Dr. Marisa Osorio

Dr. Marisa Osorio presents a case of brachial plexus palsy (BPP), associated glenohumeral dysplasia and treatment intervention.

For more general information, read about brachial plexus palsy.

Patient History

This is a 4-week-old baby boy who was seen in the Brachial Plexus Clinic for a right brachial plexus injury at birth. He was born 8 pounds, 15 ounces and had shoulder dystocia during delivery. At birth he was noted to have only finger movement. Slowly, he began to have more wrist and finger movement. His shoulder had normal range of motion, but there was prominence of the humeral head when the arm was held in internal rotation. This easily reduced when the shoulder was externally rotated.

When this baby was seen back in clinic at 3 months of age, he had more recovery of function, and he was abducting the shoulder and flexing at the elbow to bring his hand to his mouth. However, his shoulder was limited to 45 degrees of passive external rotation with prominence of the humeral head.

Imaging

Ultrasound

Ultrasound of the shoulder at 3 months of age showed nearly full dislocation of the humeral head and glenohumeral dysplasia.

Discussion

Glenohumeral dysplasia is a well-recognized phenomenon in older children with birth BPP, but recent evidence shows glenohumeral dysplasia is occurring at a very young age. These abnormal changes in the glenohumeral joint morphology over time impact recovery and function in this population.

In birth brachial plexus injuries, the shoulder internal rotators are generally unaffected and very strong, whereas the external rotators are weak. This muscle imbalance contributes to posterior shoulder joint subluxation and glenohumeral dysplasia. Magnetic resonance imaging (MRI) has been the gold standard for diagnosis of glenohumeral dysplasia in older children with BPP. More recently, principles of ultrasound examination for hip dysplasia have been applied to examination of the shoulder in infants. Use of minimally invasive ultrasound has allowed for early diagnosis and subsequent treatment of shoulder subluxation and glenohumeral dysplasia in infants with BPP.

Treatment

Child Treatment

This child was taken to the operating room for closed reduction of the glenohumeral joint and botulinum toxin injections to the shoulder internal rotators to weaken the pull of these muscles. He was placed in a shoulder spica cast for 6 weeks to maintain the reduction.

Outcome

Repeat Ultrasound

Repeat ultrasound of the shoulder following cast removal revealed successful reduction of the glenohumeral joint.

With casting completed, this child resumed physical therapy with a daily home stretching program. He was seen at 6 months of age and was maintaining full passive range of motion at the shoulder. He had some active external rotation at the shoulder and demonstrated good shoulder abduction and elbow flexion. He will continue to receive routine follow-up in the Brachial Plexus Clinic with monitoring of his range of motion and strength over time.

References

  1. Van Der Sluijs JA, Van Ouwerkerk WJR, Manoliu RA et al. Secondary deformities of the shoulder in infants with obstetrical brachial plexus lesions considered for neurosurgical treatment. Neurosurg Focus. 2004;16(5):1-5.
  2. Moukoko D, Ezaki M, Wilkes D et al. Posterior shoulder dislocation in infants with neonatal brachial plexus palsy. J Bone Joint Surg Am. 2004;86:787-793.
  3. Zhang S, Ezaki M. Sonography as a preferred diagnostic tool to assess shoulder displacement in brachial plexus palsy. J Diag Med Sonogr. 2008;24:330-343.
  4. Grissom LE, Harcke HT. Infant shoulder sonography: technique, anatomy, and pathology. Pediatr Radiol. 2001;31:863-868.
  5. Ezaki M, Malungpaishrope K, Harrison R et al. Onabotulinumtoxin A injection as an adjunct in the treatment of posterior shoulder subluxation in neonatal brachial plexus palsy. J Bone Joint Surg Am. 2010;92:2171-2177.

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