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Arm rotated medially with supination - the ARMS variant: description of its surgical correction.

Nath RK, Somasundaram C, Melcher SE, Bala M, Wentz MJ - BMC Musculoskelet Disord (2009)

Bottom Line: Mallet score increased by an average of 5.2 (p < 0.05).Overall forearm position was not significantly changed from an average of 5 degrees to an average of 34 degrees maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder.

View Article: PubMed Central - HTML - PubMed

Affiliation: Texas Nerve and Paralysis Institute, Houston, TX, USA. drnath@drnathmedical.com

ABSTRACT

Background: Patients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SHEAR deformity commonly occurs in conjunction with Medial Rotation Contracture (MRC) of the arm. OBPI also causes muscle imbalances at the level of the forearm, that lead to a fixed supination deformity (SD) in a small number of patients. Both MRC and SD will cause severe functional limitations without surgical intervention.

Methods: Fourteen OBPI patients were diagnosed with MRC of the shoulder and SD of the forearm along with SHEAR deformity during a 16 month study period, with eight patients available to long-term follow-up (age range 2.2 - 18 years). Surgical correction of the MRC was performed as a triangle tilt or humeral osteotomy depending on the age of the child, after which, the patients were treated with a radial osteotomy to correct the fixed supination deformity. Function was assessed using the modified Mallet scale, examination of apparent supination and appearance of the extremity at rest.

Results: Significant functional improvements were observed in patients with surgical reconstruction. Mallet score increased by an average of 5.2 (p < 0.05). Overall forearm position was not significantly changed from an average of 5 degrees to an average of 34 degrees maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.

Conclusion: The simultaneous presence of two opposing deformities in the same limb will visually offset each other at the level of the wrist and hand, giving the false impression of neutral positioning of the limb. In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder. Both of these deformities require surgical attention, and the presence of concurrent MRC and SD should be monitored for in OBPI patients.

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Related in: MedlinePlus

Measuring scapular elevation to quantitate the extent of the SHEAR deformity. A 3D-reconstruction of axial bilateral CT images rotated into the anterior view is used to measure scapular elevation. The area of each portion of both scapulas is measured as indicated (areas A-D). The area above the scapula is divided by the total scapular area and corrected for rotational artifacts by subtraction of the unaffected side from the affected side before multiplying by 100 to obtain percent elevation. Shown here is the CT for patient 1 with 37% scapular elevation.
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Figure 3: Measuring scapular elevation to quantitate the extent of the SHEAR deformity. A 3D-reconstruction of axial bilateral CT images rotated into the anterior view is used to measure scapular elevation. The area of each portion of both scapulas is measured as indicated (areas A-D). The area above the scapula is divided by the total scapular area and corrected for rotational artifacts by subtraction of the unaffected side from the affected side before multiplying by 100 to obtain percent elevation. Shown here is the CT for patient 1 with 37% scapular elevation.

Mentions: The presence of SHEAR deformity was determined by physical examination and quantitated from 3D-CT images [4]. Elevation of the scapula was estimated clinically by palpation and observation during routine shoulder movements and supination. Scapular elevation was quantified from a bilateral 3D-reconstruction of the CT axial images to determine the severity of the SHEAR deformity [4]. The area of the scapula appearing above the clavicle, measured using Universal Desktop Ruler (AVPsoft, version 2.8.1110), was divided by the total area of the scapula in the anterior view of the 3D-reconstruction. The percent scapular elevation for the unaffected shoulder was subtracted from that of the affected shoulder to correct for rotational artifacts of the anterior projection (Figure 3).


Arm rotated medially with supination - the ARMS variant: description of its surgical correction.

Nath RK, Somasundaram C, Melcher SE, Bala M, Wentz MJ - BMC Musculoskelet Disord (2009)

Measuring scapular elevation to quantitate the extent of the SHEAR deformity. A 3D-reconstruction of axial bilateral CT images rotated into the anterior view is used to measure scapular elevation. The area of each portion of both scapulas is measured as indicated (areas A-D). The area above the scapula is divided by the total scapular area and corrected for rotational artifacts by subtraction of the unaffected side from the affected side before multiplying by 100 to obtain percent elevation. Shown here is the CT for patient 1 with 37% scapular elevation.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2664782&req=5

Figure 3: Measuring scapular elevation to quantitate the extent of the SHEAR deformity. A 3D-reconstruction of axial bilateral CT images rotated into the anterior view is used to measure scapular elevation. The area of each portion of both scapulas is measured as indicated (areas A-D). The area above the scapula is divided by the total scapular area and corrected for rotational artifacts by subtraction of the unaffected side from the affected side before multiplying by 100 to obtain percent elevation. Shown here is the CT for patient 1 with 37% scapular elevation.
Mentions: The presence of SHEAR deformity was determined by physical examination and quantitated from 3D-CT images [4]. Elevation of the scapula was estimated clinically by palpation and observation during routine shoulder movements and supination. Scapular elevation was quantified from a bilateral 3D-reconstruction of the CT axial images to determine the severity of the SHEAR deformity [4]. The area of the scapula appearing above the clavicle, measured using Universal Desktop Ruler (AVPsoft, version 2.8.1110), was divided by the total area of the scapula in the anterior view of the 3D-reconstruction. The percent scapular elevation for the unaffected shoulder was subtracted from that of the affected shoulder to correct for rotational artifacts of the anterior projection (Figure 3).

Bottom Line: Mallet score increased by an average of 5.2 (p < 0.05).Overall forearm position was not significantly changed from an average of 5 degrees to an average of 34 degrees maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder.

View Article: PubMed Central - HTML - PubMed

Affiliation: Texas Nerve and Paralysis Institute, Houston, TX, USA. drnath@drnathmedical.com

ABSTRACT

Background: Patients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SHEAR deformity commonly occurs in conjunction with Medial Rotation Contracture (MRC) of the arm. OBPI also causes muscle imbalances at the level of the forearm, that lead to a fixed supination deformity (SD) in a small number of patients. Both MRC and SD will cause severe functional limitations without surgical intervention.

Methods: Fourteen OBPI patients were diagnosed with MRC of the shoulder and SD of the forearm along with SHEAR deformity during a 16 month study period, with eight patients available to long-term follow-up (age range 2.2 - 18 years). Surgical correction of the MRC was performed as a triangle tilt or humeral osteotomy depending on the age of the child, after which, the patients were treated with a radial osteotomy to correct the fixed supination deformity. Function was assessed using the modified Mallet scale, examination of apparent supination and appearance of the extremity at rest.

Results: Significant functional improvements were observed in patients with surgical reconstruction. Mallet score increased by an average of 5.2 (p < 0.05). Overall forearm position was not significantly changed from an average of 5 degrees to an average of 34 degrees maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.

Conclusion: The simultaneous presence of two opposing deformities in the same limb will visually offset each other at the level of the wrist and hand, giving the false impression of neutral positioning of the limb. In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder. Both of these deformities require surgical attention, and the presence of concurrent MRC and SD should be monitored for in OBPI patients.

Show MeSH
Related in: MedlinePlus