LATERAL HUMERAL ROTATION OSTEOTOMY FOR THE TREATMENT OF OBSTETRICAL PALSY OF THE BRACHIAL PLEXUS

Abstract

Introduction: Obstetrical palsy of the brachial plexus secondary to a difficult labor remains to be a challenging clinical problem, causing persistent neurologic impairment with varying degrees of functional deficit of the upper extremity if not treated properly.In our country, a considerable number of children with plexopathy have been referred to an eligible hospital or surgeon in the late period after developing persistent shoulder contractures and deformities because of lack of appropriate management. The purpose of this retrospective study is to review the outcomes of humerus lateral rotational osteotomy in children who had persistent shoulder contractures and deformities because of birth palsy.
Patients and methods: Twenty cases, with internal rotation and adduction contractures of the shoulder with a resulting joint deformity or subluxation secondary to Erb’s palsy, were managed with lateral rotational osteotomy of the humerus over a 10-year period (1990-2000). The average age of the patients was 8.1 years at the time of operation (range, 5-13 years). Follow-up averaged 8 years. The modified classification system of Mallet was used to assess the function of the upper extremity before the operation and at the latest follow-up. The outcomes were compared statistically.
Results: According to the modified classification system of Mallet, the patients had a median score of 3 for global abduction, 2 for global external rotation, 2 for hand-to-neck ability and 2 for handto- mouth ability preoperatively. At the time of final follow-up, all patients had improved shoulder function and obtained a median modified Mallet score of 4 for all abilities. Only a patient could not succeed in hand-to-neck activity because of an elbow flexion contracture. As assessed with use of modified Mallet classification, there was significant improvement in upper extremity function after humerus lateral rotation osteotomy (p<0.05).
Discussion: Fixed adduction and internal rotation contracture of the arm, with loss of external rotation of the shoulder, is the most frequent deformity of the extremity associated with Erb’s type brachial plexus birth injury. If this contracture is not treated early enough, it may result in progressive glenohumeral joint deformity and incongruency. Humerus lateral rotation osteotomy is an effective salvage procedure, for patients with this type of contractures secondary to chronic obstetrical brachial plexus palsy, when tendon transfers cannot be performed because of incongruency of glenohumeral joint. The present study supports that humerus lateral rotation osteotomy not only increases the functional range of motion of the upper extremity, but also enables the activities of daily life much better.