Purpose of study. Internal rotation (IR) contracture of the shoulder is a frequent complication of obstetric brachial plexus injury, even in the face of full neurological recovery. Surgical procedures to treat this complication include tendon transfers, capsular release and osteotomies. We compared the outcomes in patients who had arthroscopic release only and those who also underwent a tendon transfer. Methods. We retrospectively reviewed the clinical records of all patients with OBPI presenting to our unit in the years 2002–2012 who underwent surgical procedures for the treatment of an IR contracture of the shoulder. Increase in range of external rotation (ER) in adduction and abduction intra-operatively was recorded. At follow-up, active ER, the Mallet score, presence of an ER contracture and the “drop-arm” sign was recorded. Results. 25 procedures were performed in 22 patients. Mean intra-operative gain in ER was greatest in those patients who had simultaneous arthroscopic release and a tendon transfer (83.3° and 60.5° in adduction and abduction respectively). This group had the greatest average range of active ER at follow up (47.5°), the lowest incidence of a “drop-arm” sign (14%), but also the highest incidence of ER contracture (75%). Patients who underwent arthroscopic anterior shoulder release only, had the highest average Mallet score at final follow up (17.1 compared to 16.3 in the scope and tendon transfer group), 45% incidence of a “drop-arm” sign and also the lowest incidence of ER contracture (32%). General satisfaction was greatest in the scope plus tendon transfer group. Conclusion. Patients who had arthroscopic release and tendon transfer had better ER range and power but more severe ER contractures than patients who underwent arthroscopic release only. Patient satisfaction and Mallet scores were comparable between the two groups and therefore bring into question the need for early tendon transfer in these patients. NO DISCLOSURES

Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with mean age 15 years (9 to 23) and mean follow-up 21 months (8 to 51). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with torticollis, congenital myopathy and Noonans syndrome and obstetric brachial plexus injury. Mean length gained was 31 mm (15 to 41) which represens an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263) and mean external fixation index was 56 days/cm. Two patients required internal fixation following fixator removal to consolidate union and one required additional internal fixation for atrophic regenerate. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin site infections. Clavicular lengthening by distraction osteogenesis for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury following acute correction. It has the potential to improve shoulder pain, function, range of movement and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union