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Serial external rotation shoulder spica cast application: A novel treatment for fixed internal rotation contractures/shoulder dysplasia in patients with brachial plexus birth injuries
Yvette Elias, OT/L, CHT1, Aaron J Berger, MD, PhD2, Verena M. Schreiber, MD1 and Weston Thomas, PA-C1, (1)Nicklaus Children's Hospital, Miami, FL, (2)Division of Plastic and Reconstructive Surgery, Nicklaus Children's Hospital, Miami, FL

Introduction:
Despite spontaneous recovery in many patients with brachial plexus birth injury (BPBI), permanent shoulder deformities may develop that limit ultimate function.

Internal rotation contracture of the shoulder frequently develops that contributes to posterior subluxation--and in severe cases, dislocation--of the humeral head. Prevention and treatment of glenohumeral deformity is varied, including intensive therapy, complex splinting, botulinum toxin (Botox) administration, and surgical intervention in the form of muscle/tendon lengthening/release, tendon transfers and/or humeral osteotomy.

Shoulder spica cast immobilization is widely utilized to maintain glenohumeral joint reduction after secondary muscle and tendon procedures for shoulder dysplasia. Previous studies have shown that Botox injection into the internal rotator muscles of the shoulder and immobilization of the shoulder in an external rotation shoulder spica cast decreases the severity of internal rotation contractures and possibly prevents glenohumeral deformity in children with BPBI.

We seek to describe our experience with serial external rotation cast immobilization in combination with Botulinum toxin administration for treatment and prevention of fixed internal rotation contractures, as well as associated posterior subluxation/dislocation, of the glenohumeral joint.

Methods:
We retrospectively reviewed the outcome of serial external rotation cast application in 5 patients with fixed internal rotation contractures after BPBI.
Age at initiation of treatment was 16 months - 3 years.
Shoulder passive external rotation in adduction and Active Movement Scale external rotation scores were recorded before and after treatment.
The initial cast was applied in maximal adduction and maximal external rotation for four to six weeks. Two-four weeks after administration of Botox, the strut/bar on the cast was cut and the shoulder was placed into maximal external rotation with application of a longer strut/bar.

Results:
In all 5 patients, the initially fixed internal rotation contracture was fully corrected, and passive external rotation was achieved to 90 degrees. Imaging, when performed, also demonstrated reduction of the glenohumeral joint and improvement in the shape of the glenoid and humeral head.

Conclusions:
Serial external rotation cast application, combined with Botox injection, improves internal rotation contractures due to BPBI and allows for reduction of shoulder subluxation/dislocation. We believe that this technique should be attempted for fixed internal rotation contractures prior to performing open approaches for reduction of shoulder subluxation/dislocation.


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