Shoulder problems presenting at birth

Prof P. Bala

Shoulder problems presenting at birth

1. Birth injuriesbrachial plexus lesions fracture clavicle fracture humerus 2. Congenital conditionscongenital undescended scapula congenital pseudoarthrosis of clavicle cleidocranial dystosis, hypoplastic glenoid 3. Infections in the neonateseptic arthritis shoulder, septicaemia congenital syphilis

Obstetric paralysis
Brachial plexus lesions: traction on br plx delivery 0.1- 0.4 % of live births Causes increase in birth weight maternal diabetes shoulder dystocia breech delivery Transient neuropraxia to complete avlusion of nerve root. child does not move the extremity, posture of limb DD pseudoparalysis from # clavicle or # humerus Moros reflex -absent in brachial plx injury -intact in #

Congenital brachial plexus palsy: obstetric paralysis

1. Upper plexus - Erbs Duchenne C5, C6 +- C7 80% of obstetric paralysis arm adducted & internally rotated 2. Panplexus 19%, flail insensate arm 3. Lower plexus - Klumpkes, 1%, breech deliv paralysed hand intact shoulder & elbow Horners, generally preganglionic

Obstetric paralysis management

>90% spontaneous recovery Role of EM and nerve conduction studies not clear MRI and CT myelo for pre ganglionic lesions Prevent contracture of shoulder- passive rom while stabilising the scapula Natural history : upper lesions recover spontaneously Return of biceps sign of recovery Poor prognosis if no biceps recovery at 6 mo.

Obstetric paralysis : surgery

Criteria for microsurgical intervention evolving Postganglionic rupture : resect neuroma sural nerve grafting Direct repair rarely done Preganglionic avulsion: nerve transfer with intercostal or branches of spinal accessory Microsurgery in total plexopathy after 6 months

Neglected case Erbs : x-ray

Shoulder : Scapula under developed Corocoid markedly enlarged Acromion elongated anteriorly and inferiorl Head of humerus flattened glenoid hypoplastic Head subluxed posteriorly Elbow: flexion contracture, radial head posteriorly dislocated

Treatment of patients with chronic plexopathy

Muscle contracture Secondary bony deformity progressive glenoid retroversion and posterior subluxation of shoulder 1. subperiosteal release of subscapularis by 1 year 2. transfer lat dorsi and teres maj to rotator cuff + pec maj release for significant internal rotation contractures by 2-7 years Humeral ext rotn osteotomy for severe flattening of glenoid

Congenital undescended clavicle: Sprengles shoulder

Most common congenital anomaly of shoulder Interruption of normal caudal migration of scapula during foetal development. Scapula at the level of C4-5 in the 5th wk of gestation Migrates caudally below T3 by 12 wks Failure : high small malrotated scapula

Sprengles shoulder
Associated anomaliesscoliosis, hemivertebra, rib synostosis, clavicle abn, renal abnormalties, hypoplasia of shoulder girdle muscles, omo-vertebral bone 30-50%, Klippel-Feil syndrome

Sprengles shoulder
Cosmetic problem Little or no functional limitation Glenohumeral instability reported in them due to repeated capsular stretching to compensate for limited scapl-th motion A. mild no treatment, excise sup , scapula B. severe: surgery

Sprengles shoulder surgery

When indicated intervene before 6 yrs Green procedure: release of muscles from scapula & excision of supraspinous portion of scapula, ov , bring down & reattach Reflect trapezius from spine of scapula Free rhomboids and levator sacpula Remove supraspinous part of scapula Excise any omovertebral bone Displace scapula inferiorly

Woodward procedue
Transfer of origin of trapezius to more inferior position . Midline incision Origins of trapezius rhomboids freed from spinous process Lev scapula, omovertebral bone and superior angle of scapula excised Attachment of trapezius at C4 released Scapula & attached muscles displaced inferiorly Reattach aponeurosis of trapezius Complication : brach plx lesion

Congenital pseudoarthrosis of clavicle

Rare, unilateral , right side, failure of ossification of pre-cartilaginous bridge of 2 ossification centres Middle third of clavicle, painless mass Bilateral in 10-15% Present at birth May occur with cleidocranial dystosis not related to congenital pseudoarthrosis of tibia open reduction bone grafting and plating, union easier to obtain

Glenoid hypoplasia
Increasingly recognized as a primary condition. also secondary to skeletal dysplasias, MPS Rim of glenoid develops from 2 ossification centres by 9-16 yrs Glenoid hypoplasia occurs when inferior apophysis fails to ossify Dentate glenoid Bilateral and asymptomatic Multidirectional instability

Septic arthritis of shoulder in neonate

Rare, cause: indwelling cath , sepsis remain afebrile Delay in diagnosis Whole body tech scan for evaluation Multifocal OM Pseudoparalysis of shoulder X-ray widening of jt space Concomitant OM may be present Arthrotomy rather than serial aspirations Arthroscopic irrigation & debridement Delay in D damage to physis