The medial surgical approach to the humerus

The evaluation and treatment of children with brachial plexus birth palsy

The Andrew J. Weiland Medal is presented by the American Society for Surgery of the Hand to a mid-career researcher dedicated to advancing patient care in the field of hand surgery. The Weiland Medal for 2010 was presented to the author at the annual meeting of the American Society for Surgery of the Hand. The purpose of this article is to present a decade of research directed at establishing and building evidence in support of effective treatment of adolescents and children impaired by nerve injury. The primary beneficiaries of this effort are children affected by brachial plexus injury. The research goals have been to better understand their underlying problems, improve their lives via advanced diagnostic and surgical techniques, and, by applying appropriate outcome measures, better appreciate the changes to their lives brought about by therapeutic interventions.

Shoulder function after medial approach and derotational humeral osteotomy in patients with brachial plexus birth palsy

BACKGROUND

The purpose of this study was to assess outcome after rotational humeral osteotomies, using a medial approach, in children with brachial plexus birth palsy.

METHODS

A retrospective review of children with brachial plexus birth palsy who underwent external rotational humeral osteotomies, using a medial approach, for the treatment of internal rotation contractures was performed. Presurgical and postsurgical range of motion, standard Mallet, and modified Mallet scores were recorded. The traditional Mallet score was modified to include a sixth subscale that further evaluated internal rotation. This was assessed by having the patients' attempts to place their palm flat on their naval.

RESULTS

Twenty-three children underwent external rotational humeral osteotomies. The mean rotational correction achieved during the procedure was 43.2+/-11.6 degrees (range: 20-70 degrees). The mean preoperative standard aggregate Mallet score was 13.8+/-2.8 and the mean postoperative score was 16.1+/-2.5 (P=0.002). When the additional internal rotation scale was added into the score, the mean preoperative aggregate score was 18.0+/-2.1 and the mean postoperative score was 19.5+/-2.8 (P=0.032). Further analysis revealed a statistically significant improvement (P<0.05) in external rotation, hand to neck, and hand to mouth functions. Internal rotation was decreased as represented by statistically significant decreases in hand to spine and hand to belly (P<0.05).

CONCLUSIONS

Rotational humeral osteotomies can be performed safely and effectively using a medial approach. These osteotomies significantly improve activities associated with external rotation. However, the degree of external rotation must be carefully balanced against the loss of internal rotation, which would impede midline function. The addition of a sixth subscale to the Mallet score that assesses hand to belly provides more clinically relevant information regarding midline function than hand to spine.

LEVEL OF EVIDENCE

This is a Level IV study.

A lateral approach to the distal humerus following identification of the cutaneous branches of the radial nerve

We describe a lateral approach to the distal humerus based on initial location of the superficial branches of the radial nerve, the inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm. In 18 upper limbs the superficial branches of the radial nerve were located in the subcutaneous tissue between the triceps and brachioradialis muscles and dissected proximally to their origin from the radial nerve, exposing the shaft of the humerus. The inferior lateral cutaneous nerve of the arm arose from the radial nerve at the lower part of the spiral groove, at a mean of 14.2 cm proximal to the lateral epicondyle. The posterior cutaneous nerve of the forearm arose from the inferior lateral cutaneous nerve at a mean of 6.9 cm (6.0 to 8.1) proximal to the lateral epicondyle and descended vertically along the dorsal aspect of the forearm. The size and constant site of emergence between the triceps and brachioradialis muscles constitute a readily identifiable landmark to explore the radial nerve and expose the humeral shaft.