Pediatric Radiology (2022) 52:1648–1657

https://doi.org/10.1007/s00247-021-05180-y

MINISYMPOSIUM: SMALL PARTS AND MUSCULOSKELETAL ULTRASOUND

Ultrasound assessment of glenohumeral dysplasia in infants

Sarah J. Menashe 1 & Anh-Vu Ngo 1 & Marisa B. Osorio 2 & Ramesh S. Iyer 1

Received: 18 May 2021 / Revised: 10 July 2021 / Accepted: 2 August 2021 / Published online: 21 September 2021
# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Brachial plexus birth injury can lead to irreversible neuromuscular dysfunction and skeletal deformity of the upper extremity and
shoulder girdle, ultimately resulting in glenohumeral dysplasia. Diagnosis and treatment of affected infants requires a multi-
disciplinary approach in which imaging plays a vital role. While MRI is excellent for assessing both the shoulder and spine of
these children, it is costly and requires sedation and is thus typically reserved for preoperative planning. US, however, is
inexpensive, dynamic and readily available and provides excellent visualization of the largely cartilaginous glenohumeral joint.
As such, it has become a highly useful modality during early diagnosis and follow-up of children with brachial plexus birth
injuries. In this review, we describe the relevant anatomy of the glenohumeral joint, outlining the normal sonographic appearance
as well as providing tips and tricks for identifying and characterizing pathology.

Keywords Brachial plexus . Brachial plexus birth injury . Glenohumeral dysplasia . Infants . Magnetic resonance imaging .
Musculoskeletal . Ultrasound

Introduction
Brachial plexus birth injury has been reported to occur in 1.5–
4 per 1,000 live births, though some report the incidence has
been decreasing, possibly a result of an increasing rate of
cesarean sections [1–3]. Typically seen during vaginal deliv-
ery, downward traction on the infant’s head and neck com-
bined with partial obstruction of the shoulders by the maternal
pubis leads to predictable patterns of nerve injury [4]. Many
risk factors for brachial plexus birth injury have been de-
scribed and include shoulder dystocia, macrosomia, instru-
mentation during delivery, and gestational diabetes; some
children, however, present in the absence of known predispos-
ing conditions [2, 5].
The brachial plexus is primarily composed of anterior rami
originating from C5–T1 nerve roots, and provides sensory and
* Sarah J. Menashe
sarah.menashe@seattlechildrens.org
1
Department of Radiology, Seattle Children’s Hospital
and University of Washington School of Medicine,
4800 Sandpoint Way NE, MA.7.220, Seattle, WA 98105, USA
2
Seattle Children’s Hospital,
Medicine and University of Washington School of Medicine,
Seattle, WA, USA
motor innervation to the shoulder, upper chest, arm and hand.
Brachial plexus birth injury most commonly involves the up-
per trunks of the C5–T1 nerve roots, specifically C5–C6,
though isolated lower trunk injuries rarely occur [5, 6]. The
most common form of nerve injury — occurring in 70–90%
of children with brachial plexus injury — is neurapraxia, a
focal traumatic “stretching” injury without axonal disruption;
this typically resolves spontaneously, usually by 2–3 months
of age. However, the remaining 10–30% of these children
have residual impairment [7]. In 1987, the Narakas classifica-
tion divided obstetric birth palsies into four groups based on
the palsies observed clinically. Widely adopted in clinical
practice, each Narakas group corresponds with the level of
nerve root injury, whereby the higher the classification, the
more nerve roots are injured [8].
Unfortunately, brachial plexus birth injury can lead to irre-
versible neuromuscular dysfunction and skeletal deformity of
the shoulder girdle, which can include joint contractures, pos-
terior humeral head subluxation and glenohumeral dysplasia
[9–11]. The true incidence of glenohumeral dysplasia, a well-
recognized complication of brachial plexus birth injury in
children with persistent neurologic defect at 3 months, varies
widely in the literature [6, 12]. However, though a result of the
initial insult to the brachial plexus, glenohumeral dysplasia is
considered a separate and evolving pathology with respect to
the developing shoulder and can lead to significant shoulder
dysfunction and morbidity [13–15]. The pathophysiology of
Pediatr Radiol (2022) 52:1648–1657
glenohumeral dysplasia is not entirely understood but is
thought to be the result of an imbalance between the relatively
unaffected internal rotators and the paralytic external rotators,
such that when left untreated, posterior subluxation and even-
tual dislocation of the humeral head ensues [16]. As with the
pediatric hip joint, evolving joint incongruency hinders nor-
mal development of the glenoid, eventually leading to
glenohumeral dysplasia [17, 18]. Interestingly, more profound
nerve injury, and correspondingly higher Narakas classifica-
tion in the neonatal period, has been associated with less
glenohumeral dysplasia in older children; this is thought to
be a function of earlier surgical intervention in more severely
affected children [19].
Clinical presentation, treatment and imaging
algorithm
Our multidisciplinary brachial plexus injury clinic evaluates
infants starting at 1 month of age because the majority of
neurapraxic injuries have resolved by this time. Assessments
at each clinic visit include passive range of motion, active range
of motion and Active Movement Scale scoring, which grades
the infant’s ability to move the limb both with gravity eliminat-
ed and against gravity [20]. Infants are followed up at least
every 3 months to determine their recovery trajectory, and in-
terventions are based on the algorithm established by the
Hospital for Sick Children in Toronto, Canada [21].
Glenohumeral US screening typically begins at 3 months of
age because glenohumeral subluxation has been shown to be
present by this age. Infants are screened at 3 months and
6 months of age, regardless of clinical exam, and intervention
is based on humeral head alpha angle (as described later) and
passive range of motion. Unfortunately, the clinical exam is not
always predictive of shoulder subluxation, with many infants
exhibiting abnormal alpha angles despite having full passive
range of motion [19, 22]. If the alpha angle is greater than 40°
and there is restricted passive external rotation, infants undergo
manual shoulder reduction, injection of botulinum toxin A into
the pectoralis major, latissimus and subscapularis muscles, and
application of a shoulder spica cast for 6 weeks to maintain joint
reduction [23]. Of note, casting for glenohumeral dysplasia
involves abducting and externally rotating the shoulder, similar
to hip spica casting for developmental hip dysplasia. US is
initially repeated when the cast is removed to ensure appropri-
ate glenohumeral reduction, then again at 1–2 months post cast
removal to ensure the reduction is maintained.
Prevention of shoulder subluxation can be a challenging
endeavor for children with brachial plexus birth palsy. One
reasonable option to address this issue is a splinting protocol
developed at British Columbia Children’s Hospital called the
Sup-ER splint [24]. The splint is designed to keep the shoulder
passively positioned in glenohumeral reduction by supinating
1649
(Sup) the forearm and externally rotating (ER) the shoulder.
Our institution adopted the use of the Sup-ER splint, and we
employ US monthly to evaluate the glenohumeral relationship
both in and out of the splint to ensure the splint is maintaining
proper reduction. However, if the Sup-ER splint is unable to
maintain proper glenohumeral alignment and subluxation oc-
curs, the infant is placed in a spica cast (Fig. 1).
Ultrasound imaging
Imaging of infants with brachial plexus birth injury is done
primarily with gray-scale static and dynamic US and non-
contrast-enhanced MRI. CT has been used historically,
though it is no longer a preferred modality, particularly in
younger children and infants who are more susceptible to
the risks of ionizing radiation and in whom unossified carti-
lage is better visualized with other cross-sectional modalities
[5, 25]. MRI has the advantage of being able to evaluate mor-
phological changes of the glenohumeral joint and shoulder
girdle, in addition to allowing for accurate measurement of
many other established parameters of the bony and cartilagi-
nous glenohumeral joint. As such, MRI is considered the gold
standard in the preoperative assessment of glenohumeral dys-
plasia, and it is often performed in older infants or in more
advanced cases of dysplasia to delineate complex anatomy
[25]. Nevertheless, MRI has the distinct disadvantage of re-
quiring sedation outside of the neonatal period, the long-term
effects of which are poorly understood, in addition to being
more costly and, often, less available [26]. Thus, in neonates
and infants without severe palsy requiring immediate surgical
intervention, US may be used in the screening evaluation of
glenohumeral dysplasia. A rapid, safe, cost-effective, dynamic
and readily available modality, US is valuable in the early
assessment and follow-up of these children [4, 25, 27]. As
noted, in our multidisciplinary brachial plexus injury clinic,
US comprises the vast majority of imaging in infants with
suspected brachial plexus birth injury, and for routine
glenohumeral dysplasia monitoring to guide treatment
efficacy.
General approach
Ultrasound of the glenohumeral joint is performed from a
posterior approach with a high-frequency linear transducer
(e.g., 10–15 mHz). Infants are typically seated on the exami-
nation table facing away from the sonographer, head and trunk
supported by the caregiver, though the child might also be
placed in the lateral decubitus position. The arm is then
adducted against the body (i.e. elbow against the infant’s side
and wrist against the lower torso) with the shoulder in internal
rotation, to accentuate or unmask posterior glenohumeral sub-
luxation, if it is present. The probe is placed in a transverse
1650
Fig. 1 Casting. a Clinical image
of 5-month-old boy with upper
trunk brachial plexus palsy who
underwent glenohumeral
reduction, botulinum toxin
injections and placement of
shoulder spica cast to maintain
reduction. b Clinical image of a 3-
month-old girl demonstrates a
Sup-ER splint
oblique plane along the axis of the scapular spine (Fig. 2).
Both affected and unaffected sides are imaged to provide in-
ternal controls for comparison. If the child has undergone
splinting or casting, this is usually removed prior to imaging,
though both in- and out-of-splint imaging can be performed.
Two to three static images of the affected shoulder can be
helpful in ascertaining the humeral head alpha angle, and cine
sweeps through the joint can be performed either routinely or
only for troubleshooting purposes.
Sonographic evaluation of the humeral head with re-
spect to the scapula has been likened to that of the hip,
where evaluation of dysplasia is both reliable and repro-
ducible in experienced hands [28]. Conversely, a lack of
operator expertise can lead to false-negative or -positive
exams. It is therefore important that sonographers and
interpreting radiologists alike are trained in the optimal
Fig. 2 Clinical image shows glenohumeral US acquisition from the
posterior approach with the infant in the seated position, the arm
adducted, flexed at the elbow, and internally rotated with the elbow at
the infant’s side and the wrist along the lower torso. The US probe is held
in a transverse oblique plane in the axis of the scapular spine
Pediatr Radiol (2022) 52:1648–1657
positioning and imaging approach to these children.
Furtherm ore, the radiologist’s understanding of
glenohumeral anatomy and the expected evolution of
glenohumeral dysplasia is paramount for accurate
assessment.
Normal anatomy
With the probe in place posteriorly, the posterior scapular
spine is readily identified as a linear, highly echogenic struc-
ture, deep to which resultant acoustic shadowing precludes
visualization of deeper intrathoracic structures. At the lateral
margin of the scapula lies the bony glenoid; it is typically
echogenic with a sharp posterior margin or corner, similar
to that seen along the superolateral acetabular roof in the
pediatric hip. The normal glenoid fossa angles steeply away
from the transducer such that its anterior margin is difficult to
visualize from this posterior approach. The overlying
glenoid cartilage is a thin, homogeneously hypoechoic,
cap-like structure, which, along with the subjacent bony
glenoid, can be likened to a “steep cliff” on sonographic
images. Immediately superficial to the posterior corner of
the bony glenoid and the overlying cartilaginous cap, one
can identify the posterior component of the glenoid labrum,
a circumscribed, triangular, fibrocartilaginous structure that
is typically more echogenic than the surrounding subcuta-
neous tissues. Finally, the humeral head is recognized
more laterally as a round, largely hypoechoic structure
with a speckled echotexture that is similar to other epiph-
yseal cartilaginous structures. A central rounded
echogenicity with posterior acoustic shadowing might be
present soon after birth and reflects the normal ossifica-
tion center, a structure that increases in size during infan-
cy. The humeral head should be spherical in configuration
with smooth circular margins throughout. The soft tissues
superficial to the echogenic scapula at this level consist
primarily of the deltoid and infraspinatus muscles, though
portions of the supraspinatus might also be evident
(Fig. 3) [27].
Pediatr Radiol (2022) 52:1648–1657
Fig. 3 Normal glenohumeral joint. Transverse oblique US image in a 3-
month-old boy depicts the normal structures of the glenohumeral joint.
The large circle represents the margins of the unossified humeral head
Qualitative findings in glenohumeral dysplasia
The normal anatomy of the glenohumeral joint might be al-
tered in glenohumeral dysplasia and should be carefully scru-
tinized during the sonographic evaluation.
Humeral head
Humeral head morphology can be affected by glenohumeral
dysplasia, whereby progressive dysplasia can lead to humeral
head flattening or even growth arrest [10]. Comparison with
the contralateral side is useful in determining whether there is
true deficiency in humeral head size because the affected side
might be noticeably flatter or smaller than the unaffected side.
In most cases of mild to moderate dysplasia, the humeral head
retains its normal spherical configuration, though the affected
epiphysis might have less ossification than its normal contra-
lateral counterpart (Fig. 4). Importantly, if the humeral head is
imaged in external rotation, the greater tuberosity can come
into view, giving the spurious appearance of oblong or ovoid
Fig. 4 Glenohumeral joint in left arm palsy. a, b Transverse oblique US images of the glenohumeral joint in a 3-month-old boy with left arm palsy. Left-
side image (a) demonstrates a smaller humeral head epiphyseal ossification center when compared to the right (b)
1651
morphology to the posterior head, which can be mistaken for
dysplasia. Care should be taken to ensure the infant’s arm
positioning is optimal (i.e. shoulder in internal rotation) to
avoid this error (Fig. 5).
Glenoid and labrum
With progressive glenohumeral dysplasia, the
osteocartilaginous glenoid can become rounded or irregular
along its posterior margin and angle away from the transducer
less steeply than normal, turning the “cliff” into a more grad-
ual slope (Fig. 6). This appearance is analogous to the dys-
plastic hip, where the superolateral acetabulum has a blunted
appearance and the tectum becomes “shallow.” Similarly, the
posterior glenoid labrum might become irregular or
hypertrophied in appearance (Fig. 6). These findings should
be described in the imaging report; however, it is important to
keep in mind that only the posterior aspect of these structures
is well seen. If more comprehensive assessment is required,
particularly in older infants who are operative candidates,
glenohumeral morphology remains best assessed by MRI,
where glenoid shape can be categorized in the context of the
Birch classification system as concave-flat, convex or bicon-
cave [4, 29]. Such classification is important for surgical plan-
ning and can be difficult to assess by US.
Shoulder muscles
When there has been significant brachial plexus birth injury,
loss of bulk and fatty atrophy of the surrounding musculature
ensues, typically involving many of the muscles of the shoul-
der and chest, including the deltoid, supraspinatus,
infraspinatus, subscapularis, teres major and pectoralis mus-
cles [30, 31]. While readily depicted by MRI, portions of the
infraspinatus and deltoid muscles can also be visualized dur-
ing US examination of the glenohumeral joint; additionally,
portions of the supraspinatus can also be seen. As such, mus-
cular atrophy can be suggested on US, facilitated by
1652
Fig. 5 Suboptimal positioning during glenohumeral head imaging. a, b
Transverse oblique US images in a 5-month-old girl’s left glenohumeral
joint with the shoulder in maximal (a) and intermediate (b) external
rotation. In maximal external rotation (a), the greater tuberosity
(arrows) comes into view and creates an oblong appearance to the
comparisons to the unaffected shoulder or even more remote
images of the affected side. This might be evident as overall
decreased muscle bulk or increased muscle echogenicity, sug-
gestive of fatty infiltration (Fig. 7) [32]. Because muscle atro-
phy in this setting reflects sequela of nerve injury, this can take
time to develop and might not be identified in very young
infants or in children with milder dysplasia. Additionally,
asymmetrical arm positioning — whether iatrogenic or as a
result of dysplasia — can lead to perceived differences in
muscle bulk that might be inaccurate. For example, if the
unaffected side is less internally rotated, the deltoid might be
less stretched over the scapula and appear symmetrical or even
smaller than the affected side (Fig. 7).
Quantitative measurements in glenohumeral
dysplasia
Measurements of the glenohumeral joint that can be made on
US include the alpha angle and, in neonates, posterior humeral
Fig. 6 Glenoid and labrum. a Transverse oblique US image in a 1-year-
old girl with right-side glenohumeral dysplasia. Image of the right
shoulder shows a rounded configuration of the posterior glenoid margin
(solid arrow), a shallow visualized glenoid fossa (arrowhead) and an
irregularly contoured posterior labrum with heterogeneous echogenicity
Pediatr Radiol (2022) 52:1648–1657
humeral head, simulating posterior subluxation and apparent dysplasia.
In intermediate external rotation (b), the humeral head has a less
accentuated oblong configuration rather than the normal spherical
shape, which could still be falsely interpreted as dysplasia
head displacement. Some authors have used US to measure
glenoid version, or the degree of glenoid sloping as noted on
an axial images, as well [25].
Alpha angle
The humeral head alpha angle is obtained by drawing a line
along the posterior margin of the scapula and extending it
through the humeral head, then drawing a second line origi-
nating from the posterior glenoid margin and extending it
tangential to the posterior margin of the humeral head. The
angle that is formed along the posterolateral intersection of
these lines is the humeral head alpha angle. A normal angle
is considered approximately 30° or less, with angles greater
than 30° indicating increasing posterior subluxation of the
humeral head [12]. One must take care not to obtain this mea-
surement on an image captured in external rotation because
this can underestimate the alpha angle and result in a normal
angle measurement in children with mild dysplasia. Likewise,
(open arrow). b Transverse oblique US image of the normal contralateral
glenohumeral joint in the same girl is provided for comparison. Note both
the sharp margin of the posterior glenoid and the steep slope of the normal
glenoid fossa
Pediatr Radiol (2022) 52:1648–1657
Fig. 7 Shoulder muscles. Serial transverse oblique US images in an
infant girl with right-side glenohumeral dysplasia. a, b US images at
2 months of age show that although there is right brachial plexus palsy,
the right infraspinatus muscle (a) appears fairly symmetrical or even
larger than the normal left side (b). c An additional US image of the
in external rotation, the greater tuberosity, which is
posterolaterally located along the proximal humerus, comes
into view. This can mimic the posterior margin of the humeral
head and lead to overestimating the alpha angle (Fig. 8).
Posterior humeral head displacement
Posterior humeral head displacement can also be assessed by
sonography [28]. This calculation is similar to humeral head
alpha angle in that it is a metric for posterior uncovering of the
Fig. 8 Alpha angle. a, b Transverse oblique US images of bilateral
glenohumeral joints in a 3-month-old boy with left glenohumeral
dysplasia. The normal alpha angle of 25° in the right shoulder (a) is
obtained from the intersection of the posterior scapular line and the line
tangential to the posterior margin of the humeral head. Note that the
1653
right side at 7 months of age demonstrates an interval increase in
echogenicity and decrease in size of the right infraspinatus muscle,
consistent with fatty atrophy. d Axial dual-echo steady-state (DESS)
MRI sequence of bilateral shoulders at 10 months of age confirms the
atrophy of the right infraspinatus muscle
humeral head by the glenoid, but posterior humeral head dis-
placement is recorded as a percentage rather than an angle. To
make this measurement, the posterior scapular line is ex-
tended laterally through the entirety of the humeral head.
A perpendicular line is then drawn from the scapular line
to the posterior margin of the humeral head. That value is
divided by the greatest diameter of the humeral head, then
multiplied by 100, resulting in the percentage of the hu-
meral head that lies posterior to the scapular line. A nor-
mal value is considered less than 50% [28]. Posterior
posterior margin of the humeral head is appropriately rounded and
smooth, suggesting that the infant’s shoulder is internally rotated rather
than externally rotated, which might bring the irregular greater tuberosity
into view. The alpha angle on the affected left side (b) is 50°, indicating
posterior subluxation
1654
humeral head displacement is analogous to femoral head
coverage in the hip; however, this percentage refers to the
percentage of the uncovered humeral head rather than the
covered percentage that is typically reported for hips in
the setting of suspected dysplasia. Importantly, measure-
ment of posterior humeral head displacement outside the
neonatal period can be inaccurate because the humeral
ossification center grows rapidly in early life, resulting
in acoustic shadowing that limits visualization of the an-
terior margin of the humeral head. Thus, the humeral head
diameter might not be accurately measured, resulting in a
falsely exaggerated or underestimated posterior humeral
head displacement measurement (Fig. 9).
Glenoid version (glenoscapular angle)
While glenoid version measurements have been performed on
US, they have been shown to have relatively poor interrater
reliability when compared to MRI and are not routinely per-
formed at our institution [25]. Glenoid version is measured by
extending the posterior scapular line laterally through the
glenoid, then drawing a line tangential to the surface of the
glenoid. The angle created by these two lines as measured in
the posteromedial quadrant is then subtracted from 90; the
final number reflects the glenoid version. A negative value
indicates glenoid retroversion, a normal finding in children
younger than 8 years. Normal glenoid version angles range
from −23° to 8° (mean −4.2° ± 6.2°), though generally most
glenoid fossae are retroverted before the age of 2 years and
typically feature less than 10° of retroversion [33]. In more
advanced or complex cases of dysplasia where there is sub-
stantial glenoid retroversion or a biconcave glenoid and the
likelihood for surgery is high, MRI is more frequently per-
formed for glenohumeral assessment.
Fig. 9 Posterior humeral head displacement. a, b Transverse oblique US
images in a 4-month-old girl with shoulder contractures. The posterior
humeral head displacement is obtained by drawing a line parallel to the
scapular spine and measuring perpendicularly to the posterior margin of
the humeral head (solid line). This value is divided by the maximal
Pediatr Radiol (2022) 52:1648–1657
Magnetic resonance imaging
When presenting early with a significant brachial plexus
palsy, or when conservative treatment has failed and the
older infant presents with persistent shoulder dysfunction,
surgical treatment might be required to optimize upper
extremity function and minimize further deformity. MRI
should be performed in such cases of advanced dysplasia,
either in conjunction with or in lieu of US examination.
Both shoulders are imaged concurrently, allowing the un-
affected side to act as an internal normal control, with an
emphasis on a three-dimensional (3-D) gradient-recalled
echo (GRE) cartilage-sensitive sequence (i.e. dual-echo
steady-state [DESS]; Siemens, Erlangen, Germany)
(Fig. 10). This sequence offers qualitative assessment of
glenoid, labrum, humeral head and muscle morphology.
Quantitative measurement including alpha angle, glenoid
version and humeral head coverage can be readily per-
formed on this sequence, as well.
T1-weighted imaging is useful for marrow signal as well
as asymmetry of the shoulder soft tissues, as seen with
muscle atrophy. These findings, in aggregate, allow for
imaging grading of the glenohumeral deformity according
to the Waters classification, a system that is useful for
clinical and surgical planning [10]. Finally, the cervical
spine and brachial plexus nerve roots can be imaged simul-
taneously. This is facilitated with 3-D steady-state gradient
echo sequences (e.g., constructive interference in steady
state, or CISS), which allow for high contrast resolution
between cerebrospinal fluid and soft-tissue structures, with
submillimeter isovolumetric voxels to resolve nerve roots.
Such high-resolution cervical spine imaging provides ad-
ditional information about the levels of nerve root injury
and the presence or absence of pseudomeningoceles [4]
(Fig. 11).
humeral head diameter (dotted line) and multiplied by 100 to obtain a
percentage. The normal right side (a) has a posterior humeral head
displacement percentage less than 50%, a normal value, while the
affected left-side (b) posterior humeral head displacement percentage is
greater than 50%, considered abnormal
Pediatr Radiol (2022) 52:1648–1657
Fig. 10 MRI in advanced dysplasia. Axial dual-echo steady-state (DESS)
image in a 3-year-old boy with left glenohumeral dysplasia demonstrates
left glenoid retroversion (posteromedial sloping; dotted arrow) with
Surgical treatment
When surgery is required, the persistent weakness pattern,
Narakas classification and MRI findings are considered for
treatment planning. Infants with more than upper trunk in-
volvement, or in whom there is suspicion of nerve root avul-
sions or ruptures, should undergo nerve reconstruction. Often
with the surgical dissection, a neuroma involving one or more
nerve roots at the trunk level of the brachial plexus is found.
This is removed and replaced by sural nerve grafts that allow
for axon regeneration and reorganization to achieve sufficient
nerve supply to the affected muscles [34]. If C5–6 are solely
Fig. 11 MRI for
pseudomeningoceles. a, b
Coronal (a) and sagittal (b)
constructive interference steady
state (CISS) MR images in a 4-
month-old boy with left brachial
plexus palsy demonstrate left-side
pseudomeningoceles at the C6–7
and C7–T1 levels (arrows)
1655
posterior humeral head subluxation. The right glenoid (solid arrow) is
normal; note that the normal glenoid fossa is perpendicular to the long
axis of the scapula
injured, considerations are made for nerve transfers rather than
reconstruction. With this technique, the site of the nerve injury
is bypassed, the existing nerve connection to the muscle is not
disrupted, and the nerve supply to the muscle is augmented by
coaptation of a healthy adjacent nerve to the target peripheral
nerve [35]. This technique has been shown to have similar
results to nerve reconstruction with the benefit of less opera-
tive time and no lower extremity scar from sural nerve har-
vesting [35]. Outcomes literature for rebalancing the shoulder
muscles after nerve surgery reported that about 60% of pa-
tients have functional shoulder motion and do not require
secondary tendon transfer surgery [36].
1656
Conclusion
Brachial plexus birth injury can result in permanent nerve
damage and resultant upper extremity dysfunction, and there-
fore these injuries require early and regular clinical and imag-
ing assessment during infancy. US is an excellent tool for
screening and subsequent follow-up of children who suffer
clinically evident nerve dysfunction, and it provides critical
qualitative and quantitative data to guide surgical and non-
surgical management.
Declarations
Conflicts of interest None
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