Due to the nearly universal involvement of the C5 and C6 nerve roots, children with brachial plexus birth injuries usually have some impairment of the function of the shoulder and sometimes the elbow. The purpose of the shoulder is to position the hand in space. Recent studies have demonstrated the profound effect that limited shoulder motion has on the function and strength of hand. Joints require full motion to develop normal anatomic shape and function. The growth and development of the joint surface is an ongoing process that involves active growth on each side of the joint. Depending on the nature and extent of recovery, muscle weakness or lopsided muscular action around any joint in the arm may develop. Either of these may cause joint deformity and loss of function.
The shoulder joint has the most motion of any joint in the body. Elevation of the shoulder is a complex motion involving a coordinated combination of two joints, glenohumeral and scapulothoracic motion. The gleno-humeral joint is the articulation between the arm bone and the shoulder blade. The scapulo-thoracic joint consists of the muscle coated underside of the shoulder blade riding upon along the outer surface of the rib cage. Researchers have attempted to determine the minimal requisites of raising the shoulder in the air and the role and relative importance of specific muscles.
One essential condition for elevation is agreed upon: active external rotation of the shoulder,or being able to swing the arm out, is an essential requirement for normal shoulder elevation and the ability to bring the hand to the face. Without outward rotation, getting the hand to the face requires the clarion position.
If internal rotation contracture of the shoulder develops and persists, pathologic changes in the glenohumeral joint ensue with possible subluxation or dislocation, resulting in restricted motion and function. (Synonyms : ER, external rotation, outward rotation, lateral rotation IR, internal rotation, inward rotation, medial rotation).
Passive motion must be maintained in order to ensure the development of a congruent glenohumeral joint. Congruency is when both sides of the joint have shapes which match each other through the functional range of movement. For example, a hip which has egg shaped parts, is only congruent for movement in one plane, typically flexion, but incongruent in motion in other directions such as abduction or rotation on the long axis. Incongruence is suggested by lack of concentric centers. That is, the center of the ball ought to coincide with the center of contour of the socket.
With the progression of ossification of the humeral head and glenoid, the shoulder joint takes on its permanent shape at about 3 years of age. Therefore, if our therapy is unable to maintain external rotation and/or a concentrically located ball in the socket, then surgical intervention is necessary before age 3 to establish joint congruence and thus, avoid a mechanical permanent loss of motion.
It is for these reasons that we initiate a carefully supervised physical therapy program utilizing specially talented therapists knowledgeable in special needs of such children. They educate parents and care givers in the techniques proper for joint motion preservation.
To maintain external rotation (considering description in a theoretical standing posture, standing or not), the therapist or caregiver performs this exercise with the upper arm held against the side of the torso. Outward rotation of the arm swings the forearm forward to pointing straight ahead. Abducting the shoulder (moving the elbow away from the body) to 90 degrees would have the forearm still parallel with the floor. That does not get the maximum stretch out of the anterior shoulder capsule and the subscapulous, the muscle that rotate the arm inward toward the belt.
Furthermore, all motions of the upper extremity are attended to, with special care taken to isolate glenohumeral motion from scapulothoracic motion. It is important to maintain a continuous physical therapy program at home and with a therapist; interruption of this program will lead to rapid loss of function and contracture.
The experience and creativity of the therapist is critical when attempting to cajole a young patient in the non-compliant phase of development to perform therapeutic exercises designed to maintain motion and gain strength. Play activities are designed to incorporate the desired motion and exercises. In cases of complete plexus involvement where wrist drop or finger flexion contractures are a concern, a cock-up splint is used.
We also incorporate electrical stimulation into our therapy both with the therapist and at home, to minimize permanent muscle atrophy. The use of electrical stimulation in these patients is a new technique that sends small amounts of current into the muscle. While there is no definitive proof of its efficacy, the thinking is that it stimulates the muscle to prevent it from completely withering away and it may even stimulate nerve growth.
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“My daughter will turn 16 in a few days and today, she is a smart, happy and well adjusted teenager who has surpassed all expectations, thanks to the top notch and cutting edge care that she has received from Dr. Price. When anyone meets my daughter for the first time, they are not aware of her injury unless I point out her surgical scars. She has a normal appearance and most people comment that they do not notice the surgical scars. For a teenager, one of the most important things is to fit in with their peers and to live a normal, happy life. My daughter fits in and lives a normal and happy life, thanks to Dr. Price.”
— Ashby, New Jersey
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