Introduction: Shoulder relocation is commonly performed for the subluxating or dislocated shoulder secondary to Obstetric Brachial Plexus Palsy (OBPP). We have observed that even when relocation is performed at a young age, remodelling of the immature, dysplastic glenoid is often unreliable, resulting in recurrent incongruity and requiring treatment of the glenoid dysplasia. Methods and results: In a series of 19 patients, we used a posterior bone block to buttress the deficient glenoid at the time of shoulder relocation. At a mean follow up of 28 months (6–73 months), we describe failure in at least 50% with erosion of the bone block, progressive subluxation and resultant pain. A different technique of glenoplasty is now used. An osteotomy of the glenoid is performed postero-inferiorly, elevating the glenoid forward to decrease its volume. Bone graft, often taken from an enlarged and resected coracoid is then packed into the osteotomy and the whole assembly is held with a plate. In a series of 11 patients with a mean age of 6.7 years (1–18 years) we describe good results at short term followup, suggesting that this is a technique warranting further investigation. Conclusion: We believe that where a deficient glenoid is found at surgery for relocation of the shoulder in OBPP, a glenoplasty should be performed at the same time whatever the age of the patient, as glenoid remodelling will not reliably occur. We no longer advocate posterior bone block in these cases as it has a significant failure rate

Purpose of study: Glenoid dysplasia occurs early in the shoulders of some children affected by obstetric brachial plexus palsy (OBPP). Prompt treatment can reverse the deformity. A program has been devised to examine these children’s shoulders by ultrasound and the early results are described. Method: Since March 2006, all neonates born in New-castle upon Tyne with a diagnosis of OBPP have been referred to the hip ultrasound clinic. The shoulders were examined clinically for range of movement and signs of instability. A static and dynamic ultrasound examination was then performed. Treatment of subluxed shoulders involved splinting the shoulder in adduction and external rotation for six weeks after injection of the internal rotator muscles with botulinum toxin, as recommended by Ezaki and co-workers. Results: To date, six infants have been screened. Two had significant instability with ultrasonographic evidence of early glenoid dysplasia and have been treated. One had mild glenoid dysplasia with restricted external rotation which improved with physiotherapy alone. Three were clinically and ultrasonographically normal. Conclusions: The early experience of this program confirms the high incidence of shoulder dysplasia in the neonatal period in these children, as reported by others. The examination is safe and relatively easy. In the early stages of the condition the treatment to date has been simple and effective. We plan to continue with ultrasound screening for shoulder dysplasia in neonates with OBPP

We reviewed 1060 cases of OBPP prospectively at the Peripheral Nerve Injury Unit over 20 years. Data was collected for birth weight, maternal age, maternal height, maternal weight, duration of labour and associated difficulties, presentation, mode of delivery, neonatal problems, birth rank, race and social class.

The mean birth weight was 4.23 kg (Range 0.63–9.49 SD 0.72) compared to 3.47 Kg nationally [p < 0.05]. There was an association between severity of lesion and increase in birth weight.

Maternal age was 29.0 years in OBPP group [Range 14–43 SD 5.4] compared to 26.8 nationally [p < 0.05]. In 46.7% of the brachial plexus group, the mothers were > 30 years old. This was compared to 29.7% nationally.

The difference in maternal Body Mass Index (BMI) between patient group [27 with Range 14–44 SD 3.5] and national average of 25 was significant [p< 0.05]

Hypertension [11.8%] and diabetes [11.2%] were significantly [p< 0.05] higher than the national rate [6.4% and 1% respectively].

Shoulder dystocia occurred in 56% of the cases and was strongly associated with OBPP [p< 0.05].

Mean duration of labour nationally was 5.4 hours; in the patient group 10.8 hours [p< 0.05]

Breech presentation was more than three times the national average [p< 0.05]

Caesarean sections [2%] were less than national average [18%].

Instrumental deliveries [40.3%] were four times more than national rate. [P < 0.05]

The incidence of Neonatal asphyxia [22%] and Special Care Baby Unit [15.3%] was significantly [p< 0.05] higher than the national average [2% and 8% respectively]

Other factors did not prove to be statistically significant. These included; Social class, birth rank and ethnic origin.

We found that Birth weight, shoulder dystocia and body mass index are the most significant risk factors for obstetric brachial plexus plasy.

The purpose was to review the results of latissimus dorsi and teres major transfer in a group of children with shoulder disability due to brachiaI plexus palsy. Whilst their incidence has steadily declined, obstetric brachial plexus palsies are a continuing problem in paediatric orthopaedic practice. Lesions of the upper plexus (C4, C5, C6) are characterised by a loss of abduction and external rotation at the shoulder. The L’Episcopo procedure and its variants aim to address this by transfer of the latissimus dorsi and teres major. There have been conflicting reports in the literature as to the functional benefit of such procedures. A retrospective review of such procedures performed by one surgeon at a paediatric orthopaedic tertiary referral centre in New Zealand. Patients were assessed pre- and post-operatively in terms of range of movement and function. The Mallet scoring system was also used. Eight patients were examined by an independent observer up to 120 months following surgery (average 52 months). In most cases significant increases in range of movement, function and Mallet scores were noted. With regard to complications, where the paresis is severe to the extent that it is causing shoulder subluxation, tendon transfer surgery is contra-indicated. The L’Episcopo procedure was largely successful in restoring improved function to the shoulder girdle in this group of patients

Aim: To investigate the natural history and the impact of reconstruction in shoulder deformities due to obstetrical brachial plexus palsy. Methods: Pre and postoperative CT scans of bilateral upper extremities of 28 patients with obstetrical palsy were studied. The age during the preoperative CT scan ranged from 1.5 months to 10 years (average: 4 ± 3 years). 17 patients had Erbñs palsy and 11 global plexus involvement. Eighteen had primary shoulder reanimation mainly via intraplexus neurotization. Palliative surgery in 25 patients included trapezius transfer for shoulder abduction, adductors release and rerouting of the latissimus dorsi and terres major for external rotation, scapula stabilization and rotational osteotomy of the humerus. The CT measurements included: humeral head retroversion, spinoscapular angle, glenoid fossa inclination, congruence of the humeral head to the glenoid and distance of the lower angle of the scapula from the midline. Results: Preoperatively the humeral head was subluxated or dislocated posteriorly and had decreased retroversion. The hypoplastic scapula had winging and increased distance from the midline, while the glenoid fossa was more retroverted. Postoperatively all the above measurements were improved. Conclusions: Novel measurements on CT scans of bilateral shoulders provide valuable information. Surgical intervention signiþcantly improves the functional anatomy and the dynamics of the shoulder joint

Despite the impressive advancements in prenatal planning and assessment, obstetrical brachial plexus palsy remains an unfortunate consequence of difficult childbirth. Although the majority of infants with plexopathy recover with minor or no residual functional deficits, a number of children do not regain sufficient limb function and develop significant functional limitations, bony deformities and joint contractures. Recent developments in the technique of microsurgical reconstruction of peripheral nerve injuries proved to be effective in selected cases of children with obstetrical brachial plexus injury. Many of these children and those who were defined as having minor injury will remain with considerable functional limitation and deserve late orthopaedic reconstruction. Based on that, we developed a multidisciplinary Brachial Plexus clinic gathering a microsurgeon, a pediatric orthopaedic surgeon, an electrophysiologist clinician, physiotherapists and occupational therapist in order to assess and evaluate these children. A total of 105 children were seen and followed up in our clinic during the last 2 years. Most of these children were referred to our clinic from other centers and from physiotherapists treating these children on an out-patient basis. We report the orthopaedic reconstruction operations performed in 9 cases of residual functional disabilities in children born with obstetric palsy. 4 patients had latissimmus dorsi and teres major transfer. 2 patients had derotation osteotomy of the humerus. 1 patient had Steindler flexorplasty of the elbow. 2 patients had open reduction and capsulorrhapy for a dislocated shoulder. Video assessment of these children was performed before and after the operation. Function was also analyzed before and after operation by a physiotherapist and an occupational therapist. Significant functional improvement was achieved, to the satisfaction of patients and parents

Introduction: Upper root injuries (C5–C6±C7) account for 75 % of all obstetric brachial plexus palsies (OBPP). Among them, about thirty percent develop a medial contracture of the shoulder due to an imbalance between strong internal rotators and weak external rotators. This causes glenohumeral deformities. To decrease the internal contracture it had been proposed either to release the subscapularis (Sever procedure) or to perform a capsular release (Fairbank procedure). Arthroscopic capsular release was proposed in young patient to reduce the medial contracture. Material & methods: Six children with an average age of 23 months and 1 case aged 12 years old, had a medial contracture of the shoulder secondary to a C5–C6 ( 3 cases) or C5–C7 (4 cases) obstetrical palsy. An arthroscopic evaluation of the deformities was performed in 3 cases. Next a surgical subscapularis release was applied in association with a latissimus dorsi transfer. An arthroscopic evaluation of the joint associated with an arthroscopic capsular release (release of the coracohumeral ligament) was performed in 4 cases. In addition, the latissimus dorsi was transfered. Pre and Post operative passive external rotation were measured in degrees in R1 position. Pre and post operative medial rotation were evaluated according to the Mallet classification. A comparative evaluation of the glenohumeral deformities were performed between pre-operative MRI and arthroscopic results. Results: An arthroscopic evaluation of the glenohumeral joint was performed in 6 cases. In one case the arthroscopic evaluation could not be performed. In the 6 cases, arthroscopy confirmed the MRI lesion : 3 posterior subluxations, 1 posterior luxation and 2 normal joints. The subscapularis release allowed an increase in the passive lateral rotation of an average of 50°. However, a decrease of 1 point in the medial rotation was noted according to Mallet evaluation. The coracohumeral ligament arthroscopic release allowed an increase in the passive lateral rotation of an average of 60° without decreasing the passive medial rotation. Whatever the method used, a reduction of the subluxation of the glenohumeral joint was obtained. Discussion & Conclusion: Medial contracture of the shoulder may begin in the first two years of life and an early reduction with muscular release and transfers was proposed. However, the precise nature of the progressive limitation of the external passive rotation remains unclear. Is the limitation due to a contracture of the medial rotators or a capsular retraction or a combination of both? Harryman demonstrated the role of the rotator interval capsule and coracohumeral ligament in limiting the external rotation. Our hypothesis was that capsular retraction occurred before the muscular contracture. As a result we decided to perform a capsular release in patients under 24 months. The results on the passive external rotation were similar with both methods. Although, the technique of an arthroscopic release was difficult and demanding, it appears that this technique is beneficial as it allows an evaluation of the joint deformity and treatment of the contracture in the same time. Arthroscopic release is a safe but demanding technique which allows an increase in the external passive rotation in OBPP. It should be noted that this technique requires a significant practice

Introduction

Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia.