Manipulation Under Anesthesia to Treat Persistent Internal Rotation Contracture of the Shoulder in Children with Obstetric Brachial Plexus Palsy.
Ramy El-Nakeeb, MD, Damanhour Medical Institute, Damanhour, Egypt
Internal rotation contracture of the shoulder is the most common sequelae requiring treatment in patients with obstetrical brachial plexus palsy (OBPP). Physical therapy, home exercise programs, Botulinum toxin injections and surgical release of contracture aim to preserving passive range of motion which keeps the humeral head in its normally centered position and prevents secondary deformities.
Materials & Methods
The aim of this study was to evaluate the results of manipulation of the shoulder under anesthesia in children with persistent contracture despite the continued physiotherapy programs. These children were evaluated for 2 main aspects, persistence of gained passive external rotation overtime and internal rotation power which is mostly affected in cases with surgical release.
Nine children were evaluated for active external rotation, passive external rotation and active internal rotation before and after manipulation. Plain x ray (AP, Axillary and lateral view) was done to evaluate shoulder deformity; posterior subluxation was not a contraindication to manipulation. Under anesthesia gradual slow passive external rotation force was applied to the shoulder with the arm at the side and in 90 degrees of abduction followed by shoulder spica cast for 6 weeks. The cast is applied in 200 to 300 abduction and in maximum external rotation achieved.
The mean follow-up period was 14.5 months (range, 6-27 months)., the mean passive external rotation increased from -12.7° (range 0° to -300) before manipulation to 40.5° (range, -10° to 70° degrees) at the final follow-up. Before manipulation all children could bring their hands to their abdomen and press against the examiner's hand except 2 children. At the final follow up there were no apparent loss of internal rotation power in any child.
The major advantage of manipulation under anesthesia is that it is a minor procedure that restores passive external rotation while not affecting internal rotation power. The gained degree of external rotation must be maintained by passive stretching exercises in children who do not have active external rotation yet or by muscle transfer in older children. Adding this procedure to our armamentarium to manage shoulder deformities may avoid more complicated procedures later on.
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