The Upper Limb

Chapter 673 The Upper Limb



Robert B. Carrigan



Shoulder


The shoulder is a ball-and-socket joint that is similar to the hip; however, the shoulder has a greater range of motion than the hip. This is due to the size of the humeral head relative to the glenoid, as well as to the presence of scapulothoracic motion. The shoulder positions the hand along the surface of a theoretical sphere in space, with its center at the glenohumeral joint.



Brachial Plexus Birth Palsy


Injuries to the brachial plexus can occur in the peripartum time, usually as a result of a stretching mechanism. This palsy is often associated with large fetal size and shoulder dystocia. The incidence is 1-3/1,000 live births. The injury can range in severity from neurapraxia to complete rupture of the nerve root or avulsion of the nerve root from the spinal cord. More often, the upper roots (C5 and C6) are affected rather than a complete brachial plexus palsy. Rarely, in isolation, a lower plexus injury (C8 and T1) is observed. The clinical appearance of a C5-6 brachial plexus birth palsy is the waiter’s tip position. The arm is held in a position of shoulder adduction and internal rotation, elbow extension, and wrist flexion. This is the classic Erb’s palsy.



Treatment


Occupational therapy for brachial plexus injuries should be instituted quickly to maintain passive range of motion of the limb and encourage use of the arm. If the biceps muscle does not demonstrate any recovery by 3 mo of age or shows persistent weakness at 5 mo of age, rupture or avulsion of the nerve roots is suspected. Surgical exploration and nerve grafting of the brachial plexus are then indicated. MRI and electrodiagnostic testing are not consistently reliable in this setting.


Shoulder dysplasia and dislocation (analogous to developmental dysplasia of the hip) can occur as a result of muscle imbalances in infants and older children and can require arthroscopic or open reduction and muscle balancing. Older children with residual weakness in shoulder abduction and external rotation can benefit from muscle transfers. Osteotomies are reserved for children with severely deformed glenohumeral joints and functional impairment from persistent shoulder internal rotation contracture.



Sprengel’s Deformity


Sprengel’s deformity, or congenital elevation of the scapula, is a disorder of development that involves a high scapula and limited scapulothoracic motion. The scapula originates in early embryogenesis at a level posterior to the 4th cervical vertebra, but it descends during development to below the 7th cervical vertebra. Failure of this descent, either unilateral or bilateral, is the Sprengel deformity. The severity of the deformity depends on the location of the scapula and associated anomalies. The scapula in mild cases is simply rotated, with a palpable or visible bump corresponding to the superomedial corner of the scapula in the region of the trapezius muscle. Function is generally good. In moderate cases, the scapula is higher on the neck and connected to the spine with an abnormal omovertebral ligament or even bone. Shoulder motion, particularly abduction, is limited. In severe cases, the scapula is small and positioned on the posterior neck, and the neck may be webbed. The majority of patients have associated anomalies of the musculoskeletal system, especially in the spine, making spinal evaluation important.



Treatment


In mild cases, treatment is generally unnecessary, although a prominent and unsightly superomedial corner of the scapula can be excised. In more severe cases, surgical repositioning of the scapula with rebalancing of parascapular muscles can significantly improve both function and appearance.



Elbow


The elbow is the most congruent joint in the body. The stability of the elbow is imparted via this bony congruity as well as through the medial and radial collateral ligaments. Where the shoulder positions the hand along the surface of a theoretical sphere, the elbow positions the hand within that sphere. The elbow allows extension and flexion through the ulnohumeral articulation and pronation and supination through the radiocapitellar articulation.



Panner’s Disease


Panner’s disease is a disruption of the blood flow to the articular cartilage and subchondral bone to the capitellum (Fig. 673-1). It typically occurs in boys between the ages of 5 and 13 yr. Presenting symptoms include lateral elbow pain, loss of motion, and, in advanced cases, mechanical symptoms of the elbow.


image

Figure 673-1 T1 (A) and T2 (B) coronal MRI images of the elbow depicting Panner disease of the elbow.


The mechanism of injury can be impaction or overloading of the joint, as seen with sports such as gymnastics and baseball. It can also be idiopathic. Radiographs of the elbow may be normal, but they can also show a small lucency within the capitellum. MRI is the study of choice to evaluate a suspected capitellar lesion. It can demonstrate the extent of the lesion as well as the integrity of the articular surface better than plain radiographs.



Treatment


Treatment is typically conservative. Rest, activity modification, and patient education are initial treatment options. In cases where the articular cartilage fragments and loose bodies form, arthroscopy is warranted to remove the loose bodies and drill the lesion.



Radial Longitudinal Deficiency


Radial longitudinal deficiency of the forearm comprises a spectrum of conditions and diseases that have resulted in hypoplasia or absence of the radius (Table 673-1). This process was formerly referred to as radial club hand, but the name has been changed to radial longitudinal deficiency, which better characterizes the condition. Clinical characteristics consist of a small, shortened limb with the hand and wrist in excessive radial deviation.


Table 673-1 SYNDROMES COMMONLY ASSOCIATED WITH RADIAL DEFICIENCY


















SYNDROME CHARACTERISTICS
Holt-Oram syndomre Heart defects, most commonly atrial septal defects
Thrombocytopenia absent radius Thrombocytopenia present at birth but improves over time
VACTERL association Vertebral abnormalities, anal atresia, cardiac abnormalities, tracheoesophageal fistula, esophageal atresia, renal defects, radial dysplasia, lower limb abnormalities
Fanconi anemia Aplastic anemia not present at birth, develops about 6 yr of age; fatal without bone marrow transplant; chromosomal breakage challenge test available for early diagnosis

From Trumble T, Budoff J, Cornwall R, editors: Core knowledge in orthopedics: hand, elbow, shoulder, Philadelphia, 2005, Elsevier, p 425.


Radial longitudinal deficiency can range in severity from mild to severe and has been classified into four types according to Bayne and Klug (Table 673-2). Radial longitudinal deficiency can be associated with other syndromes such as Holt-Oram and Fanconi’s anemia.


Table 673-2 CLASSIFICATION OF RADIAL LONGITUDINAL DEFICIENCY


















TYPE CHARACTERISTICS
I Short radius
Minor radial deviation of the hand
II Hypoplastic radius with abnormal growth at proximal and distal ends
Moderate radial deviation of the hand
III Partial absence of the radius
Severe radial deviation of the hand
IV Complete absence of the radius
The most common type

Adapted from Bayne LG, Klug MS: Long-term review of the surgical treatment of radial deficiencies, J Hand Surg Am 12(2):169–179, 1987.



Treatment


The goals for the treatment of radial longitudinal deficiency include centralizing the hand and wrist on the forearm, balancing the wrist, and maintaining appropriate thumb and digital motion. Shortly after birth, parents are encouraged to passively stretch the wrist and hand to elongate the contracted radial soft tissues. Serial casting and splinting are ineffective at this time, due to the small size of the arm.


For surgical treatment, the preoperative plan begins with careful examination of the patient; considerations in regard to thumb and elbow function must be made before surgery. The surgery typically occurs when the child is 1 yr of age. Correction of the radial deviation as well as centralization of the wrist can be accomplished with a variety of different surgical techniques. These techniques include open release, capsular reefing, and tendon rebalancing. External fixation techniques have also been described.



Nursemaid Elbow


Nursemaid elbow is a subluxation of a ligament rather than a subluxation or dislocation of the radial head. The proximal end of the radius, or radial head, is anchored to the proximal ulna by the annular ligament, which wraps like a leash from the ulna, around the radial head, and back to the ulna. If the radius is pulled distally, the annular ligament can slip proximally off the radial head and into the joint between the radial head and the humerus (Fig. 673-2

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Jun 18, 2016 | Posted by in PEDIATRICS | Comments Off on The Upper Limb

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