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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_777_Библиотеки_им_академика_М_И_Перельмана
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24 Palliative Surgery inObstetrical Brachial Plexus Palsy
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Fig. 24.3 Coracohumeral ligament is exposed before resection. Ligament resection allows the shoulder joint to achieve
an increased external rotation
287
Unfortunately,subscapularis muscle releasefails
inabout 50% of cases [13].
Although few reports have been published
about a comparison of procedures,our impression
is that coraco-humeral release seems to be more
effective than subscapularis release. According to
Gilbert’s observations, the latter procedure seems
to be inefcient after 4 years of age. In older children, subscapularis muscle release might represent one step of a multistage procedure, but we
advise against using it as the rst choice treatment
at major age. On the other hand, the coracohumeral release may be performed during the rst
years of life to obtain room for the motion of the
humeral head that is expected to remodel during
the residual growth(Fig. 24.3).
Preventive X-ray exploration to identify
humeral head deformation is advisable, while at
older ages, MRI (magnetic resonance imaging)
and CT (computed tomography) scans are mandatory to conrm joint congruence.
Nerve transfer, as described above in very
young children, might be a successful solution in
addition to shoulder joint release. At any rate,
whichever surgery might be used, a period of 3–6
weeks of immobilization in a brace or cast with
the shoulder positioned in the abduction and
external rotation is needed to allow the transfer
(nervous or tendinous) to be stabilized.
From four to ten years of age, lack of active
external rotation can be corrected by latissimus
dorsi/teres major transfer to the rotatory cuff, as a
rst choice [8, 14].
In our experience, combined coracohumeral
releaseand latissimus dorsi/teres major transfer
can be effective, when residual stiffness of the
shoulder is detected (Fig.24.3).
When bone growth of proximal humeral physis is about to stop, approximately from ten years
on, derotational osteotomy and plating at the
upper third ofhumeral shaft in external rotation,
performed above pectoralis major insertions,can
be helpful tocorrect the internal rotational defect
and compensate the anteposition of the shoulder
girdle, additionally making up for cosmetic
appearance [15, 16]. Muscle transfers, that is,
latissimus dorsi muscle, can be added to reinforce motion (Fig.24.4).
It is extremely important to perform a mild
derotation of the bone stumps avoiding an extensive derotationover25°topreventfrom a loss of
motion in internal rotation. Excessive derotation
limits the capability to reach the median line of
the body with the hand.
During growth, some patients who developed a
severe defect of shoulder external rotation show a
typical pattern with internal rotation of the shoulder and progressive exion deformity of the elbow.
After humeral derotation procedure, parents must
be informed of the risk of losing some degrees of
internal rotation because of the achievement of the
same amount of degrees in external rotation.
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a
Fig. 24.4 (a, b) Derotational osteotomy of humeral prox-
imal metaphysis provides a satisfactory improvement of
external rotation motion of the shoulder, as is shown in
preoperative (a) and postoperative images (b). X-ray
images conrm the deformation of the humeral proximal
epiphysis
24 Palliative Surgery inObstetrical Brachial Plexus Palsy
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b
Fig. 24.4 (continued)
289
24.2.1.2 Limited Abduction
Limited abduction of the shoulder is one of the
most common features of OBPP. There are different degrees of disability, so correction is
requiredaccording to the severity of lesion.
Lack of abduction of the shoulder usually
stems from different factors, above all insufcient deltoid muscle strength, but it can also be
due to incongruence of the shoulder joint and
unbalance of shoulder girdle muscles, particularly for the predominance of internal rotators.
During the rst years of life, latissimus dorsi
muscle transfer permits to attain a satisfactory
external rotation along with a slight increasing of
abduction. Inevitably, a loss of this minimal
amount ofabduction occurs during the following
years, butthistransfer is helpful for the development of the scapulo-humeral joint, favoring joint
congruence and avoiding posterior dislocation of
the humeral epiphysis.
Late nerve surgery throughtransfer of nerve
branches of the long head of the triceps muscle
to axillary muscle in very young children is a
recent proposal which, however, is still debated
on the risk of impair a relatively good triceps
muscle [17].
In the event of severe lack of abduction, from
six to ten years of age, trapezius muscle transferred onto the deltoid insertion can be a good
solution, even though only a partial recovery of
function is expected. In this procedure, a periosteal strip is elevated and sutured onto the deltoid
insertion without skeletal anchorage to avoid progressive tightening of the transferred muscle during further growth. Excessive tension of
transferred muscle results in abduction contracture with additional scapulohumeral stiffness.
From 10 to 16 years of age, trapezius muscle
transfer with olecranon graft xed into humeral
diaphysis is more appropriate.
Trapezius muscle transfer is effective for balancing a weak shoulder, particularly when combined with other muscle transfers, even though a
limited amount of abduction is achieved
[18–20].
In young adults, shoulder joint fusion is
another option to better stabilize the scapulohumeral girdle.
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24.2.1.3 Limited Internal Rotation
A typical feature of the defect is the incapability
of reaching the median line of the body with the
hand. This defect is far more limiting than the
lack of external rotation because it has a severe
impact on many basic daily functions. It is commonly observed during growth, but it becomes
more limiting when other defects of motion are
associated (Fig.24.5).
Generally,the scapulohumeral girdle appears
hypoplastic and placedin a forward position with
a twisted clavicle. Scapular winging is always
present, sometimes extremely evident.
Very often patients present witha lack of both
external and internal rotations because of glenohumeral incongruence. Some patients show a
paradoxical pattern in forced external rotation of
Fig. 24.5 During
growth, this child
developed a singular
pattern in shoulder
rotation. Despite a good
external rotation, there is
an evident lack of
internal rotation that
limits many basic daily
functions
the shoulder with no ability to internally rotate
the upper arm.
Before ten years of age, coracoid process
resection and subscapularis muscle release to
reduce scapular winging might be helpful.
Sometimes rhomboid muscle plication can
reduce shoulder blade axis rotation.
From ten years of age on, internal derotational
osteotomy of the humerus below pectoralis major
insertion is a more advisable procedure that allows
the patient to improve internal rotation and reach
the anterior midline of the body with the hand.
Similar to external derotational osteotomy, excessive internal derotation might be dangerous to the
risk of losing the opposite function. Pectoralis
muscle insertion laterally xed onto the humeral
shaft can help improve the internal rotation.
24 Palliative Surgery inObstetrical Brachial Plexus Palsy
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Retroposition is a complex combination of
abduction and internal rotation of the shoulder.
Retropositional defect is a constant feature of
upper palsy that is usually treated through physical therapy, but rarely, it can be restored.
24.2.1.4 Posterior Subluxation
It usually occurs in adolescents with an internal
rotational pattern, namely, hypoplastic development
of the shoulder, modication of acromion, clavicle,
coracoid process, and glenoid cavity [21] (Fig.24.6).
The defect is due to incongruence between the
anomalous shaped humeral head andthe glenoid
cavity. Hyperlaxity of the joint and muscle palsy
trigger backward dislocation of the humeral head
(Fig.24.7).
Derotational osteotomy of the humeral shaft
along with coracohumeral ligament release or
coracoid resection and posterior capsuloplasty
with or without glenoid osteotomy of reorientation can help correct the instability [22].
These procedures are inconstantly rewarding
because of the possible recurrence of deformity.
291
Fig. 24.7 Shoulder clinical evaluation demonstrates a
severe posterior dislocation of the humeral head
Fig. 24.6 During growth, a large group of patients present with severe skeletal deformities of the shoulder joint.
Glenoid fossa dysplasia, coracoid process hypertrophy,
and proximal humeral head dislocation signicantly
impair shoulder motion
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24.2.2 Elbow
Impairment of elbow joint motion is another
basic point that interferes with the outcome.
Different from the shoulder which acts on multiple planes, the elbow has two axes of motion,
namely, exion and extension. Pronation and
supination of the forearm are inuenced by elbow
position even though they do not take part in
elbow motion.
Elbow joint morphology is altered by muscle
imbalance, forced position of the elbow that
causes the joint deformity, loss of perfect congruence, and growth changes due to physeal plate
asymmetrical stimulation.
A weak elbowcan present with twodifferent
patterns.The main important is due to palsy of
the biceps muscle which stems from nerve palsy
at birth, sometimes with partial strength
recovery.
Triceps muscle palsy represents the opposit
patternbut the predominance of the bicepsmuscleparadoxally causes a exion deformity.
This exion deformity posture is typical of
upper-intermediate palsy in which internal rotationpositioning of the shoulder and elbow exion due to retraction of reinnervated biceps
muscle results in a lack of elbow extension.
Elbow deformities are commonly assessed by
the Raimondi and Gilbert’s classication, which
scores the severity of elbow limitation in degrees
of exion or extension.
24.2.2.1 Lack ofActive Elbow Flexion
Lack of active elbow exion is a typical feature in
the majority of children presenting with OBPP in
the rst months of life, even though it tends to
decrease during the rst year of life. Its persistence is a typical feature of severe forms of neonatal palsy; currently, these patients are usually
enrolled as candidates for early nerve surgery.
However, older children lacking elbow exion
might be observed later in life, or they are exceptionally suffering sequela of unsuccessful brachial plexus surgery.
Palliative surgery can offer options for correcting the defect, but the number of procedures
is limited.
Recent publications about nerve transfers in
adults have shown the options to apply the same
procedure to the child. Innervation of the biceps
and/or brachialis muscle in the rst years of life
can be successful when proper indications are
followed [23]. Active elbow exion can be
obtained through different nerve trunk transfers
depending on the level of injury. In the event of a
C5–C6 palsy, fascicles of the ulnar nerve assigned
to the exor carpi ulnaris can be transferred onto
muscle cutaneous nerve or rather to biceps or
brachialis muscle branches to achieve active
elbow exion. When there is C7 involvement or
in the event of a partially recovered complete
neonatal palsy, transfer of intercostal nerves connected to muscle cutaneous nerve trunk or its fascicles represents a better option to obtain elbow
exion [24].
In already grown children, elbow exion can
be achieved through pedicled muscle transfers
(i.e., pectoralis major or minor, triceps, latissimus dorsi muscles) as well as using the classical
Steindler procedure. However, very often local
muscles are weak and unable to restore function
[25].
Free muscle transfers (i.e., free vascularized
gracilis muscle transfer) are another option, particularly in younger children when the lever arm
of the elbow is favorable and body weight is limited [26, 27].
24.2.2.2 Lack ofElbow Extension
Although lack of elbow extension is a severe
defect impairing upper limb function, lack of
elbow active extension is thought to be partially
compensated by gravitational forces (Fig.24.8).
Nevertheless, the involvement of the C7 root and
posterior cord of the brachial plexus is not negligible. When posterior trunk involvement is seen
in severely affected children, early nerve surgery
is the correct indication. Conversely, indication
for surgery might be more complicated when a
24 Palliative Surgery inObstetrical Brachial Plexus Palsy
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Fig. 24.8 Elbow extension limitation is constantly evident in the upper palsy. The deformity increases during
growth impairing elbow motion and determining cosmetic
problems in the patients
dissociated recovery of OBPP causes an isolated
triceps muscle palsy or when the child is observed
late.
In young children, nerve transfers can help
restore triceps muscle activity, essential for contrasting biceps muscle exion and avoiding progressive deformity of the joint, as described
above. There is no general agreement about late
nerve transfer and which nerve might be
transferred.
Fascicles of the ulnar nerve assigned to the
exor carpi ulnaris can be transferred onto the
radial nerve or rather on the branches of the long
head of the triceps muscle to achieve active elbow
extension. When there is C7 involvement or in
the event of a partially recovered neonatal complete palsy, intercostal nerves connected to the
293
radial nerve trunk or its fascicles can induce reinnervation of the triceps muscle. In already grown
children, elbow extension can be obtained
through pedicled muscles (latissimus dorsi muscle, deltoid muscle) [28].
24.2.2.3 Flexion Deformity
forLimited Extension
A exed attitude of the elbow with limitation of
elbow extension is the commonest pattern, usually detected in the majority of patients presenting with OBPP sequelae. Flexion degree
increases during growth, particularly during
adolescence. Incidentally, patients particularly
complain about this defect for functional and
cosmetic reasons.
Progressive exion degree of the elbow joint
can reach >90°, particularly when a strong
biceps muscle is not opposed by a weak triceps
muscle. In this condition, elbow joint geometry
is modied by muscle imbalance and loss of
articular congruency. As a consequence, there
is an alteration of the growing elbow, particularly the olecranon process that grows unhindered. These modications result in a further
decrease in motion due to the forced position of
the elbow and physeal plate asymmetrical stimulation [29, 30].
Since the surgical correction of the defect is
challenging, prevention is always attempted as
the rst step. Physical therapy can be effective in
preventing worsening deformity. Repetition of
exercises to increase the range of motion in exion and extension along with prono-supination of
the forearm permits to avoid increased exed
deformity of the elbow.
Static or dynamic nocturnal orthoses can be
useful in keeping the elbow in extension, relaxing
muscles and reducing joint stiffness. These
devices are barely toleratedby toddlers. For this
reason, progressive application of casts has been
advised along with botulin toxin injections into
the brachialis or internal rotator muscles of the
shoulder to reduce the progression of exion
deformity [31].
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At any rate, a correct approach to the shoulder
represents in itself prevention against elbow progressive deformation.
Wheneverelbow exion appears severely limiting, surgery may be requiredforboth functional
and cosmetic purposes.
In the literature, biceps tendon lengthening,
brachialis muscle release, and anterior open joint
capsulotomy have been proposed during growth,
even though recurrence of the deformity
have been often reported. Furthermore, biceps
muscle lengthening entails the risk of losing
muscle strength that had undergone reinnervation
during the rst years of life [32].
A posterior wedged osteotomy in the distal
humerus could obtain a satisfactory extension of
the elbow, with the risk, however, of losing active
exion due to the modied joint angles.
External xators have been proposed; however, they entail the risk of infections, stretching
of palsied structures, stiffness, etc. [33].
At the time being, there are no denite procedures to completely correct the elbow.
Observing the pitfalls of the other techniques,
we published an original procedure including
both anteromedial incisions of elbow joint cuff
along with brachialis aponeurosis incision (leaving biceps tendon untouched) and posteriorly a
partial resection of olecranon tip so to increase the
passive motion of the elbow. These two steps have
been performed to remove mechanical obstacles
on opposite sides of the elbow joint (Fig.24.9).
Fig. 24.9 Partial olecranon resection and anterior capsulotomy allow the exed elbow to achieve a larger range of
motion without losing exion degrees. CT scan shows an
increased length of the acromion, while X-ray pictures
give details of the level of olecranon resection
24 Palliative Surgery inObstetrical Brachial Plexus Palsy
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295
Fig. 24.9 (continued)
A mean increase of approximately 25° in
elbow extension has been constantly reached.
The results allow a good combination of functional and cosmetic advantages with the satisfaction of patients. The appropriate timing of the
procedure is during adolescence when growth
changes of the elbow joint do not lead to a recurrence of the deformity [34].
24.2.3 Forearm
The forearm is consistently involved in OBPP,
both upper-intermediate and complete, showing
different features according to palsy recovery.
Upper palsy presents with a pronation attitude, whereas severe intermediate and complete
palsy usually shows a supinated posture.
24.2.3.1 Defect ofSupination or
Pronator Deformity
Pronator deformity is a typical upper trunk
palsy sequela. The deformity stems from the
imbalance of forearm pronator muscles which
are active, whereas supinator muscles are
palsied.
Apart from cases in which severe stiffness of
the shoulder and elbow worsens forearm pronator
deformity, a mild lack of supination is usually
well tolerated. A good range of motion of the
shoulder makes up adequately for the defect.
Conversely, as the shoulder does not take part in
forearmpronation movements, a lack of pronation cannot be compensated.
Physical therapy, taping, and orthosis in the
intermediate position are conventional methods
of treatment.
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Inconstantly, skeletal deformities and interosseous membrane retraction cause more severe
pronation of the forearm. A deformity exceeding
two-thirds of xed pronation requires surgical
correction.
Uncommonly, subluxation of radial epiphysis
in a backward position generally occurs in the
oldest patients in whom uncontrolled growth of
the radial epiphysis impinges on the distal part of
humeral meta-epiphysis, further reducing forearm motion.
Someliterature reports haveproposed tendon
releases and transfers to achieve better supination
[35]. Some of them can be effective in the youngest patients; however, forced pronation in a much
grownchildren and teensrequires a derotational
osteotomy. According to the age, Kirschner wire
xation and molded cast are adequate methods of
xation, whereas in older children, xation by
plate and screws is needed.
Currently, osteoclasis in very young children
is an exceptional indication.
Radial head resection is appropriate for
achieving a passive motion of the forearm and is
commonly performed in late adolescence for
severe limitation of pronation movement.
Although ten years of age has been identied
as a hypothetical limit for performing soft tissue
or skeletal procedures, in our opinion, timing of
surgery should be established on a case-by-case
basis.
24.2.3.2 Defect ofPronation or
Supination Deformity
Supination deformity is a common feature of
complete or intermediate palsy with severe
impairment of the C7 root.
The typical appearance of the upper arm with
a exed elbow, supinated forearm, and hyperextended ail wrist springs from the dynamic
imbalance among active supinator muscles, that
is, biceps brachialis muscle and palsied pronator
muscles. Since opposite forces are stemming
from contracted muscles and gravitational forces
of the elbow joint are not controlled by palsied
muscles, further joint instability, namely radial
head subluxation, consistently arises.Soft tissue
defects, such ascontracture and shortening of the
interosseous membrane, biceps brachialis, supinator teres, and dorsal ligament of the distal
radioulnar joint are worsened byskeletal deformities of bone and joints, namely, anterior subluxation of the proximal radial epiphysis and
distal ulnar epiphysis subluxation.
Forearm xed deformity, radial dislocation,
and hand functionempowering are the main indicators for surgery.
Surgical correction of forearm xed supination is achieved using a tight interosseous membrane and joint capsule release to obtain a
reduction of capital radial head subluxation.
When the forearm can easily reach pronation, a Z
lengthening of the biceps muscle insertional tendon at the radius is performed. The distal stump
of the tendon is then rerouted around the radial
metaphysis and sutured in adequate tension to
obtain pronation motion when the elbow exes
[36, 37].
In the event of sufcient mobility of the two
bones of the forearm, the rst step can be skipped
proceeding directly to biceps rerouting.
Surgical treatment is required in the event of
progressive dislocation of the radial epiphysis at
4–6 years of age.
Hand impairment reduces chances for recovery, even though a correction of xed supination
provides chances for empowering some muscles
of the wrist or the hand.
Many authors have proposed forearm osteotomy, reporting good cosmetically and functionally results in the oldest children [38–40].
When severe instability further impairs the
chances of using the palsied forearm, radioulnar
proximal fusion gives stability to the forearm,
which, however, maintains poor function [41].
24.2.4 Wrist andHand
Wrist and hand involvements are frequent in children suffering from OBPP sequelae, particularly
in extensive paralysis.
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