Primary Shoulder Surgery As A Possible Complete Treatment For Obstetrical Brachial Plexus Palsy
Leahthan Faye Domeshek, MD1; Kristin Davidge, MD, MSc, FRCSC1; Karen Klar, BScPT2; Alison Anthony, BScPT2; Sevan Hopyan, MD3; Howard Clarke, MD, PhD, FRCSC4
1The Hospital for Sick Children, Toronto, ON, Canada, 2Hospital for Sick Children, Toronto, ON, Canada, 3Division of Plastic and Reconstructive Surgery, Hospital for Sick Children, Toronto, ON, Canada, 4Division of Plastic and Reconstructive Surgery, Hospital for Sick Children, Ontario, ON, Canada
Indications for primary nerve surgery in the treatment of obstetrical brachial plexus palsy (OBPP) vary and continue to evolve. Imbalance of shoulder musculature resulting from OBPP can lead to glenohumeral subluxation and glenoid dysplasia within the first year of life. Traditionally, surgical management of shoulder dysmorphology has been deferred until after nerve reconstruction. However, shoulder dysmorphology can alter mechanics of motion throughout the arm sufficiently to obscure functional neuromuscular recovery of the upper extremity. We evaluated the ability of early primary shoulder surgery (defined as musculoskeletal surgery about the shoulder prior to one year of age and prior to any nerve surgery) to obviate the need for primary nerve reconstruction in select patients with OBPP.
All patients presenting with OBPP between 2015 and 2017, who underwent primary shoulder surgery in the first year of life were included. Pre- and postoperative Active Movement Scale (AMS) scores, cookie test outcomes, and need for subsequent nerve surgery were assessed.
Eight patients met inclusion criteria. All underwent subscapularis release and tendon transfers of teres major and latissimus dorsi to reposition the glenohumeral joint. Preoperatively, no patients passed the cookie test and average AMS scores for shoulder external rotation and elbow flexion were 1.5 and 4.0 respectively. Postoperatively, average AMS scores improved to 3.25 and 6; seven patients passed the cookie test and did not require nerve reconstruction. One patient had persistent elbow flexion deficits and underwent median-to-biceps nerve transfer (after which they passed the cookie test).
Altered shoulder mechanics related to glenohumeral dysmorphology may obscure neural recovery. Primary shoulder surgery may preclude the need for primary nerve reconstruction in select patients with early glenohumeral subluxation in the setting of OBPP. Further study will help better define the indications for and outcomes of early shoulder surgery in patients with OBPP.
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