MISE AU POINT — CURRENT CONCEPT REVIEW

THE PARALYTIC SHOULDER OF THE ADULT BY NERVOUS LESIONS POST-TRAUMATIC PERIPHERALS

J. Y. ALNOT

SUMMARY : Paralytic shoulder secondary to posttrau- .

matic peripheral nerve lesions in the adult.
A critical review is presented of the indications for
nerve repair or transfer and for palliative operations
in the management of paralytic shoulder following
traumatic neurological injuries in the adult. Different
situations are considered : paralytic shoulder following
supraclavicular lesions of the brachial plexus, following
-
retro and infraclavicular lesions and following lesions
lesions In cases where shoulder function has not been
restored, palliative operations may be considered :
arthrodesis or, more often, derotation osteotomy of the
humerus which can be combined with transfer of the
teres major and latissimus dorsi.
II. Retro- and infraclavicular lesions of the brachial
plexus.
-
Twenty five percent of the lesions of the brachial plexus

to the terminal branches of the plexus (axillary , su- -

occur in the retro or infraclavicular region and involve
prascapular and musculocutaneous nerves) and finally the secondary trunks, most commonly the posterior
problems related to lesions of the accessory nerve and .
trunk Nerve repair should be performed early The .
the long thoracic nerve. shoulder may be affected owing to involvement of the
axillary nerve in cases of lesions of the posterior trunk,
I. Supraclavicular lesions of the brachial plexus. often associated with a lesion of the suprascapular
.
nerve Regarding the terminal branches (axillary, su -
In complete (C5 to Tl) lesions, the possibilities for prascapular and musculocutaneous nerves), spontane -
nerve repair or transfer are at best limited, and the ous recovery may be expected in a significant proportion
aim is to restore active flexion of the elbow. Palliative of cases but is often delayed (6-9 months), and the
opérations may be associated in order to stabilize the problem is to avoid unnecessary operations while not
shoulder. In case of a complete C5 to Tl root avulsion, unduly delaying surgical repair in cases where it is
amputation at the distal humerus may be considered
but is rarely performed combined with shoulder ar - .
indicated MRI may be useful to delineate those cases
where surgery is indicated : repair is usually performed
throdesis if the trapezius and serratus anterior muscles
are functioning. The shoulder may also be stabilized .
around 6 months following trauma Isolated lesions of
the axillary nerve may be repaired with good results
by a ligament plasty using the coracoacromial ligament . .
using a nerve graft The lesion may occur in combi -
In cases where the supraspinatus and long head of the nation with a lesion of the suprascapular nerve ; the
biceps have recovered, but where active external ro - latter may be interrupted at several levels. Proximal
tation is absent, function may be improved by dero - repair may be performed using a nerve graft ; distal
tation osteotomy of the humerus.
In partial C5,6 or C5,6,7 lesions, the indications for
nerve repair and transfer are wider, as well as the
indications for muscle transfers. In C5,6 lesions, a Service de Chirurgie Orthopédique et Traumatologique,
neurotization from the accessory nerve to the supras - Département de Chirurgie de la Main et du Membre Supé-
capular nerve gives 60% satisfactory results; this is also rieur, Centres Urgences Mains. Hôpital Bichat, 46 rue Henri
true following treatment of C5,6,7 lesions, whereas Huchard, F-75877 Paris cedex 18, France.
restoration of active elbow flexion is obtained in 100 % Correspondance et tirés à part : J. Y. Alnot.
Conférence donnée à la réunion de FAOLF, Louvain -la-
of cases in C5,6 lesions but only in 86% in C5,6,7
Neuve, mai 1998.

Acta Orthopædica Belgica, Vol. 65 - 1 - 1999

 L’ÉPAULE PARALYTIQUE DE L’ADULTE
lesions are more difficult to repair and may require
.
intramuscular neurotization Lesions of the musculo
cutaneous nerve may be repaired with good results using
.
a nerve graft Lesions of the axillary nerve may be seen
.
associated with lesions of the rotator cuff The treatment
varies according to the age and condition of the patient
and according to the condition of the cuff muscles and
tendons: in a young patient with avulsion of the
tendons from bone, cuff reinsertion is indicated ; in an
older patient, the cuff must be evaluated by MRI or
arthroscan, and repair is indicated unless the cuff tear
is not amenable to surgery or there is fatty degeneration
of the muscles.
Palliative surgery may be indicated in cases seen late
or after failed attempts at nerve repair. In cases with
isolated paralysis of the deltoid, transfer of the trapezius
to the proximal humerus or of the long head of the
triceps to the acromion may he performed depending
on whether active elbow flexion is associated with ante
.
or rétropulsion of the humerus In cases of deltoid
paralysis with paralysis of the external rotators, one
of these transfers may be associated with transfer of
the teres major and latissimus dorsi to the insertion
of the infraspinatus.
III. Paralytic shoulder with isolated lesions of the
accessory or long thoracic nerves.
The accessory nerve is vulnerable and often incurs
iatrogenic lesions. Excellent results may be obtained
by direct suture or nerve graft. In cases seen late or
after failure of repair, palliative operations may be
indicated, such as transfer of the levator scapulae or
rhomboid muscle. Paralysis of the serratus anterior due
to lesion of the long thoracic nerve may occur following
forceful movements or overloading of the shoulder
(haversack paralysis), in throwing sports or rugby.
Spontaneous recovery often occurs but is usually slow
(12-18 months). Palliative surgery may be considered
for cases seen late without recovery, with winging of
the scapula. Transfer of the pectoralis major or minor
has been advocated ; transfer of the latissimus dorsi
or teres major has also been advocated associated with
scapulopexia, which is the author’s preferred treatment.
Le développement des techniques de microchi-
rurgie nerveuse depuis ces 10 dernières années a
permis d’obtenir des résultats notables dans la
chirurgie des nerfs périphériques et du plexus
brachial.
11
The indications for this surgery will be based on
- anatomopathological lesions, emphasizing that
nerve surgery must always be done first, but that
secondarily or in parallel, palliative interventions
may be discussed.
Specific clinical pictures should be studied
according to the anatomic-pathological lesions and
three main chapters can be individualized:
- the paralytic shoulder as part of the lesions
supraclavicular nerves of the brachial plexus,
- the paralytic shoulder in the context of retro- and
infra-clavicular lesions of the brachial plexus and
especially of the truncal nerve lesions of the
terminal branches of the plexus, namely the axillary
nerve, the supra-scapular nerve and the muscular-
cutaneous nerve ,
- the paralytic shoulder in the context of isolated
- lesions of the nerves participating in the shoulder
function, spinal nerve (trapezius) and Charles Bell's
nerve (large serrated)
The monograph on traumatic paralysis
of the adult brachial plexus, J. Y. Alnot and
A. Narakas (7, 8) has gathered the opinion of many
authors and has reviewed the indications and the
results of this difficult surgery (11, 12, 26).
I. Paralytic shoulder in supraclavicular nerve injury
of the adult brachial plexus
The current evolution has been towards the repair
of nerve damage and the goal is to restore the best
possible function knowing that the recovery of the
bending of the elbow passes first, followed by the
function of the shoulder.
Without going back to the respective indications in
the C5-C6-C7-C8-T1 total paralysis or in the C5-
C6 or C5-C6-C7 partial paralysis it is necessary to
recall several points concerning the shoulder as part
of the overall plan nervous repair.
This nerve repair must be done every
whenever possible:
- on the supra-scapular nerve and the nerve
axillary
Acta Orthopædica Belgica, Vol. 65 - 1 - 1999
12 J. Y. ALNOT
- or, depending on the anatomo-pathological
lesions
only on the suprascapular nerve
It will not be necessary, however, to forget the
restoration of the pectoralis major muscle which
occurs after graft repair on the anterior part of
the first primary trunk and which intervenes in
the function of the shoulder.
The functional results are the result of muscle
reinnervation and in the repairs of the single
supra-scapular nerve, the abduction antepulsion
is rarely greater than 40-50 degrees.
The recovery of an active external rotation is
very important to clear the arm of the thorax,
allowing a better positioning and a better
bending of the elbow.
This flexion of the elbow is the first function to
restore and it should be noted that it contributes
to the stabilization of the shoulder by the long
portion of the biceps.
The assessment of shoulder function is difficult
in this context of radicular paralysis, but overall,
it will be necessary to assess, on the one hand
the stabilization of the shoulder and on the other
hand, the recovery of certain active movements.
Thus, we can say that we have obtained:
- a good result, if the shoulder is stable, with an
active mobility in external rotation of at least 30
degrees and an active elevation in the frontal or
sagittal plane of 40 degrees.
- a fairly good result, if the shoulder is stable
with active mobility in elevation in the frontal or
sagittal plane of at least 40 degrees, but without
or with very little active external rotation.
- a useful result, if the shoulder is only stabilized
without active mobility by differentiating,
however, the active stabilization by recovery of
the supraspinatus and infraspinal muscles at M2
or a stabilization occurring only actively when
flexing the elbow with therefore lower
subluxation reduction by
the long portion of the biceps. A possible
stiffening should also be specified,
participating in passive stabilization.
- a failure, if the shoulder is not stabilized.
1. In C5-C6-C7-C8-T1 total paralysis
(3, 4, 9)
a) The interest of nerve surgery is no longer to
defend, because on the one hand it allows to
recover some active mobility of the upper limb
and on the other hand it has an indisputable
effect on the pain by restoring certain afferences
sen - sitive at the level of the upper limb.
In 24% of cases, there is a root avulsion of all the
roots and only neurotization on the
musculocutaneous nerve is possible. No nerve
repair surgery can be performed for the shoulder
and palliative procedures will be discussed later
after recovery of active elbow flexion.
In other cases where there are one or two
graftable roots C5 or C5-C6 (Figure 1), the
option is not to disperse the fibers and perform a
graft on the anterior part of the first primary
trunk and if possible on the posterior part of the
first primary trunk in the case of two roots
transplantable. This graft on the posterior part
of the first primary trunk participates in the
resuscitation of the shoulder and it is also
necessary to graft the suprascapular nerve by
performing direct suture neurotization from the
terminal part of the spinal nerve.
The results in the literature and in our
experience show that in 82% of cases a recovery
of the active flexion of the M3 + -M4 elbow is
obtained and in 60% of cases a recovery of the
external rotation abduction at the level of
of the shoulder.
The use of the terminal part of the spinal nerve
with respect to the branches going to the upper
and middle bundles of the trapezius does not
alter the function of this muscle, as several
studies by Allieu, Alnot and Narakas have shown
(7); on the other hand these results are better
than a suprascapular nerve transplant from C5.
b) Palliative surgery
The first goal in the treatment of brachial plexus
palsy is to resuscitate the flexion of the elbow, but
this elbow flexion can only be done properly if
the shoulder is stable with active external
rotation allowing
 L’ÉPAULE PARALYTIQUE DE L’ADULTE 13

opinai at the bending of the elbow to be done without

CA C4
rubbing against the thorax.
Cs C5

Ce Ce
Stabilization of the shoulder is ensured mainly
by 3 muscles, the supraspinatus, the deltoid and
s.s the long portion of the biceps; the active external
ÜJ XC 7
*¥ Ci

Ce ¥ Ce
rotation is ensured by the sub-spinous and the
small round..
G.P.
A
'A YGP
r kf kf
/

R ?
0 * R
* Other elements come into play depending on the
MC M MC
associated lesions and sequelae of fractures or
Capsular retraction can stabilize passively
Fig. 1 a et 1 b
the shoulder emphasizing here that rehabilitation
This paralytic shoulder, whose function will always
be limited, must never seek to recover passive
mobility beyond 80 degrees of antepulsion and 30 to
Spinal Plexus cervical
40 degrees of external rotation. Palliative surgery at
the level of the shoulder finds its indications in the
failures of the nervous surgery, but also in
complement of this one and various situations can be
presented.-
C4
Spinal
¥ Cs
- the upper limb has paralysis
»
Cs

Ce total and definitive .

S.S C7 This case, which often occurred before the advent of
K
¥¥
Ce Cl
nerve surgery, is
* ¥
¥ currently frequent and it is a plexus
plexus
\ i complet avec avulsion radiculaire totale ne per-
K G. P ¥ \ i
xT
'

P-
MC
M
xt
D3
D

Ds
4

Fig. 1 c Fig. 1 d

Fig 1: .
- 1 a and 1 b. - Total paralysis with C7-C8-T1 avulsion and putting no repair by graft from
possibility of grafts from C5-C6 depending on the size and
appearance of the roots associated with spinal neurotization
- - upper scapular. If this size and this aspect are the root and where the neurotizations have failed.
- satisfactory, it is possible to bridge the posterior The shoulder is paralytic without any active muscle
- of the first primary trunk. outside the trapezius and large serratus with obvious
- - l: total paralysis with C6-C7-C8-T1 avulsion and grafts instability.
- from C5 associated with spinal neurotization - The injured person has a dangling upper limb,
- upper scapular.
insensitive and annoying, and the weight of the
- - 1 d: total paralysis with avulsion of all the roots. The only
possibility is neurotization directly on the musculo- upper limb results in a lower subluxation of the
cutaneous. shoulder with functional discomfort and
pains in the scapular girdle.
The problem of the conservation of this limb arises,
but experience shows that very few wounded (0.5
to 1%) require an amputation which will then be
made in the lower third of the humerus, associated
with an arthrodesis of the 'shoulder.
It must be emphasized that this amputation will not
solve the problem of possible painful phenomena
and that the injured must be warned. In the
majority of cases, the injured person wishes to keep
his or her upper limb and the question is

Acta Orthopædica Belgica, Vol. 65 - 1 - 1999

14 J. Y. ALNOT
to know if the shoulder should be stabilized while
it
there is no bending of the elbow.
Of course, striving for spontaneous capsular
retraction stabilization and a helical splint stage
should be attempted.
If this splint is effective, stabilization of the
shoulder by arthrodesis may be useful provided
that the large serrated muscle is present.
- paralytic upper limb with recovery
from elbow flexion to M3 + 4
The problem of the shoulder will arise depending
on the recovery or not of certain periarticular
muscles.
* the shoulder is paralytic without any muscle
active outside the trapezium and the large
serrated,
instability is evident with lower subluxation and
the weight of the upper limb causes functional
discomfort and pain.
Should stabilize the shoulder:
* by arthrodesis, the position of which must be
perfectly adjusted.
This arthrodesis should allow the movements of
the scapulothoracic to proceed with their
maximum amplitude in the most useful area.
The patient whose forearm and hand are
The paralytic must be able to put his hand in his
pocket or put it on a table so as to hold an object
and he must be able to squeeze an object against
the thorax, especially if the grand pectoralis has
recovered.
The ideal position, the scapula being in
anatomical position, corresponds, in general, to a
position of the humerus at 20 degrees of flexion,
30 degrees of abduction and 30 degrees of
internal rotation.
The approach is superior with a longitudinal
trans-deltoidal incision which gives an excellent
day on the articular cavity and the synthesis is
then ensured by 3 screws or by a plate or by an
external fixator and screws.
* by ligamentoplasty if the injured person wishes
maintain passive mobility in rotation.
A ligamentoplasty using the acro-ligament
mio-coracoid was described by Ovesen and
Acta Orthopædica Belgica, Vol 65 - 1 - 1999
,
Soejbjerg in 1988 (28) to treat lower shoulder
dislocations with transposition of the acromial-
coracoid ligament acromial insertion on the
trochin.
The modification that we propose is the transfer of
the coracoid insertion with the adjoining part of the
coracoid on the trochin which reduces the lower
subluxation and positions the shoulder in slight
external rotation with a
benefit when flexing the elbow.
• the shoulder is stabilized by the recovery of
supraspinatus muscle and long biceps with so
an active antépulsion at 30 or 40 degrees.
Two scenarios arise depending on whether the
injured person has recovered an active external
rotation or not.
In cases where there is no active rotation, bending
of the elbow is done by scraping the chest and the
arm must be released to allow better flexion.
The derotation osteotomy of the humerus is an
excellent intervention and greatly enhances the
recovery of the elbow flexors.
It is necessary to derail 30 to 40 degrees, so that the
elbow and forearm do not scrape the chest during
active bending movements while maintaining the
possibility of putting the arm on the chest and
abdomen.
In cases where there is active external rotation, no
additional indication is necessary.
2. In C5-C6 and C5-C6-C7 paralysis
The prognosis is dominated by the need to recover
a useful elbow and shoulder to allow the best use
of the hand which is no longer, as in the previous
cases, paralyzed but normal or partially reached.
(a) The indication of nerve repair must be given
early (2, 10, 22) because it is very often root
lesions or primary trunks in the scalenic region
with possibilities for nerve repair and obtaining
satisfactory functional results.
Depending on the number of graftable roots,
level of breakage and appearance and size
 L’ÉPAULE PARALYTIQUE DE L’ADULTE
from the root to the operating microscope, it will be
necessary to make a choice in the elements to be
repaired and to associate therein depending on the
cases of the complementary neurotisations or the
muscular transfers innervated by the intact roots
(figure 2).
spinai
C4
15
The therapeutic plan must be global by not
dissociating nerve surgery and the possibility of
palliative surgery.
In C5-C6 paralysis, nerve surgery or muscular
transfer allowed to recover in 100% of the cases
the bending of the elbow.
At the shoulder level, spinal neuroti-
supra-scapular allowed to obtain a good or very
good result in 60% of the cases, contrary to
C5-suprascapular grafts that gave only 25%
good or very good results.-

Cs .
In C5-C6-C7 paralysis, flexion of
/ Ce
elbow was recovered only in 86% of cases by this
s.s
n nerve surgery or muscle transfer and at the
X s s houlder neurotization surgery
C8 y,
of the suprascapular nerve gives identical results.
R

MC M
%
MC M n C5-C6 paralysis. The shoulder is a real
problem in these
Partial ralysies with however 60% of results

satisfactory by neurotization.
Fig. 2 a Fig. 2 b
In other cases, it will be necessary to move towards
palliative interventions:
Spinal
C4
Spinal
- - arthrodesis whose indications are enough
S
<T CA

- rare,
Cs
% Cs
+ Transfert - - Or derotation osteotomy that can be associated
% flexion coude
Ce

SS . with a muscle transfer using the large round and

C7 Û7
% the latissimus dorsal when they are present.
%
Ca /

R S' R

MÇ M MC
Fig. 2 c
Fig. 2 :
- 2a and 2b: C5-C6 paralysis with possibility of
grafting into
depending on the size and appearance of the roots.
If this size and appearance are satisfactory, it is
possible
to bridge the posterior part of the first primary trunk.
- 2 c: C5-C6 paralysis with a single graftable root
and graft on the anterior part of the first primary
trunk associated with neurotization of the spinal
nerve on the superior scapular nerve.
M
The technique described by L'Episcopo in
1939(24) consists in transferring both the tendon of
thelarge round and dorsal large postero-
Fig. 2 d external,but this technique often only limits the
internal rotation and acts only by tenodesis effect.
That's why we associate itat a derotation osteotomy of
20 to 30 degreesand fixing the muscles on the insertion
of the under -
- 2d: C5-C6 paralysis with avulsion of these two roots.
Elbow flexion is restored by muscle transfer
associated with neurotization of the spinal nerve on
the superior scapular nerve.
thorny.a) treatment in C5-C6 and C5-C6-C7
paralysis must therefore combine nerve surgery
and palliative surgery with results, in theseems,
very satisfactory on the bending of the elbow.The
shoulder poses, on the other hand, a real problem
and it is necessary, by multiple neurotizations and
palliative interventions, to recover the best
possible function.

Acta Orthopædica Belgica, Vol. 6 5 - 1 -

1999
16 J. Y. ALNOT
IL The paralytic shoulder in the context of
retro- and infra-clavicular lesions of the
brachial plexus and in the context of truncular
nerve lesions of the terminal branches, axillary
nerve, supra-scapular nerve and musculo-
cutaneous nerve
A. THE PARALYTIC SHOULDER IN THE
FRAMEWORK
RETRO- AND INFRA-CLAVICULAR
LESIONS
If, in traumatic palsy of the brachial plexus,
75% of the pathological lesions are root lesions
by supraclavicular lesions, 25% are retro- and
infra-clavicular lesions (1).
Trauma is diverse and nerve damage is often
associated with osteoarticular lesions of the
scapular girdle.
As for the nerve lesions, they sit at the level of
the secondary trunks behind and behind the
clavicle and pose difficult diagnostic and
therapeutic problems.
Secondary posterior trunk involvement is the
most common (50% of cases) with all degrees of
severity.
These lesions of the posterior lateral trunk are
associated in 30% of cases with lesions of the
antero-external secondary trunk.
As for the lesions of the anterolateral secondary
trunk, they are much rarer, exceptionally
isolated and exist in the total lesions with
rupture of all the trunks.
Nerve repair must be done early and will
depend on the anatomic-pathological lesions.
With regard to the shoulder, the lesions are
those of the axillary nerve in the context of the
posterior trunk lesion very often associated with
lesion of the suprascapular nerve.
Palliative surgery will only be considered
secondarily depending on the case.
B. THE PARALYTIC SHOULDER IN THE
FRAMEWORK OF NERVOUS LESIONS OF
THE TERMINAL BRANCHES, NERVE
AXILLARY, NERVE
SUPRA-SCAPULAR AND MUSCULO-SKIN
NERVE
Alnot, Jolly and Valenti (13) reported
first major round of graft repair
Acta Orthopædica Belgica, Vol. 65 - 1 - 1999
axillary nerve. They noted that, depending on the
trauma, the anatomo-pathological lesions could
range from grade 2 to grade 5 of Sun.
derland and that in many cases was occurring
spontaneous recovery.
Other authors [Coene and Narakas (19), Petrucci et
al (29), Sedel (32)] have subsequently reported
their experience; Alnot and Liverneaux (6) have, in
a recent article, reviewed this problem.
The whole diagnostic problem can be summed up
in two pitfalls to be avoided: to disregard a rupture
or to disregard a spontaneous recovery.
To ignore a break is not unusual since in about
11% of cases, the wounded have a shoulder of
almost normal mobility apart from a decrease in
strength.
This is the result of the particular physiology of the
muscles of the cuff and explains the relative
frequency of the lack of knowledge or the delay in
diagnosis, but does not justify any surgical
abstention.
Indeed, in addition to the loss of strength, the risk
of rupture by overworking of the muscles of the
legitimate headdress in these young subjects, the
nerve repair within a period of 6 to 9 months.
Ignorance of spontaneous recovery
pulled to unnecessary surgery. In
Indeed, especially in dislocations of the shoulder,
spontaneous recovery occurs in 75 to 80% of
cases, sometimes late and electromyography is
essential studying the three bundles of the deltoid,
specifying that recovery begins with the posterior
beam.
However 6 to 9 months is a long time and it would
be desirable to operate sooner and current studies
with MRI can, perhaps, allow by showing a
neuroma of interruption, to decide in a faster time.
Indeed, if the procedure is more than one year after
the initial accident, the chances of recovering after
nerve transplantation, a force at M5 without
muscular fatigability are less, but on the other
hand, the reduction of the operating delay risks
'lead to abusive surgical explorations on nerves
that can spontaneously recover between 6 to 9
months, which is why most statistics mention
interventions around the 6th month.
 L’ÉPAULE PARALYTIQUE DE L’ADULTE
- in the isolated lesions of the axillary nerve, with
rupture in the region of Velpeau's square hole, the
surgical procedure by two ways first, one delto-
pectoral and the other posterior to the posterior
edge of the deltoid allows to realize a nerve
transplant and to obtain good (M4) or very good
(M5) results in more than 65% of cases and a 22%
average result (M3).
- - In axillary nerve lesions associated with
suprascapular nerve lesions, the shoulder is
paralytic and the repair of both nerves is desirable.
- The difficulties sit on the supra-scapular nerve
which can be broken at different stages either in
the coracoid notch, or more distally at the level of
its terminal branches.
- A third approach is necessary and the possible
graft repair in proximal fractures becomes more
random during distal tearing and in some cases
intramuscular neurotization is required.
- - the associated rupture of the musculocutaneous
nerve does not pose, in general, no repair problem
with very satisfactory results by nerve graft.
- - finally, lesion of the axillary nerve may be
associated with
- not to other nerve damage but
- to rotator cuff lesions.
- These lesions greatly aggravate the prognosis, first
because they occur in older patients whose nerve
recovery potential is weakened and then because
they add to the paralysis of the deltoid muscle an
attack of other muscles of the shoulder.
- The association with a rupture either existing or
concomitant of the supraspinous muscle which is
then ineffective results in a poor functional result.
- Our attitude towards an associated headdress break
- to axillary nerve injury depends on the condition
- of the rotator cuff.
- In general, these are valid patients who do not
- feeling no trouble before the accident.
- Two scenarios then arise depending on the age
- of
the patient:
17
- if it is a relatively young patient who has bone
disinsertion of the muscles of the cap, the indication
of reintegration is formal.
- if it is an older patient, over the age of fifty, an
arthro-scanner or an MRI can assess the condition of
the muscles of the cap and the importance of the
rupture . If this rupture is reinsertion, with muscles in
stages O or I (Bernageau (17), we proceed to a
reinsertion then we follow the evolution of the axillary
nerve.If the rupture is not re-insertable with muscles
at stages 3 or 4 (amount of fat greater than or equal to
the amount of muscle) there is no indication to
intervene on the muscles of the cap if the patient did
not present disorders before the accident and it is
hoped to recover the state previous, either by
spontaneous recovery of the nerve
axillary, or by subsequent nerve graft.
A. PALLIATIVE SURGERY
The lesions of the axillary nerve should not be ignored
especially in young subjects and the nerve surgery is
the treatment of choice facilitated by the oligo-
fascicular structure of the nerve, by its constitution
predominant in motor fibers and by the proximity of
the effectors.
However, there are some failures or patients seen late
for which a palliative surgery is indicated.
In the case where the only deltoid is paralyzed, two
muscular transfers can be proposed, either the transfer
of the trapezium on the upper end
of the humerus according to Bateman (15, 16), that is
the trans-
Filling the long portion of the triceps according to
Sloaman.
The indications depend on the surgeons' preferences,
but in our experience, we must judge according to the
existence or not of an active retropulsion of the
humerus during the flexion of the elbow.
If the bending of the elbow is done with some
Active antepulsion, Bateman's trapezium transfer
seems to be a good indication (14, 23).
Léo Mayer (25) described the main intervention
vines and the technique has been modified by Lange
Acta Orthopædica Beigica, Vol. 65 - 1 - 1999
18
and Bateman in 1954 with fixation of the acromial
insertion and the outer quarter of the clavicle, as
low as possible on the humerus.
For our part, we use a longitudinal skin incision, a
booklet opening on the deltoid and a fixation of
the anterior part only of the acromion on the
trochiter in its external part, then closing of the
deltoid which will also be fixed to the trapezium
. The superficial situation of the accessory spinal
The postoperative immobilization is provided by a
thoraco-brachial for 4 to 6 weeks, followed by
reeducation.
When there is a retropulsion of the humerus and
therefore of the shoulder during the flexion of
the elbow, it seems logical to us to use the
transfer of the long triceps described by
Sloaman in 1916.
The skin incision is longitudinal along the posterior
border of the deltoid paralyzed and extended up
and forward to the tip of the acromion. The long
triceps is approached in the space between teres
minor and teres major respecting the nerve
radial and its branches.
The large calf tendon, surrounded by thick muscle
fibers, is cut flush with the glide of the scapula
and after release, the tendon can be brought into
contact with the acromion, either directly or by
passing it on. under the posterior head of the
deltoid and it will be fixed at the place where
the middle chief of the deltoid is inserted by
trans-osseous points.
This fixation and the postoperative immobilization
will be done with the abduction shoulder at 90
degrees, the elbow in extension.
The results of these two palliative procedures make it
possible to improve the function of the shoulder
with an abduction-antepul- sion which,
however, does not exceed 90 degrees.
When the paralysis of the deltoid is accompanied by
paralysis of the external rotators, we must
associate with the transfer of the trapezius or the
long portion of the triceps, a transfer of the
tendons of the big round and the latissimus dorsi
to the insertion of the sub- thorny.
If the shoulder is stiff, with impossible passive
external rotation, it is typically the indication of
a derotation osteotomy.
Acta Orthopædica Belgica, Vol. 65 - 1 - 1999
J. Y. ALNOT
III- Paralytic shoulder in the context of
isolated lesions of nerves participating in the
function of
shoulder: spinal nerve (trapezius) and nerve
Charles Bell (large serrated)
A. THE SPINAL NERVE
nerve (nerve accessorius) makes it particularly
vulnerable in any traumatic neck injury, but
the most frequent causes of this branch are
iatrogenic during ganglion dissection, exeresis
of benign tumors or simple ganglion biopsies.
These lesions pose medico-legal problems
and surgeons need to pay attention
very particular to the surgical approach of this
region even for a simple ganglionic biopsy (1).
Depending on the level of neck damage, there is
always a paralysis of the trapezius muscle and
sometimes
sternocleidomastoid.
Osgard found, like us, that all
patients have difficulty in dressing with a heavy
shoulder within hours of the procedure.
In the following days, scapular pain occurs with
frequent irradiation of the ooplatum and / or
arm.
After a month or two, the picture becomes typical
with the falling shoulder, atrophy of the
trapezius, the detachment of the scapula and
the lack of abduction beyond 90 degrees.
Registry repair is particularly
effective on this muscular nerve with a lesion close
to the effector [Osgard and Eskensen, Sedel
and Abois (13), Alnot and Aboujaoudé (2)] and
all these authors report, either by direct
suture, or especially by nerve graft of excellent
results. Some cases are failures or are seen
late, no longer allowing for nerve surgery, and
the possibility of palliative intervention such as
the transfer of the angular scapula
the technique recommended by Bigliani (3).
This procedure consists in removing the anchor
from its insertion on the superior-internal edge
of the scapula and transferring it to the
acromion.
 L’ÉPAULE PARALYTIQUE DE L’ADULTE
In the same way, the insertions of the rhomboid of
the small upper and posterior serratus are
tightened so as to avoid the tilting of the scapula
with, according to the authors, acceptable results
by decreasing the fall of the scapula and by
improving the abduction of the shoulder.
A. THE PARALYSIS OF CHARLES BELL'S
NERVE
(NERF OF THE LARGE DENTELÉ)
The involvement of Charles Bell's nerve with
paralysis of the large serrated muscle is a rare
pathology and the pathogenic hypotheses have not
been proven.
The nerve of Charles Bell which is perpendicular
to the roots of the brachial plexus is, as a rule, not
reached in the lesion mechanisms of the
paraplegia of the brachial plexus, but on the other
hand, it is sensitive to the lowering movements of
the megnon. shoulder, thwarted antepulsion or
exaggerated retropulsion.
All movements that brutally reproduce lowering
the stump of the shoulder or carrying heavy loads
on the shoulder (paralysis of the knapsack) or
pulling downwards by heavy loads carried at
arm's length are likely to damage this nerve.
Certain repetitive and daily actions can cause
nerve damage and several publications concern
the sportsman (9) with a risk in sports that require
armament thrown by a retropulsion followed by a
rapid antepultion, such as tennis, javelin, weight,
thrusts on the shoulder, like rugby.
Multiple physiopathogenic hypotheses have been
developed and, alongside inflammatory and viral
theories, the traumatic or microtraumatic theory is
that which is retained with a truncular lesion of
the nerve by elongation (4, 7, 8,
16).
Charles Bell's nerve can not support more than
10% of its length of rest and two lesions are
particularly suspected, on the one hand, between
the scalene muscles and on the other hand, at the
level of the
the 2nd coast pass.
Anyway, it's very often about lesions
types I or II of Sunderland, usually
19
regressive but with a long delay, a year or
18 months because of the length of the nerve.
There is no mention of nerve exploration at an early
stage, and it is difficult to form an opinion on this
subject, and no one at this time can say what are the
indications for neurolysis or repair of this nerve
except for iatrogenic lesions, especially during
ganglion dissection or costoclavicular parade
surgery (12, 18).
Nevertheless, a certain number of patients do not
recover and are seen a year or a year and a half after
the onset of paralysis. Palliative surgery is indicated
in view of functional disorders with shoulder blade
detachment during antepulsion movements,
limitation of mobility and decrease
of strength associated with pain in the effort (6).
Muscle transplants are intended to get as close as
possible to the normal physiology of the large
serrated muscle, but in practice, the active character
of the transplant is quickly lost by the effect of
passive tenodesis, by functional deficiency of the
transfer of a muscle. in an already unbalanced
shoulder or because of the problems of the insertion
of the transfer, its direction and its moment of
action.
The transfer of the pectoralis major was proposed,
by diverting one of its bundles extended by a graft
directly on the large dentate, like Tubby (15) or on
the spinal edge of the scapula. In 1987, Iceton and
Harris (42) reported 15
cases treated by the transfer of the sternal portion of
the pectoralis major extended by a strip of fascia
lata and fixed in transosseous level of the tip of the
scapula with, overall, satisfactory results in 9 cases.
The transfer of the small breastplate was described
by Chavez in 1951 and the entire distal insertion of
the muscle is diverted to the lower angle of the
scapula. Vastamaki in 1984 reported 6 cases with 5
good results (17).
The transfer of the dorsal dorsal reported by Dikson
and Lange and the transfer of the large round
described by Hass are part of mixed interventions
because very often they are associated with
scapulopexy.
Scapulopexy (5, 14) is the most
Acta Orthopædica Belgica, Vol. 65 - 1 - 1999
20
practiced and this is the one we recommend if,
during the initial clinical examination, the
hand held shoulder blade against the thorax
clearly improves the mobility and function of
the shoulder, which the patient can perfectly
see for himself.
The attachment of the scapula to the costal
grill is done at the spinal edge of the scapula
using nylon thread or wire interposing bone
grafts between the ribs and the scapula so as to
obtain an arthrodesis scapulothoracic.
The immobilization on a thoraco-brachialis
abduction, without any antépulsion for 2 to 3
months, followed by reeducation, allows a
stability of the scapula during the movements
of the scapulo-humeral and a very clear
improvement of the function .
CONCLUSION
In the context of posttraumatic peripheral
nerve lesions, the shoulder poses problems of
clinical diagnosis and therapeutic indication.
If there is no difficulty in recognizing a totally
paralyzed shoulder, it is not the same when
only one muscle is affected and it is necessary
to
then analyze in a precise way the various
functions
scapulohumeral and scapulo-
thoracic.
The current evolution has been towards nerve
surgery as a function of anatomo-pathological
lesions, emphasizing that this nerve surgery
must always be done first and secondarily, and
/ or at the same time
palliatives can be discussed, namely, ar-
throdesis, ligamentoplasty, muscle transfer and
Derotation osteotomy of the humerus.
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ResumeJ. Y ALNOT. Paralytic shoulder secondary to
post-traumatic peripheral nerve injuries in the adult.A
critical review of the indicias for nerve repair, the transfer
and palliative operations in the policy of the paralytic
shoulders after traumatic neurological injuries in the adult.
Different situations are considered: paralyticActa
Orthopædica Belgica, Vol. 65 - 1 - 1999
22 J. Y. ALNOT
shoulder after supraclavicular lesions of the plexus
brachialis, after retro- and infraclavicular lesions, after
lesions of the end branches of the plexus (n.axillaris, n.
suprascapularis and n. musculocutaneus) and then after
the lesions of the n. accessorius and the n. thoracicus
longus.
1. Supraclavicular injuries. With complete (C5 to Tl)
injuries, the possibilities for nerve recovery and / or
transfer are limited and the ultimate goal is to achieve
an active flexion of the elbow. Palliative operations
may be added to stabilize the shoulder. With full C5 to
Tl root emulsion, the
amputation of the distal humerus are contemplated but
this is rarely performed. It should be combined with
shoulder arthrodesis when the trapezius and serratus
anterior muscles function. The shoulder can also be
stabilized with one
ligament plastic, use the coraco-acro-
mial ligaments in case when the supraspinatus and the
biceps have been recuperated, but when active external
rotation is absent a derotation osteotomy can
of the humerus. For particle C5-6 or C5-6-C7 lesions,
the indications for nerve recovery and transfer are
broader, as are the indications for muscle transfers. In
C5-6 lesions, a neurotomization of the
accessorius nerve to the suprascapular nerve to give
60% satisfactory results. This is also the case for the
treatment of C5 to C7 lesions. When the active flexion
of the elbow is up to 100%
recovered in C5-6 injuries, this was only 86%
the C5-6-7 lesions. In cases where the shoulder
function could not be restored, palliative procedures
are indicated: arthrodesis or more frequent derotation
osteotomy of the humerus with a transfer of the teres
maior and latissimus dorsi.
2. Retro and inferoclavicular lesions of the plexus
brachialis.
29% of the lesions of the plexus occur in this zone and
affect the secondary strains, most frequently the
posterior truncus. A nerve recovery must occur
quickly. The shoulder can be affected by an injury of
the axillary nerve often in combination with an injury
of the suprascapularis. With regard to the end branches
of the plexus (axillaris, suprascapularis and
musculocutaneus), a spontaneous recovery can be
expected but often delayed (6 to 9 months). It comes
down to avoiding redundant procedures while an
urgent surgical recovery may be appropriate. MRI can
make sense to distinguish these cases. The recovery
surgery usually takes place around the sixth month
Acta Orthopædica Belgica, Vol. 65 - 1 - 1999
post trauma. Isolated lesions of the axillary nerve can be
repaired with a nervous system. This injury can be
combined with injuries of the suprascapular. The latter
can even be interrupted at different levels. A proximal
recovery with a nerve can be performed. More distal
injuries are already more difficult to repair and can be
require cular neurotonization. Injuries of the muscu-
locutaneus can be repaired with a nervous system, with
good results. Injuries of the n. axillaries can also be
combined with injuries from the rotator cuff. Treatment
varies depending on the age, general condition of the
patient and condition of the cuff muscles and tendons. In
a young patient with
avulsion of the tendons a cuff reincidence is indicated.
In the older patient, the cuff can be evaluated with an
MRI or an artro-CT and the recovery is indicated when
the cuff muscles are relatively well-preserved. If these
show a fat degeneration, surgery is contraindicated.
Palliative surgery can be
employed in these cases where the nerve recovery has
failed. In cases with isolated paralysis of the deltoid,
transfer from the trapezius to the proximal humerus or
from the long head of the triceps to the acromion can be
performed. This is determined by the active elbow
flexion depending on the anti-or retropulsion of the
humerus. In cases of deltoid paralysis with paralysis of
the exorotators
one of previous transfers is associated with transfer of
the teres maior and latissimus dorsi to the insertion of
the infraspinatus.
1. Paralytic shoulder due to isolated injuries of the n.
accessorius or the thoracicus longus. Pine tree.
accessorius is vulnerable and often suffers from
iatrogenic injuries. Excellent results can be achieved by
direct suture or nervous. In late cases or after failure of
nerve recovery, palliative procedures are indicated, such
as a transfer of the levator scapulae or m rhomboidus.
Paralysis
of the serratus anterior due to a thoracic injury to the
longus often occurs in the case of strong movements
such as rugby or shoulder overload (backpack paralysis).
This is sometimes also seen in throwing sports.
Spontaneous recovery happens often but slowly (12 to
18 months). Palliative surgery can be used in cases
where a wing of the scapula is too tedious. Transfer
from the pectoralis maior or minor
have been proposed. Transfer of the latissimus dorsi or
teres maior are also associated with a scapulopexy. The
latter is the preferential treatment of the author.