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 Table of Contents  
Year : 2020  |  Volume : 18  |  Issue : 3  |  Page : 254-260

Open subscapularis release for treatment of internal rotation shoulder contracture in obstetric brachial plexus palsy

Departments of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Submission17-May-2020
Date of Decision18-Jun-2020
Date of Acceptance07-Jul-2020
Date of Web Publication30-Oct-2020

Correspondence Address:
Ahmed Abdelkreem Ahmed
Gmal Abdelnasr Street, 6th of October City, Giza 12566
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AZMJ.AZMJ_80_20

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Background One of the most common deformities that results from untreated obstetric brachial plexus palsy (OBPP) is internal rotation shoulder contracture. There are various surgical options for treating this deformity such as muscle release, tendon transfer, and humeral osteotomy.
Objective This study expresses the outcome of isolated subscapularis release performed in children with internal rotation shoulder contracture as a consequence of unresolved OBPP.
Patients and methods This prospective case series study was conducted in Al Azhar University Hospitals between April 2018 and January 2020. A total of 20 patients aged between 2 and 5 years (mean: 3.2 years) with internal rotation contracture of shoulder residual deformity from OBPP were included. Of the 20 patients, eight were males and 12 were females, and 12 patients were operated on right side and eight were operated on left side, and they were followed up for a period of at least 1 year.
Results The mean abduction improved from 61.0±14.1° preoperatively to 103.0±15.25° postoperatively, the mean passive external rotation in adduction improved from −9.5±11.4° preoperatively to 30.5±11.91° postoperatively, the mean active external rotation in abduction improved from 0.5±8.26 preoperatively to 60.25±10.57 postoperatively, and the mean modified mallet score improved from 12.60±1.09 preoperatively to 17.70±1.17 postoperatively.
Conclusion Open subscapularis muscle release is a proper starting surgical option in children who present with internal rotation adduction contracture of the shoulder owing to unresolved OBPP.

Keywords: contracture, subscapularis release, obstetric brachial plexus palsy

How to cite this article:
Zayed FH, Hamouda IA, Ahmed AA. Open subscapularis release for treatment of internal rotation shoulder contracture in obstetric brachial plexus palsy. Al-Azhar Assiut Med J 2020;18:254-60

How to cite this URL:
Zayed FH, Hamouda IA, Ahmed AA. Open subscapularis release for treatment of internal rotation shoulder contracture in obstetric brachial plexus palsy. Al-Azhar Assiut Med J [serial online] 2020 [cited 2023 Apr 1];18:254-60. Available from: http://www.azmj.eg.net/text.asp?2020/18/3/254/299582

  Introduction Top

Obstetric brachial plexus palsy (OBPP) is caused by excessive traction to the brachial plexus during difficult delivery. Most of the patients (about 60% of them) recover without intervention, whereas others gain some sort of functional impairment [1]. C5 and c6 are considered most common affected roots in OBPP, and if not resolved, this affection will lead to internal rotation-adduction contracture of the shoulder [2].

Unopposed force of internal rotator muscles of the shoulder and weakness of external rotator of the shoulder and deltoid lead to adduction and internal rotation contracture of the shoulder, which are considered the most important secondary deformity in unresolved upper plexus injury, and this deformity may appear early in life [3].

Rotator cuff muscles play an important role in stabilization of shoulder joint; three of them insert on greater tuberosity while subscapularis muscle insert on lesser tuberosity. Shoulder external rotators (teres minor and infraspinatus) are weaker than internal rotator (pectoralis major, latissimus dorsi, teres major, and subscapularis) [4].

There are multiple surgical procedures for the treatment of adduction internal rotation shoulder contracture as in severe operation in which anterior release of internal rotators and adductors muscles of the shoulder was done [5]. Then L’Episcopo added to this operation latissimus dorsi and teres major tendon transfer to the lateral aspect of the humerus that gave better results [6], Later Hoffer suggested another modification is that transferring the latissimus dorsi and teres major to the rotator cuff [7],[8].

One of the indications that requires subscapularis muscle release with or without teres major and latissimus dorsi tendon transfer to the greater tuberosity of the humerus is defect in passive external rotation movement of the shoulder [9].

  Patients and methods Top

This prospective study included 20 patients with OBPP who went through release of subscapularis muscle at Al-Azhar University Hospitals. All the patient’s parents were required to hand over a written consent, and approval of the Ethical Committee was taken. This study was conducted between April 2018 and January 2020.

Inclusion criteria

The following were the inclusion criteria:
  1. Children with Erb’s palsy who presented with adduction (active abduction <90°, active external rotation at 90° abduction <20°) and internal rotation (passive external rotation at adduction <10°) shoulder contracture.
  2. Age from 2 to 5 years.

Exclusion criteria

The following were the exclusion criteria:
  1. Children with Erb’s palsy associated with other anomalies such as cerebral palsy.
  2. Age of patient less than 2 years or more than 5 years.
  3. Patients with history of previous operation for Erb’s palsy.
  4. Patients with passive external rotation more than 10°.
  5. Other paralytic conditions.
  6. Poor hand function.

Preoperative evaluation

All patients were evaluated preoperatively clinically to record range of motion (ROM) of active abduction, active external rotation in abduction, passive external rotation in adduction, and modified Mallet score.

The modified Mallet classification system

The modified Mallet classification system ([Figure 1]) classifies the actions of the upper limb mainly at shoulder and elbow to five actions, which are global abduction of the arm, global external rotation of the arm, putting the hand at back of head, touching back by hand, and touching the mouth by the hand. It predominantly reflects the integrity of the C5 and C6 roots and the upper trunk of the brachial plexus [10].
Figure 1 The modified Mallet classification of shoulder function. Patients were asked to perform actively five different shoulder movements: abduction, external rotation, placing the hand behind the neck, placing the hand as high as possible on the spine, and placing the hand to the mouth. Each shoulder movement is subsequently graded on a scale of I (no movement) to V (normal motion symmetric to the contralateral, unaffected side) [11].

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Surgical technique

Patients are positioned in supine position on the operating table, putting a small support under the scapula of the operated side. The whole operated upper limb with chest should be prepared and become easily acceptable. Before starting our operation, we assessed the affected side after anesthesia by examination of internal rotation contracture of the shoulder and external rotation of the arm, either arm in adduction or 90 abduction ([Figure 2]); this examination helps to determine the desired amount of external rotation from subscapularis release.
Figure 2 Passive external rotation under anesthesia (a) in adduction; (b) in abduction.

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A deltopectoral incision was made from the tip of coracoid process proximally to a point distal to tendinous insertion of pectoralis major. With a blunt dissection, the interval between the deltoid and pectoralis major is developed, followed by retraction of the anterior margin of deltoid laterally and the pectoralis major medially. The cephalic vein is identified and retracted laterally. The coracoid was exposed, and identification of the coracobrachialis muscle and short head of biceps muscle is done, and then retract them medially. Now, a tendinous part of subscapularis would be visible. A step-cut lengthening of the subscapularis tendon was made, leaving the medially based flap superior ([Figure 3]). The underlying shoulder capsule should be protected. We put the arm in 90° abduction and external rotation position when we stitched subscapularis tendon, and then closure of subcutaneous tissue and skin was done. We put the patient’s arm in a cast connected to a body corset to keep the shoulder in abduction external rotation position ([Figure 4]a). The cast was removed after 4 weeks.
Figure 3 Schematic drawing of the surgical procedure: Z lengthening of the subscapularis tendon [12].

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Figure 4 Postoperative. (a) Cast, (b) night splint.

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Postoperative rehabilitation

Each child underwent a postoperative physiotherapy program immediately after cast removal. This consisted of two sessions weekly, for 3 months. In these sessions, physiotherapist work on improving active and passive ROM of the shoulder joint, and also they should instruct parents some exercises to stretch muscles of the shoulder joint, which have to be done for half an hour daily. Patients were immobilized at night by abduction external rotation splint ([Figure 4]b) for 4 weeks.

Statistical analysis

Data were analyzed using Statistical Program for the Social Sciences version 15.0 (IBM SPSS Inc., Chicago, USA). Quantitative data were expressed as mean±SD. Qualitative data were expressed as frequency and percentage. The following tests were done:
  1. Paired t test of significance: was used when comparing between two means.
  2. P values were:
    1. P value less than 0.05 was considered significant.
    2. P value less than 0.001 was considered as highly significant.
    3. P value greater than 0.05 was considered insignificant.

  Results Top

This study included 20 patients with internal rotation shoulder contracture owing to OBPP operated with subscapularis release. [Table 1] demonstrates the demographic data in studied patients. Postoperative functional outcomes were measured according to active external rotation in abduction, passive external rotation in adduction, abduction, and modified Mallet score at least 1 year postoperative. [Figure 5] shows preoperative and 1-year postoperative ROM.
Table 1 Description of demographic data in studied patients.

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Figure 5 Preoperative limited range of motion (a) active ER (b) hand to mouth, postoperative increase range of motion (c) active ER (d) hand to mouth.

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[Table 2] and [Table 3] summarize the results of our study.
Table 2 Preoperative and postoperative range of motion and modified mallet score

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Table 3 Correlation study between age and postoperative assessment in studied patients

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  Discussion Top

The research studies regarding the results of subscapularis muscle release for treatment of late sequelae of OBPP are not enough, considering the fact that this operation is one among many other operations that have been used since approximately one hundred years ago [2],[13].

Our study shows good results after subscapularis muscle release operation, mainly in abduction and active external rotation in abduction, passive external rotation in adduction, and Mallet score.

Our results are similar to those reported by Naoum et al. [2], Newman et al. [13], and Chen et al. [14].

Naoum et al. [2] reported that treatment of internal rotation adduction contracture due to OBPP could be achieved easily and efficiently by performing subscapularis muscle release, and this leads to improvement in both active abduction and external rotation.

Newman et al. [13] reported that valuable increase in ROM of the shoulder was achieved in patients with unresolved OBPP who underwent subscapularis release and followed by good rehabilitation.

Similarly, Chen et al. [14] reported marked changes in movements of shoulder according to Mallet score, despite the average period of follow-up for patients being less than 12 months.

Regarding the suitable age of patients at surgery, there is no evidence about that, but the common choice now to prevent glenohumeral deformities is to perform shoulder surgery early [12],[15].

We found a statistically significant negative correlation between age and postoperative ROM and modified Mallet score.

In this study, significant improvement of shoulder function can be reached in children by subscapularis muscle release, which are performed before the glenohumeral deformities occur.

The first authors who described the relation between age of patients and postoperative results of operation were Gilbert et al. [16] who showed good results for children operated in age less than 2 years compared with children older than 4 years.

No remarkable difference between the younger and older age groups regarding postoperative results was reported by Newman et al. [13]; this may be owing to small sample size.

This study addresses the treatment of internal rotation contracture of the shoulder by performing subscapularis muscle release. The pool of patients consisted of eight boys and 12 girls; 12 patients had right extremity involvement, whereas the remainder eight patients had involvement of the left extremity, and there was no bilateral involvement ([Table 1]).

In our study, two patients of 20 patients have cosmetically bad scar but not causing any functional problem.

Our study was limited by the short follow-up and small sample size owing to the low incidence of OBPP and increased rate of early microsurgical intervention.

Study strength is that we focused on a single procedure (subscapularis lengthening) instead of multiple procedures (subscapularis lengthening plus tendon transfer), which means our results are absolutely correlated with this procedure.

  Conclusion Top

It could be concluded that subscapularis muscle release is an efficient operation that could be a primary procedure to alleviate internal rotation contracture of the shoulder owing to unresolved OBPP with normal glenohumeral joint. It increases the ROM of the shoulder regarding external rotation and abduction. In our experience, it is an easy operation with little adverse effects that provides great possibility of significant clinical improvement.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Pondaag W, Malessy MJA, Van Dijk JG, Thomeer RTW. Natural history of obstetric brachial plexus palsy: a systematic review. Dev Med Child Neurol 2007; 46:138–144.  Back to cited text no. 1
Naoum E, Saghbini E, Melhem E, Ghanem I. Proximal subscapularis release for the treatment of adduction–internal rotation shoulder contracture in obstetric brachial plexus palsy, J Child Orthop 2015; 9:339–344.  Back to cited text no. 2
Moukoko D, Ezaki M, Wilkes D, Carter P. Posterior shoulder dislocation in infants with neonatal brachial plexus palsy. J Bone Joint Surg 2004;86-A: 787–793.  Back to cited text no. 3
Winston G Jr, Tyrrell Burrus M. Anatomy chapter of Miller’s review of orthopedics by Mark DM and Thompson SR. Philadelphia, PA: Elsevier. 7th ed. 2016. 160–277.  Back to cited text no. 4
Clarke HM, Curtis CG. An approach to obstetrical brachial plexus injuries. Hand Clin 1995; 11:563–580.  Back to cited text no. 5
L’Episcopo J. Tendon transplantation obstetrical paralysis. Am J Surg 1934; 25:122–125.  Back to cited text no. 6
Hoffer MM, Wickenden R, Roper B. Brachial plexus birth palsies. Results of tendon transfers to the rotator cuff. J Bone Joint Surg Am 1978; 60:691–695.  Back to cited text no. 7
Elkady R, Fekry H. Treatment of posterior shoulder dislocation in obstetric brachial plexus palsy using subscapularis release and tendon transfer. Am Res J Orthop Traumatol 2017; 2:1.  Back to cited text no. 8
Cohen G, Rampal V, Cohen F, Seringe R, Wicart P. Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer. Orthop Traumatol Surg Res 2010; 96:334–339.  Back to cited text no. 9
Piatt JH. Birth injuries of the brachial plexus. Pediatr Clin N Am 2004; 51:421–440.  Back to cited text no. 10
Mallet J. Primaute du traitement de l’épaule—méthoded éxpression des résultats. Rev Chir Orthop Reparatrice Appar Mot 1972; 58S:166–168.  Back to cited text no. 11
Kruit A, Choukairi F, Jester A. Subscapularis Z lengthening in children with brachial plexus birth palsy loses efficiency at midterm follow-up: a retrospective cohort study. Int Orthop 2016; 40:783–790.  Back to cited text no. 12
Newman CJ, Morrison L, XXXX PT, Lynch B, Hynes D. Outcome of subscapularis muscle release for shoulder contracture secondary to brachial plexus palsy at birth. J Pediatr Orthop 2006; 26:647–651.  Back to cited text no. 13
Chen L, Gu Y, Xu J. Operative treatment of medial rotation contracture of the shoulder caused by obstetric brachial plexus palsy. Chin J Traumatol 2000; 3:13–17.  Back to cited text no. 14
Nath RK, Karicherla P, Mahmooduddin F. Shoulder function and anatomy in complete obstetric brachial plexus palsy: long-term improvement after triangle tilt surgery. Childs Nerv Syst 2010, 26:1009–1019.  Back to cited text no. 15
Gilbert A, Brockman R, Carlioz H. Surgical treatment of brachial plexus birth palsy. Clin Orthop 1991; 264:39Y47.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3]

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