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Surgical correction of unsuccessful derotational humeral osteotomy in obstetric brachial plexus palsy: Evidence of the significance of scapular deformity in the pathophysiology of the medial rotation contracture

DOI: 10.1186/1749-7221-1-9

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Four patients with Scapular Hypoplasia, Elevation And Rotation (SHEAR) deformity who had undergone unsuccessful humeral osteotomies to treat internal rotation underwent acromion and clavicular osteotomy, ostectomy of the superomedial border of the scapula and posterior capsulorrhaphy in order to relieve the torsion developed in the acromio-clavicular triangle by persistent asymmetric muscle action and medial rotation contracture.Clinical examination shows significant improvement in the functional movement possible for these four children as assessed by the modified Mallet scoring, definitely improving on what was achieved by humeral osteotomy.These results reveal the importance of recognizing the presence of scapular hypoplasia, elevation and rotation deformity before deciding on a treatment plan. The Triangle Tilt procedure aims to relieve the forces acting on the shoulder joint and improve the situation of the humeral head in the glenoid. Improvement in glenohumeral positioning should allow for better functional movements of the shoulder, which was seen in all four patients. These dramatic improvements were only possible once the glenohumeral deformity was directly addressed surgically.Obstetric brachial plexus injury (OBPI) has been described as a discrete entity since 1754 [1]. The pathophysiology of the secondary deformities encountered in this population was described succinctly in 1905 by Whitman who wrote that the large majority of internal rotation and subluxation deformities of the shoulder in children with obstetric brachial plexus injuries were caused by fibrosis and contractures developed as a consequence of the neurological injury [2]. The medial rotation contracture (MRC) is the most significant secondary shoulder deformity in children with severe OBPI, requiring surgery in more than one third of patients whose injury did not resolve spontaneously [3].The current surgical approach to treating persistent MRC in OBPI patients is derotational humeral ost


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