shoulder problems presenting at birth

7/28/2019 Shoulder Problems Presenting at Birth

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Shoulder problems presenting

at birth

Prof P. Bala



Shoulder problems presenting at

birth1. Birth injuries-

brachial plexus lesions

fracture clavicle

fracture humerus

2. Congenital conditions-

congenital undescended scapula

congenital pseudoarthrosis of clavicle

cleidocranial dystosis, hypoplastic glenoid3. Infections in the neonate-

septic 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

Moro’s reflex -absent in brachial plx injury

-intact in #



Congenital brachial plexus

palsy: obstetric paralysis

1. Upper plexus - Erb’s Duchenne

C5, C6 +- C7

80% of obstetric paralysis

arm adducted & internally rotated2. Panplexus 19%, flail insensate arm

3. Lower plexus - Klumpke’s, 1%, breech deliv

paralysed handintact shoulder & elbow

Horner’s, generally preganglionic



Obstetric paralysis management

• >90% spontaneous recovery

• Role of EM and nerve conduction studies notclear

• 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 interventionevolving

• 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 Erb’s : 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 headposteriorly 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:

Sprengle’s 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




• Associated anomalies-

scoliosis, hemivertebra,

rib synostosis,

clavicle abn,

renal abnormalties,

hypoplasia of shoulder girdle muscles,omo-vertebral bone 30-50%,

Klippel-Feil syndrome




• Cosmetic problem

• Little or no functional limitation

• Glenohumeral instability reported in themdue to repeated capsular stretching to

compensate for limited scapl-th motion

A. mild no treatment, excise sup , scapulaB. severe: surgery



Sprengle’s 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 2ossification 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

shoulder problems presenting at birth

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