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Subcoracoid Impingement is a Variant of Thoracic Outlet Syndrome Found in Neonatal Brachial Plexus Palsy
Kevin J. Little, MD; Charles T. Mehlman, DO, MPH; Linda Michaud, MD; Cincinnati Children's Hospital, University of Cincinnati
Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
Introduction: Shoulder pain as a result of Neonatal Brachial Plexus Palsy (NBPP) is poorly understood and difficult to treat. Abnormal scapular posture and mechanics can lead to inferior pressure of the coracoid onto the cords of the brachial plexus, leading to generalized shoulder ache or pain, numbness, tingling, and/or early fatigue. The purpose of this study is to define a subset of patients with pain symptoms similar to thoracic outlet syndrome (TOS) due to subcoracoid impingement and their subsequent treatment. Materials & Methods: We retrospectively reviewed 9 consecutive patients with NBPP and complaints of shoulder pain consistent with subcoracoid impingement who were treated with Pectoralis Minor release (PMR) from the coracoid. All patients had a Putti sign, positive evocative impingement tests related to the brachial plexus and were diagnosed with subcoracoid impingement prior to surgical intervention. Patient demographics, surgical procedures, VAS pain scores, Mallet scale, Narakas grade and active and passive ROM measurements were tabulated from prospectively collected data and analyzed with Mann-Whitney test with significance set at P<0.05. Results: The average age of patients was 10.3 years, and all were Narakas I(6) or II(3). Subcoracoid impingement presented as chronic discomfort about the shoulder with generalized aching pain in 7/9 worse with carrying in 5/9, numbness and tingling in 6/9 and shoulder fatigue in 1/9. PMR was performed alone in one patient, or was combined with arthroscopic anterior release (2), arthroscopic release and Latissimus Dorsi and/or Teres Major tendon transfer (4), or humeral external rotation osteotomy (4). At average 17 month follow up (7-39), VAS pain scores improved 1.5 points (p=0.029) and complete relief of symptoms was noted in 7/9 patients, with significant improvement noted in the remaining 2(p<0.001). The Putti sign was resolved in 6/9 patients and improved in 3/9 patients (p<0.001). No patient demonstrated worsening shoulder function based on Mallet scale and ROM measurements, but no firm conclusions can be drawn due to the heterogeneity of the surgical procedures. Conclusion: Shoulder pain in NBPP should be carefully evaluated and treated as a part of the global management for these patients and can significantly improve patient satisfaction. Subcoracoid impingement is a variation of TOS that can be seen in patients with NBPP and is diagnosed based on history and physical examination findings. Abnormal pressure of the coracoid can be alleviated with release of the Pectoralis Minor tendon through a 1 cm anterior incision without apparent loss of shoulder function.
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