Secondary Surgery, Shoulder
Subscapular Release, Levator Scapulae & Trapezius Transfer, Latissimus Dorsi Transfer, Anterior Release of the shoulder
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.
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.
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.
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 .