Secondary Surgery, Shoulder

Subscapular Release, Levator Scapulae & Trapezius Transfer, Latissimus Dorsi Transfer, Anterior Release of the shoulder


Introduction

The most typical partial recovery at the shoulder level is an abduction which does not reach the right angle (90°) with a partial or total lack of external rotation of the arm. The hand can reach the mouth and frequently to do this movement the child elevates the shoulder (which is called the "trumpet sign").  The child's hand can hardly reach his ear and very seldom he can reach the nape of the neck.

To avoid the direction in which the muscular unbalance could lead, with growth, to lasting bone and joint deformities, if the passive external rotation of the shoulder is less than 20° an operation is indicated at one year of age. The subscapular muscle is released in order to improve the passive external rotation. This operation can aid to strengthen the weak external rotators muscles.

Subscapular release

1. The skin incision is along the lateral border of the scapula
2. The latissimus dorsi muscle is retracted and the border of the scapula is exposed
3. The internal rotation is substained by the retracted subscapular muscle that must be detached by its scapular insertions
4. The muscle is completely detached from the scapula
5. Now the arm can be externally rotated thanks to the complete detachement of the subscapular muscle
6. The arm is imobilized with a cast for 3 weeks with the shoulder adducted and completely externally rotated


At the age of two the recovery of the shoulder function, either spontaneously or after primary surgery, is considered completed. At that age, if a deficit of abduction or external rotation does still exist, an indication for secondary surgery is given.

The secondary surgery has the aim to improve function by means of transferring active muscles by changing their original bone insertion and turning them towards the paralysed or poorly functioning muscles.
In the shoulder area for instances the operation has the aim to reduce the power of internal rotation and to gain external rotation by means of changing the insertion of one or more muscles transforming them by internal into external rotators.

In severe deficit of shoulder abduction, the trapezius muscle transfer, eventually associated with the levator scapulae muscle transfer can restore, even though partially, a useful function.

Trapezius Transfer


1. The trapezius muscle (see arrow) is detached from its distal bone insertion
2. The trapezius is trasposed and fixed to the humerus to substitute the paralyzed muscle
3. Insert of the muscle and closer
4. The limb is immobilyzed with a plaster cast with abduction of 120° and maximal external rotation for the duration of 5 weeks
5. Result Transfer



Latissimus Dorsi Transfer




An 18-month-old child with a spontaneous recovery with 95° of shoulder abduction with no external rotation neither active nor passive. There is an indication for subscapular release and latissimus dorsi transfer for external rotation in the same time.



1. The skin incision follows the lateral border of the scapula and the posterior margin of deltoid
2. The latissimus dorsi muscle is isolated (see arrow). The aim of the operation is to transform the intrarotation function of the muscle into an extrarotation one
3. The latissimus dorsi insertion has been devided from the humerus in order to change its distal insertion

4. The tendon is reinserted to the rotator cuff transforming in this way the action of the latissimus dorsi into an external rotation
The functional result two years after surgery with good recovery af the active external rotation and a significant improvement of shoulder abduction

Anterior Release of the Shoulder

In older children the cause of internal rotation contracture may be the shortening of the Coraco-humeral ligament , due to the hypertrophy of the coracoid bone .

This can be seen on XRays and CT scan . In those cases , resection of the Coracoid bone and the ligament will give immediately an excellent external rotation .
The incision is anterior , short ( 4-5 cm) and allow the bony resection . The ligament is resected with the bone .

After the release , the child is not immobilized and the physiotherapy starts immediately . To obtain a good result , it is necessary to have previously some extrarotator muscles .