REVISTA DE ORTOPEDIA INFANTIL DEL
HOSPITAL DE NIÑOS RICARDO GUTIERREZ

Editor: Dr.Néstor Vallejos Meana

PAPER Nº 10

STUDY OF THE SUBSCAPUARIS MUSCLE IT’S INCIDENCE ON OBSTETRICAL PALSY

• NESTOR VALLEJOS MEANA M.D
• JORGE A: BUCCINO M:D:
• ADOLFO RICARDO GRANDAL MD.
• JOSÉ ALBERTO CIFONE MD

I. INTRODUCTION

OBSTRETICAL PALSY IS THE RESULT OF THE ELONGATION OF THE BRACHIAL PLEXUS~ DUE TO CERTAIN PARTURITION PROCEDURES.. IT IS WELL KNOWN THAT THE MOST EFFECTED AREA IS THAT OF THE UPPER ROOTS AS A RESULT OF THEIR OBLIOUITY WITH RESPECT TO THE SPINE ( THE ETIOLOGY OF OBSTETRICAL PALSY INVOLVES MATERNAL, FETAL AND/OR TOCOLOGICAL FACTORS WHICH PRODUCE A PATHOLOGIC RESULT, AND THE DEGREE OF DETRIMENT TO THE AFFECTED EXTREMITY SHALL DEPEND ON THE TYPE OF NERVOUS NEUROLOGICAL AFFECTION (NEUROPRAXIS AXONOTMESIS-NEUROTMESIS)

Incidence

WORLD STATISTICS SHOWS A DECREASE IN ITS INCIDENCE (FROM 1 /1000 TO .0,38/1OO0) THOUGH NOT A COMPLETE VANISHING

HISTORY

OBSTETRICAL PALSY WAS DESCRIBED FOR THE FIRST TIME BY AN OBSTRETICIAN, SMELLIE, IN 1764 DUCHENNE AND ERB IN 1852 MADE ACOMPLETE DESCRIPTION OF THE AFFECTION , .SINCE THEN; ORTHPEDISTS, NEUROLOGISTS, ETC, HAVE DISTINGUISHED THREE CLINICAL EVOLUTION PERIODS:

1) INITIAL: IN WHICH THE CHILD SHOWS A FLACCID PARALYSIS WITH HIS EXTREMITY AT THE SIDE OF HIS BODY IN INTERNAL ROTATION AND WITHOUT MOBILITY. MORO’S MANEUVRE CLEARLY SHOWS THE EFFECTS OF THIS LIMITATION. PARALYSIS OF EXTERNAL ROTATORS IS EVIDENT IN THE KERCHIEF OR SCARF MANEUVRE’ IT IS NOT OUR AIM TO DESCRIBE IN LARGER DETAIL THE PERIODS AND THE ALARM SIGNS (WHICH CONCERN THE PROGNOSIS) SUCH AS THE PARALYSIS OF THE DIAPHRAGM THE CLAUDE BERNARD HORNER SYNDROME THE ALTERATIONS IN THE SYMPATHICUS..

2) DELIMITATION: SHOWED BY THE PROGRESSIVE RECOVERING OF THE GLOBAL MOBILITY OF THE EXTREMITY, BY THE END OF A 90-DAY PERIOD

3) SEQUELAES OR DEFECTIVE ATTITUDES: WHICH, GIVEN THEIR CHARACTERISTICS, ARE RELEVANT TO THE PATHOLOGY UNDER ANALISYS WE ANALIZE AN INTERESTING TECHNIQUE AIMING TO SOLVE THE MOST IMPORTANT PROBLEMS AS HAVE BEEN ALREADY SHOWN AS THE LIMITATION OF THE EXTERNAL ROTATION , THE RAISING OF SHOULDERS AND GLOBAL ALTERATIONS WHICH WE BELIEVE SHOULD BE TREATED SINCE THE MOMENT THE DIAGNOSIS IS MADE. .

. MATERIAL AND METHODS

TOTAL CASES: 432 (1973-1999)

CASES ANALYZED 135 (31,25 %)

CASES WITH DRAWN ARE 297 (68,75%) FOR DIFFERENT REASONS THAT WERE DISCARDED

THERE ARE ANALIZED ONLY VIRGIN CASES WE WERE LEFT THEN WITH A TOTAL OF 135 CHILDREN WITH AN OBSTETRICAL PALSY DIAGNOSIS, WHO WERE CHECKED DURING AN AVERAGE PERIOD OF 6.5 YEARS (RANGE BETWEEN 3 AND 10 YEARS).

FROM THE VARIETIES COMMONLY DESCRIBED WE FOUND: 22 CASES

(16.30) OF TOTAL TYPE (C5-6-7-8-T1) (DEJERINE-KLUMPKE), 86 CASES (63.70) OF UPPER TYPE (C5-C6) (ERB), AND 27 CASES (20%) OF UPPER AND MEDIUM TYPE (CS-C6-C7) (3,6,18,19].

SEX: 87 MALE (64.44%), 48 FEMALE (35.. 55%)..

SIDE

THE INJURY OCCURRED MORE FREOUENTLY ON THE LEFT SIDE (93 CASES (68.89%]) THAN ON THE RIGHT SIDE 42 CASES ( 31.11%). ALL CASES WERE UNILATERAL. (TABLE III).

THE AGE INCLUDED IN THE CASES TREATED RANGED FROM 13 DAYS TO 10 YEARS.

WE DIVIDED THE PATIENTS INTO TWO CATEGORIES: ACUTE (LESS THAN 2 MONTHS OLD)₅

AND SEQUELAR (ABOVE TWO MONTHS).

IN ORDER TO HAVE A PREVIOUS APPRAISAL OF RESULTS, WE CHECKED THE PASSIVE MOBILITY AT THE FIRST EXAMINATION AND THE( CLINICAL EVALUATION) SUBSEQUENT MOBILITY AT 3O, 90 AND 120 DAYS AS FROM THIS FIRST EXAMINATION.

OUT OF THE AGE GROUP BETWEEN 2 AND 10 YEARS WE EXAMINED THOSE WHO HAD RECEIVED SURGICAL TREATMENT, AFTER HAVING CHECKED THEIR PRE-SURGICAL MOBILITY . THUS THE DISTINCTION BETWEEN PRE AND POST-SURGICAL KINESITHERAPY. WE WISH TO HIGHLIGHT THAT THE SURGERY PERFORMED WAS THE MODIFIED SEVER, SUCH AS WE HAVE BEEN DOING SINCE 1974 THE DESCRIPTION OF THE THREE EVOLUTION PERIODS (DETAILED HEREINBEFORE) IS NOT SIGNIFICANTLY DIFFERENT FROM THE ONE TYPICALLY FOUND IN THE LITERATURE ON THE SUBJECT; THE MAIN DIFFERENCE BEING THE DURATION OF THE PERIODS. WE BELIEVE THE INITIAL PERIOD LASTS JUST 3 MONTHS, AND THAT AS FROM THEN ON THE CHILD WILL HAVE SEQUELAES OF DIFFERENT DEGREES (DELIMITATION) TILL THE TIME THESE ARE ESTABLISHED (WITHIN ABOUT 3 YEARS). BUT ONCE THIS REGRESSION PERIOD IS OVER, THE SEOUELAE WILL UNFAILINGLY BE FINAL.

THEREFORE, WE HAVE DEVOTED OURSELVES TO THE INVESTIGATION AND TESTING OF A TECHNIQUE WHICH WILL REDUCE THE SEQUELAE AS EFFICIENTLY AS POSSIBLE.

LEVEUFF DESCRIBED THE PARADOX MANOUVRE: AS THE HIPERTONICITY OF THE MUSCULAR GROUP WHICH BECOMES FIBROTIC .THE SUBSCAPULARIS MUSCLE BEING THE MOST IMPORTANT SINCE IT COMPLETELY ALTERS THE VOLUNTARY MOVEMENT OF THE SHOULDER. THIS FIBROTIC RETRACTION FIXES THE HUMERUS AGAINST THE GLENOID CAVITY IN SUCH A WAY THAT WHEN TRYING TO MOVILIZE THIS -AT A CERTAIN POINT WILL HAVE TO BE PERFORMED THROUGH THE PENDULAR OSCILLATION OF THE SCAPULA, BY MEANS OF A SCAPULOTHORACIC MOVEMENT . THIS MOVEMENT IS, TO OUR BELIEF, OBVIOUSLY PRODUCED BY THE EARLY RETRACTION OF THE SUBSCAPULARIS MUSCLE, THIS BEING THE KEY MUSCLE IN THE OBSTETRICAL INJURY OF THE UPPER EXTREMITY.

III.EXAMINATION PROCEDURE ---NEW PROCEDURE

ONCE THE PATIENT IS IN DORSAL DECUBITUS, THE SCAPULA IS FIXED (THE THUMB RESTS ON THE FRONT SIDE OF THE THORAX WHILE THE REST OF THE HAND MAKES CONTACT WITH THE SCAPULA BY THE BACK PORTION),AND THE ELBOW AND SHOULDER OF THE PATIENT IS TACKING TO A 90 DEGREES ANGLE THUS, A MANEUVER IS PERFORMED WHICH TAKES THE EXTREMITY TO A COMPLETE EXTERNAL ROTATION, WITHOUT ANY KIND OF OBSTRUCTIONS. .

WHEN TRYING TO LEAD THE EXTREMITY TO THE EXTERNAL ROTATION IT CAN BE EASILY FELT THAT AT ABOUT THE 100-120 DEGREE ANGLE THERE IS AN ELASTIC RESISTENCE WHICH, WHEN FORCED, MAKES THE SCAPULA MOVE IN ITS SCAPULOTHORACIC ARTICULATION.

IN OUR OPINION, THIS IS THE CONSEQUENCE OF THE SUBSCAPULARIS RETRACTION.

KINESIC PROCEDURE SUBSCAPULARIS MANEUVRE IN KINESIC THERAPY THE ARM SHOULD BE FORCED ATTEMPTING TO BEAT ELASTIC RESISTANCE, AND AS CLOSE AS POSSIBLE TO THE BED PLANE (180 TECHNIQUE IS TAUGHT TO RELATIVES SO THAT THEY WORK AT HOME

IV. SURGERY TECHNIOUE filmacion

AN AXILLARY INCISION IS PERFORMED FROM THE FRONT PILLAR OF THE AXILLA TO THE BACK PILLAR (FIG.13). FIRST A DISECTION IS PERFORMED ON THE FRONT SIDE BETWEEN THE DELTOID AND THE MAJOR PECTORAL. THIS LATTER IS PALPATED IN ORDER TO CHECK ITS RESISTENCE AND CAN BE PARTIALLY SECTIONED (AT THE BEGINNING IT WAS COMPLETELY SECTIONED.. NOWADAYS, IN MOST CASES, NOT EVEN PARTIAL SECTIONS ARE INDICATED).

THE DISSECTION IS MADE DEEPER IN ORDER TO FIND THE GROUP OF CORACHOBRAQUIAL MUSCLES (MINOR PECTORAL, BICEPS -SHORT HEAD-AND CORACHOBRAQUIAL) (FIG.14),

WHICH, ONCE LOCATED, AREFOLLOWED TO THEIR INSERTION AT THE CHORACOID, WHERE THEY AREMETICULOUSLY SECTIONED AT THEIR VERTEX. IT IS NOT NECESSARY TO SPUD THE BONE, BUT IT IS IMPORTANT TO BE CAREFUL WITH THE CASSERIO'S PERFORANS NERVE (MUSCLECUTANEOUS) WHICH GOES THROUGH THE CORACHOBRACHIAL AT THIS POINT.

THE ABOVE PROCEDURE AIMS TO ALLOW THE CORRECT VISUALIZATION

OF THE SUBSCAPULARIS WHICH APPEARS AT THE BOTTOM OF THIS DISSECTION WITH A UNMISTAKABLE PEARL-COLORED ASPECT, AND WHICH HINDERS OR LIMITS THE EXTERNAL ROTATION MOVEMENT (FIG 15).

COMPLETE SECTIONING OF THIS MUSCLE SHOWS THE FREEDOM OF THE EXTERNAL ROTATION. SECONDLY, THE BACK PART IS DISSECTIONED, LOOKING FOR THE JOINT TENDON OF THE LATISSIMUS DORSI AND TERES MAJOR (FIG16) AND PERFORMING ITS SECTION FOR A BETTER MOVEMENT OF THE EXTREMITY.. THIS IS PROVED BY INTRASURGICAL PROCEDURES, WHICH SHOW THE FREEDOM IN INTERNAL MOVEMENT AND ABDUCTION. SUTURE IS PERFORMED BY PLANES AND A THORACHOBRAQUIAL CAST IS PLACED IN A POSITION OF MAXIMUM ABDUCTION WITH ARM AND FOREARM IN SUPINATION.. THE CAST IS LEFT FOR 30 DAYS, AND IMMEDIATELY AFTER ITS WITHDRAWAL, WE START WITH THE PASSIVE AND ACTIVE MOBILIZATION THROUGH THE SUBSCAPULARIS PROCEDURE, PERFORMED AS DESCRIBED HEREINBEFORE (FIG. 17-18-19)

1) RESULTS: ACUTE AND NON-SURGICAL

GLOBAL IMPROVEMENT MAY BE SEEN AT THE CHART, IT BEING OF 106 DEGREES P < 0.001

THE INTERNAL ROTATION WAS 12,5 DEGREES IN THE FIRST EXAMINATION,AND 120 DAYS LATER THE EXAM SHOWED A MOBILITY OF 119 DEGREES.

2) RESULTS: SURGICAL SEQUELAR

. THE FINAL IMPROVEMENT WAS OF 67 DEGREES P <~ 0.()01. TABLE IX.

THE INTERNATAL ROTATION AT THE FIRST EXAMINATION WAS OF 80 DEGREESAND 120 DAYS LATER WAS OF 147 DEGREES.

THIS REPRESENTS AN IMPROVEMENT IN USEFUL MOVEMENT AND

OF THE RELEVANT FUNCTION.

CONTINUES WITH KINESIC TREATMENT.

THE TOTAL NUMBER OF OPERATED PATIENTS WAS 108 (29~%) OUT OF THE 432 CASES..

VII. DISCUSSION

WE BELIEVE THE UTILIZATION OF THE TECHNIQUE DESCRIBED IS VERY IMPORTANT IN THE CLINIC EXPLORATION OF OBSTETRICAL PALSIES.

IT IS ALSO RECOMMENDED IN KINESIC THERAPIES FOR SUCH AFFECTION, AS A MEANS OF AVOIDING EARLY RETRACTION OF THE SUBSCAPULAR IS MUSCLE, WHICH IS RELATED TO THE GLOBAL MOBILITY OF THE EXTREMITY.. MOBILITY IS QUICKLY AND SIGNIFICANTLY IMPROVED WITH THE UTILIZATION OF THIS TECHNIQUE.

IT IS IMPORTANT TO APPLY IT DURING A LONG PERIOD.. OUR STATISTICS GO –UP TO NOW- TO AN AVERAGE OF 6.5 YEARS SINCE IT WAS FIRST USED AND WE ARE CONVINCED OF ITS BENEFICIAL

VIII .CONCLUSION

THE IMPORTANCE OF SUBSCAPULARIS MUSCLE AS A KEY FACTOR IN OBSTETRICAL PALSY IS STRESSED. A NEW TECHNIQUE IS DESCRIBED FOR THE EARLY DETECTION AND TREATMENT OF SUBSCAPULARIS MUSCLE RETRACTION.

THIS TECHNIQUE HAS BEEN USED FOR THE INITIAL TREATMENT OF OBSTETRICAL PALSY.

FOLLOW-UP OF 135 PATIENTS AFTER 6.5 YEARS REVEALS SIGNIFICANT IMPROVEMENT. ITS USE IS RECOMMENDED IN ORDER TO DIMINISH THE INCIDENCE OF SURGICAL PROCEDURES.

ALSO, AS A PART OF PRE AND POST SURGICAL KINESITHERAPY, IT SHOWS SIGNIFICANT IMPROVEMENTS AFTER SURGERY