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Posterior Shoulder Dislocation in Infants with Neonatal Brachial Plexus Palsy
Didier Moukoko, MD1; Marybeth Ezaki, MD1; David Wilkes, MD1; Peter Carter, MD1
1 Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219. E-mail address for M. Ezaki: marybeth.ezaki@tsrh.org
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Texas Scottish Rite Hospital for Children, Dallas, Texas

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Apr 01;86(4):787-793
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Background: Glenoid dysplasia and posterior shoulder subluxation with resultant shoulder stiffness is a well-recognized complication in infants with neonatal brachial plexus palsy. It is generally considered to be the result of a slowly progressive glenohumeral deformation secondary to muscle imbalance, physeal trauma, or both. Recent publications about infantile posterior shoulder dislocation have suggested that the onset of dysplasia occurs at an earlier age than has been previously recognized. The prevalence of early dislocation in infants with this disorder has not been previously reported, to our knowledge.

Methods: We studied 134 consecutive infants with neonatal brachial plexus palsy who were seen at our institution over a period of two years. All infants were examined at monthly intervals to assess neurological recovery and the status of the upper extremity until recovery occurred or a treatment plan was established. The type of brachial plexus involvement was classified. Specific clinical signs associated with subluxation and dislocation were recorded. These included asymmetry of skin folds of the axilla or the proximal aspect of the arm, apparent shortening of the humeral segment, a palpable asymmetric fullness in the posterior region of the shoulder, or a palpable click during shoulder manipulation. The infants who were identified as having these clinical signs were evaluated with ultrasonographic imaging studies.

Results: Eleven (8%) of the 134 infants had a posterior shoulder dislocation. The mean age at the time of diagnosis was six months (range, three to ten months). There was no correlation between the occurrence of dislocation and the type of initial neurological deficit. A rapid loss of passive external rotation between monthly examinations indicated a posterior shoulder dislocation.

Conclusions: Posterior shoulder dislocation can occur earlier (before the age of one year) and more rapidly in infants with neonatal brachial plexus palsy than has been appreciated previously. As with developmental dysplasia of the hip, a high index of suspicion, recognition of clinical signs, and the use of ultrasonography will allow the diagnosis to be established. Following early diagnosis, attention should be focused on improving the stability and congruency of the shoulder joint.

Level of Evidence: Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

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    Johannes A. van der SLuijs
    Posted on May 11, 2004
    Posterior shoulder dislocation in infants with neonatal brachial plexus palsy
    Vrije Universiteit Med.Cen, PObox 7057, 1007 MB Amsterdam, Holland

    To the Editor:

    I read the article “Posterior shoulder dislocation in infants with neonatal brachial plexus palsy”( 2004;86A:787-793) by Moukoko et al. with keen interest and I would like to make some remarks on their findings.

    First, contrary to the authors' statement, not only incidental reports of shoulder deformities in obstetric brachial plexus lesion (OBPL) infants are available, but these deformities were the subject of an MRI study of infants considered for neurosurgical treatment (van der Sluijs et al., 2001), which showed that the majority had some kind of shoulder deformity. As to the clinical findings reported by Moukoto et al, the dorsally dislocated humeral head has been described by Birch (Birch R, 1998) as the lump sign.

    Second, the more subtle shoulder deformities seem absent from this study. As the authors remark, a spectrum of shoulder deformities is present in some OBPL infants. Yet in the reported study only the extreme end of this spectrum ( the dislocations) seem present while all other patients have normal shoulders.

    Third, the reported prevalence of 11 out of 134 children developing an internal rotation contracture seems low compared to other studies (Waters, 1999). The prevalence of deformities is influenced by the definition used and the cohort studied. Since the majority of OBPL infants show a full recovery, studies which do not include all infants directly post partum will show higher percentages of residual symptoms. Because the referral bias in the Moukoko study is unknown, the value of the reported prevalence is unclear.

    Fourth, concerning the relevance of these deformities, shoulder function depends on neuromuscular and skeletal factors. While neuromuscular injury may lead to changes in skeletal deelopment, some of these skeletal changes could be adaptive processes that optimise the residual neuromuscular function. Recent experience with operative treatment of internal rotation contractures showed mixed results (van der Sluijs et al., 2004).

    Finally, I wish to compliment the authors for showing the potential of ultrasonography,a technique that may replace either CT or MRI, for imaging shoulder deformities in OBPL infants,

    J.A. van der Sluijs, MD PhD,

    Reference List

    1.Birch R. Birth lesions of the brachial plexus. In: Birch R, Bonney G, Wynn Parry CB, eds., Surgical disorders of the peripheral nerves. London, Churchill Livingstone, 1998: 209-233 2. van der Sluijs, van Ouwerkerk WJ, de Gast A, Nollet F, Winters H, Wuisman PI. Treatment of internal rotation contracture of the shoulder in obstetric brachial plexus lesions by subscapular tendon lengthening and open reduction: early results and complications. J Pediatr.Orthop.B 2004; 13:218-224 3. van der Sluijs, van Ouwerkerk WJ, de Gast A, Wuisman PI, Nollet F, Manoliu RA. Deformities of the shoulder in infants younger than 12 months with an obstetric lesion of the brachial plexus. J Bone Joint Surg Br. 2001; 83:551-555 4. Waters. Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J.Bone Joint Surg.Am. 1999; 81:649-659

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