JBJS | Article

The Journal of Bone & Joint Surgery, Volume 80, Issue 7

Articles | July 01, 1998

Closed Reduction and Tendon Transfer for Treatment of Dislocation of the Glenohumeral Joint Secondary to Brachial Plexus Birth Palsy*

M. MARK HOFFER, M.D.†, LOS ANGELES, CALIFORNIA; GARY J. PHIPPS, M.D.‡, DOWNEY, CALIFORNIA

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Investigation performed at Orthopaedic Hospital, Los Angeles, and Rancho Los Amigos Hospital, Downey

The Journal of Bone & Joint Surgery. 1998; 80:997-1001

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Abstract

Dislocation of the glenohumeral joint developed, in the first few years of life, in eight children who had brachial plexus birth palsy. The palsy involved the fifth and sixth cervical nerve roots in six children and the fifth, sixth, and seventh cervical nerve roots in two. All of the children had a release of the insertions of the pectoralis major, latissimus dorsi, and teres major followed by a closed reduction of the glenohumeral joint. The latissimus dorsi and the teres major were then transferred to the rotator cuff. All of the children had a well located glenohumeral joint with at least 25 degrees (mean, 51 degrees) of external rotation and at least 135 degrees (mean, 164 degrees) of abduction at the latest follow-up examination, at least two years postoperatively. Strength in abduction increased at least one grade, and strength in external rotation increased at least two grades. The improved motion and strength allowed the children to place the hands more effectively above the head and helped them to perform activities of daily living easily.

Figures in this Article

Introduction

Dislocation of the glenohumeral joint due to brachial plexus palsy in young children is thought to be uncommon^1,2,6,8. Such dislocation probably occurs secondary to muscle imbalance between strong internal rotators and weak or paralyzed external rotators. This imbalance causes an internal rotation contracture, resulting in a posterior dislocation of the shoulder. We reported two such dislocations in fifty-six patients who were managed operatively between 1968 and 1990 for weakness of the shoulder in external rotation due to brachial plexus palsy⁷. Since then, eight dislocations were treated with closed reduction and muscle-balancing in eight children who were being followed for brachial plexus palsy in our clinics. The principle behind the treatment was to release the contracted internal rotators, which consisted of the pectoralis major, teres major, and latissimus dorsi, in order to permit external rotation of the shoulder and relocation of the dislocated joint.

The purpose of the present study was to discuss the methods of early detection and treatment of dislocation as well as the results of treatment in children who had a dislocation of the shoulder secondary to brachial plexus palsy.

*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.

†Orthopaedic Hospital, 2300 South Flower Street, Suite 200, Los Angeles, California 90007.

‡Rancho Los Amigos Hospital, 7601 East Imperial Highway, Downey, California 90242.

*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.

†Orthopaedic Hospital, 2300 South Flower Street, Suite 200, Los Angeles, California 90007.

‡Rancho Los Amigos Hospital, 7601 East Imperial Highway, Downey, California 90242.

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TABLE I DATA ON THE PATIENTS

*Preoperatively/postoperatively.

Case	Gender	Side	Age at Presentation (wks.)	Age at Op. (yrs. + mos.)	Duration of Follow-up (yrs. + mos.)	Passive Motion* (degrees)		Strength* (grade)
Abduction	External Rotation	Deltoid	External Rotators
1	F	R	2	3 + 4	4 + 3	50/180	-10/40	3/4	0/4
2	M	L	2	1 + 9	2 + 5	100/160	0/45	2/4	0/4
3	F	R	1	2 + 2	2 + 3	70/150	-20/45	2/3	0/2
4	F	R	6 mos.	1 + 11	2 + 0	90/180	-45/70	1/4	0/4
5	F	R	3	3 + 11	2 + 0	90/180	0/45	2/3	0/3
6	F	R	2	1 + 3	4 + 8	90/170	0/60	1/2	0/2
7	M	R	8	1 + 2	5 + 0	75/160	-25/25	1/3	0/3
8	M	R	10	3 + 7	2 + 2	105/135	10/75	2/3	0/4

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TABLE I DATA ON THE PATIENTS

*Preoperatively/postoperatively.

Case	Gender	Side	Age at Presentation (wks.)	Age at Op. (yrs. + mos.)	Duration of Follow-up (yrs. + mos.)	Passive Motion* (degrees)		Strength* (grade)
Abduction	External Rotation	Deltoid	External Rotators
1	F	R	2	3 + 4	4 + 3	50/180	-10/40	3/4	0/4
2	M	L	2	1 + 9	2 + 5	100/160	0/45	2/4	0/4
3	F	R	1	2 + 2	2 + 3	70/150	-20/45	2/3	0/2
4	F	R	6 mos.	1 + 11	2 + 0	90/180	-45/70	1/4	0/4
5	F	R	3	3 + 11	2 + 0	90/180	0/45	2/3	0/3
6	F	R	2	1 + 3	4 + 8	90/170	0/60	1/2	0/2
7	M	R	8	1 + 2	5 + 0	75/160	-25/25	1/3	0/3
8	M	R	10	3 + 7	2 + 2	105/135	10/75	2/3	0/4

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Figs. 1-A and 1-B: Drawings illustrating the procedure. Fig. 1-A: The insertion of the pectoralis major is released through the anterior part of the incision. LAT = latissimus dorsi, and TM = teres major.

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Fig. 1-B The combined insertions (arrow) of the latissimus dorsi (LAT) and the teres major (TM) are released through the posterior part of the incision. A closed reduction is then performed, and the tendons are sutured to the rotator cuff.

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Figs. 2-A, 2-B, and 2-C: Case 1. Photographs demonstrating the method of measurement of the range of motion postoperatively. Fig. 2-A: Passive external rotation of 20 degrees.

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Fig. 2-B: Full active abduction while lifting a 250-gram handpiece.

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Fig. 2-C Active abduction of 90 degrees in external rotation while lifting a 250-gram handpiece.

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Figs. 3-A and 3-B: Case 2. Fig. 3-A: Axillary radiograph showing a posterior dislocation of the left glenohumeral joint. The solid arrow indicates the posterior margin of the glenoid, the open arrow indicates the humeral head, and the asterisks outline the acromion.

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Fig. 3-B Axillary radiograph, made two years and five months postoperatively, showing a located glenohumeral joint. The arrow indicates the posterior margin of the glenoid.

Materials and Methods

Eight children had an operation to relocate a dislocated glenohumeral joint secondary to brachial plexus birth palsy (Table I). Two of the palsies involved the fifth, sixth, and seventh cervical nerve roots, and six involved the fifth and sixth cervical nerve roots. The involved extremity was flail at birth as reported by the primary physician and a physical therapist. The senior one of us (M. M. H.) examined five of the children at one to three weeks after birth; one, at eight weeks; one, at ten weeks; and one, at six months. All children who were seen at our institution because of brachial plexus palsy were routinely examined by one of us every three months.

Shortly after birth, a stretching program was begun by an occupational therapist, with emphasis on abduction and external rotation of the shoulder. The family was taught the exercises as well. The child's progress was monitored very closely by the therapist on a monthly basis.

Muscle strength and the passive and active ranges of motion (abduction, internal rotation, and external rotation) of the involved upper extremity were recorded by us and by the therapists. The strength of the muscles was rated on a scale of 0 to 5 according to the international grading system^5,7. Rotation was measured with the humerus against the lateral aspect of the chest wall and the elbow flexed 90 degrees.

Anteroposterior and axillary radiographs of the involved shoulder were made when there was persistent internal rotation contracture and progressive loss of external rotation despite vigorous physical therapy, as documented during the examinations performed every three months. All eight children had such radiographs. The axillary radiograph was made with the arm abducted 90 degrees with respect to the chest wall, and the cassette was placed on the superior aspect of the shoulder to allow the beam to pass through the axilla. No computerized tomography scans, magnetic resonance images, or arthrograms were made. The operation to relocate the shoulder was performed soon after the dislocation was identified.

Operative Procedure

The mean age of the children at the time of the operation was two years and four months (range, one year and two months to three years and eleven months). The operation was performed through an axillary approach^5,7 with a transverse axillary incision that was approximately three centimeters long. The insertion of the pectoralis major was released through the anterior part of the incision (Fig. 1-A). The combined insertions of the latissimus dorsi and the teres major were released through the posterior portion of the incision (Fig. 1-B). Closed reduction of the glenohumeral joint was not possible before these releases. Reduction, which was confirmed by a palpable clunk, was easily obtained after the releases by external rotation of the arm followed by placement of the shoulder in abduction. The reduction of the humeral head could be felt with a finger placed beneath the deltoid against the rotator cuff. The insertions of the teres major and the latissimus dorsi were sutured onto the posterior-superior aspect of the rotator cuff, where the infraspinatus normally inserts. Non-absorbable 2-0 sutures were placed in the cuff, and the muscles were then pulled proximally onto the cuff. The joint was not opened; a posterior capsulorrhaphy was not necessary.

A plaster body jacket, made before the operation, was applied postoperatively. An above-the-elbow cast was also applied and was attached to the body jacket with the shoulder in 120 degrees of abduction, full external rotation, and 20 degrees of forward elevation in order to take pressure off the brachial plexus.

Postoperative Management

Postoperative management consisted of immobilization in the plaster cast for six to eight weeks, after which the child was weaned from the cast during the therapy sessions and adduction was permitted gradually. Internal rotation was not begun until three months after the procedure. The occupational therapist encouraged active external rotation. As strength in external rotation and abduction improved, the duration for which the child did not wear the cast was increased by one hour each day. The strength of the transfer was monitored during the therapy sessions, and the eventual goal was for the cast to be worn only at night. The exercises were performed, with the aid of the therapist, three times a week for one to two months and then, after the child demonstrated active external rotation, once a week for three months. Use of the cast was then discontinued, and the family was taught to perform daily therapy at home. The children continued to be followed by us every three months.

Results

The mean duration of follow-up was three years and one month (range, two to five years). All of the children had increased muscle strength in abduction and external rotation and greater motion of the shoulder at the latest follow-up examination. The mean maximum passive range of abduction was 84 degrees (range, 50 to 105 degrees) preoperatively and 164 degrees (range, 135 to 180 degrees) postoperatively. The mean maximum passive range of external rotation was -11 degrees (range, -45 to 10 degrees) preoperatively and 51 degrees (range, 25 to 75 degrees) postoperatively (Fig. 2-A). The strength of the deltoid was grade 1, 2, or 3 preoperatively and grade 2, 3, or 4 postoperatively (Fig. 2-B). The strength of the external rotators was grade 0 preoperatively and grade 2, 3, or 4 postoperatively (Fig. 2-C). The mean strength of the internal rotators (the teres major, latissimus dorsi, and subscapularis) was grade 5 preoperatively and postoperatively.

The increased motion and muscle strength allowed the children to touch the top of the head, to position the forearm on a tabletop easily, and to place the hand around objects at the side without twisting the trunk.

Axillary radiographs made at the latest follow-up examination showed the glenohumeral joint to be well reduced in all children. The humeral heads were normal in appearance.

Case Report

CASE 2. A boy who was born with brachial plexus palsy that involved the fifth, sixth, and seventh cervical nerve roots on the left had a normal passive range of motion of all joints at birth. At six months of age, he had recovered all function of the hand and was regaining active extension of the elbow. At one year of age, the strength of the triceps was grade 4 and the strength of the biceps was grade 2. However, he gradually lost 50 per cent of external rotation despite vigorous therapy. At one and a half years of age, the child had no passive external rotation and only 100 degrees of passive abduction. The strength of the internal rotators was grade 5, that of the deltoid was grade 2, and that of the external rotators was grade 0. An axillary radiograph of the shoulder made at this time showed a posterior dislocation of the humeral head (Fig. 3-A). At one year and nine months of age, the dislocated glenohumeral joint was relocated with the method described earlier.

Follow-up radiographs made at approximately four years of age showed the humeral head to be located in the glenohumeral joint (Fig. 3-B). The child had 160 degrees of passive abduction and 45 degrees of passive external rotation. The strength of the deltoid and of the external rotators was grade 4. The child was able to actively abduct and externally rotate the shoulder, against resistance, through the entire passive range of motion.

Discussion

The posterior dislocation of the shoulder in our eight patients was, we believe, secondary to brachial plexus birth palsy and was not true congenital dislocation of the shoulder³. These children had a full range of motion of the shoulder initially, but external rotation and abduction were gradually lost and the shoulder dislocated. Although dislocation of the glenohumeral joint secondary to brachial plexus palsy is known to occur in older children⁹, it has not been reported frequently in younger children. We are aware of only six reported cases of such a paralytic dislocation in the first few years of life^1,2,6,8, and all of those dislocations were posterior. Four of the dislocations were treated with open reduction through an anterior approach, and two were treated with open reduction through a posterior approach. Although all six of those patients appeared to have a stable shoulder postoperatively, most had residual loss of motion, presumably because of residual muscle imbalance. Perhaps release of the pectoralis major, latissimus dorsi, and teres major would have allowed a closed reduction in those patients.

Although minor loss of motion is common with muscle imbalance secondary to brachial plexus palsy, axillary radiographs should be made if there is persistent progressive loss of external rotation despite vigorous therapy. Some authors have found axillary radiographs difficult to make and have suggested evaluation of these children with computerized tomography⁴. This has not been our experience and, with care, an excellent axillary radiograph can be made for most children. The technique requires a trained technician and an orthopaedic surgeon to position and hold the cassette. The perpendicular approach through the axilla is used with the cassette held over the deltoid. We make these radiographs for all of our patients who have brachial plexus palsy before release and transfer of the tendons. Most of these patients have a well located joint, although, in some, the humeral head appears to be positioned posteriorly in the glenoid and may be interpreted as being subluxated. Only children who have the dislocation discussed in the present study need operative treatment as outlined. We do not make magnetic resonance images or arthrograms of these children because these studies require deep sedation and they are costly.

In children who have brachial plexus palsy, function of the muscles returns gradually in an unpredictable fashion and therefore it is difficult to know what the final strength of the muscles will be. For this reason, we usually delay transfer of the tendons until the patient is four years of age, by which time the recovery of muscle strength will have plateaued. However, children who have a dislocated glenohumeral joint secondary to brachial plexus palsy should have better results with an earlier operative procedure that also relocates the joint and balances muscle power. We believe that this procedure should be performed when the dislocation is first noted. Thus, if we saw the subject of our Case Report (Case 2) now, we would perform the procedure at the age of one year and six months rather than wait three months.

The eight children in the present study have done well since the procedures and, on the basis of our previous experience with two patients who were followed for seventeen years and six and a half years⁷, we believe that they will continue to function well. The treatment program that we described allows early reduction of the glenohumeral joint in children who have paralytic dislocation of the shoulder due to muscle imbalance secondary to brachial plexus palsy. Release of the contracted muscles enabled us to perform a closed reduction easily. The muscle transfers increased the ranges of active external rotation and abduction and, therefore, improved the function of the shoulder.

References

Babbitt, D. P., and Cassidy, R. H.: Obstetrical paralysis and dislocation of the shoulder in infancy. J. Bone and Joint Surg.,50-A: 1447-1452, Oct. 1968.50-A1447 1968

Dunkerton, M. C.: Posterior dislocation of the shoulder associated with obstetric brachial plexus palsy. J. Bone and Joint Surg.,71-B(5): 764-766, 1989.71-B(5)764 1989

Heilbronner, D. M.: True congenital dislocation of the shoulder. J. Pediat. Orthop.,10: 408-410, 1990.10408 1990

Hernandez, R. J., and Dias, L.: CT evaluation of the shoulder in children with Erb's palsy. Pediat. Radiol.,18: 333-336, 1988.18333 1988 [PubMed]

Hoffer, M. M.; Wickenden, R.; and Roper, B.: Brachial plexus birth palsies. Results of tendon transfers to the rotator cuff. J. Bone and Joint Surg.,60-A: 691-695, July 1978.60-A691 1978

Liebolt, F. L., and Furey, J. G.: Obstetrical paralysis with dislocation of the shoulder. A case report. J. Bone and Joint Surg.,35-A: 227-230, Jan. 1953.35-A227 1953

Phipps, G. J., and Hoffer, M. M.: Latissimus dorsi and teres major transfer to rotator cuff for Erb's palsy. J. Shoulder and Elbow Surg.,4: 124-129, 1995.4124 1995

Troum, S.; Floyd, W. E., III; and Waters, P. M.: Posterior dislocation of the humeral head in infancy associated with obstetrical paralysis. A case report. J. Bone and Joint Surg.,75-A: 1370-1375, Sept. 1993.75-A1370 1993

Wickstrom, J.; Haslam, E. T.; and Hutchinson, R. H.: The surgical management of residual deformities of the shoulder following birth injuries of the brachial plexus. J. Bone and Joint Surg.,37-A: 27-36, Jan. 1955.37-A27 1955

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Figs. 2-A, 2-B, and 2-C: Case 1. Photographs demonstrating the method of measurement of the range of motion postoperatively. Fig. 2-A: Passive external rotation of 20 degrees.

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Fig. 2-B: Full active abduction while lifting a 250-gram handpiece.

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Fig. 2-C Active abduction of 90 degrees in external rotation while lifting a 250-gram handpiece.

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Fig. 3-B Axillary radiograph, made two years and five months postoperatively, showing a located glenohumeral joint. The arrow indicates the posterior margin of the glenoid.

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TABLE I DATA ON THE PATIENTS

*Preoperatively/postoperatively.

Case	Gender	Side	Age at Presentation (wks.)	Age at Op. (yrs. + mos.)	Duration of Follow-up (yrs. + mos.)	Passive Motion* (degrees)		Strength* (grade)
Abduction	External Rotation	Deltoid	External Rotators
1	F	R	2	3 + 4	4 + 3	50/180	-10/40	3/4	0/4
2	M	L	2	1 + 9	2 + 5	100/160	0/45	2/4	0/4
3	F	R	1	2 + 2	2 + 3	70/150	-20/45	2/3	0/2
4	F	R	6 mos.	1 + 11	2 + 0	90/180	-45/70	1/4	0/4
5	F	R	3	3 + 11	2 + 0	90/180	0/45	2/3	0/3
6	F	R	2	1 + 3	4 + 8	90/170	0/60	1/2	0/2
7	M	R	8	1 + 2	5 + 0	75/160	-25/25	1/3	0/3
8	M	R	10	3 + 7	2 + 2	105/135	10/75	2/3	0/4

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TABLE I DATA ON THE PATIENTS

*Preoperatively/postoperatively.

Case	Gender	Side	Age at Presentation (wks.)	Age at Op. (yrs. + mos.)	Duration of Follow-up (yrs. + mos.)	Passive Motion* (degrees)		Strength* (grade)
Abduction	External Rotation	Deltoid	External Rotators
1	F	R	2	3 + 4	4 + 3	50/180	-10/40	3/4	0/4
2	M	L	2	1 + 9	2 + 5	100/160	0/45	2/4	0/4
3	F	R	1	2 + 2	2 + 3	70/150	-20/45	2/3	0/2
4	F	R	6 mos.	1 + 11	2 + 0	90/180	-45/70	1/4	0/4
5	F	R	3	3 + 11	2 + 0	90/180	0/45	2/3	0/3
6	F	R	2	1 + 3	4 + 8	90/170	0/60	1/2	0/2
7	M	R	8	1 + 2	5 + 0	75/160	-25/25	1/3	0/3
8	M	R	10	3 + 7	2 + 2	105/135	10/75	2/3	0/4

Babbitt, D. P., and Cassidy, R. H.: Obstetrical paralysis and dislocation of the shoulder in infancy. J. Bone and Joint Surg.,50-A: 1447-1452, Oct. 1968.50-A1447 1968

Dunkerton, M. C.: Posterior dislocation of the shoulder associated with obstetric brachial plexus palsy. J. Bone and Joint Surg.,71-B(5): 764-766, 1989.71-B(5)764 1989

Heilbronner, D. M.: True congenital dislocation of the shoulder. J. Pediat. Orthop.,10: 408-410, 1990.10408 1990

Hernandez, R. J., and Dias, L.: CT evaluation of the shoulder in children with Erb's palsy. Pediat. Radiol.,18: 333-336, 1988.18333 1988 [PubMed]

Hoffer, M. M.; Wickenden, R.; and Roper, B.: Brachial plexus birth palsies. Results of tendon transfers to the rotator cuff. J. Bone and Joint Surg.,60-A: 691-695, July 1978.60-A691 1978

Liebolt, F. L., and Furey, J. G.: Obstetrical paralysis with dislocation of the shoulder. A case report. J. Bone and Joint Surg.,35-A: 227-230, Jan. 1953.35-A227 1953

Phipps, G. J., and Hoffer, M. M.: Latissimus dorsi and teres major transfer to rotator cuff for Erb's palsy. J. Shoulder and Elbow Surg.,4: 124-129, 1995.4124 1995

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These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

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M. MARK HOFFER, GARY J. PHIPPS; Closed Reduction and Tendon Transfer for Treatment of Dislocation of the Glenohumeral Joint Secondary to Brachial Plexus Birth Palsy*. The Journal of Bone & Joint Surgery. 1998 Jul;80(7):997-1001.

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