although with generally poor outcomes for lateral rotation. A recent report suggested a selective infraspinatus reinnervation technique using a radial nerve branch for SSN transfer. This cadaveric study was performed in 7 specimens (14 shoulders). We present technical modifications to achieve additional length to the recipient nerve (suprascapular) that would facilitate direct repair. Key elements of the technique are (1) isolation of the SSN immediately distal to its motor branch to supraspinatus near the superior transverse scapular ligament; and (2) delivery of the transected SSN through the spinoglenoid notch and deep to the infraspinatus for emergence in the infraspinatus‐teres minor interval. Nerve overlap of at least 21 mm was observed in all 14 dissected shoulders between the harvested SSN and radial nerve branches. The mean nerve overlap between harvested branches was 26 mm (range 21–32 mm). The mean harvested SSN length was 59 mm (range 46–80 mm). The mean length of the harvested radial nerve branch was 72 mm (range 65–85 mm). No measurements were significantly different between left and right shoulders or between males and females (smallest P value = 0.1249). Nerve diameter of the two harvested branches was judged to be appropriately compatible for surgical coaptation in all 14 dissected shoulders. We present a variation on a described technique to increase recipient suprascapular nerve length. Additional length of the recipient nerve is achieved through utilization of a more proximal dissection of the suprascapular nerve near the level of the superior transverse scapular ligament and delivering the nerve through the teres minor‐infraspinatus interval. These surgical modifications are of clinical interest when selective reinnervation of the infraspinatus muscle is considered. We believe such a targeted approach can potentially increase shoulder lateral rotation function. Clin. Anat. 32:131–136, 2019. © 2018 Wiley Periodicals, Inc.
... In patients with severe BPIs who have had successful restoration of elbow flexion, the lack of ER leads to a hand that is blocked by the abdomen when the patient tries to flex the elbow (hand on belly position), which limits the functional use of the hand in the space and the patient's ability to perform many ADLs. 4,5,20,27 Langer et al 27 examined the ability of 31 healthy individuals wearing a custom orthosis to prevent ER to perform 12 common ADLs. Increasing degrees of loss of ER hampered their ability to perform all ADLs tested, with the most marked limitations in activities performed above the waist. ...
Background:
Management of massive irreparable posterior-superior rotator cuff tear can be very challenging. This study reports the outcome of the lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear.
Methods:
Included were 33 patients with an average age of 53 years (range, 31-66 years). All patients had symptomatic massive irreparable rotator cuff tear that failed conservative or prior surgical treatment and underwent reconstruction with lower trapezius transfer prolonged by Achilles tendon allograft. The tear was considered irreparable based on the magnetic resonance imaging finding of ≥2 full-thickness rotator cuff tears associated with shortening and retraction of the tendon to the level of the glenoid and a high grade of fatty infiltration of the muscles. This was confirmed at the time of the surgery.
Results:
At an average follow-up of 47 months, 32 patients had significant improvement in pain, subjective shoulder value, and Disabilities of the Arm, Shoulder and Hand score and shoulder range of motion, including flexion, 120°; abduction, 90°; and external rotation 50°. One patient, with a body mass index of 36 kg/m(2), required débridement for an infection and then later underwent shoulder fusion. Patients with >60° of preoperative flexion had more significant gains in their range of motion. Shoulder external rotation improved in all patients regardless of the extent of the preoperative loss of motion.
Conclusions:
Transfer of the lower trapezius prolonged with Achilles tendon allograft to reconstruct massive irreparable posterior-superior rotator cuff tear may lead to good outcome in most patients, specifically for those who have preoperative flexion of >60°.
... In patients with severe BPIs who have had successful restoration of elbow flexion, the lack of ER leads to a hand that is blocked by the abdomen when the patient tries to flex the elbow (hand on belly position), which limits the functional use of the hand in the space and the patient's ability to perform many ADLs. 4,5,20,27 Langer et al 27 examined the ability of 31 healthy individuals wearing a custom orthosis to prevent ER to perform 12 common ADLs. Increasing degrees of loss of ER hampered their ability to perform all ADLs tested, with the most marked limitations in activities performed above the waist. ...
Purpose:
To evaluate the outcome of contralateral lower trapezius origin transfer (CLTOT) to restore shoulder external rotation in patients with shoulder paralysis after brachial plexus injury (BPI).
Methods:
We evaluated 12 patients with a history of BPI with persistent shoulder paralysis. All patients had compromised ipsilateral lower trapezius muscle function. All patients underwent CLTOT prolonged with lumbar fascia to the affected infraspinatus tendon either isolated (7 patients) or as part of multiple tendon transfer (5 patients). Standardized patient outcomes measures were obtained.
Results:
At 23 months' follow-up, 10 patients had improved shoulder external rotation from no motion preoperatively to an average external rotation 110° from the abdomen. Five patients had marked improvement of pain, including 2 with isolated CLTOT and 3 with additional tendon transfers. Two patients experienced no change in pain. There were noted improvements in the Constant shoulder scores, simple shoulder value, and Disabilities of the Arm, Shoulder, and Hand scores. One patient sustained a fall resulting in stretch injury to the transfer, underwent successful revision surgery, and regained 100° active shoulder external rotation away from the abdomen more than a year after revision surgery. Another patient's transfer failed during rehabilitation but the patient elected not to pursue treatment. No patients had changes in contralateral shoulder motion or strength or any pain from the contralateral shoulder.
Conclusions:
This study demonstrated that CLTOT to the infraspinatus tendon was effective in improving shoulder external rotation in patients with BPI.
Type of study/level of evidence:
Therapeutic IV.
... Above neutral external rotation of the shoulder is required to perform basic activities of daily living well. [11][12][13] Active external rotation is poor without adequate infraspinatus function, which can be improved by different tendon transfers. 8,14,15 Infraspinatus function can be restored by neurotizing the suprascapular nerve, which can be performed at an earlier age than tendon transfers. ...
The authors present a new technique to improve active shoulder external rotation in patients with brachial plexus birth injury. Eight brachial plexus birth injury patients (aged 1.5 to 4.7 years) lacking active external rotation in adduction (<10 degrees) with congruent glenohumeral joints and no significant internal rotation contracture (passive external rotation >45 degrees) underwent neurotization of the infraspinatus branch of the suprascapular nerve with the spinal accessory nerve. Active and passive range of shoulder motion was measured postoperatively (3, 6, and 12 months). Parents’ satisfaction was assessed. At 1-year follow-up, mean improvement for active external rotation was 47 degrees (range, 20 to 85 degrees) in adduction and 49 degrees (range, 5 to 85 degrees) in abduction. All but one patient’s parents were satisfied. Functionally significant active external rotation can be restored in brachial plexus birth injury by direct neurotization of the infraspinatus muscle. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
... Using a computer model, they suggested a design-dependent increase in moment arms of the external rotators and therefore the potential of a corresponding increase in range of movement for the patient. While this has not been proven clinically, the disability caused by limitation of external rotation at the shoulder is well recognised and an important impairment in performing activities of daily living [67]. Rotation appears to be of particular practical importance during abduction or elevation away from the body. ...
The management of irreparable rotator cuff tears associated with osteoarthritis of the glenohumeral joint has long been challenging. Reverse total shoulder arthroplasty (RSA) was designed to provide pain relief and improve shoulder function in patients with severe rotator cuff tear arthropathy. While this procedure has been known to reduce pain, improve strength and increase range of motion in shoulder elevation, scapular notching, rotation deficiency, early implant loosening and dislocation have attributed to complication rates as high as 62 %. Patient selection, surgical approach and post-operative management are factors vital to successful outcome of RSA, with implant design and component positioning having a significant influence on the ability of the shoulder muscles to elevate, axially rotate and stabilise the humerus. Clinical and biomechanical studies have revealed that component design and placement affects the location of the joint centre of rotation and therefore the force-generating capacity of the muscles and overall joint mobility and stability. Furthermore, surgical technique has also been shown to have an important influence on clinical outcome of RSA, as it can affect intra-operative joint exposure as well as post-operative muscle function. This review discusses the behaviour of the shoulder after RSA and the influence of implant design, component positioning and surgical technique on post-operative joint function and clinical outcome.
... [1][2][3] The internally rotated position of the limb is cosmetically and functionally disturbing. 4,5 To bring the hand to the face the shoulder is abducted, elevating the elbow; the so-called trumpet sign, 6 and patients may have difficulty with activities of daily living. ...
We present the long-term results of open surgery for internal shoulder rotational deformity in brachial plexus birth palsy (BPBP).
From 1997 to 2005, 207 patients (107 females, 100 males, mean age 6.2 (0.6 to 34)) were operated on with subscapularis elongation and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder joints were relocated. The early results of these patients has been reported previously. We analysed 118 (64 females, 54 males, mean age 15.1 (7.6 to 34)) of the original patient cohort at a mean of 10.4 years (7.0 to 15.1) post-operatively. A third of patients with relocated joints had undergone secondary internal rotational osteotomy of the humerus.
A mixed effects models approach was used to evaluate the effects of surgery on shoulder rotation, abduction, and the Mallet score. Independent factors were time (pre-and post-surgery), gender, age, joint category (congruent, relocated, relocated plus osteotomy) and whether or not a transfer had been performed. Data from a previously published short-term evaluation were reworked in order to obtain pre-operative values.
The mean improvement in external rotation from pre-surgery to the long-term follow-up was 66.5° (95% confidence interval (CI) 61.5 to 71.6). The internal rotation had decreased by a mean of 22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95% CI 8.4 to 9.0) to 11.8 (11.5 to 12.1).
Our results show that open subscapularis elongation achieves good long-term results for patients with BPBP and an internal rotation contracture, providing lasting joint congruency and resolution of the trumpet sign, but with a moderate mean loss of internal rotation.
Cite this article: Bone Joint J 2014;96-B:1411–18
... The importance of shoulder external rotation in ADLs was corroborated by a study that limited this motion in unaffected volunteers by use of a custom shoulder orthosis that limited shoulder movement. There was perceived increased difficulty during all ADLs tested and higher self report of disability scores while wearing these external rotationlimiting orthoses [21]. ...
Brachial plexus palsy evaluation and treatment have grown over the past few decades. In this review article we will address advances in evaluation and treatment, both surgically and conservatively, as well as new findings in outcomes, function and theories on central nervous system involvement. We will also touch on scientific impact other than from the field of medicine.
... Internal rotation contracture and associated skeletal changes can secondarily prevent full range of even otherwise recovered muscle action leading to significant functional consequences. For example, glenohumeral abduction is limited significantly with the humerus internally rotated, and flexion of the elbow becomes problematic when the abdomen gets in the way of the internally rotated hand [17]. In cases where shoulder pathology exists to a degree that global arm movements are affected, skeletal and tendon transfer surgeries may be recommended to decrease the effective permanent deformity or disability [14,20,26], but no surgery recreates close to normal skeletal anatomy. ...
Background:
Birth-related brachial plexus injury (BRBPI) occurs in 1.2/1,000 births in British Columbia. Even in children with "good" recovery, external rotation (ER) and supination (Sup) are often weaker, and permanent skeletal imbalance ensues. A preventive early infant shoulder passive repositioning program was created using primarily a novel custom splint holding the affected arm in full ER and Sup: the Sup-ER splint. The details of the splint and the shoulder repositioning program evolved with experience over several years. This study reviews the first 4 years.
Methods:
A retrospective review of BCCH patients managed with the Sup-ER protocol from 2008 to 2011 compared their recovery scores to matched historical controls selected from our database by two independent reviewers.
Results:
The protocol was initiated in 18 children during the study period. Six were excluded due to the following: insufficient data points, non-compliance, late splint initiation, and loss to follow-up. Of the 12 matches, the Sup-ER group final score at 2 years was better than controls by 1.18 active movement scale (AMS) points (p = 0.036) in Sup and 0.96 AMS points in ER (but not statistically significant (p = 0.13)). Unexpectedly, but importantly, during the study period, zero subjects were assessed to have the active functional criteria to indicate brachial plexus reconstruction, where previously we operated on 13 %.
Conclusions:
Early application of passive shoulder repositioning into Sup and ER may improve outcomes in function of the arm in infants with BRBPI. A North American multi-site randomized control trial has been approved and has started recruitment.
Aim
Anatomic total shoulder arthroplasty (TSA) is commonly used for glenohumeral osteoarthritis (OA) in patients with an intact rotator cuff. The aim of this study was to quantify advantages and disadvantages of the stemmed and stemless designs in terms of clinical outcome and complications.
Methods
A review was developed based on the PRISMA statement and registered on PROSPERO. Inclusion criteria were comparative studies analyzing stemmed vs. stemless TSA in adults with OA. The literature search was performed in PubMed, Web of Science, and Wiley Cochrane Library up to January 2024. Constant and Murley Score (CMS), Range of Motion, and operative time were documented, as well as complications divided into minor and major complications. The Downs and Black’s “Checklist for Measuring Quality” was used to assess risk of bias and quality of evidence.
Results
Out of 1876 articles retrieved; 14 were included in the meta-analysis for a total of 1496 patients (51.4% men, 48.6% women). The CMS was 74.8 points in the stemmed group and 76.9 points in the stemless group, with no differences in both overall score and subscales. No differences were found in elevation and abduction, while external rotation was 3.9° higher in the stemless group (p < 0.05) No differences were found in operating time and overall complications. However, deep infections were higher in the stemless group (2.2% vs. 0.8%, p < 0.05). The quality was assessed as poor, fair, good, and excellent in 0, 2, 7, and 5 studies, respectively.
Conclusion
Stemless TSA may offer minor advantages in terms of external rotation, although the clinical relevance appears doubtful. On the other hand, a lower deep infection rate was documented for stemmed implants. Overall, stemmed and stemless TSA provided good clinical results, with similar benefits in terms of clinical outcomes and complications.
Study Design
Invited review.
Background
Shoulder osteoarthritis can result in significant functional deficits. To improve diagnosis and treatment, we must better understand the impact of osteoarthritis on shoulder biomechanics and the known mechanical benefits of currently available treatments.
Purpose
The purpose of this paper is to present up-to-date data on the effects of osteoarthritis and rehabilitation on the biomechanical parameters contributing to shoulder function. With this goal, we also reviewed the anatomy and the ranges of motion of the shoulder.
Methods
A search of electronic databases was conducted. All study designs were included to inform this qualitative, narrative literature review.
Results
This review describes the biomechanics of the shoulder, the impact of osteoarthritis on shoulder function, and the treatment of shoulder osteoarthritis with an emphasis on rehabilitation.
Conclusions
The shoulder is important for the completion of activities of daily living, and osteoarthritis of the shoulder can significantly reduce shoulder motion and arm function. Although shoulder rehabilitation is an integral treatment modality to improve pain and function in shoulder osteoarthritis, few high-quality studies have investigated the effects and benefits of shoulder physical and occupational therapies. To advance the fields of therapy and rehabilitation, future studies investigating the effects of therapy intensity, therapy duration, and the relative benefits of therapy subtypes on shoulder biomechanics and function are necessary.
Résumé
Introduction
L’arthrodèse scapulo-thoracique peut être proposée aux patients atteints de dystrophie facio-scapulo-humérale afin d’améliorer les mobilités de l’épaule et de soulager la douleur. Cette étude avait pour but d’évaluer les mobilités de l’épaule, la douleur et les scores fonctionnels au dernier recul et de présenter une méthode de mesure scannographique de la position de l’arthrodèse afin d’étudier leurs corrélations avec les mobilités postopératoires de l’épaule.
Patients et méthodes
Sept patients (11 arthrodèses) ont été inclus. Les mobilités de l’épaule, la douleur, la fonction respiratoire et la force du deltoïde ont été comparées aux valeurs préopératoires et les scores de Constant, Brooke et Vignos ont été évalués lors du dernier suivi. La position d’élévation/abaissement et la rotation de la scapula ont été mesurées en réalisant une reconstruction tomodensitométrique 3D postopératoire. La position d’abduction/adduction a été mesurée à l’aide de reconstructions 2D en vue axiale. Toutes les complications durant le suivi ont été reportées.
Résultats
Nous avons constaté une amélioration significative de l’EVA moyenne (de 3 ± 2 à 1 ± 1, p = 0,008), de la flexion de l’épaule (de 64°± 11 à 113° ± 20, p = 0,003), et de l’abduction (de 63° ± 9 à 92° ± 13°, p = 0,004). Les arthrodèses étaient principalement positionnées entre la 1e et la 6e côte. La position moyenne d’abduction/adduction et de rotation de la scapula était de 38,5° ± 8° et 92° ± 15°, respectivement. Aucune corrélation n’a été trouvée entre la position de la STA et la flexion et l’abduction de l’épaule.
Conclusions
L’arthrodèse scapulothoracique pour dystrophie facio-scapulo-humérale a permis d’améliorer la douleur, la flexion et l’abduction de l’épaule et a donné de bons résultats fonctionnels après 3,5 à 13 ans de suivi. Une évaluation scannographique de l’arthrodèse est présentée mais aucune corrélation avec les mobilités de l’épaule n’a été trouvée. L’évaluation préopératoire de la fonction du deltoïde et de la scapula alata semblait être les facteurs prédictifs les plus importants des gains de mobilités de l’épaule après cette intervention.
Niveau de preuve
III, étude de cohorte rétrospective.
Introduction: Scapulothoracic arthrodesis may be proposed to patients having facio-scapulohumeral dystrophy to achieve gains in shoulder motion and pain relief. This study aimed to assess shoulder motion, pain and functional scores at last follow-up and to present a method of computed tomography measurements of the position of the scapulothoracic arthrodesis and study their correlations with shoulder motion.
Patients and Methods: Seven patients (11 arthrodesis) were included. Shoulder motion, pain, respiratory function and deltoid strength were compared with preoperative values and Constant, Brooke and Vignos scores were assessed at last follow-up. The elevation/depression and upward/downward position of the scapula were measured by performing postoperative 3D CT reconstruction. The protraction/retraction position was measured with 2D CT reconstructions on axial view. Correlations between these measurements and shoulder flexion and abduction were analysed. All complications were searched.
Results: We found a significant improvement in mean VAS (from 3±2 to 1±1, p = 0,008) shoulder flexion (64°± 11 to 113° ± 20, p = 0,003) and abduction (from 63° ± 9 to 92° ± 13°, p = 0,004). Postoperative external rotation wasn’t significantly different (from 49° ± 19 to 43° ± 10, p = 0,112) and on internal rotation, the hand reached on average the 9th thoracic vertebra (S1-T2). Scapulothoracic arthrodesis was mainly positioned in regard to the 1st and the 6th rib. The mean protraction/retraction position was 38,5° ± 8° and the mean scapular upward/downward rotation position was 92° ± 15°. No correlations were found between the scapular position and shoulder flexion and abduction.
Conclusions: Scapulothoracic arthrodesis for facioscapulohumeral dystrophy improved pain, shoulder flexion and abduction and provided good functional outcomes at 3,5 to 13 years of follow up. A method of CT assessment of the position of the arthrodesis is presented to analyse precisely the position of the scapula but no correlations with shoulder motions were found. Preoperative evaluation of deltoid function and scapular winging seemed to be the most important predictors of shoulder motions gains after this procedure.
Level of evidence: III, Retrospective cohort study
Background
To investigate the functional outcomes of reverse shoulder arthroplasty (RSA) in acute complex proximal humerus fractures (PHF) in patients with an anatomic greater tuberosity union in comparison to patients with a displaced or resorbed tuberosity. Method: It is a retrospective study with prospective data collection including 32 consecutive PHF with a minimum two-year follow-up treated with RSA. A radiological study and a CT scan were performed specifically for the study. Two shoulder surgeons and a musculoskeletal radiologist assessed the position and union of the greater tuberosity. The functional outcomes were assessed with the Constant-Murley, DASH, ASES and ADLER scores. Results: The mean overall CS was 59.55. In 17 cases, the greater tuberosity healed in an anatomical position. In 15 cases, it was non-anatomical. In 53% of patients, greater tuberosity union was obtained. The CS was 62.76 in the anatomic union group and 55.9 in the non-anatomic union group. No significant differences were observed. No differences were observed in the ASES, DASH and ADLER scores. Conclusion: After RSA for PHF, anatomic greater tuberosity healing was obtained in 53% of patients. The influence of the position and union of the greater tuberosity on the functional results could not be evidenced.
Background
Reverse Total Shoulder Arthroplasty (rTSA) improves shoulder elevation in patients treated for cuff tear arthropathy (CTA) or irreparable massive cuff tears. Patient satisfaction can be limited by reduced active external rotation (AER). Rotator cuff muscles that externally rotate the shoulder are Infraspinatus and Teres Minor (TM).
Aim
The purpose of this study was to assess the correlation between preoperative TM fatty degeneration and postoperative AER after rTSA performed for CTA or irreparable cuff tears.
Methods
Constant Scores (CS) and Active Range of Motion (AROM) were consecutively collected for 109 shoulders in 97 patients (mean 75.73±8.94 years; 31Male, 66 Female) over a 10-year period. AER was evaluated with the humerus in adduction (AER1) and in abduction (AER2). TM muscle atrophy was scored according to Goutallier’s classification, assessed on preoperative CT scans.
Results
Multivariate analysis showed that TM fatty infiltration was a predictor of AER1. AER1 decreased by 4.9 degrees preoperatively, and by 6.4 degrees at final follow-up, for each increment in Goutallier grade (p=0.02). Postoperatively, AER2 improved significantly (p<0.001), but did not correlate with TM Goutallier grade. At a mean follow-up of 38 months (range: 24 to 96), mean Constant Score improved from 20.5± 11.1 to 68.4 ± 14.9 (p <0.001), as did shoulder AROM in all planes including AER1 (p < 0.001).
Conclusion
This is the first study to quantify the inverse correlation between AER and TM Goutallier grade, both preoperatively and following rTSA; this information guides prognosis for patients with TM degeneration undergoing rTSA. Further studies are necessary to have a better understanding and find reliable solutions.
Brachial plexus injuries involving the C5–C7 roots result not only in disability of shoulder abduction, shoulder external rotation, and elbow flexion but also in extension of the elbow, wrist, and fingers. Elbow flexion is the first priority for reconstruction. Recently reconstruction of the elbow extension has grown in popularity. Without elbow extension, the patient cannot reach out in space. Outcomes of the reconstruction of shoulder abduction and external rotation in the C5–C7 root injury are not as good as in the C5–C6 root injury. The deficit of the shoulder external rotation and instability of the scapula result in the poor function of overhead activity. Loss of wrist and fingers extension impacts the hand function.
Introduction
The probability of spontaneous recovery of shoulder external rotation in neonatal brachial plexus injury (NBPI) is very low after the age of 18 months. We report the outcomes of double nerve transfers to restore active external rotation of the glenohumeral joint in children with NBPI after this age.
Patients and methods
Retrospective analysis of 20 children of mean age of 23.8 months with a mean follow‐up of 14.8 months. Inclusion criteria were: age > 18 months, full passive glenohumeral external rotation in abduction, and absence of severe joint deformity on MRI. The spinal accessory nerve was transferred to the infraspinatus motor branch and the long head of the triceps motor branch to the teres minor motor branch. Anterior shoulder release was associated when passive shoulder external rotation in adduction (pERADD) was <30° (n = 13, Group R vs. Group N‐no release n = 7). Active shoulder elevation and external rotation in abduction (aERABD) of the glenohumeral joint were evaluated pre‐ and postoperatively.
Results
All children except two in Group R, recovered aERABD 4–6 months after surgery. Mean postoperative aERABD was 70 ± 32.4 and 82.9 ± 11.1° and shoulder elevation gain was 24.6 ± 22.2 and 27.1 ± 29.2° for Group R and N, respectively, without statistically significant differences.
Conclusions
Late nerve transfers to external rotator muscles are effective in children with NBPI. This might be explained not only by muscle reinnervation, but also by the interruption of a previous co‐contraction or developmental apraxia.
Level of evidence
Therapeutic IV.
Background
Proximal humerus fractures are common in the elderly population and are often treated with reverse shoulder arthroplasty (RSA). The purpose of this systematic review was to compare tuberosity healing and functional outcomes in patients undergoing RSA with humeral inclinations of 135°, 145°, and 155°.
Methods
A systematic review was performed of RSA for proximal humerus fracture using Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. Radiographic and functional outcome data was extracted to evaluate tuberosity healing according to humeral inclination. Analysis was also performed of healed vs non-healed tuberosities.
Results
A total of 873 patients in 21 studies were included in the analysis. The mean age was 77.5 (range of 58-97) years and the mean follow-up was 26.2 months. Tuberosity healing was 83% in the 135° compared to 69% in the 145° and 66% in the 155° groups (p=.030). Postoperative abduction was highest in the 155° group (p<.001). No significant difference was found in forward flexion, external rotation, or postoperative Constant score between groups. Patients with tuberosity healing demonstrated 18° higher forward flexion (p=.008) and 16° greater external rotation (p<.001) compared to those with unhealed tuberosities.
Conclusion
RSA for fracture with 135° humeral inclination is associated with higher tuberosity healing rates compared to 145° or 155°. Postoperative abduction is highest with a 155° implant, but there is no difference in in postoperative forward flexion, external rotation, or Constant score according to humeral inclination. Patients with healed tuberosities have superior postoperative forward flexion and external rotation compared to those with unhealed tuberosities.
Total shoulder arthroplasty (TSA) is an effective procedure for patients with glenohumeral (GH) joint arthritis and trauma with the aim of reducing pain as well as improving motion and function. Reverse total shoulder arthroplasty (RTSA) reverses the normal anatomy of the GH joint and is used in rotator cuff deficient patients. RTSA overcomes the rotator cuff deficiency by optimizing the action of the deltoid muscle. Reversing the glenohumeral anatomy has certain biomechanical advantages but also confers potential challenges, some of which have been addressed by developments in prosthesis design and surgical technique. This chapter aims to review the biomechanics of RTSA, the evolution of prosthesis design, and development of surgical techniques to overcome the biomechanical issues created by replacing the native glenohumeral joint.
Résumé
Introduction
Dans le cadre des lésions traumatiques du plexus brachial, l’obtention d’une épaule mobile, stable et forte fait partie des objectifs prioritaires. Les arthrodèses scapulo-humérales (ASH) restent principalement utilisées en complément ou après échec d’une chirurgie nerveuse initiale. Notre objectif était de comparer les résultats obtenus au niveau de l’épaule après chirurgie nerveuse directe (CND) ou ASH dans les paralysies supra-claviculaires traumatiques du plexus brachial.
Hypothèse
Les ASH, considérée comme un traitement palliatif, peuvent être considérées comme une alternative thérapeutique aux CND.
Matériel et méthodes
Cinquante-huit patients, d’âge moyen 24 ans, ont été rétrospectivement inclus avec un recul minimum de 2 ans. Vingt patients ont fait l’objet d’une neurotisation du nerf spinal accessoire partiel sur le nerf supra-scapulaire (groupe CND) et 38 patients d’une ASH. Nous avons évalué les mobilités de l’épaule, la force musculaire isométrique et le score DASH.
Résultats
Le recul moyen était de 46 mois (24–156). Il n’existait pas de différence statistiquement significative entre les deux groupes concernant les mobilités de l’épaule. La dispersion des données était statistiquement plus importante dans le groupe CND que dans le groupe ASH en antépulsion (p = 0,0011), abduction (p < 0,001) et rotation externe (p = 0,0066). La force était statistiquement plus importante dans le groupe ASH comparé au groupe CND dans toutes les amplitudes de mouvement. Les scores DASH ne montraient pas de différences statistiques entre les deux groupes.
Conclusions
Nos résultats contrastent avec ceux classiquement admis selon lesquels la neurotisation du nerf supra-scapulaire permettrait l’obtention de meilleurs résultats cliniques que les ASH. Nous n’avons pas retrouvé cette supériorité dans la présente étude. Les différences de dispersion des données indiquent que la chirurgie nerveuse procurerait des résultats imprévisibles et hétérogènes en opposition avec l’ASH qui procurerait des résultats modestes, mais homogènes et prédictibles.
Niveau de preuve
IV, étude rétrospective, série clinique.
Background:
Restoring shoulder mobility, stability, and strength is a key goal in patients with brachial plexus injuries. Shoulder arthrodesis is chiefly used as an adjunct to, or after failure of, initial direct nerve surgery. The objective of this study was to compare clinical and functional shoulder outcomes after direct nerve transfer vs. shoulder arthrodesis in adults with supra-clavicular brachial plexus injuries.
Hypothesis:
Shoulder arthrodesis, currently used as a salvage procedure in brachial palsy injuries, deserves to be viewed to a valid alternative to direct nerve transfer.
Material and methods:
A retrospective study was conducted in 58 patients with a follow-up of at least 2 years. Among them, 20 were managed by transfer of a spinal accessory nerve fascicle to the supra-scapular nerve and 38 by shoulder arthrodesis. Outcome measures were shoulder range-of-motion, isometric shoulder strength, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score.
Results:
Mean age at surgery was 24 years and mean follow-up was 46 months (range, 24-156 months). Motion ranges of the shoulder were not significantly different between the two treatment groups. Data variance was significantly greater in the nerve transfer group than in the shoulder arthrodesis group for scapular antepulsion (p=0.0011), abduction (p<0.001), and external rotation (p=0.0066). Strength was significantly greater in the arthrodesis group in all directions of motion. The DASH scores showed no significant between-group differences.
Conclusions:
The results of this study conflict with the widely help opinion that nerve transfer to the supra-scapularis nerve produces better clinical outcomes compared to shoulder arthrodesis. Nerve transfer was not better than shoulder arthrodesis in our patients. The data variance heterogeneity suggests poor predictability and reliability of nerve transfer, in contrast to the modest but predictable and uniform results of shoulder arthrodesis.
Level of evidence:
IV, retrospective observational comparative study.
Throughout the world, the number of reverse total shoulder arthroplasties (RTSA) performed continues to rise. Stemless anatomic implants have been available for more than a decade, and now awareness of the potential advantages of stemless RTSA is growing. Advantages include bone preservation, shorter operative time, less blood loss, ease of revision and the potential to reduce stem-related complications such as periprosthetic fractures and stress shielding. In this chapter the rationale for stemless design and the different designs of stemless RTSA are described. Evidence from the literature is reviewed. Overall, promising short- to medium-term clinical and radiological results of stemless RTSA have been achieved. Further long-term studies are required to help inform survivorship attributes and implant choices. However, the future of RTSA could be stemless!
Savitzky, JA, Abrams, LR, Galluzzo, NA, Ostrow, SP, Protosow, TJ, Liu, SA, Handrakis, JP, and Friel, K. Effects of a novel rotator cuff rehabilitation device on shoulder strength and function. J Strength Cond Res 35(12): 3355-3363, 2021-The glenohumeral joint, a multiaxial ball and socket joint, has inherent instability counterbalanced by the muscular stability of the rotator cuff (RC) and connective tissue. Exercise has been shown to alleviate pain and disability arising from degenerative changes of the RC due to overuse, trauma, or poor posture. This study compared the training effects of ShoulderSphere (SS), an innovative device that uses resistance to centrifugal force, to TheraBand (TB), a traditional device that uses resistance to elasticity. Thirty-five healthy male and female adults (24.2 ± 2.4 years) were randomized into 3 groups: SS, TB, and control. Five outcomes were assessed before and after the twice-weekly, 6-week intervention phase: strength (shoulder flexion [Fx], extension [Ext], external rotation [ER], and internal rotation [IR]), proprioception (6 positions), posterior shoulder endurance (ShEnd), stability (Upper Quarter Y-Balance Test [YBal] (superolateral [YBalSup], medial [YBalMed], and inferolateral [YBalInf]), and power (seated shot put [ShtPt]). Data were analyzed using a 3 (group: SS, TB, and control) × 2 (time: pre and post) generalized estimating equation. Analyses demonstrated a main effect of time for all strength motions (p < 0.01): YBalInf (p < 0.0001), ShtPt (p < 0.05), and ShEnd (p < 0.0001) but no interaction effects of group × time. There were no main or interaction effects for proprioception. Both SS and TB groups had significant within-group increases in Ext, IR, YBalInf, and ShEnd. Only the SS group had significant increases in ER, Fx, and ShtPt. ShoulderSphere demonstrated comparable conditioning effects with TB and may afford additional strength gains in Fx and ER, and power. ShoulderSphere should be considered a viable alternative in RC conditioning.
An active upper limb orthosis was developed for patients who cannot move their upper limb. The system has two independent motors that allow flexion and extension of the shoulder and elbow, and in addition, rotation of the upper arm. By incorporating arm rotation, activities of daily living (ADLs) are improved. If the patient is able to move their wrist as in Erb’s paralysis, electromyogram (EMG) generated by the movement of the wrist is processed by an original system and used to control the orthosis. Evaluations were performed on moving range of orthosis by a healthy subject and on ADL tasks by an Erb’s palsy subject. There were tasks that the subject could not complete because of lack of function or range of motion of orthosis. However, tasks that require use of two arms, which the subject could not complete previously, were completed using the orthosis.
Background:
Theoretically, patients with only one functional arm secondary to contralateral amputation or paralysis will subject their only functional upper extremity to increased loads. This could become an issue after reverse shoulder arthroplasty (RSA). However, there is no reported data on the implant survival or function for patients with a non-functional contralateral upper extremity.
Objective:
To report the outcomes of RSA in patients with contralateral upper extremity amputation or paralysis.
Design:
Retrospective case series.
Setting:
Tertiary University Hospital.
Patients:
All patients undergoing RSA between January 2004 and December 2013.
Methods:
Of 1335 RSA procedures performed, 5 patients had a minimum 2-year follow-up and non-functional contralateral upper extremity. There were 3 men and 2 women, with a mean (SD) age and length of follow-up of 72.4 (7.5) years and 56.4 (24-132) months. Two of the patients had a contralateral upper extremity amputation and the other three had contralateral upper extremity paralysis as a result of stroke, traumatic brain injury, and traumatic brachial plexus injury at birth.
Main outcomes:
Pain, range of motion (ROM), functional scores (Simple Shoulder Test (SST), American Shoulder and Elbow Society (ASES) and Quick-Disability of the Arm, Shoulder and Hand (Quick-DASH)), satisfaction, complications/reoperations, and radiographic loosening.
Results:
RSA resulted in substantial improvement in pain (p=0.008), forward flexion (p=0.02) and external ROM (p=0.01). The mean (SD) SST, ASES, and Quick-DASH scores were 9.8 (1.3), 82 (13), and 17.8 (13.4), respectively. The results were excellent in three, satisfactory in one, and unsatisfactory in one patient (due only to external rotation limited to 10?). Subjectively, all five patients felt greatly improved and stated they would undergo RSA again. There were no complications or reoperations. There were no shoulders with component loosening.
Conclusions:
RSA seems to be a safe, effective, and successful surgical procedure for patients with a non-functional contralateral upper extremity. Studies with larger sample sizes and longer follow-up will hopefully validate the present findings.
Background:
The purpose of this study was to analyze a population of patients with bilateral reverse total shoulder arthroplasty (RTSA) to evaluate their ability to perform activities of daily living and personal hygiene tasks.
Methods:
At a minimum 2-year follow-up, we retrospectively reviewed 50 patients (100 shoulders) with a mean age of 72 years who underwent staged bilateral RTSA. The average follow-up period was 61 months (range, 24-121 months), with a minimum 2-year follow-up after the second surgical procedure. Functional outcomes were assessed with American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Short Form 12 (SF-12) scores. In addition, a unique questionnaire regarding personal hygiene habits and activities of daily living reliant on shoulder rotation was administered to all patients.
Results:
Patients showed significant improvements in pain (mean improvement in visual analog scale score from 5.7 to 1.0, P < .001) and forward elevation (mean improvement from 71° to 136°, P < .001). Clinical outcome scores showed significant improvements: The mean American Shoulder and Elbow Surgeons score improved from 35.8 to 76.5 (P < .001), Simple Shoulder Test score improved from 2.4 to 8.0 (P < .001), SF-12 mental component subscore improved from 51.9 to 54.1 (P < .001), and SF-12 physical component subscore improved from 30.5 to 39.7 (P < .001). Internal and external rotation showed significant improvements (from 33° to 53° [P < .005] and from 27° to 44° [P < .001], respectively). All patients retained independence with personal hygiene and activities of daily living. Complications included prosthetic instability (3%), acromial fracture (5%), and periprosthetic joint infection (1%). The overall reoperation rate was 5%.
Conclusions:
Bilateral RTSA provides predictable pain relief and improved function. Hygiene practices are unaltered for most patients, and the other patients rapidly develop simple compensatory strategies and retain independence in activities of daily living.
Patients with neuromuscular disorders experience problems with the activities of daily living (ADL) due to limited muscle strength. Upper limb weight-bearing orthoses have been developed to increase quality of life by enabling patients to move their arms freely. Most existing designs help patients lift their arm by compensating the gravitational force on the sagittal plane. However, the essential ADL for a patient's actual life, such as eating, drinking, scratching the face, and receiving phone calls, require motion in 3D space that is mainly performed by forearm movement. To assist forearm motion, weight should be compensated by elbow flexion/extension and shoulder medial/lateral rotation. In this study, a weight-bearing mechanism that compensates the weight in 3D space with only two zero-initial-length springs is presented. We built a 4 degree of freedom passive weight-bearing orthosis (WBO) with three rotational axes on the shoulder and one rotational axis on the elbow to mimic the natural movement of a human arm. To design the WBO, joint placement was considered, and a slider-crank mechanism was used to solve the joint misalignment problem caused by the overlapping of the joint between the WBO and the human arm. A prototype was built to verify the function of the proposed mechanism. It showed sufficient weight compensation performance to enable self-reliance in ADL by reducing the effort required to move the arm.
Restoration of shoulder function in patients with brachial plexus injury can be challenging. Initial reported efforts were focused on stabilizing the shoulder, improving inferior subluxation and restoring abduction and flexion of the joint. Recent advancements and improved understanding of coordinated shoulder motion and the biomechanical properties of the muscles around the shoulder applicable to tendon transfer have expanded available surgical options to improve shoulder function, specifically external rotation. Despite the advances in reconstructive options, brachial plexus injury remains a serious problem that requires complex surgical solutions, prolonged recovery, and acceptance of functional loss.
Purpose:
Our objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results.
Methods:
Fifty-one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with >1 year follow-up. The primary outcome measured was shoulder ER. The outcomes we utilized included "clinically useful ER" (motion ≥ -35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation.
Results:
EMG evidence of re-innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow-up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: -60° to 90°) and MRC grade 2.2 (2-4). The only predictor of ER improvement was an isolated upper trunk (C5-C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5-C6-C7 and panplexus injuries, respectively (P < 0.03).
Conclusions:
Although 85% had EMG signs of recovery, the SAN to SSN transfer failed to provide useful recovery of ER through reinnervation of the infraspinatus muscle in injuries involving more levels than a C5-C6 root/upper trunk pattern. In patients with greater than C5-6 level injuries alternatives to SAN to SSN transfer should be considered to restore shoulder ER. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.
Background:
Limitations in abduction and external rotation are the sequel of brachial palsy. The purpose of this study was to evaluate functional outcomes of modified L'Episcopo procedure in children with brachial palsy who do not have gross shoulder joint subluxation.
Methods:
From 2002 to 2012, a continuous series of 22 patients with brachial plexus birth palsy underwent a modified L'Episcopo procedure. Through an axillary approach, subscapularis release with latissimus dorsi rerouting and transfer of pectoralis major to subscapularis footprint was performed.
Results:
The mean age of patients at surgery was 49 months. The mean follow-up time was 51 months (range, 24 to 90 mo). Preoperatively, the mean active abduction and external rotation were 77.5 and 2.5 degrees, respectively. The mean active abduction and external rotation were 135.6 and 32 degrees, respectively, at the final follow-up (P<0.001).
Conclusions:
This modified L'Episcopo technique is an effective and reproducible procedure that improves shoulder function significantly.
Level of evidence:
Level III.
The purpose of this study was to evaluate outcomes in patients with rotator cuff tear arthropathy after staged bilateral reverse shoulder arthroplasties (RSAs) and to compare them with an age-, gender-, and diagnosis-matched control group with a unilateral RSA.
We identified 11 patients with bilateral RSAs for rotator cuff tear arthropathy with a minimum of 2-year follow-up in a prospective shoulder arthroplasty registry. The bilateral group was matched to a control group of 19 patients with a unilateral RSA. Shoulder function scores, mobility, patient satisfaction, and activities of daily living were assessed preoperatively and at final follow-up.
There was no statistical difference between the first RSA or second RSA and the control group regarding age, gender, or follow-up. No group differences were noted preoperatively for shoulder function scores or mobility (P > .10). All groups significantly improved on all shoulder function scores (Constant score, American Shoulder and Elbow Surgeons score, Western Ontario Osteoarthritis of the Shoulder index, Single Assessment Numeric Evaluation score) and mobility at final follow-up (all P < .01). There were no significant differences in shoulder function scores or mobility between the first and second RSA in the bilateral group or between either shoulder in the bilateral group and the unilateral group (all P > .10). Patient satisfaction improved and patients were successfully able to perform many important activities of daily living after bilateral RSAs.
Patients with bilateral rotator cuff tear arthropathy can be advised that staged bilateral RSAs can be successful when indicated. Improvements in shoulder function scores, patient satisfaction, and mobility are possible for both the first RSA and the second RSA.
Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Purpose/hypothesis:
The purpose of this study was to determine the reliability and validity of two smartphone applications: (1) GetMyROM - inclinometery-based and (2) DrGoniometry - photo-based in the measurement of active shoulder external rotation (ER) as compared to standard goniometry (SG).
Participants:
Ninety-four Texas Woman's University Doctor of Physical Therapy students from the School of Physical Therapy - Houston campus, were recruited to participate in this study.
Materials/methods:
Two iPhone applications were compared to SG using both novice and experienced raters. Active shoulder ER range of motion was measured over two time periods in random order by blinded novice and experienced raters.
Results:
Intra-rater reliability using novice raters for the two applications ranged from an intraclass correlation coefficient (ICC) of 0.79 to 0.81 with SG at 0.82. Inter-rater reliability (novice/expert) for the two applications ranged from an ICC of 0.92 to 0.94 with SG at 0.91. Concurrent validity (when compared to SG) ranged from 0.93 to 0.94. There were no significant differences between the novice and experienced raters.
Conclusion:
Both applications were found to be reliable and comparable to SG. A photo-based application potentially offers a superior method of measurement as visualizing the landmarks may be simplified in this format and it provides a record of measurement.
Clinical relevance:
Further study using patient populations may find the two studied applications are useful as an adjunct for clinical practice.
The importance of external rotation of the shoulder is well accepted. Patients with inadequate recovery of shoulder function after nerve transfers for a brachial plexus injury have difficulty in using their reconstructed limb. The options for secondary procedures to improve shoulder function are often limited, especially if the spinal accessory nerve has been used earlier for nerve transfer or as a donor nerve for a free functioning muscle transfer. We have used the contralateral lower trapezius transfer to the infraspinatus in three cases, to restore shoulder external rotation. All patients had significant improvement in shoulder external rotation (mean 97°; range 80°-110°) and improved disability of the arm, shoulder and hand scores. The rotation occurred mainly at the glenohumeral joint, and was independent of the donor side. All patients were greatly satisfied with the outcome. Contralateral lower trapezius transfer appears to help in overall improvement of shoulder function by stabilizing the scapula. The results have remained stable after mean follow-up of 58 months (range 12-86). No donor site deficit was seen in any patient.
Some surgeons are reluctant to perform a reverse total shoulder arthroplasty (RTSA) on both shoulders because of concerns regarding difficulty with activities of daily living post-operatively as a result of limited rotation of the shoulders. Nevertheless, we hypothesised that outcomes and patient satisfaction following bilateral RTSA would be comparable to those following unilateral RTSA. A single-surgeon RTSA registry was reviewed for patients who underwent bilateral staged RTSA with a minimum follow-up of two years. A unilateral RTSA matched control was selected for each shoulder in those patients undergoing bilateral procedures. The Constant–Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Values (SSV), visual analogue scale (VAS) for pain, range of movement and strength were measured pre- and post-operatively. The mean CMS, ASES, SSV, VAS scores, strength and active forward elevation were significantly improved (all p < 0.01) following each operation in those undergoing bilateral procedures. The mean active external rotation (p = 0.63 and p = 0.19) and internal rotation (p = 0.77 and p = 0.24) were not significantly improved. The improvement in the mean ASES score after the first RTSA was greater than the improvement in its control group (p = 0.0039). The improvement in the mean CMS, ASES scores and active forward elevation was significantly less after the second RTSA than in its control group (p = 0.0244, p = 0.0183, and p = 0.0280, respectively). Pain relief and function significantly improved after each RTSA in those undergoing a bilateral procedure.
Bilateral RTSA is thus a reasonable form of treatment for patients with severe bilateral rotator cuff deficiency, although inferior results may be seen after the second procedure compared with the first.
Cite this article: Bone Joint J 2013;95-B:1232–8.
Background: In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve
Lesions affecting the upper roots of the brachial plexus result in paralysis of shoulder abduction and external rotation. In longstanding lesions, neurological surgery is not recommended in which case muscle transfers become an option to improve shoulder function. We describe the surgical treatment of seven adult patients with longstanding lesions of the upper roots of the brachial plexus, in whom the upper trapezius muscle was transferred to the humeral head, whereas the lower trapezius muscle was sutured to the infraspinatous muscle tendon. Within an average of 11.7 months after surgery, patients had recovered 38° of abduction and 104° of external rotation, as measured from full internal rotation. The results of this preliminary series involving the combined transfer of both the upper and lower trapezius muscle seems promising for the treatment of chronic paralysis of abduction and external rotation following brachial plexus injury.
Upper extremity (UX) movement analysis by means of 3D kinematics has the potential to become an important clinical evaluation method. However, no standardized protocol for clinical application has yet been developed, that includes the whole upper limb. Standardization problems include the lack of a single representative function, the wide range of motion of joints and the complexity of the anatomical structures. A useful protocol would focus on the functional status of the arm and particularly the orientation of the hand. The aim of this work was to develop a standardized measurement method for unconstrained movement analysis of the UX that includes hand orientation, for a set of functional tasks for the UX and obtain normative values. Ten healthy subjects performed four representative activities of daily living (ADL). In addition, six standard active range of motion (ROM) tasks were executed. Joint angles of the wrist, elbow, shoulder and scapula were analyzed throughout each ADL task and minimum/maximum angles were determined from the ROM tasks. Characteristic trajectories were found for the ADL tasks, standard deviations were generally small and ROM results were consistent with the literature. The results of this study could form the normative basis for the development of a 'UX analysis report' equivalent to the 'gait analysis report' and would allow for future comparisons with pediatric and/or pathologic movement patterns.
Analysis of hand therapy programmes used in various hand therapy centres shows that the programmes primarily aim to restore a maximum range of motion, although basic activities of daily living do not often require full joint mobility. This report of our investigations, which commenced in 2003, presents the results of an evaluation of the range of motion in the joints of the upper limb, including both proximal and hand joints, during selected daily activities.
Right-handed students of physical therapy were examined using a three-dimensional motion analysis system in the Biokinetics Laboratory of the Division of Biomechanics at the University of Physical Education in Kraków. Spatial registration of movement focused on three daily activities that primarily involve the upper limb, namely, natural movements associated with combing, closing a zip fastener and answering a telephone call. Angular changes in the joints recorded in three movement planes were used as analysis inputs.
The range of motion in the analysed joints during daily activities never reached the respective maximal values, usually centering around the middle point of the ranges.
Daily activities require only limited mobility in the upper limb joints. Three-dimensional motion analysis is a useful tool to monitor and assess this phenomenon. The results of such assessments should be taken into account by hand therapists designing and implementing rehabilitation programmes.
Three-dimensional motion analysis of the lower limb has been an approved method of diagnosis and therapy planning for several years. In this study we observed the range of motion of the shoulder and elbow in 10 activities of daily life (ADL) with a marker-based biomechanical model for the upper extremity. With this database we hope to improve the evaluation of different handicaps of the upper limb.
The used biomechanical model is based on 14 infrared light-reflecting markers. The ranges of motion in ADL for shoulder and elbow were measured in a standardised case setting in seven test persons with a mean age of 25 years (SD 15 years). The 10 observed ADL were eating with a spoon, combing hair, genital hygiene, using a telephone, typing on a keyboard, drinking from a glass, turning a key, turning a page, pouring water in a glass and drawing.
For the ten explored ADL, the test persons needed a range of motion in the shoulder of 91 - 0 - 9 degrees (total 100 degrees) flexion/extension, 112 - 23 - 0 degrees (total 89 degrees) abduction/adduction, and 91 - 0 - 114 degrees (total 205 degrees) external/internal rotation. Most of the ADL were performed in external rotation and, excluding the motion genital hygiene, the test persons only needed an internal rotation of 10 degrees. Maximal shoulder flexion was used with opening a door, the minimum was reached with genital hygiene. The maximum angles of abduction and rotation were reached with combing hair and the minimum values were reached with genital hygiene. To perform the ADL, an elbow extension/flexion of 0 - 36 - 146 degrees (total 110 degrees), and 55 - 0 - 72 degrees (total 127 degrees) pro-/supination was needed. Maximal pronation was reached with "pour from a pitcher". Maximal supination was present with genital hygiene.
The decisive benefit of 3D motion analysis is the exact capturing of complex and dynamic movements at any time. Therefore, not only static joint positions can be recorded, but also the dynamic course of a movement can be traced. By using our model on every day movements, we were able to collect data that can serve as the basis for the desired range of motion of the upper extremities in patients.
Ziel: Die dreidimensionale Bewegungsanalyse ist an der unteren Extremität ein seit Jahren bewährtes Mittel zur Therapieplanung. In dieser Studie wurde das Bewegungsausmaß für Schulter und Ellenbogen bei 10 Alltagsbewegungen anhand der 3D-Bewegungsanalyse untersucht. Somit können die Relevanz und das Ausmaß von Bewegungseinschränkungen besser beurteilt werden. Methode: Das verwendete biomechanische Modell der oberen Extremität basierte auf 14 Infrarotlicht reflektierenden Markern. Es wurde standardisiert bei 7 Probanden (Alter 25, SD 15 Jahre) das Bewegungsausmaß des Schulter- und Ellenbogengelenks bei 10 Alltagsbewegungen ermittelt. Die untersuchten Bewegungen waren im Einzelnen: Essen mit einem Löffel, Kämmen mit einem Kamm, Intimhygiene, Telefonieren, Tippen auf einer Tastatur, Trinken aus einem Glas, Drehen eines Schlüssels im Türschloss, Umblättern einer Seite, Wasser in ein Glas eingießen und Zeichnen einer Acht. Ergebnisse: Zur Durchführung von 10 Alltagsbewegungen wurde im Schultergelenk bei der Anteversion/Retroversion ein Bewegungsausmaß von 91 - 0 - 9°, d. h. insgesamt 100°, bei der Abduktion/Adduktion von 112 - 23 - 0° (insgesamt 89°) und eine Außen-/Innenrotation von 91 - 0 - 114° (insgesamt 205°) benötigt. Die meisten Alltagsbewegungen konnten in Außenrotationsstellung durchgeführt werden und ohne die Bewegung Intimhygiene wäre nur eine Innenrotation von 10° nötig gewesen. Der Maximalwert der Anteversion wurde bei der Bewegung Drehung des Schlüssels im Türschloss und der Minimalwert bei der Intimhygiene erreicht. Bei der Abduktion und Rotation wurden der Maximalwert beim Kämmen und der Minimalwert bei der Intimhygiene erreicht. Im Ellenbogen benötigten die Probanden im Mittel ein Bewegungsausmaß bei Extension/Flexion von 0 - 36 - 146° (d. h. insgesamt 110°) und bei Pro- und Supination von 55 - 0 - 72° (insgesamt 127°), wobei die größte Pronation beim „Wasser eingießen“ und die größte Supination bei der Intimhygiene festzustellen war. Schlussfolgerung: Mit der 3D-Bewegungsanalyse können komplex-dynamische Bewegungen und Gelenkwinkel zu jedem beliebigen Zeitpunkt erfasst werden. Durch die Anwendung der 3D-Bewegungsanalyse bei Alltagsbewegungen konnten wir Daten gewinnen, die als Grundlage für das anzustrebende Bewegungsausmaß an der oberen Extremität dienen.
In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve grafts or nerve transfers for isolated upper trunk or C5-C6-C7 root injuries. The purpose of our study was to compare, with systematic review, the outcomes for modern intraplexal nerve transfers for shoulder and elbow function with autogenous nerve grafting for upper brachial plexus traumatic injuries.
PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies in which patients had surgery for traumatic upper brachial plexus palsy within one year of injury and with a minimum follow-up of twelve months. Strength and shoulder and elbow motion were assessed as outcome measures. The Fisher exact test and Mann-Whitney U test were used to compare outcomes, with an alpha level of 0.05.
Thirty-one studies met the inclusion criteria. Two hundred and forty-seven (83%) and 286 (96%) of 299 patients with nerve transfers achieved elbow flexion strength of grade M4 or greater and M3 or greater, respectively, compared with thirty-two (56%) and forty-seven (82%) of fifty-seven patients with nerve grafts (p < 0.05). Forty (74%) of fifty-four patients with dual nerve transfers for shoulder function had shoulder abduction strength of grade M4 or greater compared with twenty (35%) of fifty-seven patients with nerve transfer to a single nerve and thirteen (46%) of twenty-eight patients with nerve grafts (p < 0.05). The average shoulder abduction and external rotation was 122° (range, 45° to 170°) and 108° (range, 60° to 140°) after dual nerve transfers and 50° (range, 0° to 100°) and 45° (range, 0° to 140°) in patients with nerve transfers to a single nerve.
In patients with demonstrated complete traumatic upper brachial plexus injuries of C5-C6, the pooled international data strongly favors dual nerve transfer over traditional nerve grafting for restoration of improved shoulder and elbow function. These data may be helpful to surgeons considering intraoperative options, particularly in cases in which the native nerve root or trunk may appear less than optimal, or when long nerve grafts are contemplated.
Elbow range of motion for functional tasks has been previously studied. Motion arcs necessary to complete contemporary tasks such as using a keyboard or cellular telephone have not been studied and could have implications on what is considered to be a functional arc of motion for these tasks. The purpose of this study was to determine elbow range of motion, including flexion-extension, pronation-supination, and varus-valgus angulation, with use of three-dimensional optical tracking technology for several previously described positional and functional tasks along with various contemporary tasks.
Twenty-five patients performed six positional and eleven functional tasks (both historical and contemporary). Elbow flexion-extension, varus-valgus, and forearm rotation (pronation and supination) ranges of motion were measured.
Positional tasks required a minimum (mean and standard deviation) of 27° ± 7° of flexion and a maximum of 149° ± 5° of flexion. Forearm rotation ranged from 20.0° ± 18° of pronation to 104° ± 10° of supination. Varus and valgus angulations ranged between 2° ± 5° of varus to 9° ± 5° of valgus. For functional tasks, the maximum flexion arc was 130° ± 7°, with a minimum value recorded as 23° ± 6° and a maximum value recorded as 142° ± 3°. All of these were for the cellular telephone task. The maximum pronation-supination arc (103° ± 34°) was found with using a fork. Maximum pronation was found with typing on a keyboard (65° ± 8°). Maximum supination was found with opening a door (77° ± 13°). Maximum varus-valgus arc of motion was 11° ± 4°. Minimum valgus (0° ± 6°) was found with cutting with a knife, while maximum valgus (13° ± 6°) was found with opening a door.
Functional elbow range of motion necessary for activities of daily living may be greater than previously reported. Contemporary tasks, such as using a computer mouse and keyboard, appear to require greater pronation than other tasks, and using a cellular telephone usually requires greater flexion than other tasks.
Restoration of shoulder stability in post-traumatic plexopathy patients is very important because more distal functions depend on a stable and functioning shoulder. The purpose of this study is to present our experience with secondary surgeries in patients with devastating paralysis. Functional outcomes were analyzed in relation to age, severity score and type of reconstruction. The medical records of 55 post-traumatic plexopathy patients who underwent secondary shoulder reconstruction, by a single surgeon, between 1978 and 2006, were reviewed. 55 patients had 73 procedures, 44 for shoulder abduction and 29 for external rotation. 38 patients underwent secondary surgery to augment shoulder abduction. Trapezius advancement was performed in 14 patients, double free muscle transfer in 18, free latissimus dorsi in 4 and triceps muscle transfer in 2 patients. 26 patients had secondary procedures for enhancement of shoulder external rotation. Dynamic rerouting of latissimus dorsi and teres major was carried out in 18 patients and rotational humerus osteotomy in 11 patients. All patients had improvement of shoulder stability and function. Shoulder abduction reached 40.80 ± 15.93 and external rotation at 24.28 ± 17.90°. Trapezius advancement yielded 41.81 ± 9.02° of abduction. Latissimus dorsi yielded stronger shoulder abduction than adductor longus. Rerouting of latissimus dorsi and teres major attained 22.33 ± 20.31° of dynamic external rotation while humerus osteotomy produced 26.87 ± 10.32 of external rotation. Secondary procedures such as pedicle and free muscles transfers, tendon transfers, and rotational humerus osteotomy augment shoulder stability and function in patients with irreparable paralysis.
Enhancement of upper-extremity function, specifically shoulder function, after brachial plexus injury requires a good understanding of nerve repair and transfer, with their expected outcome, as well as shoulder anatomy and biomechanics enabling the treating surgeon to use available functioning muscles around the shoulder for transfer, to improve shoulder function. Surgical treatment should address painful shoulder subluxation in addition to improvement of function. The literature focuses on improving shoulder abduction, but improving shoulder external rotation should take priority because this function, even if isolated, will allow patients to position their hand in front of their body. With a functional elbow and hand, patients will be able to do most activities of daily living. The lower trapezius has been shown to be a good transfer to restore external rotation of the shoulder. Other parts of the trapezius, levator scapulae, rhomboids, and, when available, the latissimus dorsi, pectoralis major, teres major, biceps, triceps, and serratus anterior muscles can all be used to replace the rotator cuff and deltoid muscle function. To optimize the results, a close working relationship is required between surgeons reconstructing brachial plexus injury and shoulder specialists.
As the number of survivors of motor vehicle accidents and extreme sporting accidents increases, the number of people having to live with brachial plexus injuries increases. Although the injured limb will never return to normal, an improved understanding of the pathophysiology of nerve injury and repair, as well as advances in microsurgical techniques, have enabled the upper extremity reconstructive surgeon an opportunity to improve function in these life-altering injuries. The purpose of this review is to detail some of the current concepts of the treatment of adult brachial plexus injuries and give the reader an understanding of the nuances of the timing, available treatment options, and outcomes of treatment.
Brachial plexus birth palsy, although rare, may result in substantial and chronic impairment. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed to help the child maximize function in the affected upper extremity. Many present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery remain unresolved in infants with brachial plexus birth palsies. Recent literature has enhanced our understanding of the pathoanatomy and natural history of the injury as well as the surgical indications, expected outcomes, and complications; this literature has led to improved care of these patients. Based on the present evidence, recommendations for both microsurgery and shoulder reconstruction with tendon transfer and arthroscopic and open reductions are presented.
Persistent shoulder paralysis after brachial plexus injury is a challenging and difficult problem to treat1,2. Deltoid and rotator cuff muscle recovery has been reported to be incomplete, resulting in loss of abduction and little to no external rotation3,4. The resulting muscle weakness leads to a “hand-on-belly” internally rotated position that limits positioning of the hand anterior to the coronal plane with elbow flexion. For patients who do not receive timely and successful nerve reconstruction, complete axillary and suprascapular nerve paralysis can result in painful inferior glenohumeral subluxation2. As the majority of periscapular muscles are generally paralyzed, there may be few functioning muscles about the shoulder available for tendon transfer. In these instances, upper trapezius transfer has been attempted to restore shoulder abduction, with variable results reported5-15. Transfers of the latissimus dorsi and/or teres major muscles, which have been described for the treatment of upper plexus (Erb-Duchenne pattern) palsy to improve external rotation and abduction, typically do not function with global injury6. The need to restore external rotation in particular is important because it enables the patient to position the hand away from the body, especially when elbow flexion has been restored. Despite the important need for external rotation, we know of no report describing external rotation transfers for patients with a complete brachial plexus palsy, especially for those who present late. We report the preliminary findings of a novel technique of transferring the middle and lower segments of the trapezius muscle, extended with a tendon allograft, to restore external rotation of the shoulder. The patient was informed that data concerning the case would be submitted for publication, and he consented.
A fifty-five-year-old, right-hand-dominant man was seen with residual paralysis in the right shoulder eighteen …
It has been many years now since the introduction of nerve transfers for repair of traumatic brachial plexus lesions and more recently, we have seen its application in the field of obstetric brachial plexus palsy. These nerve transfers do not represent an alternative to anatomical repair by means of nerve grafting, but represent an additional possibility to increase the reconstructive options and improve the final results. This pushes the surgeon to decide: which function is to be restored by nerve grafting, which one by nerve transfer? What is the more reliable procedure? Does the age of the patient, the delay after the accident, or the type of accident influence this choice? If we add in the possibilities of palliative treatment, one can state that many therapeutic options are available today for brachial plexus reconstruction, and that no real consensus does exist. But some tendencies, some trends are apparent.
Traumatic brachial plexus injuries are devastating and management is complex. Treatment involves a multidisciplinary approach. Primary reconstruction involves nerve repair, grafting, and transfer techniques. Secondary reconstruction includes microneurovascular free-functioning muscle transfer, tendon transfers, and arthrodesis to improve or restore function. These procedures are indicated when patients present more than 12 months from injury or when primary reconstruction procedures fail, and should focus on elbow flexion and shoulder stability. A free-functioning muscle transfer is often indicated for elbow flexion, with double free-functioning muscle transfers providing possible prehension. Shoulder reconstruction focuses on restoring stability to the glenohumeral joint and restoring abduction. This article outlines these techniques, their principles, and important details.
The focus of this article is on evaluating the various outcome measures of surgical interventions for adult brachial plexus injuries. From a surgeon's perspective, the goals of surgery have largely focused on the return of motor function and restoration of protective sensation. From a patient's perspective, alleviation of pain, cosmesis, return to work, and emotional state are also important. The ideal outcome measure should be valid, reliable, responsive, unbiased, appropriate, and easy. The author outlines pitfalls and benefits of current outcome measures and offers thoughts on possible future measures.
This study was designed to quantify the range of upper limb joint motion required during the performance of a specific type of functional activity. Ten able-bodied men were studied as they performed three feeding tasks--eating with a spoon, eating with a fork, and drinking from a handled cup. Three shoulder joint rotations, one elbow joint rotation, one forearm joint rotation, and three wrist joint rotations were quantified simultaneously using a three-dimensional measurement system. It was found that the required ranges of motion for the feeding tasks were 5 degrees to 45 degrees shoulder flexion, 5 degrees to 35 degrees shoulder abduction, 5 degrees to 25 degrees shoulder internal rotation, 70 degrees to 130 degrees elbow flexion, from 40 degrees forearm pronation to 60 degrees forearm supination, from 10 degrees wrist flexion to 25 degrees wrist extension, and from 20 degrees wrist ulnar deviation to 5 degrees wrist radial deviation. Wrist rotation was also measured, but it was found to be negligible.
Adult traumatic brachial plexus injuries are devastating, and they are occurring with increasing frequency. Patient evaluation consists of a focused assessment of upper extremity sensory and motor function, radiologic studies, and, most important, preoperative and intraoperative electrodiagnostic studies. The critical concepts in surgical treatment are patient selection as well as the timing and prioritizing of restoration of function. Surgical techniques include neurolysis, nerve grafting, neurotization, and free muscle transfer. Results are variable, but increased knowledge of nerve injury and repair, as well as advances in microsurgical techniques, allow not only restoration of elbow flexion and shoulder abduction but also of useful prehension of the hand in some patients.
Shoulder stabilization is of utmost importance in upper extremity reanimation following paralysis from devastating injuries. Although secondary procedures such as tendon and muscle transfers have been used, they never achieve a functional recovery comparable to that following successful reinnervation of the supraspinatus, deltoid, teres minor, and infraspinatus muscles. Early restoration of suprascapular and axillary nerve function through timely brachial plexus reconstruction offers a good opportunity to restore shoulder-joint stability, adequate shoulder abduction, and external rotation function. Overall, in our series, 79% of patients achieved good and excellent shoulder abduction (muscle grade, +3 or more), and 55% of patients achieved good or excellent shoulder external rotation after reinnervation of the suprascapular nerve. The best results were seen when direct neurotization of the suprascapular nerve from the distal spinal accessory nerve or neurotization by the C5 root was carried out. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction and external rotation function.
Derotational humeral osteotomies have been used in older children with brachial plexus birth palsy and glenohumeral joint deformity to place the upper extremity in a more functional position. The purpose of this study was to determine the effects of these procedures on shoulder function and joint morphology.
Forty-three patients underwent a derotational humeral osteotomy for functional impairment in the setting of internal rotation contracture and/or glenohumeral joint deformity at our institution from 1996 to 2004. Osteotomies were performed proximal to the deltoid insertion and were stabilized with plate-and-screw fixation. The average age of the patients at the time of surgery was 7.6 years (range, 2.3 to 17.0 years). Shoulder function was graded according to the modified Mallet classification system. Glenohumeral deformity was graded according to the classification scheme of Waters et al. The results for twenty-seven patients who were followed for a minimum of two years (average, 3.7 years) are reported.
The average amount of external rotation achieved with osteotomy was 64 degrees (range, 35 degrees to 90 degrees). The mean aggregate Mallet classification score improved from 13 to 18 points (p < 0.01). The mean Mallet classification scores for the individual elements similarly demonstrated improvement following osteotomy, with the greatest gains in hand-to-mouth, hand-to-neck, and external rotation motions. The mean classification of the glenohumeral deformity was type IV preoperatively and postoperatively, signifying the persistence of glenohumeral dysplasia. There were no nonunions. One patient required a revision osteotomy for inadequate initial correction. One patient sustained a humeral fracture distal to the plate fixation because of sports-related trauma.
Derotational humeral osteotomy improves shoulder function in patients with brachial plexus birth palsy, internal rotation contracture, and/or advanced glenohumeral joint deformity. This osteotomy provides an attractive treatment option for patients with brachial plexus birth palsy who have advanced glenohumeral dysplasia precluding soft-tissue releases and tendon transfers.
Children with brachial plexus birth palsy may have permanent loss of shoulder external rotation strength. This impairment may result to a difficulty in reaching the face and head with the affected hand for grooming activities, and in reaching overhead for participation in sports or work-related tasks. In addition, the contracture that results from unopposed internal rotation may further restrict range of motion and cause glenohumeral joint deformity and subluxation.A combination of muscle release and transfers reliably improves the child's ability to position the hand, and may halt the development of joint deformity. Postoperative rehabilitation is necessary to maximize the strength and range of motion obtained from this operation.
In patients with brachial plexus birth palsy, persistent muscular imbalance across the developing shoulder results in progressive glenohumeral dysplasia, characterized by increased glenoid retroversion, humeral head flattening, and posterior subluxation of the humeral head. Soft-tissue procedures-such as tendon transfers and musculotendinous lengthenings--will provide limited functional improvements in the setting of advanced glenohumeral deformity. For patients with internal rotation contracture and external rotation weakness associated with severe glenohumeral dysplasia, external rotation osteotomy of the humerus may be used to improve global shoulder function. The purpose of this article is to review the history, indications, and surgical technique of external rotation humeral osteotomy for patients with brachial plexus birth palsy.
Measuring outcomes in adult brachial plexus reconstruction.
- Bengston K.A.
- Spinner R.J.
- Bishop A.T.
- Kaufman K.R.
- Coleman-Wood K.
- Kircher M.F.