- See:
Brachial Plexus Injury:
- Indications:
- shoulder paralysis:
- may include paralytic dislocation or combined rotator cuff / deltoid paralysis (in which case
shoulder arthroplasty would be contra-indicated);
- as a requirement for shoulder fusion, the muscles of forearm and hand need to be functional
as do the
serratus anterior and
trapezius;
- the later muscles need to be strong inorder to control scapulothoracic motion after the fusion;
- degenerative or rheumatoid arthritis;
- Functional Position:
- fusion should allow the patient to reach the face as well as the back pocket;
- when trapezius and serratus anterior function is acceptable, position in:
- abduction:
- recommendations have ranged from 15 deg to 45 deg;
- historically recommended positions for shoulder fusion have ranged from 30-45 deg;
- abduction beyond 45 deg may be associated with pain and winging of the scapula;
- when
serratus anterior is paralyzed, the shoulder should be fused in no more than 30 deg of abduction;
- otherwise, the weight of the arm may depress the lateral part of the scapula and overstretch and
weaken the trapezius;
-
flexion: less than 10-30 deg;
-
internal rotation: 20-45 deg;
- allows patient to reach contra-lateral should, belt, and mouth;
- deg of rotation can be the most important factor determining extremity function;
- references:
-
A functional analysis of shoulder fusions.
- Re-evaluation of the position of the arm in arthrodesis of the shoulder in the adult.
CR Rowe.
JBJS. Vol 56-A. 1974. p 913-922.
- Technical Considerations:
- incision: begin at the scapular spine, continue across the anterior aspect of the acromion,
and down the anterior aspect of the proximal part of the humeral shaft;
- deltoid is detached from the anterior aspect of the acromion, and the fibers are split distally;
- rotator cuff is excised, the articular surfaces of the glenoid and humeral head are removed,
and the undersurface of the acromion is decorticated;
- attempt both intra-articular fusion (glenohumeral) and extra-articular fusion (acromio-humeral) fusion;
- if glenohumeral contact is inadequate w/ the superior placement of the humeral head, a partial osteotomy
of the acromion can be performed at the junction with the scapular spine;
- acromion is then displaced downward, hinging at the AC joint;
- plate is contoured against the scapular spine, over the acromion, and against the proximal humerus;
- Post Op Evaluation:
- motion of scapula then compensates for the lack of motion in joint;
- single most important cause of complications following shoulder arthrodesis is malposition, either too much flexion or too much
abduction, which results in periscapular pain;
- Arthrodesis in Children:
-
indicatioins:
- children w/ paralysis of shoulder girdle muscles w/ subluxation or dislocation (as might occur in Polio) inorder to stabilize the flail shoulder;
-
prerequisites for procedure:
- functional results are related to neurologic status of distal arm & hand, & therefore normal function of forearm & hand is a prerequisite;
- strong
trapezius &
serratus anterior muscles are required in order to allow for increased scapulothoracic movement;
-
optimal age is controversial;
- since it is difficult to predict the final position, some delay shoulder arthrodesis until skeletal maturity;
-
pseudoarthrosis: may occur in 20%;
- solid fusion is technically difficult to achieve in children because of the amount of cartilage in pediatric humeral head;
- care must be taken to preserve the proximal humeral growth plate in skeletally immature patient;
-
optimal position of arthrodesis:
-
abduction: 15 deg (but 45 deg as been recommended historically);
- excessive abduction should be avoided, because excessive scapular winging can result;
- there may be loss of 10-20 degrees of abduction during first 12 months in young children;
-
flexion: 25 deg;
-
internal rotation: 25 deg;
A functional analysis of shoulder fusions.
Glenohumeral arthrodesis. Operative and long-term functional results.
Early arthrodesis for a flail shoulder in young children.
A simplified compression arthrodesis of the shoulder.
Shoulder arthrodesis using a pelvic-reconstruction plate. A report of eleven cases.
Arthrodesis of the shoulder in children
Treatment of Complications of Shoulder Arthrodesis.
G.L. Groh MD, G.R. Williams MD, R.N. Jarman MD, and C.A. Rockwood MD.
JBJS Vol 79-A, No 6, June 1997. p. 881.
A simple method of shoulder arthrodesis.
NS El Said Mahammed.
JBJS Vol 80-B. No 4. July 1998. p 620.
