United Brachial Plexus Network, Inc.

Thus far -- knock on wood -- my daughter, 5 years of age, has not experienced shoulder dislocation. Yet in preparation for her placement into school I provided her teacher with precautions particularly for the event of dislocation. The teacher looked at me curiously and asked: But your child as yet as not experienced dislocation, why would you be concerned? I responded: Well it is something that I am just anticipating.

Then I wondered? Is shoulder dislocation inevitable? Is there a physical presentation in the child that suggests that dislocation may soon occur? Using my hands, is there a way that I can explore my daughter's shoulder for some suggestion of bone growth imbalance, thus eventual dislocation?

Thanks!

Dislocation (thank God) is NOT inevitable. I think that one of the ways to see what's going on inside and how things are doing is to have a 3D ct scan. That will show how well formed (or deformed) the whole shoulder joint is, whether or not she has the possibility of becoming dislocated (they can see the glenoid fossa and if it is flat or has a lip, etc.). But I also think that you should bring your 3D ct scan to your bpi specialist because often the regular radiology docs don't know enough about bpi to write up a report that makes sense. There is a "look" that a posterior dislocation has. With my child there was (1) pain (2) huge reduction in range (3) internal rotation (3) the "look" (sorry - can't explain it well) (4) and you could actually put the arm back in the glenoid and it would fall right out (nauseating). I know that it may be different for other children, they might not have all the symptoms that mine did and that is why you should rely on your bpi specialist to help you with this.

The best thing you can do for your child is to get them weight bearing. There's crawling but there is also this weight bearing on elbows (like you would if you were watching tv and laying on the floor on your stomach - with your elbows on the floor and your hands under your chin). Also good are the overhead and behind the head movements.

We had a dislocation , had the surgery and have seen huge differences in scans since the therapy we did with the weightbearing and over head movements. Another thing we are doing is estim'ing the muscles that give the shoulder joint more stability. We are doing the weakest muscles that my daughter has, another child's might be different however.

Please try not to be scared. You can teach and educate and do all these things and it's my experience that most of them won't remember anyways. You can only do your best and I think that strengthening the shoulder joint and getting that glenoid formed to avoid the situation in the first place is your best bet.

I agree with Rich, that an MRI would give you better understanding of the humeral head to cartiledge relationship. Also, the dislocations in our kids are caused by a double whammy of muscle imbalances and poor glenoid fossa formation.

That being said, there is no way to say that in the case of a growth spurt that the muscles won't become so imbalanced that they pull the shoulder out.

I think if you take proper precautions, without being overbearing, your child will do fine. NO CHILD'S arm should be pulled on, and your child's arm is weaker so any pull would be amplified.

In answer to your teacher's question: many of the children affected by bpi have dislocations and dislocations can occur at anytime during a child's growth. It is a "side effect" of having a bpi.

Good luck. Our daughter is headed to Kindergarten and we are very excited!!!

claudia

BPI-related dislocations are most likely to follow a long period of malformation of the shoulder joint, where the joint gradually becomes "subluxed" (the ball is shifted out of place but still in socket) and "dysplasic" (where both ball and socket ossify abnormally). A malformed joint doesn't have all the features holding in the ball of the humerus, and so real dislocation (where the ball completely pops out of joint) is more possible. Because of the malformation of the joint, however, putting the ball back into the socket is also a lot easier than reducing a dislocation in a "normal" shoulder.

Subluxation and resulting malformation can be detected early in the process on MRI scans, which shows changes in the cartilage before it converts to bone. Early changes can be inferred from x-rays and CT scans (which only show the ossified bone) and in a five year old, the joint should be fully formed enough to show up on either test. This malformation is not inevitable, but recent studies are showing upwards of 65% rate of occurrance. It is something we all need to watch out for!

You can look for the signs that might suggest a malformed shoulder joint is likely. Internal rotation contractures have been correlated with a malformed shoulder joint. In addition, some doctors can physically palpate "fullness" on the back side of the shoulder (for a posterior subluxation - the most common type). I also saw a test somewhere that shows how you can actually push on the arm a certain way to see if it pops out of the joint. That sounds like a bad idea for a layperson to do, though!

One way or another, it might be good to know that status of your child's shoulder, either by physical exam by a professional or a scan of the shoulder itself. That should give you some peace of mind about what risks she has.

Kate

Kate,

What is the presentation of an "Internal rotation contracture"? Please.

Guest,

Sorry about that!

Doctors have varying opinions on what constitutes a contracture, but basically you are looking for a reduction of range of motion on the BPI side, especially in external rotation exercises. Depending on the severity of the reduction of range, some doctors call it a "contracture" while some call it "tightness". Here's a paper that discusses the correlation between contracture (which they defined as reduction of range of 10% or more) and bony deformity of the shoulder joint.

http://www.ncbi.nlm.nih.gov/entrez/quer ... s=12571311

Check out this site for explanations of the various movements of the shoulder. If you have animations turned on, it is really informative:

http://membrane.com/bpp/range.html

Here is a site with ROMs:

http://elaine.membrane.com/bpp/range.html

The "shoulder rotation" one shows both internal to external rotation - the first picture is neutral, the second is externally rotated, the third is internally rotated. You can do external rotation exercises with the upper arm abducted as on ROM website (straight out to the side) or adducted as on the EXRX page (down at the side).

So check your child's range of motion and, depending on who you ask, larger or smaller differences of range between the sides is an indication that something may be wrong.

Kate

Also, the paper

http://www.ncbi.nlm.nih.gov/entrez/quer ... s=12571311

actually talks about "the look" of kids with contracture/subluxation:

"Although 10° of restriction may not be clinically relevant, we believe that our definition was accurate in determining whether there was any restriction of mobility. The accuracy of the definition was confirmed by the parents’ observation of an asymmetric appearance of children with no neurological deficit who were shown to have a decrease in passive range of motion of only 10°. "

We parents are very tuned in to our kids; it's nice to see researchers noticing!
Kate

Bless you, Kate, for this information...

Null #2,
what type of surgery did you have for your child's shoulder dislocation? and at what age? I am always worried about Kate's shoulder development.

thanks.