United Brachial Plexus Network, Inc.

Hi all, at this moment I do not have a lot to add to this excellent discussion regarding the Humeral Osteotomy but want to say that I am reading every word and paying close attention. Kate, your insight is fabulous, thank you.

Ashley's Ortho Surgeon wishes to perform this surgery on Ashley for her Internal Rotation and elbow issues also. Right now Ashley says no way , and both my husband and I are thinking along this lines of Francines husband...lets wait till she finishes growing. It is so hard to decide to force my child to have a surgery and to not know if the outcome will be for the best.

I'll keep reading if you all keep writing.

Francine.........it's great to see you !!

Lenni

Hey Marnie we are having the same trouble but its Thomas' elbow his joint is deformed we meet with Dr. Law
and another doctor at children's in B-ham. We had started back therapy and casting which did not work........They say do nothing for his elbow till the growth plate and joint have turned to bone. I don't know if we should wait his contractor is 30 we got to 25 and it would not cast out anymore so we did an mri on his elbow and he has a bony block but most of the joint is still cartalige. So many nerves and vessels feeding the hand I am scared to do any thing because the one thing he has is use of his hand.

Francine and other Moms here on this Topic,
You are G-r-e-a-t Moms and Dads!

I want to commend you Francine,for being "tuned in" to your daughter's emotional issues which are "Secondary Medical Conditions/Injuries" of OBPI's.This is from somewhere in the "Medical Resources for Adults with OBPI" on the "Medical Information" Link on this web site.
BTW, everyone is welcome to all "Adult with Links" too. There is alot of information there about our "Lifetime Care Issues" including "Secondary Conditions" of Living with these injuries.

Hugs all around,
Carolyn J
LOBPI,68 & Proud of it!


Message was edited by: Carolyn J

Francine,

I've really appreciated our talking this week, too. It means a lot to me not to be "the bad guy" in your eyes, truly And I'm glad if I can help at all, too!

Just some quick thoughts... I'm thinking the range of results from the osteotomy, like the range of results from tendon transfers, really depends on how much innervation the deltoids actually have. For instance, Joshua really has very weak deltoids. The ACR gave him really great external rotation, but his deltoids still aren't really good enough so he gets about 110-120 degrees abduction with his supraspinatus and that's it. That's one reason why we probably won't do tendon transfers - they don't really directly help abduction except to help get the deltoids into a better working position (they are stronger in external rotation) and so tendon transfers probably wouldn't help him much.

I believe it is the same with the osteotomy. It really just helps the deltoids be in a more functional position. So if the deltoids were strong at one point, I would expect better results than if they have always been weak.

I hear what you say about the biceps contracture. I don't think the osteotomy would help that, because it won't change where the biceps tendon crosses the joint, the biceps would still be in an awkward position.

I myself lean towards what your husband is thinking - let growth finish, first, as long as function isn't degenerating really really badly. I've seen some really backward twisting BPI arms, of course you want to prevent that if you can. But otherwise, I don't see a big rush at this point, especially if Maia can do what she wants.

Sorry if this seems garbled... I'm just throwing the words on the screen! Hope something makes sense!!

Kate

I am getting the same reservations as most of you moms are getting. My son Joshua (now 9) was recommended for the osteotomy about 2 years ago by 3 drs. In my research I found mixed results. I am just not feeling comfortable with the surgery and results for MY SON. Just like Francine said, each dr does the surgery differently--which makes it hard---which way is the "right" way and is there a "right" way---its so confusing. A few years ago I went to a gathering in New Jersey and met a nice young man in High School who just had the osteotomy and was quite happy with it. I would like to wait till my son is old enough to make that decision for himself. Sounds good, right!?! I just hope it all works out like that.

Oh this is all so interesting....

So, Kate, I have another question then:

What you said about the deltoids was very interesting and I talked to our therapist this morning and we had a good discussion about this. Maia has extremely strong anterior deltoids (strong internal rotators) and no middle deltoids, and probably no posterior deltoids (external rotators).

You can actually see this when she's running... her arm lifts up and tightens into internal rotation to "power" her movement. And for the last year I've always said to Lou - how are we ever going to stop this internal rotation issue if this is her POWER MOVER?

So with that said, and thinking about regressions, I wonder if everyone should be checking on the middle and posterior deltoids and supraspinatus before doing any huge intervention? If there's no (nerve) muscle power for external rotation then how will any procedure change anything concerning internal rotation?

And if that's the case, then I should be doing an EMG on these muscles and if they ARE innervated then should we be e-stimming them to strengthen and by doing that, can we change the position of her humeral head?

-francine

Francine,

Strength in the anterior delts actually has been implicated as the major cause of subluxation in at least one paper I read (I know it is here somewhere... Lord I'm disorganized right now!) The anterior deltoids internally rotate the arm (as you noticed) but also as they act on an internally rotated arm they push the humeral head backwards. So unbalanced deltoids can be a major factor in subluxation force.

The osteotomy (which basically converts the anterior deltoid to a more middle deltoid position) helps improve both the action of the deltoid and reduces their subluxing influence. This is where the osteotomy may actually prevent worsening of the joint, especially if the main cause is overpowering anterior deltoids.

The MQ enables the deltoids by supplementing external rotation power with additional transferred muscles - lats and/or teres major. If those muscles have sufficient strength, they will also help externally rotate the arm and put the deltoids into a better position. But improvements still depend on supraspinatus and deltoid strength. The ACR, which releases internal contracture in the capsule and subscapularis, enables the external rotators to work (if they are functional; the majority of time they are) which enables the deltoids/supraspinatus. In all cases, innervation of the anterior/lateral/posterior deltoids and supraspinatus will dictate how much improvement there will be.

Personally, I think you are right about a doctor needs to very seriously examine ALL the muscles before doing any huge intervention. That's one of the reasons we are still not doing any tendon transfers for Joshua. At this point, the muscles the doctor would transfer (lats and teres major) really aren't strong enough to bother. He wants to see them a grade or two higher in strength before transferring them would be worth it. But it's tough to figure out how strong a muscle can be when it is currently in a functionally disabling position. Joshua's PT and I both very strongly felt that his external rotators had nerve recovery but were just unable to work. But we didn't have a good way of testing that idea before the ACR, since they were so weak from being not used at all for so long.

I think you may be on the right track in trying to strengthen Maia's posterior deltoids to balance the strong internal ones. It sounds like most of her lifting power is going into internal rotation instead. We've never done an EMG on Joshua, but have done a lot of NMES. The basic test is, if you can find a motor point and get a response, there is intervention! We do "flutter" contractions with our "el-cheapo" estim machine because Joshua finds these comfortable. I shoot for light contractions about 10Hz, not enough to move anything but it sort of pulses the muscle and increases awareness. E-stim for actual strength really doesn't have a lot of evidence behind it. I think any effect is really from increased brain awareness/bio-feedback of the muscles. They can be innervated but still completely ignored by the brain.

There's something that worries me, though. At this point I'm just thinking out loud, but part of me worries that even if you could effect major changes in the musculature of an older child, would that itself have damaging consequences for the joint (such as arthritis)? If over the first 5-10 years the joint has formed in harmony with a specific muscle balance, what happens to the joint if that harmony disrupted by rearranging muscles or bone? Just like in weightlifting it is important to develop opposing muscle sets equally, is it the same for our kids? If they grow (and the joints develop) with unbalanced muscles, is it equally bad to effectively then *unbalance* them by selective strengthening, tendon transfer or osteotomy?

I guess what I'm saying is that, if the body has adapted to unbalanced muscles, is it really beneficial to attempt to "rebalance" them? Maybe the unbalanced muscles *are* balanced when the joint configuration also is taken into account. I was reading about the wedge-osteotomy for glenoid retroversion recently (after bringing it here) and it seems that although it increases function quite a bit and reduces posterior instability, it has a high rate of degenerative changes (arthritis). Is this because the now "normal" glenoid position is actually ABnormal for that shoulder? It's as if you put in a complete, normally shaped shoulder replacement, but only hooked up half the muscles. It would be a real problem!

Kate

Thanks for reminding me... I can do my quick and easy EMG test.... I put the active electrode on my palm and the inactive elecrode on her arm and turn up the "juice" and use my index finger to find her motor points and feel for response. Have you ever done that? It's very cool to feel the response right in your own finger. That would be much better than a needle EMG for an 8 1/2 year old freakout girl! lol

Is a physiatrist the right person to go and analyze the anatomy of movement as it pertains to Maia and her joint? Or can it even be done... I want someone to tell me THIS IS WHAT'S HAPPENING - this is what's working, this is what's not working, this is how she's compensating inside - this is what you can do and this is what you can't do because it would cause arthritis and damage to her joint. No I'm not asking for the world am I ?? Who would be able to do this kind of assessment and have these kinds of answers?

How interesting! In all these years, I've never had this type of in depth conversation before. Little glimmers of hope for the future.... and a greater understanding. FINALLY, I'm getting it!

Francine,

If you find someone to give you those answers, you'd better share!! I *wish* I had some idea who to ask. I've pretty much given up and am just doing my own anatomy homestudy instead! But I *was* the one who was convinced that Joshua had ER recovery, so there!

You know, there is a gait lab at Shriners that Dr. Kozin thought might be possible for Joshua when he gets a little older. There is also a professor her in Southern California using class gait analysis to determine normal and abnormal patterns of muscle activation (same type of thing). But the child has to be old enough to wear a bunch of EMG electrode needles while following instructions. Not suitable for a young or sensitive child, it sounds like.

On your fingertip electrode test, where do you put the return electrode? On you or on Maia? I tried it once a long time ago, but my skin has such poor conductivity that I couldn't make it work. I should try it again... sounds like a great idea!

Kate

Active electrode on MY palm.
Return electrode on Maia's arm on any muscle that's distal to the muscle being tested.

Test it out on your husband first... mighty interesting.

Turn it up until you feel a small sensation.... you won't feel anything as you hunt around but when you get closer to the motor point you'll feel the sensation and feel the little jump or a slight raising up. Keep the "volume" down so that you don't scare yourself! hehehe

As you continue to try this you will however have to turn it up higher and higher because your brain and his brain gets used to the "volume".

Have fun now!