Second Shoulder and Elbow Reanimation Procedures in Late Obstetrical Paralysis Patients

ABSTRACT

Obstetrical brachial plexus palsy invariably involves the upper roots. The natural history of the injury shows that if the condition is left untreated, spontaneous reinnervation that occurs in a variable degree in these patients leaves characteristic deformities of the shoulder and elbow. Common sequelae are the internal rotation and adduction deformity of the shoulder, and elbow flexion contractures. Early microsurgical reconstruction of the affected plexus leads to more rewarding overall function of the shoulder and elbow, but residual deformities might appear again, similar to the ones noticed in untreated cases, that are even less serious. Thus, secondary procedures are mandatory to reanimating the shoulder and elbow, and especially to provide adequate abduction and external rotation of the shoulder and a more neutral appearance of the elbow regarding flexion-extension equilibrium.

KEYWORDS

Obstetric - brachial plexus paralysis - secondary procedures - shoulder - elbow deformities

REFERENCES

• 1 Pollock A N, Reed M H. Shoulder deformities from obstetrical brachial plexus paralysis.  Skeletal Radiol. 1989;  18 295-297
• 2 Hernandez R J, Dias L. CT Evaluation of the shoulder in children with Erb's palsy.  Pediatr Radiol. 1988;  18 333-336
• 3 Brunelli P C, Robecchi D, Lenzi L. Tomografia assiale computerizzata nella paralisi ostetrica di plesso brachiale.  Ital J Orthop Traumatol. 1986;  12 507-514
• 4 Terzis J K, Vekris M D, Okajima S, Soucacos P N. Shoulder deformities in obstetric brachial plexus paralysis: a computed tomography study.  J Pediatr Orthop. 2003;  23(2) 254-260
• 5 Saha A K. Surgery of the paralyzed and flail shoulder.  Acta Orthop Scand. 1967;  (Suppl 97) 5-90
• 6 Narakas A O. Muscle transpositions in the shoulder and upper arm for sequelae of brachial plexus palsy.  Clin Neurol Neurosurg. 1993;  95(suppl) S89-S91
• 7 Comtet J J, Herzberg G, Al Naasan I. Biomechanical basis of transfers for shoulder paralysis.  Hand Clin. 1989;  5 1-14
• 8 Howell S M, Imobersteg A M, Seger D H, Marone P J. Clarification of the role of the supraspinatus muscle in shoulder function.  J Bone Joint Surg [Am]. 1986;  68 398-404
• 9 Burkhalter E B. Tendon transfers in brachial plexus injuries.  Orthop Clin North Am. 1974;  5 259-270
• 10 Leffert R D, Pess G M. Tendon transfer for brachial plexus injury.  Hand Clin. 1988;  4 273-288
• 11 Mayer L. Transplantation of the trapezius for paralysis of the abductors of the arm.  J Bone Joint Surg. 1927;  9 412-420
• 12 Tang C Y, Mak A F, Hung L K, Wong H S, Pacaldo T. Stability of reconstructed paralyzed shoulders using a reflected long head biceps technique.  J Biomech Eng. 2001;  123(3) 227-233
• 13 Harmon P H. Surgical reconstruction of the paralytic shoulder by multiple muscle transplantations.  J Bone Joint Surg [Am]. 1950;  32 583-595
• 14 Hou C, Tai Y. Transfer of the upper pectoralis major flap for functional reconstruction of deltoid muscle.  Chin Med J (Engl). 1991;  104 753-757
• 15 Itoh Y, Sasaki T, Ishiguro T, Uchinishi K, Yabe Y, Fukuda H. Transfer of latissimus dorsi to replace a paralyzed anterior deltoid. A new technique using an inverted pedicle graft.  J Bone Joint Surg [Br]. 1987;  69 647-651
• 16 Rudiger J. Schultergurlter, oberarm, ellenbogen. In: Buck-Gramko D, Nigst H Motorische Ersatzoperationen der Oberen Extremitat. Stuttgart; Hippocrates Verlag 1991: 36-38
• 17 Fairbanks H T. A lecture on birth palsy: subluxation of the shoulder joint in infants and young children.  Lancet. 1913;  1 217-223
• 18 Sever J W. The results of a new operation for obstetrical paralysis.  Am J Orthop Surg. 1918;  16 248-257
• 19 Kleinberg S. Reattachment of the capsule and external rotators of the shoulder for obstetric paralysis.  JAMA. 1932;  98 294-299
• 20 Zancolli E A. Classification and management of the shoulder in birth palsy.  Orthop Clin North Am. 1981;  12 433-457
• 21 Gilbert A. long term evaluation of brachial plexus surgery in obstetrical palsy.  Hand Clin. 1995;  11(4) 583-593
• 22 Price A E, Grossman J A. A management approach for secondary shoulder and forearm deformities following obstetrical brachial plexus injury.  Hand Clin. 1995;  11(4) 607-617
• 23 L'Episcopo J B. Restoration of muscle balance in the treatment of obstetrical paralysis.  N Y State J Med. 1939;  39 336-357
• 24 Zachary R B, Leeds M B. Transplantation of terres major and latissimus dorsi for loss of external rotation at shoulders.  Lancet. 1947;  2 757-776
• 25 Freund R K, Terzis J K, Jordan L, Taylor G. Modified latissimus dorsi and terres major transfer for external rotation deficit of the shoulder.  Orthopedics. 1986;  9 505-506
• 26 Hoffer M M, Wickenden R, Roper B. Brachial plexus birth palsies. Results of tendon transfers to the rotator cuff.  J Bone Joint Surg [Am]. 1978;  60 691-695
• 27 Keppler P, Holz U, Thielemann F W, Meinig R. Locked posterior dislocation of the shoulder: treatment using rotational osteotomy of the humerus.  J Orthop Trauma. 1994;  8(4) 286-292
• 28 Terzis J K, Papakonstantinou K C. Outcomes of scapula stabilization in obstetrical brachial plexus palsy: a novel dynamic procedure for correction of the winged scapula.  Plast Reconstr Surg. 2002;  109(2) 548-561
• 29 Marshall R W, Williams D H, Birch R, Bonney G. Operations to restore elbow flexion after brachial plexus injuries.  J Bone Joint Surg [Br]. 1988;  70 577-582
• 30 Chen W S. Restoration of elbow flexion by modified Steindler flexorplasty.  Int Orthop. 2000;  24(1) 43-46
• 31 Brunelli G A, Vigasio A, Brunelli G R. Modified Steindler procedure for elbow flexion restoration.  J Hand Surg [Am]. 1995;  20 743-746
• 32 Hoffer M M, Phipps G J. Surgery about the elbow for brachial palsy.  J Pediatr Orthop. 2000;  20(6) 781-785
• 33 van Egmond C, Tonino A J, Kortleve J W. Steindler flexorplasty of the elbow in obstetric brachial plexus injuries.  J Pediatr Orthop. 2001;  21(2) 169-173
• 34 Ruhmann O, Schmolke S, Gosse F et al.. Transposition of local muscles to restore elbow flexion in brachial plexus palsy.  Injury. 2002;  33(7) 597-609
• 35 Chuang D C, Hattori Y, Ma And H S, Chen H C. The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy.  Plast Reconstr Surg. 2002;  109(1) 116-126
• 36 Tachjian M O. Pediatric Orthopedics. Philadelphia; WB Saunders 1990
• 37 Egloff D V, Raffoul W, Bonnard C, Stalder J. Palliative surgical procedures to restore shoulder function in obstetric brachial palsy. Critical analysis of Narakas' series.  Hand Clin. 1995;  11 597-605
• 38 Kawabata H, Masada K, Tsuyuguchi Y, Kawai H, Ono K, Tada K. Early microsurgical reconstruction in birth palsy.  Clin Orthop. 1987;  215 233-242
• 39 Boome R S, Kaye J C. Obstetric traction injuries of the brachial plexus. Natural history, Indications for surgical repair and Results.  J Bone Joint Surg Br. 1988;  70 571-576
• 40 Xu J, Cheng X, Gu Y. Different methods and results in the treatment of obstetrical brachial plexus palsy.  J Reconstr Microsurg. 2000;  16(6) 417-420
• 41 Dodds S D, Wolfe S W. Perinatal brachial plexus palsy.  Curr Opin Pediatr. 2000;  12(1) 40-47
• 42 Narakas A, Hentz V. Neurotization in brachial plexus injuries. Indications and results.  Clin Orthop. 1988;  237 43-56
• 43 Kattan K, Spitz H B. Roentgen findings in obstetrical injuries to the brachial plexus.  Radiology. 1968;  91 462-467
• 44 Waters P M, Smith G R, Jaramillo D. Glenohumeral deformity secondary to brachial plexus birth palsy.  J Bone Joint Surg [Am]. 1998;  80 668-677
• 45 Aitken J. Deformity of the elbow joint as a sequel to Erb's obstetrical paralysis.  J Bone Joint Surg [Br]. 1952;  34-B 352-365
• 46 Cummings R J, Jones E T, Reed F E, Mazur J M. Infantile dislocation of the elbow complicating obstetric palsy.  J Pediatr Orthop. 1996;  16(5) 589-593
• 47 Troum S, Floyd 3rd W E, Waters P M. Posterior dislocation of the humeral head in infancy associated with obstetrical paralysis. A case report.  J Bone Joint Surg [Am]. 1993;  75 1370-1375