Triangle tilt surgery in an older pediatric patient with obstetric brachial plexus injury

Abstract

Children with an obstetric brachial plexus injury have an elevated risk of long-term impairment if they do not fully recover by the age of 3 months. Persistent nerve damage leads to muscle abnormalities and progressive muscle and bone deformities. Several procedures have been described to treat this severe deformity. We have demonstrated the benefits of the triangle tilt procedure in young children with a mean age of 6.4 years (2.2 to 10.3), yet the treatment of humeral head subluxation secondary to obstetric brachial plexus injury represents a challenge in older pediatric patients. This case report demonstrates the effectiveness of triangle tilt surgery for the treatment of glenohumeral joint deformity in a 12 year old pediatric patient with left sided residual brachial plexus injury. The patient in this study showed noticeable clinical improvements, an improvement in glenohumeral joint dysplasia, and a reduction in humeral head subluxation 2 years after triangle tilt surgery. There was functional improvement 25 months after surgery. The patient's total Mallet score for shoulder function improved from 14 to 20 (of 25). In this case report, we demonstrate that the triangle tilt procedure can be used for older pediatric patients without modification. This observation has provided valuable information and is, to our knowledge, the first documented improvement of a glenohumeral joint deformity in an older pediatric patient. Future studies will be needed to determine the long-term success of triangle tilt surgery in this age group.

Figure 1

Axial computerized tomographic scans of the affected shoulder: 5.5 months before surgery (left) and 25 months after surgery (right) showing improved posterior humeral head subluxation (‐11% to 34%) and glenoid retroversion (‐53° to ‐22°). Both scans are at the level of the humeral head and have been chosen to best represent the relationship between the humeral head and glenoid.

Figure 2

Arm appearance and shoulder function before and after triangle tilt surgery. Preoperative (a–c) images were taken the day before surgery. Postoperative (d–f) images are 5 months after surgery and show improvements that were maintained at last follow-up (25 months). Three positions are shown: resting position (a, d), supination showing improvement due to improved shoulder position (b, e), and the Mallet and hand-to-mouth movements (c, f).