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Ultrasound Screening for Posterior Shoulder Dislocation in Infants with Persistent Brachial Plexus Birth Palsy
Andrea S Bauer1, Justin F Lucas, Nasser Heyrani
11Department of Orthopaedic Surgery (A.S.B.) and Clinical Research Center (L.A.K.), Boston Children's Hospital, Boston, Massachusetts 2Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, California 3University of California Davis School of Medicine, Sacramento, California 4Shriners Hospitals for Children-Northern California, Sacramento, California.
Insights
Posterior shoulder dislocation is common in infants with brachial plexus birth palsy (BPBP), affecting 29% of cases. Ultrasound screening is recommended, using passive external rotation in adduction ≤60° to identify infants needing further evaluation.
Area of Science:
- Pediatric Orthopedics
- Diagnostic Imaging
- Neonatal Care
Background:
- Early detection of posterior shoulder dislocation in infants with brachial plexus birth palsy (BPBP) is crucial for effective management.
- Physical examination alone may not reliably detect shoulder dislocation in this population.
Purpose of the Study:
- To determine the prevalence of shoulder dislocation in infants with BPBP using ultrasound.
- To identify physical examination measurements that correlate with shoulder dislocation.
Main Methods:
- Retrospective review of ultrasound screening data from infants with BPBP.
- Physical examination included Active Movement Scale (AMS) and passive external rotation measurements.
- Ultrasound measurements included percentage of humeral head displaced posterior (PHHD) and alpha angle.
Main Results:
- 29% of infants with BPBP presented with shoulder dislocation.
- Infants with dislocation showed significantly less passive external rotation (≤60°) and greater AMS score differences.
- Passive external rotation in adduction demonstrated high sensitivity (94%) and specificity (69%) for detecting dislocation.
Conclusions:
- Shoulder dislocation is a frequent complication in infants with BPBP.
- Ultrasound screening is appropriate for infants diagnosed with BPBP.
- A passive external rotation in adduction cutoff of ≤60° is recommended for selecting infants for ultrasound screening.
Background:
Early detection of posterior shoulder dislocation in infants with brachial plexus birth palsy (BPBP) is essential, but it may be difficult to accomplish with physical examination alone. The aim of this study was to determine the prevalence of shoulder dislocation in patients with BPBP using ultrasound and to identify which physical examination measurements correlated most with dislocation in these patients.
Methods:
This study was a retrospective review of data obtained in an ultrasound screening program of infants with BPBP born from January 2011 to April 2014. Physical examination included the use of the Active Movement Scale (AMS) and measurement of passive external rotation of the shoulder. Ultrasound measurements included PHHD (percentage of the humeral head displaced posterior to the axis of the scapula) and the alpha angle (intersection of the posterior scapular margin with a line tangential to the humeral head through the glenoid). Shoulder dislocation was defined as both a PHHD of >0.5 and an alpha angle of >30°.
Results:
Of sixty-six infants who had undergone a total of 118 ultrasound examinations (mean, 1.8; range, 1 to 5), 19 (29%) demonstrated shoulder dislocation with the shoulder positioned in internal rotation; the dislocation was first detected between 2.1 and 10.5 months of age. Infants with a dislocated shoulder demonstrated significantly less mean passive external rotation in adduction (mean, 45.8° versus 71.4°, p < 0.001) and a greater difference between internal rotation and external rotation AMS scores (mean, 5.5-point versus 3.3-point difference, p < 0.001) than those without shoulder dislocation. Passive external rotation in adduction was a better measure for discriminating between dislocation and no dislocation (area under receiver operating characteristic curve [AUC] = 0.89) than was the difference between internal and external rotation AMS scores (AUC = 0.73). A cutoff of 60° of passive external rotation in adduction (≤60° versus° >60) yielded a sensitivity of 94% and a specificity of 69%.
Conclusions:
Shoulder dislocation is common in infants with BPBP; 29% of the infants presenting to our tertiary care center had a dislocation during their first year of life. Ultrasound shoulder screening is appropriate for infants with BPBP. If passive external rotation in adduction is used to determine which infants should undergo ultrasound, ≤60° should be utilized as the criterion to achieve appropriate sensitivity.
Level Of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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