Journal of Children's Orthopaedics

, Volume 10, Issue 6, pp 665–672 | Cite as

Evaluation of functional outcomes and preliminary results in a case series of 15 children treated with arthroscopic release for internal rotation contracture of the shoulder joint after Erb’s palsy

  • Mohamed Mansour Elzohairy
  • Adel Mohamed Salama
Open Access
Original Clinical Article



The purpose of this study was to evaluate shoulder function following minimally invasive subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release in children with Erb’s palsy.


A prospective study was conducted on 15 consecutive children who underwent subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release to treat internal rotation contracture of the shoulder joint after Erb’s palsy. Age at surgery ranged from 24 to 38 months (average 28.3) (2.4 years). All of the patients were assessed clinically and radiologically preoperatively and postoperatively at regular intervals. The Mallet scoring system was used to analyze the results.


The mean external rotation improved from −24° to +46° (p = 0.001) at the last follow-up. Active internal rotation was preserved in all cases. At the final follow-up, there had been no loss of the external rotation gained and no recurrence of internal rotation contracture of the shoulder, and the mean Mallet score (total) had improved from 11 to 17 points (p = 0.001).


In children aged from 1 to 3 years, an arthroscopic release procedure alone may successfully restore function and yield a centered glenohumeral joint, which has a beneficial effect on glenoid remodeling.

Level of evidence

Level IV.


Arthroscopic Release Internal rotation Contracture Shoulder joint Erb’s palsy 


Shoulder dysfunction in infants who suffer brachial plexus injuries as a result of C5/C6 upper trunk lesions leads to an imbalance between the medial rotators of the shoulder (which are relatively unaffected) and the lateral rotators of the shoulder [1, 2, 3]. Therefore, associated internal rotation myostatic contractures of the subscapularis and pectoralis major with significant periarticular capsuloligamentous tightness can often develop, which require release [2, 4]. These soft-tissue imbalances around the glenohumeral articulation, if left untreated, will result in secondary dislocation or subluxation and a fixed articular deformity of both the humeral head and the glenoid with overgrowth of the coracoid [5]. Recently, arthroscopic release has been performed in young children for the anterior glenohumeral ligaments, capsule, and upper intra-articular subscapularis tendon, with or without tendon transfer(s), to restore external rotation and abduction of the shoulder and subsequently improve the morphology of the glenohumeral joint [6]. The aim of the present study was to evaluate minimally invasive subtotal subscapularis muscle and periarticular capsuloligamentous arthroscopic release alone (i.e., without tendon transfer) for the treatment of internal rotation contracture of the shoulder joint due to Erb’s palsy, and to compare this procedure with other relevant methods reported in the literature. The Mallet score was used to evaluate functional outcome [7, 8].

Materials and methods

This prospective study was conducted from January 2009 to December 2014. Fifteen patients (9 boys and 6 girls) were operated on for internal rotation contracture of the shoulder joint due to residual Erb’s palsy. The average age of the children at surgery was 28.3 (24.2–38.1) months (2.4 years). Clinical follow-up was carried out monthly in all children, which involved recording the range of movement for both shoulder joints. Combined abduction and anterior flexion was measured while the child was playing. Rotation was evaluated based only on passive movements as it is difficult to quantify active movements in children. Passive external rotation was measured preoperatively and postoperatively with the arm by the side of the body. The Mallet classification score was used to assess upper extremity function in children with brachial plexus birth palsy (Table 1) [7, 8]. A rapid loss of passive external rotation between monthly examinations is indicative of progressive capsular and muscular contracture and the subsequent onset of subluxation or dislocation. The main indication for the surgical procedure was a passive external rotation of ≤0°. The second indication for it was an age of 1–3 years.
Table 1

Measurement of internal rotation by the Mallet score (functional parameter)

Hand to great trochanter

1 point

Hand to buttocks

2 points

Hand to L4

3 points

Hand to T12

4 points

Hand to T6 (normal)

5 points

Inclusion/exclusion criteria

Inclusion criteria were: children from 12 to 38 months (1–3.2 years) of age; unilateral; involvement of the C5, C6, and C7 nerve roots; patients received functional rehabilitation from 3 weeks of life and active and effective flexion of the elbow was recovered at between 3 and 6 months of age; and patients did not undergo surgery of the nerves or plexus (either neurolysis or neurotization) before or after the arthroscopic release procedure. Other patients who were above or below the specified age range or did not meet these criteria were excluded from the study. All surgeries were performed by the authors of this paper.

Operative technique

Under general anaesthesia, and without any traction apparatus, passive mobility was reassessed in the supine beach chair position. Passive external rotation (with the arm at the side and at 90° of abduction) and passive abduction of the shoulder were evaluated. After the landmarks had been identified (Fig. 1), a small-joint 2.7 mm 30° short arthroscope was used in all procedures. Using a 20G spinal needle, the glenohumeral joint was distended with about 20 ml of saline. Taking care not to go too low (to avoid injury to the articular surface), the posterior portal was created at the posterolateral corner of the acromion. The assistant held the arm at approximately 90° of abduction while applying longitudinal traction to overcome the joint contracture and to facilitate the entry of the arthroscope into the joint through the posterior portal. With the aid of a spinal needle, the anterior portal was arthroscopically visualized from the posterior portal. The anterior capsule, anterior glenohumeral ligaments, rotator interval, and subscapularis tendon were identified. An electrocautery vapor was introduced through the anterior portal (Fig. 2). The thickened superior and middle glenohumeral ligaments along with the upper intra-articular portion of the subscapularis tendon were released. Then the transition of the subscapularis tendon to its muscular portion was identified, and the release was continued to the capsule, taking care to preserve the inferior and lateral portions of the subscapularis tendon to maintain the active internal rotation (Fig. 3). An arthroscopic punch was then used to release the inferior glenohumeral ligament, taking care not to injure the axillary nerve (Fig. 4). Eventually, if passive external rotation of >70° was obtained, no additional release of the subscapularis tendon or the axillary pouch was deemed necessary. The postoperative immobilization was by shoulder spica cast at 90° of abduction and 70° of external rotation for 4 weeks. As soon as the plaster was removed, the rehabilitation program was started (see the video in the Electronic supplementary material, ESM).
Fig. 1

Anatomical landmarks with anterior and posterior portal identification; clav clavicle, Acr acromion

Fig. 2

An electrocautery vapor was introduced through the anterior portal; VC vapor cutter

Fig. 3

The subscapularis tendon to its muscular portion was identified, and release was continued solely to the capsule, taking care to preserve the inferior and lateral portions of the subscapularis tendon

Fig. 4

An arthroscopic punch was then used to release the inferior glenohumeral ligament

Statistical analysis

SPSS for Windows, version 16.0 (Chicago, IL, USA, 2007) was used for data analysis, and p > 0.05 was considered to indicate statistical significance.

The Wilcoxon signed-rank test was used to compare preoperative with final follow-up values in the present study.


The children were followed up for periods ranging from 26 to 59 (average 40.1) months (3.3 years). All cases were unilateral. In eleven of them, the C5 and C6 nerve roots were involved, while the C5, C6, and C7 nerve roots were involved in the other four. The mean parameters—the mean external rotation, the mean elevation, and the mean Mallet score (total)—were improved at the last follow-up. The mean percentage of the humeral head anterior to the middle of the glenoid fossa (PHHA) and the mean glenoid retroversion were improved at the last follow-up. No complications were observed in this series. Regarding the learning curve, the mean operative time decreased from an average of 60 to 37 min for the last case to be operated on, including patient positioning. There was no recurrence of the internal rotation contracture at the last follow-up (see Figs. 5, 6, and 7 and Tables 2 and 3).
Fig. 5

Evolution of external rotation with time (in months)

Fig. 6

Evolution of abduction with time (in months)

Fig. 7

Evolution of Mallet score with time (in months)

Table 2

The mean pre and postoperative last follow-up, angles and parameters






M.Pre. (PHHA)

M.Post. (PHHA)

M.Pre. GRV

M.Post. GRV



Mean value





15 %

45 %











M.Pre.Ex.Ro. mean preoperative external rotation, M.Post.Ex.Ro. mean postoperative external rotation, M.Pre.E. mean preoperative elevation, M.Post.E. mean postoperative elevation, Pre. PHHA mean preoperative percentage of the humeral head anterior to the middle of the glenoid fossa, Post. PHHA mean postoperative percentage of the humeral head anterior to the middle of the glenoid fossa, M.Pre. GRV mean preoperative glenoid retroversion, M.Post. GRV mean postoperative glenoid retroversion, M.Pre.M.S. mean preoperative Mallet score (total), M.Post.M.S. mean postoperative Mallet score (total),

* p > 0.05 or was considered to indicate a statistically significant difference

Table 3

Summary of the results of applying the present technique, and comparison of that technique with similar and other relevant surgical techniques reported in the last 10–15 years


Number of patients included

Type of surgery


(mean, years)

FU (years)

PHHA (%)

Glenoid retroversion






Kozin et al. [24]


Arthroscopic release (n = 28);

arthroscopic release/tendon transfer (n = 16)



19 ± 12

33 ± 12

−34 ± 15

−19 ± 13

Mehlman et al. [20]


Arthroscopic release (n = 34);

arthroscopic release/tendon transfer (n = 16)







Pearl et al. [22]


Arthroscopic release only (n = 15)



Arthroscopic release/late tendon transfer (n = 4)


Arthroscopic release/tendon transfer (n = 14)


Pedowitz et al. [23]


Arthroscopic release (n = 7);

arthroscopic release/tendon transfer (n = 15)


1 month (postop; imaging in spica cast)

15.6 ± 13.5

46.9 ± 11.2

−37 ± 2

−8 ± 8

Kany et al. [4]


Arthroscopic release/tendon transfer (n = 16)



Kokkalis et al. [6]


Arthroscopic release (n = 1)



Naoum et al. [25]


Carlioz proximal subscapularis release (n = 64)



Current study


Arthroscopic release (n = 15)



15 %

45 %





External rotation


Elevation (°)

Mallet score (total)









Kozin et al. [24]

2.9 ± 1.0

1.9 ± 0.4

−26 ± 20

47 ± 17

112 ± 28

130 ± 38

12.7 ± 1.6

17.1 ± 1.4

Mehlman et al. [20]





Pearl et al. [22]

Marked remodeling in 12 of 15 children with a pseudoglenoid deformity













Pedowitz et al. [23]

Kany et al. [4]

The average preoperative external rotation was −11.5° (0–20°), the internal rotation according to Mallet’s score was on average 2.3 points, and the average abduction and forward flexion was +62° (50–90°). In the immediate postoperative period, the passive external rotation was +65.5° (60–70°), with an average gain of +77° (70–90°). On follow-up, the external rotation was +54.5° (45–80°), internal rotation remained unchanged, and the gain in abduction and forward flexion averaged +150° (130–170°)

Kokkalis et al. [6]







Naoum et al. [25]

Improved by 52° (40–60°) at 6 months, but showed a gradual loss of improvement with time, reaching an overall improvement of 35° (25–45°) at last follow-up

Improved by 21° (15–45°) at 6 months and continued to improve right up to the last follow-up, at which there was an overall improvement of 31° (20–50°)

Improved by 0.58 points (0.4–0.9) at 6 months and continued to improve over time, reaching 0.6 points (0.45–0.95) at last follow-up

Current study







FU follow-up, PHHA percentage of the humeral head anterior to the middle of the glenoid fossa, External rotation passive external rotation with the arm at the side, Elevation active elevation against gravity (approximated by compelling the child to reach for objects overhead)


Several surgical techniques to achieve shoulder alignment and function after internal rotation contracture of the shoulder joint following Erb’s palsy have been described [6]. In most procedures, the external rotation is obtained by tenotomy, lengthening, or release of the prime internal rotators of the shoulder—the subscapularis or pectoralis major muscles. Strecker et al. [9] studied 16 cases treated by the L’Episcopo–Sever technique [10, 11] and noted an average reduction in the active internal rotation of the shoulder joint 39 months after the operation. In a cadaveric study by Ferrari [12] and Harryman et al. [13], they concluded that the capsuloligamentous structures are the main restraints on external rotation. Although tendon transfer operations can improve the range of motion, these operations do not restore the normal glenohumeral joint alignment long term [14, 15, 16]. In a study by Van der Sluijs et al. [17] in which 19 patients underwent open reduction with subscapularis tendon lengthening, there was a significant increase in the Mallet score, but 42 % of their patients later developed an external rotation contracture which did not improve over time. Significant decreases in glenoid retroversion after open reduction with tendon lengthening or transfer were reported [15, 18]. The authors reported improvement after a subtotal subscapularis muscle, capsule, and tight ligament arthroscopic release procedure for internal rotation contracture of the shoulder joint due to Erb’s palsy with or without tendon transfer [4, 20, 21, 22, 23, 24]. In a study by Pearl et al. [22] in which they studied 33 children with a mean age of 3.7 years who were treated with arthroscopic release with or without latissimus dorsi tendon transfer, they reported improvements in passive external rotation of up to 45° in all but one patient after the arthroscopic release. Pearl et al. [22] concluded that, in children up to 3 years of age, arthroscopic release alone effectively restores near-normal passive external rotation and a centered glenohumeral joint at the time of surgery. The authors reported rapid remodeling of the glenoid after the arthroscopic shoulder joint reduction [20, 21, 24]. Kozin et al. [19] studied 44 children with Erb’s palsy and reported significant improvement in both clinical and radiologic outcomes of shoulder joint function after arthroscopic release with or without tendon transfer to restore glenohumeral joint alignment. Those successful and promising results are in good accord with the results of the current study, as all patients in the present series were 1–3 years old, which was the main age group targeted for the arthroscopic release alone procedure.

In summary, there are many advantages of the arthroscopic release procedure, as it allows more precise identification of the coracohumeral, superior glenohumeral, and middle glenohumeral ligaments. At the same time, as much release as required and dynamic assessment can be performed under arthroscopic control. Unlike open techniques, this procedure can be repeated for revision without much difficulty or scar tissue, and also it prevents permanent glenohumeral deformation, which is not always reversible. However, this approach does have disadvantages and complications. The first relates to the learning curve of the surgeon, as the number of pediatric shoulder arthroscopies performed is currently very small. Second, an excessive loss of internal rotation strength upon subscapularis insertional release may necessitate internal rotation humeral osteotomy. Third, the proximity of the axillary nerve puts it at risk of injury. Fourth, anterior instability may be created with the release of the associated glenohumeral ligaments. The current study also had some limitations, such as the lack of a control group and the fact that the operating surgeon also performed the follow-up evaluation.


In conclusion, arthroscopic release alone yields good results in children aged from 1 to 3 years suffering from internal rotation contracture of the shoulder joint after Erb’s palsy. It has many advantages, as it addresses the primary pathology, associated with the capsuloligamentous structures. This procedure preserves the subscapularis and, at the same time, active internal rotation, so it prevents subsequent glenohumeral instability and later deformity.



We would like to express our sincere thanks to Dr. Ola Hegab and Dr. Ahmed Fatthay, Egypt, for their help and support during the preparation of this study.

Compliance with ethical standards

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1975 Helsinki Declaration as revised in 2000. Informed consent was obtained from the parents of all individual participants included in the study.

Conflict of interest

The authors did not receive grants or outside funding in support of their research or for preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Supplementary material

11832_2016_773_MOESM1_ESM.mp4 (39.1 mb)
Supplementary material 1 (MP4 39991 kb)


  1. 1.
    Goddard N (1993) The development of the proximal humerus in the neonate with particular reference to bony lesions around the shoulder. In: Tubiana R (ed) The hand, vol IV. W.B. Saunders Co., Philadelphia, pp 624–631Google Scholar
  2. 2.
    Ruchelsman DE, Grossman JAI, Price AE (2011) Glenohumeral deformity in children with brachial plexus birth injuries: early and late management strategies. Bull NYU Hosp Jt Dis 69(1):36–43PubMedGoogle Scholar
  3. 3.
    Pearl ML, Edgerton BW (1998) Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 80(5):659–667CrossRefPubMedGoogle Scholar
  4. 4.
    Kany J, Kumar HA, Amaravathi RS, Abid A, Accabled F, de Gauzy JS, Cahuzac JP (2012) A subscapularis preserving arthroscopic release of capsule in the treatment of internal rotation contracture of shoulder in Erb’s palsy (SPARC procedure). J Pediatr Orthop B 21(5):469–473CrossRefPubMedGoogle Scholar
  5. 5.
    Birch R (2002) Obstetric brachial plexus palsy. J Hand Surg (Br) 27(1):3–8CrossRefGoogle Scholar
  6. 6.
    Kokkalis ZT, Ballas EG, Mavrogenis AF (2013) Arthroscopic release of shoulder internal rotation contracture in children with brachial plexus birthpalsy. Acta Orthop Belg 79(4):355–360PubMedGoogle Scholar
  7. 7.
    Mallet J (1972) Obstetrical palsy. Rev Chir Orthop 58(Suppl 1):115–200 (in French) Google Scholar
  8. 8.
    Bae DS, Waters PM, Zurakowski D (2003) Relialiblity of three classification systems measuring active motion in brachial plexus birth palsy. J Bone Joint Surg Am 85:1733–1738CrossRefPubMedGoogle Scholar
  9. 9.
    Strecker WB, McAllister JW, Manske PR, Schoenecker PL, Dailey LA (1990) Sever–L’Episcopo transfers in brachial palsy: a retrospective review of twenty cases. J Pediatric Orthop 10:422–444Google Scholar
  10. 10.
    Sever JW (1918) The results of a new operation for obstetrical paralysis. J Bone Joint Surg Am 16:248–257Google Scholar
  11. 11.
    L’Episcopo JB (1934) Tendon transplantation in obstetrical paralysis. Am J Surg 25:122–152CrossRefGoogle Scholar
  12. 12.
    Ferrari DA (1990) Capsular ligaments of the shoulder. Anatomical and functional study of the anterior superior capsule. Am J Sports Med 18:20–24CrossRefPubMedGoogle Scholar
  13. 13.
    Harryman DT, Sidles JA, Harris SL, Matsen FA (1992) The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg (Am) 74:53–66CrossRefGoogle Scholar
  14. 14.
    Pagnotta A, Haerle M, Gilbert A (2004) Long-term results on abduction and external rotation of the shoulder after latissimus dorsi transfer for sequelae of obstetric palsy. Clin Orthop Relat Res 426:199–205CrossRefGoogle Scholar
  15. 15.
    Hui JH, Torode IP (2003) Changing glenoid version after open reduction of shoulders in children with obstetric brachial plexus palsy. J Pediatr Orthop 23:109–113PubMedGoogle Scholar
  16. 16.
    Van der Sluijs JA, van Ouwerkerk WJ, de Gast A et al (2002) Retroversion of the humeral head in children with an obstetric brachial plexus lesion. J Bone Joint Surg 84-B:583–587CrossRefGoogle Scholar
  17. 17.
    Van der Sluijs JA, van Ouwerkerk WJ, de Gast A et al (2004) Treatment of internal rotation contracture of the shoulder in obstetric brachial plexus lesions by subscapular tendon lengthening and open reduction: early results and complications. J Pediatr Orthop B 13:218–224PubMedGoogle Scholar
  18. 18.
    Waters PM, Bae DS (2008) The early effects of tendon transfers and open capsulorrhaphy on glenohumeral deformity in brachial plexus birth palsy. J Bone Joint Surg 90-A:2171–2179CrossRefGoogle Scholar
  19. 19.
    Kozin SH, Boardman MJ, Chafetz RS, Williams GR, Hanlon A (2010) Arthroscopic treatment of internal rotation contracture and glenohumeral dysplasia in children with brachial plexus birth palsy. J Shoulder Elbow Surg 19:102–110CrossRefPubMedGoogle Scholar
  20. 20.
    Mehlman CT, DeVoe WB, Lippert WC et al (2011) Arthroscopically assisted Sever–L’Episcopo procedure improves clinical and radiographic outcomes in neonatal brachial plexus palsy patients. J Pediatr Orthop 31:341–351CrossRefPubMedGoogle Scholar
  21. 21.
    Pearl ML, Edgerton BW, Kon DS et al (2003) Comparison of arthroscopic findings with magnetic resonance imaging and arthrography in children with glenohumeral deformities secondary to brachial plexus birth palsy. J Bone Joint Surg 85-A:890–898CrossRefPubMedGoogle Scholar
  22. 22.
    Pearl ML, Edgerton BW, Kazimiroff PA, Burchette RJ, Wong K (2006) Arthroscopic release and latissimus dorsi transfer for shoulder internal rotation contractures and glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg 88-A:564–574Google Scholar
  23. 23.
    Pedowitz DI, Gibson B, Williams GR, Kozin SH (2007) Arthroscopic treatment of posterior glenohumeral joint subluxation resulting from brachial plexus birth palsy. J Shoulder Elbow Surg 16:6–13CrossRefPubMedGoogle Scholar
  24. 24.
    Kozin SH, Chafetz RS, Barus D, Filipone L (2006) Magnetic resonance imaging and clinical findings before and after tendon transfers about the shoulder in children with residual brachial plexus birth palsy. J Shoulder Elbow Surg 15:554–561CrossRefPubMedGoogle Scholar
  25. 25.
    Naoum E, Saghbini E, Melhem E, Ghanem I (2015) Proximal subscapularis release for the treatment of adduction–internal rotation shoulder contracture in obstetric brachial plexus palsy. J Child Orthop 9(5):339–344Google Scholar

Copyright information

© The Author(s) 2016

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • Mohamed Mansour Elzohairy
    • 1
    • 2
  • Adel Mohamed Salama
    • 1
  1. 1.Orthopaedic Surgery departmentFaculty of Medicine Zagazig UniversityZagazigEgypt
  2. 2.ZagazigEgypt

Personalised recommendations