Brachial Plexus Birth Injury: US Screening for Glenohumeral Joint Instability

Pöyhiä, Tiina; Lamminen, Antti; Peltonen, Jari; Kirjavainen, Mikko; Willamo, Patrick; Nietosvaara, Yrjänä

doi:10.1148/radiol.09090570

Cited by 70 publications

(54 citation statements)

References 22 publications

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“…The important question of when to best identify infantile shoulder dislocations was addressed by Pöyhiä and colleagues 15 , who found posterior glenohumeral joint subluxation (defined as an alpha angle of >30°) in one-third of infants with permanent BPBP. In their study, 24 infants had shoulder ultrasound performed at 1, 3, 6, and 12 months of age; 5 of the 9 cases of glenohumeral joint subluxation were identified at 3 months of age and 8 of the 9, by 6 months of age.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound Screening for Posterior Shoulder Dislocation in Infants with Persistent Brachial Plexus Birth Palsy

Bauer

Lucas

Heyrani

et al. 2017

The Journal of Bone and Joint Surgery

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Background: Early detection of posterior shoulder dislocation in infants with brachial plexus birth palsy (BPBP) is essential, but it may be difficult to accomplish with physical examination alone. The aim of this study was to determine the prevalence of shoulder dislocation in patients with BPBP using ultrasound and to identify which physical examination measurements correlated most with dislocation in these patients. Methods: This study was a retrospective review of data obtained in an ultrasound screening program of infants with BPBP born from January 2011 to April 2014. Physical examination included the use of the Active Movement Scale (AMS) and measurement of passive external rotation of the shoulder. Ultrasound measurements included PHHD (percentage of the humeral head displaced posterior to the axis of the scapula) and the alpha angle (intersection of the posterior scapular margin with a line tangential to the humeral head through the glenoid). Shoulder dislocation was defined as both a PHHD of >0.5 and an alpha angle of >30°. Results: Of sixty-six infants who had undergone a total of 118 ultrasound examinations (mean, 1.8; range, 1 to 5), 19 (29%) demonstrated shoulder dislocation with the shoulder positioned in internal rotation; the dislocation was first detected between 2.1 and 10.5 months of age. Infants with a dislocated shoulder demonstrated significantly less mean passive external rotation in adduction (mean, 45.8° versus 71.4°, p < 0.001) and a greater difference between internal rotation and external rotation AMS scores (mean, 5.5-point versus 3.3-point difference, p < 0.001) than those without shoulder dislocation. Passive external rotation in adduction was a better measure for discriminating between dislocation and no dislocation (area under receiver operating characteristic curve [AUC] = 0.89) than was the difference between internal and external rotation AMS scores (AUC = 0.73). A cutoff of 60° of passive external rotation in adduction (≤60° versus° >60) yielded a sensitivity of 94% and a specificity of 69%. Conclusions: Shoulder dislocation is common in infants with BPBP; 29% of the infants presenting to our tertiary care center had a dislocation during their first year of life. Ultrasound shoulder screening is appropriate for infants with BPBP. If passive external rotation in adduction is used to determine which infants should undergo ultrasound, ≤60° should be utilized as the criterion to achieve appropriate sensitivity. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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Section: Discussionmentioning

confidence: 99%

Ultrasound Screening for Posterior Shoulder Dislocation in Infants with Persistent Brachial Plexus Birth Palsy

Bauer

Lucas

Heyrani

et al. 2017

The Journal of Bone and Joint Surgery

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“…Obstetrical Brachial Plexus Palsy (OBPP) is a common birth injury, occurring in approximately three in every 1000 births 3; 26; 29; 37 . Children who do not recover completely are left with shoulder muscle imbalance, contracture, disuse, and significant glenoid-humeral deformities 20; 24; 40; 41; 50 .…”

Section: Introductionmentioning

confidence: 99%

“…Two-dimensional (2D) glenoid retroversion and glenohumeral subluxation have been well studied in OBPP 10; 21; 23; 27; 34; 37 , but few studies have quantified humeral deformity in isolation. The studies that have focused on humeral pathology demonstrated atrophy 28; 37; 38 and “retroversion” on the involved side 46 .…”

Section: Introductionmentioning

confidence: 99%

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Three-dimensional humeral morphologic alterations and atrophy associated with obstetrical brachial plexus palsy

Sheehan

Brochard

Behnam

et al. 2014

Journal of Shoulder and Elbow Surgery

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Background Obstetrical Brachial Plexus Palsy (OBPP) is a common birth injury, resulting in severe functional losses. Yet, little is known about how OBPP affects the 3D humeral morphology. Thus, the purpose of this study was to measure the 3D humeral architecture in children with unilateral OBPP. Methods Thirteen individuals (4F/9M, age=11.8±3.3 years, Mallet score=15.1±3.0) participated in this IRB-approved study. A three-dimensional T1-weighted gradient-recalled-echo magnet resonance image set was acquired for both upper limbs (involved/non-involved). Humeral size, version, and inclination were quantified from 3D humeral models derived from these images. Results The involved humeral head was significantly less retroverted and in declination (medial humeral head pointed anteriorly and inferiorly), relative to the non-involved side. Osseous atrophy was present in all three dimensions and affected the entire humerus. The inter-rater reliability was excellent (ICC = 0.96–1.00). Discussion This study demonstrated that both humeral atrophy and bone shape deformities associated with OBPP are not limited to the axial plane, but are three-dimensional phenomena. Incorporating information related to these multiplanar, 3D, humeral deformities into surgical planning could potentially improve functional outcomes following surgery. The documented reduction in retroversion is an osseous adaptation, which may help maintain glenohumeral congruency by partially compensating for the internal rotation of the arm. The humeral head declination is a novel finding and may be an important factor to consider when developing OBPP management strategies, as it has been shown to lead to significant supraspinatus inefficiencies and increased required elevation forces. Level of evidence Anatomic Study, Imaging

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“…Ultrasound has previously been reported as a useful tool in screening for instability in this joint. 13 Longstanding muscle imbalances in the shoulder girdle can result in progressive glenohumeral joint deformity and joint dysplasia. Patients can also develop functionally limiting internal rotation contractures that require subsequent surgical intervention.…”

Section: Discussionmentioning

confidence: 99%

Ultrasonography for neonatal brachial plexus palsy

Joseph¹,

DiPietro

Somashekar

et al. 2014

PED

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Ultrasonography has previously been reported for use in the evaluation of compressive or traumatic peripheral nerve pathology and for its utility in preoperative mapping. However, these studies were not performed in infants, and they were not focused on the brachial plexus. The authors report a case in which ultrasonography was used to improve operative management of neonatal brachial plexus palsy (NBPP). An infant boy was born at term, complicated by right-sided shoulder dystocia. Initial clinical evaluation revealed proximal arm weakness consistent with an upper trunk injury. Unlike MRI or CT myelography that focus on proximal nerve roots, ultrasonography of the brachial plexus in the supraclavicular fossa was able to demonstrate a small neuroma involving the upper trunk (C-5 and C-6) and no asymmetry in movement of the diaphragm or in the appearance of the rhomboid muscle when compared with the unaffected side. However, the supra- and infraspinatus muscles were significantly asymmetrical and atrophied on the affected side. Importantly, ultrasound examination of the shoulder revealed posterior glenohumeral laxity. Instead of pursuing the primary nerve reconstruction first, timely treatment of the shoulder subluxation prevented formation of joint dysplasia and formation of a false glenoid, which is a common sequela of this condition. Because the muscles innervated by proximal branches of the cervical nerve roots/trunks were radiographically normal, subsequent nerve transfers were performed and good functional results were achieved. The authors believe this to be the first report describing the utility of ultrasonography in the surgical treatment planning in a case of NBPP. Noninvasive imaging, in addition to thorough history and physical examination, reduces the intraoperative time required to determine the extent and severity of nerve injury by allowing improved preoperative planning of the surgical strategy. Inclusion of ultrasonography as a preoperative modality may yield improved outcomes for children with NBPP.

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Brachial Plexus Birth Injury: US Screening for Glenohumeral Joint Instability

Abstract: US is a fast and useful tool for diagnosis of posterior subluxation of the humeral head, and examination of the glenohumeral joint should be performed at 3 and 6 months of age in infants with BPBI if symptoms persist.

Cited by 70 publications

References 22 publications

Ultrasound Screening for Posterior Shoulder Dislocation in Infants with Persistent Brachial Plexus Birth Palsy

Ultrasound Screening for Posterior Shoulder Dislocation in Infants with Persistent Brachial Plexus Birth Palsy

Three-dimensional humeral morphologic alterations and atrophy associated with obstetrical brachial plexus palsy

Ultrasonography for neonatal brachial plexus palsy

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