A new strategy of muscle transposition for treatment of shoulder deformity caused by obstetric brachial plexus palsy

Cross-innervation (caused by misdirection of regenerated axons), muscular imbalance (caused by muscle paresis or earlier recovery), and growth are the three main causes of shoulder deformity due to obstetric brachial plexus palsy. If perioperative studies demonstrate the existence of muscle recovery by cross-innervation, a new strategy of muscle transposition to minimize the influence of cross-innervation is used. Release of antagonistic muscles (pectoralis major and teres major muscles) and augmentation of paretic muscles (transferring teres major to the infraspinatus muscle, reinserting both ends of the clavicular part of the pectoralis major muscle laterally) are performed for reconstruction. Since 1993, 29 patients having shoulder deformity caused by obstetric brachial plexus palsy underwent reconstruction utilizing this strategy of muscle transposition. The timing for the reconstruction was at an average of 8.5 years (range, 4 to 21 years). The average shoulder abduction following the muscle transposition was 151 degrees (i.e., average gain 104 percent, or 77 degrees) and that of external rotation was 72 degrees (average gain 200 percent, or 48 degrees). Compared with the patients who had no surgery for shoulder deformity caused by obstetric brachial plexus palsy and early nerve surgery for the infant obstetric brachial plexus palsy, the results of the strategy seem to be significantly impressive.     

Glenohumeral deformity secondary to brachial plexus birth palsy

Ninety-four patients who had brachial plexus birth palsy were entered into a prospective study to evaluate the association between persistent palsy, age-related musculoskeletal deformity, and functional limitations. Of these patients, forty-two had either computerized tomography or magnetic resonance imaging to assess the presence and degree of incongruity of the glenohumeral joint, deformity of the humeral head, and hypoplasia of the glenoid as part of the preoperative planning for a reconstructive operation. Functional ability was rated with use of the classification of Mallet, on a scale of 1 to 5. The mean glenoscapular angle (the degree of retroversion of the glenoid) on the affected side was -25.7 degrees compared with -5.5 degrees on the unaffected side. Twenty-six (62 per cent) of the forty-two shoulders had evidence of posterior subluxation of the humeral head, with a mean of only 25 per cent (range, 0 to 50 per cent) of the head being intersected by the scapular line. Progressive deformity was found with increasing age (p < 0.001). The natural history of untreated brachial plexus birth palsy with residual weakness is progressive glenohumeral deformity due to persistent muscle imbalance. The status of the glenohumeral joint must be addressed when the choice between tendon transfer and humeral derotation osteotomy for reconstruction of the shoulder is considered for these patients.     

Late treatment of brachial plexus palsy secondary to birth injuries: rotational osteotomy of the proximal part of the humerus

We retrospectively reviewed the results of rotational osteotomy that had been performed distal to the surgical neck of the humerus in twenty-two patients who had sustained an injury of the brachial plexus at birth. Eighteen patients had a lesion of the superior trunk of the brachial plexus (the fifth and sixth cervical nerve roots), and four had involvement of the entire brachial plexus. The patients ranged in age from four to seventeen years old (average age, ten years and three months old) at the time of the operation. The average duration of follow-up was fourteen years (range, two to thirty-one years). Preoperatively, the patients had been unable to perform self-care activities, such as grooming, feeding, and washing themselves, because of limited active external rotation or fixed internal rotation of the shoulder. All patients had decreased strength of the lateral rotator and abductor muscles and normal strength of the subscapularis and pectoralis major muscles. Radiographs showed some flattening of the humeral head, and four patients had posterior subluxation of the humeral head. A lateral rotational osteotomy of the proximal part of the humerus was performed between the insertions of the subscapularis and pectoralis major muscles. The site of the osteotomy was stabilized with catgut sutures in the periosteum in ten patients and with one or two staples in twelve. The extremity was immobilized in a plaster shoulder-spica cast for six weeks. At the latest follow-up evaluation, the average increase in active abduction was 27 degrees (range, 0 to 60 degrees) and the average increase in the arc of rotation was 25 degrees (range, 5 to 85 degrees). Supination of the forearm also had increased commensurate with the increase in external rotation. The appearance of the extremity had improved as well.     

Excimer laser photoastigmatic refractive keratectomy: eighteen-month follow-up

A new technique of shoulder fusion is presented using a posterior approach. After removal of the articular cartilage, a Rush pin is introduced from the spine of the scapula, through the glenoid into the medullary canal of the humerus. This is supplemented by tension-band wiring from the acromion to the neck of the humerus and a muscle pedicle graft attached to the acromion. A shoulder spica is applied for four to six weeks. Four patients with injuries to the upper brachial plexus and 14 with paralysis of the upper arm due to anterior poliomyelitis have been followed for three years. One of the 18 patients developed nonunion; she had removed her own cast prematurely. This method of fixation provides high shear resistance and low axial stiffness without deforming plastically. It does not affect bone growth in young patients, is effective in patients with osteoporosis, and gives a high rate of union.     

Helicobacter pylori: pretherapeutic resistance status in Germany (Ruhr area)

The hung up shoulder, or anterior subluxation locking in abduction, is a bizarre clinical picture which is not frequently seen. It is probably due to the fact that, in the subluxed position, the subscapularis muscle becomes an abductor, rather than an internal rotator. External rotation might shift the subscapular muscle fibres towards the proximal aspect of the humeral head, while joint laxity favors subluxation. It is possible that the hung up shoulder is just one aspect of multidirectional shoulder instability, given the tendency to generalised joint laxity, the frequent autoreduction, the positive sulcus sign, and initiation of subluxation by either abduction-external rotation or extension. In this series three out of four patients were treated conservatively and performed well in daily life; however, only the fourth patient had almost unlimited access to sports, thanks to surgical stabilization.     

The rotator cuff-deficient arthritic shoulder: diagnosis and surgical management

The symptomatic rotator cuff-deficient, arthritic glenohumeral joint poses a complex problem for the orthopaedic surgeon. Surgical management can be facilitated by classifying the disorder in one of three diagnostic categories: (1) rotator cuff-tear arthropathy, (2) rheumatoid arthritic shoulder with cuff deficiency, or (3) degenerative arthritic (osteoarthritic) shoulder with cuff deficiency. If it is not possible to repair the cuff defect, surgical management may include prosthetic arthroplasty, with the recognition that only limited goals are attainable, particularly with respect to strength and active motion. Glenohumeral arthrodesis is a salvage procedure when other surgical measures have failed. Arthrodesis is also indicated in patients with deltoid muscle deficiency. Humeral hemiarthroplasty avoids the complications of glenoid loosening and is an attractive alternative to arthrodesis, resection arthroplasty, and total shoulder arthroplasty. The functionally intact coracoacromial arch should be preserved to reduce the risk of anterosuperior subluxation. Care should be taken not to "overstuff" the gleno-humeral joint with a prosthetic component. In cases of significant internal rotation contracture, subscapularis lengthening is necessary to restore anterior and posterior rotator cuff balance. If the less stringent criteria of Neer's "limited goals" rehabilitation are followed, approximately 80% to 90% of patients treated with humeral hemiarthroplasty can have satisfactory results.     

Thrombolysis for stroke

The fate of 89 patients with meningomyelocele operated at the Institute of Orthopedics and Rehabilitation in Poznań between 1970 and 1989 due to paretic deformities of lower extremities has been traced by the authors. Deformities prevented nursing, standing or ambulating; their type and results of treatment have been related to the level of neurosegmental lesion. Modified Sharrard's classification served to group the patients. The level of lesion established during lower extremities muscles testing has been verified after neurological examination supplemented with electrophysiological tests: sensory response within L3-S2 dermatomes, afferent conduction velocity of the peroneal nerve and selected muscles of lower extremity electromyogram. Deformities due to inadequate nursing (hip and knee contractures and equinus foot) were the main obstacle in the rehabilitation in patients with spinal Th12-L2 lesion. In patients with L3-L5 lesion hip contractures were accompanied by dislocation or subluxation of the hip due to muscular imbalance. Knee contracture was less frequent in this group and foot deformities were diverse. Surgical correction of paretic deformity of the hip was the last stage of management designed to promote rehabilitation, following previous foot and knee surgery. In patients with Th12-L2 lesion recurrence of contractures made standing and walking impossible. In patients with L3-L5 neurosegmental lesion surgery for paretic dislocation or subluxation of the hip inclusive of open reduction, varus-derotation osteotomy of the proximal femur, transiliac osteotomy and iliopsoas transfer to the greater trochanter according to Mustard resulted in stable hip. Seventy percent of patients with L3-L4 lesion and all patients with L5 lesion profited from hip surgery with reduced orthotic use and effective gait.     

Neurophysiological assessment of children with obstetric brachial plexus palsy]

INTRODUCTION: The objectives of the neurophysiological evaluation of infants with brachial plexus palsy are to determine the time of occurrence of the lesion, to locate the lesion and to determine its course. METHODS AND CONCLUSIONS: These objectives are achieved by studying affected upper extremity muscles by needle electromiography (EMG) and affected nerves by motor and sensory conduction studies. EMG is performed in the first week of life in those patients with brachial plexus palsy of unknown etiology to determine the age of the lesion for medico-legal reasons. EMG is performed before surgery for tendon transfer in the selected muscles to assure that they are normal. EMG and motor and sensory conduction studies are performed at the age of 3 and 6 months in infants with less than 4 muscle weakness to determine candidates for surgical exploration. Motor and sensory nerve conduction studies are performed intraoperative to determine the functional status of the affected axons and the best surgical procedure (neurotization, neurolysis and/or neuroma resection and homologous nerve graft).     

Blocking of the brachial plexus: which technique(s) should be chosen?]

Brachial plexus blocks for upper extremity surgery: what are the preferred techniques? Brachial plexus anaesthesia for all types of upper extremity surgical procedures cannot be adequately achieved with a single technique. At least, two approaches are required: above the clavicle, Winnie's interscalene brachial plexus block, using a neurostimulator, has become the standard technique for shoulder surgery. Below the clavicle, midhumerus approach is the most successful approach for elbow, fore arm and hand surgery, especially for outpatient surgery. The best approach for catheter insertion along brachial plexus nerves/trunks remain controversial. The supraclavicular approach using surface landmarks might be the best approach due to its efficacy in achieving complete anaesthesia of the upper extremity and the rarity of secondary displacement of the catheter. Whatever the selected approach(es) to brachial plexus nerves, nerve location it best achieved by neurostimulation and often multiple neurostimulation. Insulated needles are being increasingly used due to accuracy but, currently, there is no general agreement concerning the type of needle bevel to be preferred in regard to both safety and accuracy.     

The timing of congenital brachial plexus injury: a study of electromyography findings in the newborn piglet

OBJECTIVE: Permanent congenital brachial plexus palsy is a recognized serious complication associated with shoulder dystocia. The timing and etiology of this injury remains controversial. Previous authorities have used adult-derived, non-brachial plexus data to extrapolate the anticipated timing for electromyographic denervation changes to date such injuries in the newborn. With use of a domestic swine model, this investigation tests the hypothesis that electromyographic evidence of brachial plexus denervation in the newborn is temporally different than that in the adult. STUDY DESIGN: Five healthy 2-day-old and two adult pigs underwent unilateral sharp transection of the brachial plexus. Daily electromyographic studies were performed in brachial plexus innervated muscle groups on the involved and contralateral (control) front limbs. Postmortem measurements of the transected nerve segments were obtained in one piglet and one adult animal. Representative hard copy recordings of individual electromyographic studies were collected. RESULTS: Immediately after surgical transection of the brachial plexus, no electromyographic evidence of denervation was observed. Uniformly in the newborn piglets, at 24 hours after transection, denervation in the form of fibrillation potentials, positive sharp waves, and complex repetitive discharges was seen. Serial testing demonstrated proximal to distal gradients of denervation over the next 24 to 48 hours. A delay in electromyographic evidence of denervation was observed in the two adult pigs until days 5 and 8, respectively. Control limb studies remained normal throughout the study period. Nerve length measurements for individual muscle groups were as follows for the adult and newborn pigs, respectively: deltoid 11.4 cm, 2.5 cm; cleidobrachialis 16.0 cm, 4.0 cm; triceps 15.5 cm, 4.5 cm; forelimb flexors 26.0 cm, 6.5 cm; and extensor carpi radialis 31.0 cm, 9.0 cm. CONCLUSION: Electromyographic evidence of brachial plexus denervation after surgical transection differs between the newborn and the adult pig. Consistent with wallerian degeneration, a correlation exists between length of the distal nerve segment and timing for electromyographic signs of denervation. These findings suggest it would be inappropriate to extrapolate the anticipated timing for electromyographic changes in the newborn on the basis of previously established adult non-brachial plexus data.     

Newborn clavicle fractures

A prospective screening program of 9106 newborns identified 43 infants with clavicle fractures for a prevalence of 1 fracture in every 213 live births (0.5%). The fractures were equally distributed by right and left side involvement, and male and female sex. All fractures occurred during vaginal deliveries. None were breech presentation. Risk factors for fracture included large birth-weight, shoulder dystocia, mechanically assisted delivery, and prolonged gestational age. One in 11 newborns with a clavicle fracture also had a brachial plexus palsy.     

CT myelography for diagnosis of brachial plexus avulsion in small animals

Avulsion of nerve roots of the brachial plexus can be diagnosed clinically, neurologically, radiographically and by electromyography. But like the myelography these techniques are inprecise for determination of the severity (partial or complete disruption) and the localization of the lesion. In human medicine the combination of computerized tomography with myelography shows high accuracy. Veterinary reports of experience in this field are not yet known. The aim of the present study was to demonstrate nerve root avulsions using myelography and computerized tomography. Three dogs and one cat with traumatic lesions of the brachial plexus were examined. The lesion could be seen in all patients. Thus CT-myelography results in an improved prognostic assessment of brachial plexus paralysis. Moreover, this technique could become one of the most important diagnostic methods for brachial plexus lesions involving nerve root reinsertion--neurotizations in veterinary medicine.     

Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity

Sixteen infants with conducting neuromas-in-continuity at primary brachial plexus exploration underwent microsurgical neurolysis of their lesions. For each patient, the immediate preoperative scores for individual joint movements were compared with scores at the last examination. In the Erb's palsy group (n = 9), significant improvement was seen in shoulder movements, elbow flexion, supination, and wrist extension (paired t test, p < 0.05). Clinically useful improvements in function was seen at the shoulder and elbow (Fisher's exact test, p < 0.05). In the total palsy group (n = 7), significant improvement in shoulder abduction, shoulder adduction, elbow flexion, and extension of the wrist, fingers, and thumb was seen (paired t test, p < 0.05), but there was no significant improvement in the proportion of patients with useful functional outcomes. Neurolysis in Erb's palsy improves both muscle grade and the functional ability of patients. Neurolysis does not provide useful functional recovery in patients with total plexus palsy.     

Surgical release of elbow-capsular contracture in pediatric patients

Nine pediatric patients with elbow-capsular contractures were treated by surgical release. Six patients had sustained prior trauma and three patients had medical conditions leading to capsular contracture. A lateral approach was used to release the anterior and posterior capsules, as well as to remove sites of bony impingement. All patients were treated with postoperative range of motion and splinting, with six patients receiving a continuous brachial plexus block to facilitate therapy. Average loss of extension improved from 47 to 15 degrees, mean angle of flexion from 102 to 124 degrees, and total arc of motion increased from 55 to 108 degrees at an average of 17 months after surgery. Complications included wound infection and catheter-site erythema.     

Brachial plexus paralysis: its incidence, predisposing factors and outcome

METHODS: We have studies, retrospectively, the risk factors, incidence and outcome of obstetric palsy in all infants delivered between January 1990 and December 1994 at the Obstetric and Gynecological Department and afferent to the Neonatological Division of the University of Messina. Twenty-eight of the 5556 live born full term infants (5/1000) were at birth diagnosed as having a brachial plexus paresis. Of these eight (1.6/1000) had persistent palsy. RESULTS: In about 40-50% of the infants with brachial plexus palsy the obstetric history was characterized by high birthweight, shoulder dystocia, and parity 1. The infants who recovered totally did so during the first 12 months of life. All infants had upper brachial plexus, or Erb's palsy, which is more favorable than entire brachial plexus palsy. At follow-up (15 months-5 years), all infants with persistent palsy were afflicted by varying degrees of arm function compromise. CONCLUSIONS: We stress that, in several cases, obstetric brachial plexus palsy results in life-long handicap, and that prevention, early diagnosis and therapy need to be the goals of the obstetrical and pediatric management.     

A comparison of 0.5% bupivacaine, 0.5% ropivacaine, and 0.75% ropivacaine for interscalene brachial plexus block

The onset time and duration of action of ropivacaine during an interscalene block are not known. The potentially improved safety profile of ropivacaine may allow the use of higher concentrations to try and speed onset time. We compared bupivacaine and ropivacaine to determine the optimal long-acting local anesthetic and concentration for interscalene brachial plexus block. Seventy-five adult patients scheduled for outpatient shoulder surgery under interscalene block were entered into this double-blind, randomized study. Patients were assigned (n = 25 per group) to receive an interscalene block using 30 mL of 0.5% bupivacaine, 0.5% ropivacaine, or 0.75% ropivacaine. All solutions contained fresh epinephrine in a 1:400,000 concentration. At 1-min intervals after local anesthetic injection, patients were assessed to determine loss of shoulder abduction and loss of pinprick in the C5-6 dermatomes. Before discharge, patients were asked to document the time of first oral narcotic use, when incisional discomfort began, and when full sensation returned to the shoulder. The mean onset time of both motor and sensory blockade was <6 min in all groups. Duration of sensory blockade was similar in all groups as defined by the three recovery measures. We conclude that there is no clinically important difference in times to onset and recovery of interscalene block for bupivacaine 0.5%, ropivacaine 0.5%, and ropivacaine 0.75% when injected in equal volumes. IMPLICATIONS: In this study, we demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 0.75% fails to improve the onset or duration of interscalene brachial plexus block.     

Closed treatment of displaced middle-third fractures of the clavicle gives poor results

We evaluated 242 consecutive fractures of the clavicle in adults which had been treated conservatively. Of these, 66 (27%) were originally in the middle third of the clavicle and had been completely displaced. We reviewed 52 of these patients at a mean of 38 months after injury. Eight of the 52 fractures (15%) had developed nonunion, and 16 patients (31%) reported unsatisfactory results. Thirteen patients had mild to moderate residual pain and 15 had some evidence of brachial plexus irritation. Of the 28 who had cosmetic complaints, only 11 considered accepting corrective surgery. No patient had significant impairment of range of movement or shoulder strength as a result of the injury. We found that initial shortening at the fracture of > or = 20 mm had a highly significant association with nonunion (p < 0.0001) and the chance of an unsatisfactory result. Final shortening of 20 mm or more was associated with an unsatisfactory result, but not with nonunion. No other patient variable, treatment factor, or fracture characteristic had a significant effect on outcome. We now recommend open reduction and internal fixation of severely displaced fractures of the middle third of the clavicle in adult patients.     

Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases

Thirty-two patients with absent elbow flexion secondary to brachial plexus injury underwent nerve transfer using 1 or 2 fascicles of the ulnar nerve to the motor branch of the biceps muscle. Twenty-six patients had root avulsion injury of C5 and C6; 4 had root avulsion injury of C5, C6, and C7; and 2 had lateral and posterior cord injury with distal injury of the musculocutaneous nerve. The follow-up period ranged from 11 to 40 months (average, 18 months). Thirty patients had biceps strength of M4 (flexion power ranged from 0.5 to 7 kg) and 1 had biceps strength of M3. All but 1 patient demonstrated signs of recovery of the biceps muscle. No notable impairment of hand function was observed.     

Surgical treatment of children with brachial plexus paralysis

OBJECTIVE AND METHODS: A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.     

Impurity energy level in the Haldane gap

The electrophysiological properties of normal brachial plexus and functional motor innervation during the operation of contralateral healthy side C7 transfer were studied different roots of brachial plexus were stimulated and maximum amplitudes were recorded. The results showed functional motor innervation of brachial plexus roots are (1)C5 mainly forms the axillary nerve which innervates deltoid muscle; (2)C5 constructs most of the musculocutaneous nerve fibers which innervate biceps muscle; (3)main component of the radial nerve comes from C7, which innervates triceps muscle; (4)Medial nerve mainly comes from C8, which innervates flexor digitorum muscle; (5)T1 forms most of the ulnar nerve which innervates intrinsic muscle. Based on the relationship between brachial plexus roots and their functional distribution, the particular aspects of functional innervation of C7 as well as the possibility of utilization of other cervical roots were discussed.