Dr. Nath's reply about MQ/Caps/Biceps questions on other post

[francine]

The capsulodesis surgery is relatively new to TCH because of the evolution of
our understanding of this complex injury. Basically, what we believe now is
that the shoulder joint is a very common site of deformity following brachial
plexus injury in developing children. This is probably due to 2 causes: the
muscle imbalances that exist as a result of C5 and C6 nerve injury (the most
common parts of the plexus involved). The muscle imbalances exist because the
deltoid muscle (abductor of the shoulder) and supraspinatus and infraspinatus
muscles (external rotators of the shoulder) are weakened as a result of the C5
injury; this allows the opposing muscles, the latissimus dorsi, the teres
major, the subscapularis, the pectoralis major and minor muscles (adductors
and internal rotators of the shoulder) to become short, tight and scarred
(contractures).

Because the predominant forces are now internal rotation and adduction, the
classic "waiter's tip" posture is seen at birth in many cases. This is the
earliest abnormal posture creating forces that prevent proper formation of the
shoulder joint. In addition, the nerve injury itself causes changes in the
development of bone so that development of the joint may be affected by this
factor as well.

The quad surgery was developed to address the contracture component of this
deformity, and has been very effective in improving abduction as well as
external rotation. However, it is possible that if an advanced degree of
shoulder joint deformity exists at the time of the quad surgery, it will not
reverse the internal rotation deformity completely. This is because the arm
bone (the humerus) is too far out of the area of the joint socket to return
easily even once the contracture is surgically released. Usually, the arm
moves backward (posteriorly) out of the region of the socket (actually, the
socket has not developed, so it cannot really be considered a true socket, but
is just a flattened area where the socket should be). This is known at
"posterior glenohumeral dislocation or instability".

So, even if the contracture component is treated with the quad surgery, we
sometimes need to assist the humerus back into the socket area with a surgery
that pushes the humerus forward and holds it there with a series of stitches
(the capsulodesis surgery). The hope is that this will allow formation at
least of a partial socket because movement directions will be more normal.

As an aside it is often noted that coexistent with the shoulder problem is a
contracture of the biceps tendon. This gives a bent elbow posture that is
surgically repaired if splinting over several months does not help. The biceps
tendon is split lengthwise then allowed to lengthen; it is then sewn together
in its longer position, thus allowing straightening of the elbow.

It is not true that the quad surgery causes the shoulder dislocation. The quad
surgery may unmask an existing shoulder deformity because suddenly there is a
dramatically greater range of motion. Magnification of internal rotation
movements that now noticeable whereas previously this was not the case,
because range of motion was severely restricted due to contractures discussed
above.

In our practice we have seen all possible combinations of shoulder anatomy
from normal position in severe BPI's to complete dislocation without
contractures or the need for any other surgery, including primary. Therefore,
it must be a combination of factors that combine to produce the shoulder
deformity.

If the capsulodesis does not work, or fails after some time, than humeral
osteotomy (cutting the bone and rotating it) will get the arm into the
position we want. However, this does require the use of plates and screws as
well as a significantly visible incision on the arm, so that it is not usually
the preferred first choice for shoulder joint management. We find that the
earlier the quad surgery is done, the less the need for capsulodesis (probably
the contractures are released before permanent changes can occur in the
shoulder joint). And, the earlier the capsulodesis is done, the less the
requirement for osteotomy.

The end goal is the same: to normalize the posture and anatomy of the shoulder
joint components so that shoulder, arm and hand function can be more natural.

The shoulder joint is a complex structure that requires normal nerve supply to
it and to its muscles in order to develop normally. We do not see the shoulder
deformities of children in adults with severe traumatic brachial plexus
injuries, who routinely have the same contracture patterns.

This is a complicated area and I will be happy to provide ongoing explanations
including diagrams as we get them made. If anyone wishes to contact me
directly I am always happy to do so by phone (832) 824-3193 or by email at
rnath@bcm.tmc.edu

[francine]

just bringing this back up to the top

I'm going to save this post....there's a lot of questions answered in this one, don't ya think?

[LeeAnne]

Thank you Francine, I needed this info! L

[julieanddean]

Francine, thank you for soliciting this information. Very helpful!

[Elisa]

This is awesome information. It made me realize how much I didn't know. I sure appreciate his detailed response.

Thank you Francine!

[Kathleen M]

I think this information will really help to explain many questions regarding the different types of surgery and why...

I would benifit from the osteotomy --- but would not want to do it at this stage of my life... if I were younger I think I would go for it...
Kath

[Missy K]

Thanks Francine.

How nice of Dr. Nath to take the time to answer.

Missy

[Susie]

Thank for the very interesting info Francine. I think I understood 75% of it since this is all so new to me.

Susie

[Alice]

Wow Francine thanks for posting the response. I need to read it a few times before I can understand the whole thing. I am hoping this will help make my decision for the caps surgery for my son easier....we'll see. Again thanks.

[francine]

Alice - lol - i've read it over about 5 times...and I'm still digesting it...it'll take me another 5 times I think... and then I"ll read it again in 6 months and get more out of it. LOL -francine