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Late Treatment of Brachial Plexus Palsy Secondary to Birth Injuries: Rotational Osteotomy of the Proximal Part of the Humerus*

JOHN M. KIRKOS, M.D. and ISIDOROS A. PAPADOPOULOS, M.D., KILKIS, GREECE

Investigation performed at Kilkis General Hospital, Kilkis

	Abstract

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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.

	Introduction

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Injuries of the brachial plexus secondary to a difficult labor are still a problem in terms of clinical treatment^1,2,10,12. The prognosis varies depending on the extent and level of the lesion. Advances in obstetrics have made it possible to decrease the severity of the injury. This has led to a better prognosis^21,24, and complete recovery within the first year of life may be expected in 75 to 95 per cent of patients^2,9,11,24. (Eighteen of twenty-four arms had complete recovery in the study by Bennet and Harrold², and fifty-six of fifty-nine infants had complete recovery in the study by Gordon et al.⁹.) Paralysis of the superior trunk of the brachial plexus (Erb palsy) is associated with a better prognosis than total paralysis is^3,15. In total paralysis, the function of the proximal part of the extremity is affected more than that of the distal part²⁰.

Several authors have recommended direct repair of the brachial plexus in the supraclavicular region^5,6,23,25; however, this should be performed only in properly selected patients by specialized, experienced surgeons and staff¹². The results of these procedures vary greatly.

In the current study, we reviewed the results of treatment of established deformities of the arm. The late clinical problems in brachial plexus palsy are secondary either to a fixed internal rotation deformity or to limitation of active external rotation and abduction of the shoulder, which makes it difficult or impossible for the patient to bring the affected hand to the mouth. Furthermore, the affected elbow is held away from the side of the trunk when the patient is walking, leading to a cosmetic problem, which is particularly troubling to girls.

	Materials and Methods

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Between 1957 and 1985, we performed a rotational osteotomy distal to the surgical neck of the humerus in twenty-two patients (seventeen boys and five girls) who had loss of external rotation or a fixed internal rotation deformity of the arm secondary to an injury of the brachial plexus that had been sustained at birth. The patients were between four and seventeen years old at the time of the operation (average age, ten years and three months).

Eighteen patients had a lesion of the superior trunk of the brachial plexus (the fifth and sixth cervical nerve roots), and four (Cases 1, 13, 16, and 22) had various degrees of involvement of the entire brachial plexus. The right arm was affected in sixteen patients, and the left arm was affected in six. Eight patients previously had received some form of physical therapy for one to two years, and the remaining patients had received intermittent physical therapy before the index operation. Two patients (Cases 10 and 14) previously had had a Sever procedure (release of the pectoralis and subscapularis muscles)²²; however, the deformity had recurred three years later. One (Case 16) of the four patients who had a total brachial plexopathy previously had had transfer of the flexor carpi ulnaris to the extensor tendons of the fingers and thumb; the other three patients had little limitation of the function of the hand.

The specific indications for the procedure were (1) an age of at least four years and a fixed internal rotation deformity of the arm with decreased strength of the teres major and latissimus dorsi muscles, a dislocated or deformed humeral head, or recurrent deformity of the arm after a soft-tissue procedure, or (2) an age of more than eight years and a fixed internal rotation deformity or limitation of active external rotation of the arm. We recommend soft-tissue procedures for young children who are less than six years old and have a severe internal rotation contracture without osseous changes in the humeral head. Regular follow-up evaluations should be performed to detect any evidence of recurrence of the deformity.

Preoperatively, we assessed the ability of the patients to perform activities of daily living (feeding, washing, and grooming themselves) with the affected extremity. The active and passive ranges of motion of the entire upper extremity as well as muscle strength were recorded. Eleven patients had great difficulty placing the affected hand over the mouth and behind the head, neck, and back, and the remaining patients could not perform these activities at all.

None of the affected arms could be externally rotated either actively or passively beyond neutral. Seventeen patients had a fixed internal rotation deformity ranging from 30 to 80 degrees. Passive internal rotation was 15 to 30 degrees greater than active internal rotation, whereas there was no detectable difference between the active and passive ranges of external rotation. Active abduction of the arm ranged from 25 to 170 degrees and occurred with flexion rather than in the coronal plane. Passive abduction was 10 to 40 degrees greater than active abduction, especially if the arm was held in the coronal plane. Except for the pectoralis major and the subscapularis, which were normal, the muscles around the shoulder had decreased strength, with the latissimus dorsi, teres major, and external rotators being the weakest muscles.

Anteroposterior radiographs of both shoulders demonstrated a smaller, more elevated scapula on the affected side. Moreover, there was elongation and beaking of the acromion and the coracoid process, and the glenoid was smaller and shallower than that on the normal side. There was hypoplasia of the clavicle, and the proximal humeral epiphysis was smaller and pear-shaped. In all patients, the distance between the humeral head and the acromion was longer than that on the normal side; the metaphysis and diaphysis of the humerus were thinner, and the humerus was shorter. Axial radiographs of the shoulder, made for the last eight patients who had the operation, revealed posterior subluxation of the humeral head in four of them (Cases 15, 17, 20, and 22). We did not perform arthrographic or electrodiagnostic studies for any patient.

A modification of the classification system of Mallet¹⁷ was used to assess the function of the shoulder. This system is based on five criteria: the ability to actively abduct the arm, the ability to externally rotate the arm, the ability to place the hand behind the neck as well as behind the back, and the ability to place the hand over the mouth. Grade I indicates a stiff shoulder or a flail arm. Grade II indicates active abduction of 30 degrees or less, no active external rotation, and the inability to place the hand behind the neck and the mid-portion of the back. The hand is brought to the mouth with the arm in abduction (the trumpeter sign) (Fig. 1-A). Grade III indicates active abduction of 30 to 90 degrees, active external rotation of 20 degrees or less, and difficulty placing the hand behind the neck and cephalad to the sacrum. The hand can be brought to the mouth with slight abduction of the arm (the trumpeter sign). Grade IV indicates active abduction of at least 90 degrees, active external rotation of more than 20 degrees, and the ability to place the hand behind the neck and over the thoracolumbar region of the back without difficulty. The hand can be brought to the mouth without abduction of the arm. Grade V indicates a clinically normal shoulder. If a patient does not meet all five criteria for a grade, he or she is assigned a lower grade. Mallet¹⁷ suggested that a grade-III result permits satisfactory function of the extremity.

View larger version (119K): [in this window] [in a new window]   FIG1: Figs. 1-A and 1-B: Case 9. Preoperative and postoperative photographs showing improvement in the function of the shoulder of a male patient who had Erb palsy. Fig. 1-A: Preoperatively, at the age of six years, the boy had difficulty bringing the hand to the mouth without holding the arm in the trumpeter position.

Operative Technique
The operation was performed with the patient under general anesthesia and in the supine position. A sandbag was placed under the involved shoulder.

An anterior incision was used to expose the proximal part of the humerus between the anterior border of the deltoid muscle and the biceps. The osteotomy was performed between the insertions of the subscapularis and pectoralis major muscles. Holes were drilled along the line of the osteotomy, which was not completed at this stage. The elbow was maintained in a flexed position while the distal fragment of the humerus was rotated laterally and kept adjacent to the body until the hand could be brought to the mouth. The osteotomy then was completed, and the two fragments were impacted and stabilized. The wound was closed in layers without any drains. The osteotomy site was stabilized with one staple in eight patients and with two staples in four patients in whom the fixation was unstable. In the remaining ten patients, the two fragments were well impacted and stabilization was maintained with use of strong catgut sutures in the periosteum.

A plaster shoulder-spica cast was applied with the shoulder in 90 degrees of abduction and full external rotation, the elbow in 90 degrees of flexion, and the forearm in full supination. The portion of the cast encircling the chest was applied on the day before the operation, and the remainder of the cast was applied in the operating room. The cast was removed after six weeks.

Radiographs were made each week for the first three weeks postoperatively to verify the alignment of the humerus.

Complications
There were no vascular or neurological complications intraoperatively or postoperatively. The osteotomy site healed in all patients within six weeks after the operation.

Of the ten patients in whom catgut sutures had been used to stabilize the osteotomy site, four (Cases 1, 2, 10, and 13) had an angular deformity in the first postoperative week that was corrected by wedging of the plaster cast. In twelve patients, the osteotomy site healed with a valgus deformity ranging from 12 to 25 degrees.

	Results

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The patients were followed for an average of fourteen years (range, two to thirty-one years). Fourteen patients were followed for at least twelve years, and three were followed for at least thirty years. At each follow-up visit, the patients were evaluated clinically and radiographically. The results were graded with use of the modified classification system of Mallet¹⁷. The patients also were asked about their perception of the final result.

There was no loss of external rotation several weeks after removal of the cast. Postoperatively, abduction ranged from 40 to 180 degrees; external rotation, from 0 to 60 degrees; and internal rotation, from 15 to 80 degrees. The average increase in active abduction of the arm 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) (Table I). Supination of the forearm also improved, corresponding to the increase in external rotation (Figs. 2-A, 2-B), 2-C, 2-D, 2-E and 2-F. There was no clinically detectable difference between the active and passive rotational movements of the arm. In six patients (Cases 2, 7, 8, 12, 16, and 20), passive abduction was 10 to 15 degrees more than active abduction. There was no clinically detectable difference in muscle strength except for an increase in that of the abductor muscles.

View larger version (122K): [in this window] [in a new window]   FIG2-A: Figs. 2-A through 2-F: Case 6. Photographs showing the preoperative and long-term postoperative range of motion of the arm of a female patient who had an Erb-type palsy. Figs. 2-A: Preoperatively, at the age of ten years, the arm was kept in 70 degrees of internal rotation with further active rotation to 110 degrees. Supination of the forearm was limited.

View larger version (115K): [in this window] [in a new window]   FIG2-B: Figs. 2-B: Preoperatively, at the age of ten years, the arm was kept in 70 degrees of internal rotation with further active rotation to 110 degrees. Supination of the forearm was limited.

View larger version (100K): [in this window] [in a new window]   FIG2-C: Figs. 2-C: Preoperatively, at the age of ten years, the arm was kept in 70 degrees of internal rotation with further active rotation to 110 degrees. Supination of the forearm was limited.

View larger version (100K): [in this window] [in a new window]   FIG2-D: Fig. 2-D Eighteen years after the osteotomy, the active range of motion of the arm had increased; external rotation was 45 degrees, and internal rotation was 80 degrees. Supination of the forearm also had improved secondary to the increase in external rotation.

View larger version (142K): [in this window] [in a new window]   FIG2-E: Fig. 2-E Eighteen years after the osteotomy, the active range of motion of the arm had increased; external rotation was 45 degrees, and internal rotation was 80 degrees. Supination of the forearm also had improved secondary to the increase in external rotation.

View larger version (103K): [in this window] [in a new window]   FIG2-F: Fig. 2-F Eighteen years after the osteotomy, the active range of motion of the arm had increased; external rotation was 45 degrees, and internal rotation was 80 degrees. Supination of the forearm also had improved secondary to the increase in external rotation.

View larger version (114K): [in this window] [in a new window]   FIG1-B: Fig. 1-B: Fourteen years after the osteotomy, the patient was able to bring the hand to the mouth without any difficulty and the trumpeter sign was not present.

View larger version (126K): [in this window] [in a new window]   FIG3-A: Figs. 3-A and 3-B: Case 19. Preoperative and postoperative photographs showing an increase in abduction in a male patient who had Erb palsy. Fig. 3-A: Preoperatively, at the age of seventeen years, active abduction of the arm was decreased and was possible more in an anterior than in a frontal plane.

View larger version (133K): [in this window] [in a new window]   FIG3-B: Fig. 3-B: Five years after the osteotomy, abduction had improved and was possible in the frontal plane.

	Discussion

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The most common deformities of the extremity in patients who have a brachial plexus birth injury are fixed adduction and internal rotation of the arm of varying severity. In addition, there is usually a degree of fixed pronation of the forearm with limited flexion or extension of the elbow. The functional use of the entire upper extremity is affected, and operative intervention to correct the shoulder deformity places the arc of motion within a more functional range and position. This is especially true if the patient has paralysis of the latissimus dorsi and teres major muscles and radiographic changes of the glenohumeral joint. A fixed internal rotation deformity of more than 20 degrees makes it difficult to bring the hand to the mouth without flexion of the head forward and toward the involved side as well as awkward abduction and flexion of the shoulder²⁸. If external rotation is limited by more than 65 degrees and abduction is less than 80 degrees it is impossible for the hand to reach the mouth, particularly if mobility of the elbow, wrist, or hand is impaired²⁷.

Release of the soft-tissue contracture²² improves the cosmetic appearance but produces only slight functional improvement³⁰. There is an increase in external rotation without an increase in abduction, and there is also a risk of anterior dislocation of the shoulder. In addition, the range of rotational movement that is achieved decreases with time²⁸ and with recurrence of the fixed internal rotation deformity (Cases 10 and 14). A Sever-type release²² of the soft tissues, performed either alone or in combination with transfer of the teres major and latissimus dorsi muscles posteriorly and laterally to allow those muscles to act as external rotators¹⁴, is effective only when muscle strength is satisfactory and there is no deformity of the glenohumeral joint.

Rogers was the first author, to our knowledge, to recommend osteotomy of the proximal portion of the humerus for the late treatment of brachial plexus birth injuries¹⁹. Since then, a number of authors have recommended rotational osteotomy of either the proximal or the distal part of the humerus when there is a fixed internal rotation deformity of the arm and flattening of the humeral head or posterior subluxation of the shoulder^{4,7,8,13,16-19,26,27,29}. The osteotomy usually has been performed between the insertions of the pectoral and deltoid muscles and has been stabilized with a plate and screws or an intramedullary nail, followed by application of a shoulder-spica cast. The rotational osteotomy can be performed when there is recurrence of the fixed internal rotation deformity after a soft-tissue release such as the Sever procedure²². The purpose of the osteotomy is to achieve a more functional arc of rotation of the extremity. Intensive physical therapy is not needed; this makes it easier to manage younger patients, because a high level of cooperation and compliance is not necessary as it is after soft-tissue operations, especially tendon transfers. There is a gradual increase in the arc of active motion at the expense of passive motion. It is possible that growth of the extremity in a position of neutral alignment increases rotation of the extremity. This in turn alters the relationship between the joint surfaces and the periarticular soft tissues. The surgeon must be aware of the changes that occur with growth and avoid overcorrection of the deformity.

The operative technique that we have described has several advantages. First, earlier consolidation of the osteotomy site is facilitated because the proximal part of the humerus consists of cancellous bone. Second, the staples that are used are small and easy to insert, necessitate minimum exposure, and do not have to be removed. Finally, placement of the insertion of the deltoid in a more lateral position provides a mechanical advantage to the tendon. The patient is able to hold the arm in the frontal plane during abduction. Furthermore, internal rotation of the arm is increased because of functional shortening of the pectoralis major muscle, the insertion of which has moved to a more lateral position secondary to the osteotomy.

Our results suggest that rotational osteotomy of the humerus should be considered for the late treatment of a deformity of the shoulder and arm in patients, particularly growing children, who have a brachial plexus palsy secondary to an injury at birth.

NOTE: The authors thank Dr. Theodore Papademetriou, M.D., for his help in the translation of the manuscript, and Ms. Artemis Kyrkou for her important contributions.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Department of Orthopaedics, Aristotle University of Thessaloniki, 138 Al., Papanastasiou Str., 542 49 Thessaloniki, Greece.

22 Agias Sofias Str., 546 22 Thessaloniki, Greece.

	References

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