Forearm rotational profile in obstetric brachial plexus injury

Kinematic Effects of Derotational Osteotomy of the Humerus in Patients with Internal Shoulder Contracture Secondary to Erb's Palsy-A Retrospective Cohort Study

Background: Internal rotation contractures of the shoulder are common sequelae of conservatively treated obstetric brachial plexus palsy (OBPP) with incomplete spontaneous neurological recovery. Humerus derotation osteotomy has been suggested as a possible treatment option to improve arm positioning. However, consensus as to whether humerus derotation osteotomy can successfully restore limb function is missing. Methods: In the present controlled cohort study, we aimed at analyzing global upper extremity kinematics with a 3D-video analysis system in children with shoulder internal rotation contractures secondary to OBPP before, and one year after, humerus derotation osteotomy. Patients under 18 years of age that presented to our center with conservatively treated internal rotation contractures of the shoulder and subsequently underwent humerus derotation osteotomy were included. The unimpaired arm served as a respective control. Results: Pre-operatively, all patients showed severe internal rotation contractures of the shoulder of almost 60° at rest. At the follow-up, the position of the shoulder at rest was greatly shifted to 9° of internal rotation. The patients showed statistically significant improvement in maximum external rotation and abduction of the shoulder, as well as in maximum flexion of the elbow, and the range of motion of pro/supination. The maximum internal rotation of the shoulder, however, was diminished after the osteotomy. Conclusions: Our data indicated that derotational osteotomy is a promising procedure which can be used to correct for internal rotation contractures secondary to OBPP. Moreover, 3D-video analysis proved to be a useful tool that supplies the surgeon with both precise information about the degree of distortion pre-operatively, thus helping to decide on the amount of correction, and secondly, a measurement of the post-operative gain in upper extremity function.

Interrater reliability of face-to-face, tele- and video-based assessments with the modified Mallet classification in brachial plexus birth injuries

The modified Mallet classification is widely used to measure motor function in brachial plexus birth injuries. The aim of the study was to investigate agreement and reliability of this classification under three different evaluation conditions: face-to-face; live tele-assessment; and delayed video-based assessment. A total of 100 children aged 4-15 years were included. Children were assessed by two raters except for live tele-assessment, which was performed by four raters. Agreement between the three different assessment conditions for the same rater were between strong and excellent for both raters 1 and 2. The interrater reliability for raters 1 and 2 under different assessment conditions was strong to excellent. Interrater reliability among the four raters was moderate to strong in tele-assessment. The modified Mallet classification may have appropriate reliability to be used in remote medical follow-up.Level of evidence: III.

The Relationship Between Elbow Flexion Postures and Overhead Reaching in Birth Brachial Plexus Injuries

PURPOSE

The aim of this study was to investigate the effect of alterations in muscle length of the biceps in various elbow postures during shoulder elevation and muscle activation.

METHODS

Participants aged 5 years and older with a birth brachial plexus injury were asked to perform elevation shoulder (abduction and flexion) in 7 elbow conditions. Surface electromyography was applied to bilateral biceps and triceps.

RESULTS

Peak shoulder elevation was present in the immobilized 20° elbow posture. Muscle activity of the triceps and biceps was impacted by the elbow posture via immobilization.

CONCLUSIONS

Elbow postures in elongated postures, via immobilization, may result in higher shoulder elevation due to increased passive forces when there is an altered muscle state of the biceps in this population. Clinicians should consider the optimal elbow joint posture (<30°) to improve overhead reaching in this population.

Forearm Deformities in Birth Brachial Plexus Palsy - Patient Profile and Management Algorithm

Forearm deformities are often seen in children with severe birth brachial plexus palsy (BBPP). They may be either a supination or a pronation deformity and both hinder normal use of the hand and parents often request for corrective surgery. However, the correction of these deformities can be challenging due to a paucity of options. Also, there is less information in literature on the management of forearm deformities in BBPP compared to the information with regard to nerve surgery or correction of shoulder deformities. This article presents a synopsis of incidence, pathogenesis, clinical presentation and parental concerns related to these deformities. The decision-making considerations, management strategies and outcome expectations are also discussed. Patient selection is very crucial, and the treatment plan must be individualised depending on the disability, parental expectations and existing motor power in the involved limb. Correction of both the deformities have different considerations; however, effective correction of these deformities is immensely satisfactory to the patient/parents in terms of improved function and appearance of the limb. Level of Evidence: Level V (Therapeutic).

Outcomes of humeral osteotomies versus soft-tissue procedures in secondary surgical procedures for neonatal brachial plexus palsy: a meta-analysis

Secondary surgical procedures can be used in brachial plexus birth injury to correct shoulder movement imbalances. This study compares outcomes of the two secondary surgical procedure types: humeral osteotomies and soft tissue procedures. Outcome measures assessed included active and passive internal and external rotation, active and passive abduction and adduction, active and passive flexion and extension, percentage of the humeral head anterior to the middle glenoid fossa, glenoid version, and Mallet Score. Nineteen full-text articles were included in the analysis. Humeral osteotomies resulted in a loss of internal rotation postoperatively (-15.94°). Active internal rotation was not evaluated for soft tissue procedures. All other assessed outcomes were improved postoperatively for bony and soft tissue procedures. Bony procedures exhibited a greater degree of active external rotation postoperatively when compared to soft tissue procedures (+67° vs. +40°). Both bony and soft tissue procedures Improve shoulder function in children with neonatal brachial plexus palsy, however, soft tissue procedures showed greater consistency in outcomes. Level of Evidence: IV.

Natural history of elbow flexion and forearm rotation contractures in obstetric brachial plexus injury

A prospective database study was undertaken to investigate the severity and progression of elbow and forearm contractures in patients with obstetric brachial plexus injury. One-hundred and fifty-nine patients, who had not undergone nerve repair (mean age 12 years at last follow-up) (56 Narakas Group 1, 66 Group 2, 27 Group 3, 10 Group 4) were studied. Mean fixed flexion of the elbow at last follow-up was 13° for Group 1, 15° for Group 2, 19° for Group 3 and 24° for Group 4. Severe contracture of 30° or more developed in 31 children (mean age 118 months), with poorer active shoulder abduction being a significant risk factor. Onset of contracture was before the age of 5 years but did not increase substantially beyond 12 years. Active and passive pronation and supination tended to decrease with increasing injury severity. Seventeen children developed severe restriction of passive pronation (supination contracture) (mean age 69 months), and 12 developed severe restriction of passive supination at a mean of 137 months.Level of evidence: III.

'Switch' technique to restore pronation and radial deviation in 17 patients with brachial plexus birth palsy

We report outcomes of 17 children with brachial plexus birth palsy that underwent extensor carpi ulnaris to brachioradialis and brachioradialis to abductor pollicis longus transfers to correct supination and ulnar deviation deformity. Mean age at the time of surgery was 8.7 years and mean follow-up time was 21 months (8-44). These patients had marked increases in active forearm rotation and Canadian Occupational Performance Measure scores. Activity performance score on the measure increased from 1.1 to 6.7 and satisfaction score increased from 0.8 to 8.7 at final follow-up. We conclude from our patient series that these tendon transfers are effective in correction of the supination and ulnar deviation deformities in brachial plexus birth palsy. Level of evidence: IV.

Derotational Pronation-producing Osteotomy of the Radius and Biceps Tendon Rerouting for Supination Contractures in Neonatal Brachial Plexus Palsy Patients: A Review of 20 Cases

BACKGROUND

Forearm supination contractures can occur as a result of neurological derangement of the upper extremity in patients with neonatal brachial plexus birth palsy. The contractures become problematic in childhood as patients begin requiring forearm pronation for activities of daily living including typing on a keyboard and writing. There have been several techniques described to remedy this deformity. We present a case series describing the early clinical results of combined radial osteotomy and intraosseous biceps rerouting to realign the forearm in resting pronation and convert the biceps from a supinator to a pronator.

METHODS

A retrospective review identified patients who had a radial osteotomy and biceps rerouting for supination contracture between 2006 and 2016. Inclusion criteria required a fixed forearm supination contracture, patients below 18 years of age and at least 1 year of clinical and radiographic follow-up. Demographic and surgical variables, early clinical results, complications, reoperations, and revisions were documented.

RESULTS

Twenty patients were identified who met inclusion criteria. The mean follow-up was 3 years (range, 1 to 9 y). We observed a statistically significant difference in the mean resting position of the forearm from 56 degrees of supination preoperatively to 17 degrees of pronation postoperatively. Correspondingly, there was an increase in passive forearm pronation from 0 degree preoperatively to 66 degrees postoperatively and an expected decrease in passive forearm supination from 78 degrees preoperatively to 41 degrees postoperatively. There were 2 complications which were both radial osteotomy nonunions. Excluding revisions, there were 14 reoperations in 14 patients (63%) for hardware removal. Hardware removal was considered an expected return to the operating room, not an unplanned reoperation. There were 2 revisions for osteotomy nonunion, both of which went on to eventual union. Overall survivorship from the need for revision surgery was 95% at 12 months, 88% at 24 months, and 88% at 60 months. There were no recurrences of the supination contracture.

CONCLUSIONS

We present results of a novel surgical solution to forearm supination contractures through the combination of a derotational osteotomy of the radius and biceps tendon rerouting. The results show a significant benefit in forearm positioning and passive pronation with excellent survivorship and maintenance of correction.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Natural History of the Elbow Bony Architecture in Patients With Obstetric Brachial Plexus Injury and the Association With Flexion Contractures

PURPOSE

The purposes of this study were to evaluate the radiographic anatomy of the elbow and try to determine its possible relation to elbow flexion contracture in patients with obstetric brachial plexus injury (OBPI).

METHODS

All patients with a history of OBPI with elbow flexion contracture who were evaluated clinically and radiographically were included in the study. A review was performed to include serial elbow examinations and previous treatment. Radiographs of the elbow were examined for the presence of bony abnormalities as a potential cause of elbow flexion contracture or the presence of progressive arthritic changes over time.

RESULTS

Fifty-nine patients with a history of OBPI with elbow flexion contracture were included in the study. Of them, 53 had normal bony architecture, 2 had mild radial head subluxation, and 4 had chronic anterior radial head dislocations. At a mean age at final clinical follow-up of 21 years (range, 7 to 83 years), only 7% of patients had pain localized to their elbow. There were only three patients with elbow arthritis, including two of the four with radial head dislocations.

CONCLUSIONS

In the absence of a radial head dislocation, most elbow joints do not seem to undergo abnormal anatomic bony changes in patients with OBPI and flexion contractures.

LEVEL OF EVIDENCE

Level IV (retrospective case series).

Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy

OBJECTIVE The use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting. METHODS This retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year. RESULTS No significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups. CONCLUSIONS The preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.

Derotational Pronation-producing Osteotomy of the Radius and Biceps Tendon Rerouting for Supination Contractures in Neonatal Brachial Plexus Palsy Patients

Forearm supination contractures can occur as a result of neurological derangement of the upper extremity. Primarily, this is observed in patients with neonatal brachial plexus birth palsy. The contractures develop slowly over time and become problematic in childhood as the patients begin requiring forearm pronation for activities of daily living including typing on a keyboard and writing. Although supination contracture is a well-described sequelae of neonatal brachial plexus birth palsy, there is a paucity of literature describing techniques and outcomes for reconstruction and restoration of forearm pronation. The initially described technique included release of the interosseous membrane for flexibility combined with rerouting of part of the biceps tendon to change its biomechanical pull from supination to pronation. More recently, bone and soft tissue procedures have been combined with various forearm osteotomies. We present a combined derotational radial osteotomy and biceps rerouting to realign the forearm in resting pronation and convert the biceps from a supinator to a pronator. This novel surgical technique has not been described as a solution for supination contracture to restore pronation and provide biomechanical advantage of the biceps insertion.

The natural history of recovery of elbow flexion after obstetric brachial plexus injury managed without nerve repair

In this study, we report the outcome for spontaneous recovery of elbow flexion in obstetric brachial plexus injury managed without nerve reconstruction. Excluding those with transient paralysis, our records revealed 152 children with obstetric brachial plexus injury born before our unit routinely offered brachial plexus reconstruction. Five had had nerve repairs. Of the remainder, only one patient had insufficient flexion to reach their mouth. Elbow flexion started to recover clinically at a mean age of 4 months for Narakas Group 1, 6 months for Group 2, 8 months for Group 3 and 12 months for Group 4. The mean active range of elbow flexion, in 44 cases, was 138°. The mean isometric elbow flexion strength, in 39 patients, was 63% (range 23%-100%) of the normal side. It appears to be rare for elbow flexion not to recover spontaneously, although recovery occurs later in more severe injuries. It is doubtful if nerve reconstruction can improve elbow flexion above the likely spontaneous recovery in babies with obstetric brachial plexus injuries.

LEVEL OF EVIDENCE

II.

Significant improvement in nerve conduction, arm length, and upper extremity function after intraoperative electrical stimulation, neurolysis, and biceps tendon lengthening in obstetric brachial plexus patients

Background

Progressive loss of extension and concomitant bony deformity of the elbow are results of persistent biceps contracture in obstetric brachial plexus injury (OBPI) patients, if they do not fully recover. This adversely affects the growth and development and functions of the upper extremity.

Patients and method

We have performed biceps tendon lengthening (BTL) using a Z-plasty technique on OBPI patients aged 4 years to adulthood, who had been diagnosed with biceps tendon fixed flexion contractures. Ulnar, radial, and median nerve decompression was also performed at the same sitting. Somatosensory evoked potential (SSEP) monitoring was performed by stimulating the median and ulnar nerves at the wrist and the radial nerve over the dorsum of the hand and recording the peripheral, cervical, and cortical responses.

Seven children with obstetric brachial plexus palsy with an average age of 11 years (8.7–14.2 years) were included in this report. Mean follow-up time was 7.4 months (4–11 months). All the patients in this report had the elbow flexion contractures greater than 30°.

Results

Mean flexion contracture was 35° (30°–45°) preoperatively, which was improved to 0°–10° postoperatively with an average follow-up of 7 (4–11) months. This surgical procedure corrected the elbow flexion contractures, about an average of 25° and an improved length almost to normal, and improved the upper extremity functions. Neurophysiological data showed significant improvement in conduction of all three nerves tested after neurolysis. Further, median and radial nerve amplitude increase was statistically significant.

Conclusion

Statistically significant improvement in biceps length as well as nerve conduction was observed after the surgery. None of the children in our study lost biceps function, although weakness of the biceps is both a short- and long-term risk associated with biceps lengthening.

Treatment of supination deformity for obstetric brachial plexus injury: a systematic review and meta-analysis

PURPOSE

To conduct a systematic review and meta-analysis of the literature evaluating treatment outcome for supination deformity in obstetric brachial plexus injury.

METHODS

We included studies on brachial plexus and supination deformity with follow-up of at least one year and quantitative measurements of forearm mean passive pronation and position at rest. Meta-analysis was used to explore modifying factors.

RESULTS

An elaborate search strategy resulted in 366 studies, of which 13 were included totaling 238 patients (157 osteotomies and 71 biceps rerouting). There was a 75° gain in position at rest and a 65° gain in passive pronation for the osteotomy group, compared to a 79° gain in position at rest for the biceps rerouting group. More severe deformities had greater gains. No influence of age was found. Important adverse effects were hardware failure and a biceps rupture. Recurrence in the osteotomy group was 20% to 40%, versus none in the soft-tissue group.

CONCLUSIONS

This review showed an overall benefit for forearm osteotomies and for biceps rerouting for supination deformity with the gain proportionate to the severity of the deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

The prevalence, rate of progression, and treatment of elbow flexion contracture in children with brachial plexus birth palsy

BACKGROUND

Elbow flexion contracture is a well-known complication of brachial plexus birth palsy that adversely affects upper-extremity function. The prevalence, risk factors, and rate of progression of elbow flexion contracture associated with brachial plexus birth palsy have not been established, and the effectiveness of nonoperative treatment involving nighttime splinting or serial casting has not been well studied.

METHODS

The medical records of 319 patients with brachial plexus birth palsy who had been seen at our institution between 1992 and 2009 were retrospectively reviewed to identify patients with an elbow flexion contracture (≥10°). The chi-square test for trend and the Kaplan-Meier estimator were used to evaluate risk factors for contracture, including age, sex, and the extent of brachial plexus involvement. Longitudinal models were used to estimate the rate of contracture progression and the effectiveness of nonoperative treatment.

RESULTS

An elbow flexion contracture was present in 48% (152) of the patients with brachial plexus birth palsy. The median age of onset was 5.1 years (range, 0.25 to 14.8 years). The contracture was ≥30° in 36% (fifty-four) of these 152 patients and was accompanied by a documented radial head dislocation in 6% (nine). The prevalence of contracture increased with increasing age (p < 0.001) but was not significantly associated with sex or with the extent of brachial plexus involvement. The magnitude of the contracture increased by 4.4% per year before treatment (p < 0.01). The magnitude of the contracture decreased by 31% when casting was performed (p < 0.01) but thereafter increased again at the same rate of 4.4% per year. The magnitude of the contracture did not improve when splinting was performed but the rate of increase thereafter decreased to <0.1% per year (p = 0.04).

CONCLUSIONS

The prevalence of elbow flexion contracture in children with brachial plexus birth palsy may be greater than clinicians perceive. The prevalence increased with patient age but was not significantly affected by sex or by the extent of brachial plexus involvement. Serial casting may initially improve severe contractures, whereas nighttime splinting may prevent further progression of milder contractures.

Biceps brachii long head overactivity associated with elbow flexion contracture in brachial plexus birth palsy

BACKGROUND

The etiology of elbow flexion contracture in children with brachial plexus birth palsy remains unclear. We hypothesized that the long head of the biceps brachii muscle assists with shoulder stabilization in children with brachial plexus birth palsy and that overactivity of the long head during elbow and shoulder activity is associated with an elbow flexion contracture.

METHODS

Twenty-one patients with brachial plexus birth palsy-associated elbow flexion contracture underwent testing with surface electromyography. Twelve patients underwent repeat testing with fine-wire electromyography. Surface electrodes were placed on the muscle belly, and fine-wire electrodes were inserted bilaterally into the long and short heads of the biceps brachii. Patients were asked to perform four upper extremity tasks: elbow flexion-extension, hand to head, high reach, and overhead ball throw. The mean duration of muscle activity in the affected limb was compared with that in the contralateral, unaffected limb, which was used as a control. Three-dimensional motion analysis, surface dynamometry, and validated function measures were used to evaluate upper extremity kinematics, elbow flexor-extensor muscle imbalance, and function.

RESULTS

The mean activity duration of the long head of the biceps brachii muscle was significantly higher in the affected limb as compared with the contralateral, unaffected limb during hand-to-head tasks (p = 0.02) and high-reach tasks (p = 0.03). No significant differences in mean activity duration were observed for the short head of the biceps brachii muscle between the affected and unaffected limbs. Isometric strength of elbow flexion was not significantly higher than that of elbow extension in the affected limb (p = 0.11).

CONCLUSIONS

Overactivity of the long head of the biceps brachii muscle is associated with and may contribute to the development of elbow flexion contracture in children with brachial plexus birth palsy. Elbow flexion contracture may not be associated with an elbow flexor-extensor muscle imbalance, as previously hypothesized. The negative impact of elbow flexion contracture on upper extremity function warrants future research in the development of preventive and therapeutic techniques to address elbow flexion contractures in children with brachial plexus birth palsy.

Range of motion and strength after surgery for brachial plexus birth palsy

BACKGROUND

There is little information about the range of motion (ROM) and strength of the affected upper limbs of patients with permanent brachial plexus birth palsy.

PATIENTS AND METHODS

107 patients who had brachial plexus surgery in Finland between 1971 and 1998 were investigated in this population-based, cross-sectional, 12-year follow-up study. During the follow-up, 59 patients underwent secondary procedures. ROM and isometric strength of the shoulders, elbows, wrists, and thumbs were measured. Ratios for ROM and strength between the affected and unaffected sides were calculated.

RESULTS

61 patients (57%) had no active shoulder external rotation (median 0° (-75-90)). Median active abduction was 90° (1-170). Shoulder external rotation strength of the affected side was diminished (median ratio 28% (0-83)). Active elbow extension deficiency was recorded in 82 patients (median 25° (5-80)). Elbow flexion strength of the affected side was uniformly impaired (median ratio 43% (0-79)). Median active extension of the wrist was 55° (-70-90). The median ratio of grip strength for the affected side vs. the unaffected side was 68% (0-121). Patients with total injury had poorer ROM and strength than those with C5-6 injury. Incongruity of the radiohumeral joint and avulsion were associated with poor strength values.

INTERPRETATION

ROM and strength of affected upper limbs of patients with surgically treated brachial plexus birth palsy were reduced. Patients with avulsion injuries and/or consequent joint deformities fared worst.

Pronator teres transfer to correct pronation deformity of the forearm after an obstetrical brachial plexus injury

A pronation deformity of the forearm following an obstetric brachial plexus injury causes functional and cosmetic disability. We evaluated the results of pronator teres transfer to correct their deformity in 14 children treated over a period of four years. The mean age at surgery was 7.6 years (5 to 15). The indication for surgery in each case was impairment of active supination in a forearm that could be passively supinated provided that there was no medial contracture of the shoulder and normal function of the hand. The median follow-up was 20.4 months (8 to 42). No patient was lost to follow-up. Qualitative results were also assessed. The median active supination improved from 5 degrees (0 degrees to 10 degrees ) to 75 degrees (70 degrees to 80 degrees ) with no loss of pronation. A passively correctible pronation contracture can be corrected safely and effectively by the transfer of pronator teres.

The supination deformity and associated deformities of the upper limb in severe birth lesions of the brachial plexus

We reviewed 42 consecutive children with a supination deformity of the forearm complicating severe birth lesions of the brachial plexus.

The overall incidence over the study period was 6.9% (48 of 696). It was absent in those in Narakas group I (27.6) and occurred in 5.7% of group II (13 of 229), 9.6% of group III (11 of 114) and 23.4% of group IV (18 of 77).

Concurrent deformities at the shoulder, elbow, wrist and hand were always present because of muscular imbalance from poor recovery of C5 and C7, inconsistent recovery of C8 and T1 and good recovery of C6. Early surgical correction improved the function of the upper limb and hand, but there was a tendency to recurrence. Pronation osteotomy placed the hand in a functional position, and increased the arc of rotation of the forearm. The supination deformity recurred in 40% (17 of 42) of those treated by pronation osteotomy alone, probably because of remodelling of the growing bone.

Children should be followed up until skeletal maturity, and the parents counselled on the likelihood of multiple operations.

Arm rotated medially with supination - the ARMS variant: description of its surgical correction

BACKGROUND

Patients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SHEAR deformity commonly occurs in conjunction with Medial Rotation Contracture (MRC) of the arm. OBPI also causes muscle imbalances at the level of the forearm, that lead to a fixed supination deformity (SD) in a small number of patients. Both MRC and SD will cause severe functional limitations without surgical intervention.

METHODS

Fourteen OBPI patients were diagnosed with MRC of the shoulder and SD of the forearm along with SHEAR deformity during a 16 month study period, with eight patients available to long-term follow-up (age range 2.2 - 18 years). Surgical correction of the MRC was performed as a triangle tilt or humeral osteotomy depending on the age of the child, after which, the patients were treated with a radial osteotomy to correct the fixed supination deformity. Function was assessed using the modified Mallet scale, examination of apparent supination and appearance of the extremity at rest.

RESULTS

Significant functional improvements were observed in patients with surgical reconstruction. Mallet score increased by an average of 5.2 (p < 0.05). Overall forearm position was not significantly changed from an average of 5 degrees to an average of 34 degrees maximum apparent supination after both shoulder rotation and forearm rotation corrective surgeries.

CONCLUSION

The simultaneous presence of two opposing deformities in the same limb will visually offset each other at the level of the wrist and hand, giving the false impression of neutral positioning of the limb. In reality, the neutral-appearing position of the hand indicates a fixed supination posture of the forearm in the face of a medial rotation contracture of the shoulder. Both of these deformities require surgical attention, and the presence of concurrent MRC and SD should be monitored for in OBPI patients.