Purpose of the study: A stiff shoulder in internal rotation is a classical complication of obstetrical injury to the brachial plexus. The condition generally associates glenohumeral dysplasia. In 2003, Pearl proposed arthroscopic release of the shoulder, with or without latissimus dorsi transfer as an alternative to an open procedure. We report a series of 13 patients who underwent this procedure.

Material and method: From 2004 to 2007, 13 children aged 1 to 11 years (range 3.5) underwent surgery. The procedure was an arthroscopic tenotomy of the intra-articular portion of the subscapularis associated with release of the anterior capsuloligament structures without tendon transfer. A thoracobrachial resin cast maintained the shoulder in maximal external rotation for six weeks. The functional outcome was assessed on the basis of the passive and active range of motion and the Mallet score. Pre and postoperative MRI was used to assess glenohumeral dysplasia and check its correction.

Results: Mean follow-up was 23 months (range 5–40). There were no complications. Mean immediate postoperative gain was 53 (range 30–70) for external rotation (RE1). On average, passive RE1 improved from −5.4 to +57.7. Eight patients (61%) recovered active external rotation (57.5 on average). Mean active abduction improved from 45.8 to 56.5. Active internal rotation declined in 38% of the shoulders. The Mallet score improved in 69% of the shoulders. The best results were observed for children aged less than 4 years. There was one failure, related to major dyplasia which could not be reduced with an open procedure. Correction of the glenohumeral dysplasia was noted on 7 of the 9 MRI performed and the retroversion angle of the glenoid improved from −28.2 to −25.6, on average.

Discussion: Open techniques are aggressive and only variably effective. A majority of our patients (8/13) achieved improved passive and active RE1 solely with the arthroscopic procedure. Correction of the glenohumeral dysplasia with growth appears to correspond to the clinical improvement but further follow-up is needed.

Conclusion: Our results are comparable with those reported by Pearl. This is a minimally invasive easy-to-perform technique. For children aged less than 4 years, systematic tendon transfer does not appear to be necessary.

Purpose of the study: Amputation of the thumb is a serious hand injury producing a major functional and aesthetic handicap. In 1980, Foucher proposed a twisted two toes transfer associating elements harvested from the first and second toes on the same pedicle for the reconstruction of an ‘articulated’ thumb with preserved potential for growth.

Material and method: Since 2002, two children aged 10 and 14 years underwent this procedure. The thumb amputation was trans MP for one and at the base of P1 for the second. The transfer associated a sheath of skin from the hallux to wrap around the skeleton of the second toe which was harvested as need to the IP or the MP. The aesthetic, functional (400 point scale), and radiological outcomes were assessed.

Results: Follow-up was 5 years and 2.5 years. The aesthetic result was comparable to wrap-around transfers. Regarding the functional outcome, the overall hand function was scored 86% and 72% of normal, mobility 77% and 72%, and force 75% and 79%. One patient had persistent deficient active flexion of the interphalangeal joint because of flexor adherences. Despite the reconstruction of the “two-joint” thumb, fine movements were difficult. Sensitivity was noted normal: Weber 5 and 8 mm. Healing of the donor site was rapid and the sequelae discrete. The first ray was preserved. Gait was not hindered. In one patient, radiographs showed skeleton growth.

Discussion: Transfer of the second toe provides a potential for growth, but the aspect is less than satisfactory and the functional results often disappointing. There are no indications except for very proximal amputations. Total transfer of the great toe would also provide potential for growth, but the voluminous aspect and the very important sequelae for the foot rule out this option.

Conclusion: For growing children, the twisted two toe transfer for amputations of the metacarpophalangeal region is the only available technique allowing nearly normal reconstruction of the thumb in terms of mobility, force, sensitivity, appearance, and growth. The foot reconstruction is simple, aesthetic and functional. The complexity of the procedure may nevertheless limit is use.