Figure - available via license: Creative Commons Attribution 2.0 Generic
Content may be subject to copyright.
Modified Mallet scale evaluation of function and arm appearance. In addition to assessing the classical shoulder functions of the classical Modified Mallet system, supination and the resting position are evaluated. In the resting position, medial rotation at the shoulder is scored on a scale of 1 to 5. Fixed forearm supination is noted in the resting position as indicated by the drawings labeled 2A (first web space visible) and 4A (palm visible). Lateral rotation position can also be noted in the resting position. A total Mallet score is calculated from the scores for abduction, hand to neck, hand to spine, hand to mouth, and lateral rotation, giving a maximum score of 25. Angles are measured from video stills for abduction, hand to mouth and apparent supination and estimated for lateral rotation.
Source publication
Patients who have suffered obstetric brachial plexus injury (OBPI) have a high incidence of musculoskeletal complications stemming from the initial nerve injury. The presence of muscle imbalances and contractures leads to typical bony changes affecting the shoulder, including the SHEAR (Scapular Hypoplasia, Elevation and Rotation) deformity. The SH...
Citations
... The grading scale is between I (no function) and V (normal movement, symmetric with the healthy side). A total Mallet score is calculated from the scores for the abduction of the shoulder, hand to the neck, hand to back, hand to mouth, and external rotation of shoulder which adds to a maximum score of 25. [29] Angles are measured from video recordings at patient visits for the abduction of the shoulder, hand to mouth. External rotation of shoulder was usually estimated as less or more than 20 degrees. ...
Objectives:
Functional limitation of the upper extremity (UE) in obstetrical brachial plexus paralysis (OBPP) restricts a child's participation in daily living and social activities. In treatment, the participation of UE in rehabilitation is important. Constraint-induced movement therapy (CIMT) is a promising rehabilitation approach that is used to improve the UE functions of patients with neurological dysfunctions.
Methods:
This single-blinded randomized controlled clinical trial includes 30 pediatric patients diagnosed with chronic OBPP aged between 2 and 12 years. The patients were divided into two groups as a modified CIMT group and a control group. Patients in both groups underwent classical rehabilitation treatment 4 times a week for 8 weeks. Range of motion (ROM), stretching, strengthening, and proprioceptive exercises were given to both control and CIMT group. The patients in the CIMT group had to wear constraining arm slings 2 h per day and 4 days a week for 8 weeks. The patients were evaluated both before and after treatment using the Mallet classification system and the Melbourne unilateral upper limb assessment-2 (The MA2) scale.
Results:
In both groups, the Mallet and MA2 scores significantly increased after the treatment process. However, the percentage of improvement was higher for the CIMT group.
Conclusion:
Modified CIMT improves the joint ROM and the functional use of the extremity among OBPP-diagnosed children. This improvement is greater in the CIMT group compared to the improvement in the control group. Implementation of CIMT in a routine rehabilitation process may be helpful.
... in addition to that, supination position was evaluated and scored on a scale of 1-5. A total score was calculated from the scores of the previously mentioned 5 shoulder movements, with a maximum score of 25 [21]. ...
Introduction
Functional improvement is the primary goal in chronic cases with neurological deficits. The aim of this study was to compare using modified constraint-induced movement therapy and Kinesio taping to improve functional outcomes in children with Erb’s palsy.
Methods
The study investigated 46 children with Erb’s palsy aged 5–7 years. They were randomly classified into 2 equal groups. Patients in group A engaged in a modified constraint-induced movement therapy program which included restraining of the movement of the non-involved upper extremity, while those in group B received a selected rehabilitative program based on the Kinesio taping method. The treatment programs were conducted 5 times per week for 6 successive weeks. Measurements obtained included active range of motion of shoulder flexion, abduction, and external rotation, as well as modified Mallet scale scores. These measurements were recorded before and after the application of the treatment program in both groups.
Results
There was a significant improvement in external rotation range of motion and forearm supination when comparing pre- and post-treatment mean values in each study group. There were no differences between the groups regarding any of the measured variables.
Conclusions
According to the applied procedures and collected data, there was no evidence for a superiority of modified constraint-induced movement therapy when compared with Kinesio taping in improving functional outcomes in children with Erb’s palsy.
... Traditionally, the external rotation humeral osteotomy (ERHO) is performed on older children with dislocated shoulders. [16][17][18][19][20][21][22][23][24][25] These osteotomy results have been shown to be satisfactory with the improvement of external rotation, and some loss of internal rotation (manifested by the child's inability to reach their abdomen with their hand). ERHO improves the cosmetic effect of shoulder subluxation while having no effect on the underlying structural (glenohumeral deformity, and scapular elevation and rotation) and functional problems. ...
... Moreover, ERHO has been performed on patients with OBPI up to only 17 years of age. [15][16][17][18][19][20][21][22][23][24][25] The authors have previously demonstrated that the mod Quad procedure may improve upper extremity functions, including shoulder abduction, in adult patients with OBPI. 26 Untreated adult patients with this injury, in general, use compensatory strategies to achieve their lost upper extremity functions, which may cause adverse effects. ...
... Patients were evaluated through video recordings using a modified Mallet scale. 25 Depending on their ability to perform shoulder and arm movements (shoulder abduction, external rotation, hand-to-mouth, hand-to-neck, hand-to-spine, and supination), patients were scored on a scale of 1 to 5, with 1 being most affected and 5 being normal. The overall Mallet score (6 to 30) was calculated based on these 6 movements. ...
Background. External Rotational Humeral osteotomy is used to address the external rotation deficit in older children with obstetric brachial plexus Injury (OBPI). Although this procedure improves the cosmetic effect of shoulder subluxation, it has no effect on the underlying structural (glenohumeral deformity and scapular elevation and rotation) and functional problems. In this study, improvements in glenohumeral joint alignment; scapular hypoplasia, elevation, and rotation (SHEAR) deformity; and upper extremity functional movements were demonstrated in adult patients with OBPI 1 year after the mod Quad and/or triangle tilt surgeries.
Methods and Materials. The outcome of humeral rotational osteotomy reported in the literature was compared with the results from 43 adult patients with OBPI (21 men and 22 women; 23 right and 20 left sides) with a mean age of 21.3 years ( range, 17 to 38 years) who underwent mod Quad and/or triangle tilt surgeries and had over 12 months of postoperative follow-up (mean 22.9 months; range, 12 to 50 months).
Results. The preoperative average modified total Mallet score, including supination, was 14.6 ± 3.5 (P < 0.0001) in the 43 adult patients with OBPI in this report. This total Mallet score was significantly improved to 22 ± 3.9 (P < 0.0001) over 12 months after mod Quad and/or triangle tilt surgeries. Thirty-two (75%) of the patients showed great improvement in all upper extremity functions: shoulder abduction, external rotation, hand-to-mouth, hand-to-neck, hand-to-spine, and supination. The improvement after humeral osteotomy reported in the literature was a cosmetic effect that did not address the underlying structural and functional problems and was found to decrease the improved shoulder abduction in long-term follow-up.
Conclusions. Thirty-two (75%) of 43 adult patients with OBPI showed great improvement in all upper extremity functions 1 year after mod Quad and/or triangle tilt surgeries. The other 11 patients (25%) showed improvement in hand-to-mouth movement and/or supination. In contrast, humeral osteotomy, as reported in the literature, improved the cosmetic effect of shoulder subluxation but had no effect on the underlying structural and functional problems.
... We have previously published on the successful outcomes of this procedure in OBPI patients. [27][28][29][35][36][37][38] Patients who had these 2 surgeries with us between 2005 and 2008 were eligible for this 10-year follow-up study. Majority of these patients previously had 1, 2, or 5-year postsurgical follow-up at our center. ...
Aim: To evaluate whether obstetric brachial plexus injury (OBPI) children who had mod Quad and triangle tilt surgeries maintained their recovered upper extremity functional movements over 10 years.
Background: The short-term outcomes of surgery in OBPI patients are well documented. However, only a few publications with results over 10-year postoperative follow-up exist. We have previously reported the outcomes of these 2 surgeries in OBPI after 1, 2, and 5 years. Here, we report the successful outcomes in 17 of these patients over 10 years.
Methods: Seventeen OBPI patients, who had mod Quad, a modified muscle release operation and triangle tilt, a bony surgical procedure with us between 2005 and 2008, had postoperative follow-up of 10 years and met the inclusion criteria. Patients who had multiple surgeries and did not have 10-year follow-up are excluded in this study.
Results: Fifteen of 17 children maintain their recovered upper extremity functions for extended long period (mean, 10 years; range, 9–13 years). There was statistically significant improvement in total functional Mallet score after 3 years (mean, 18.8 ± 2.1; P ≤ 0.01) from the preoperative mean total Mallet score of 14.5 ± 1.2. This improvement was not only maintained for extended period but also improved (mean total Mallet score, 20.35 ± 2.3; P ≤ 0.01) in some patients.
Conclusions: Overall, all upper extremity functions improved greatly after mod Quad and triangle tilt surgeries in OBPI children, and they were able to maintain their recovered functional movements over extended period of 10 years.
... These surgical treatments do not address these two osseous deformities. We have published extensively the effectiveness of triangle tilt surgery in correcting glenohumeral joint incongruity and thereby improving upper extremity functions in OBPP patients [20][21][22][23][24][25][26][27][28]. Here, we show both functional and anatomical improvements significantly after triangle tilt and or mod Quad as revision surgeries in 20 OBPP patients, who had other surgical treatments at outside clinics before visiting our clinic for further treatment. ...
... We measured PHHA, glenoid version [29] and Scapular hypoplasia, elevation and rotation [30] using computed tomography and magnetic resonance imaging pre-and post-TT operative procedure. Triangle tilt [20][21][22][23][24][25][26][27][28] and mod Quad procedures [14,31,32] have been demonstrated successful outcomes in OBPP. ...
... Eighteen OBPP children, who had shoulder joint incongruency and SHEAR undergone TT bony operation with us. We demonstrated that this procedure effectively addressed the bony deformities of the affected upper extremity and improved it's anatomy and functions [20][21][22][23][24][25][26][27][28]. After undergone these two revision surgical procedures with us, these twenty patients had better results both functionally and anatomically. ...
AIM
To compare outcomes of our revision surgical operations in obstetric brachial plexus palsy (OBPP) patients to results of conventional operative procedures at other institutions.
METHODS
We analyzed our OBPP data and identified 10 female and 10 male children aged 2.0 to 11.8 years (average age 6.5 years), who had prior conventional surgical therapies at other clinics. Of the 20 patients, 18 undergone triangle tilt, 2 had only mod Quad. Among 18 patients, 8 had only triangle tilt and 10 had also mod Quad as revision surgeries with us. We analyzed the anatomical improvements and functional modified Mallet statistically before and after a year post-revision operations.
RESULTS
Pre-revision surgery average modified Mallet score was 12.0 ± 1.5. This functional score was greatly improved to 18 ± 2.3 (P < 0.0001) at least one-year after revision surgical procedures. Radiological scores (PHHA and glenoid version) were also improved significantly to 31.9 ± 13.6 (P < 0.001), -16.3 ± 11 (P < 0.0002), at least one-year after triangle tilt procedure. Their mean pre-triangle tilt (yet after other surgeon’s surgeries) PHHA, glenoid version and SHEAR were 14.6 ± 21.7, -31.6 ± 19.3 and 16.1 ± 14.7 respectively.
CONCLUSION
We demonstrate here, mod Quad and triangle tilt as successful revision surgical procedures in 20 OBPP patients, who had other surgical treatments at other clinics before presenting to us for further treatment.
... However, these procedures may not address the glenohumeral dysplasia and joint incongruity, which impair the bone growth and development [12]. The triangle tilt surgery was developed by the surgeon (RKN) to mainly correct this bony deformity and shown to have a high success rate [13][14][15][16][17][18][19][20][21][22][23]. ...
... The triangle tilt operative technique includes osteotomies of the clavicle, neck of the acromion and scapula in order to release the distal acromioclavicular triangle and allow it to reorient itself in a more neutral position into the glenoid [13][14][15][16][17][18][19][20][21][22][23]. The lead author and surgeon, who has over 17 years of experience with obstetric brachial plexus injury, performed all the surgical procedures, and evaluated the pre-and postoperative shoulder functions of these patients in the clinic. ...
... Modified Quad procedure releases the soft tissue contractures, which greatly improves the shoulder abduction and flexion, but does not correct the glenohumeral joint incongruence. In order to address this, the triangle tilt [13][14][15][16][17][18][19][20][21][22][23], a unique bony surgical intervention has been performed on these patients. This procedure realigns the glenohumeral joint, and improves the other upper extremity functions such as external rotation, hand to mouth, and neck [13][14][15][16][17][18][19][20][21][22][23]. ...
... Many traditional procedures have been described to treat obstetric brachial plexus deformity [13][14][15][16]. Here, we report the clinical outcome of one OBPI pediatric patient, who had undergone the triangle tilt surgical procedure as a salvage procedure at our institution [17][18][19][20][21][22][23][24]. ...
... The triangle tilt is an established novel osseous surgical procedure, consisting of osteotomy of the clavicle at the junction of the middle and outer thirds, osteotomy of the acromion at its junction with the spine of the scapula, ostectomy of the superomedial angle of the scapula, anterior shoulder capsule, and soft tissue releases and splinting of the limb in adduction, 5 ∘ of external rotation, and full forearm supination [17][18][19][20][21][22][23][24]. These individual procedures together release the distal acromioclavicular triangle and allow it to reorient itself in a more neutral position into the glenoid fossa. ...
... This placed the humerus into an internally rotated position in the glenohumeral joint and, therefore, resulted in the abnormal posture prior to surgery. The patient's findings specifically indicated treatment with triangle tilt surgery [17][18][19][20][21][22][23][24] at our clinic. The senior author (RKN) performed the surgical procedures. ...
Introduction. Obstetric brachial plexus injury (OBPI) occurs during the process of labor and childbirth. OBPI has been reported to be associated with shoulder dystocia, macrosomia, and breech delivery. Its occurrence in uncomplicated delivery is possible as well. Case Presentation. The patient in the present report is a 6.5-year-old girl, who suffered a severe brachial plexus injury at birth and had many reconstructive surgical procedures at an outside brachial plexus center before presenting to us. Discussion. The traditional surgical treatments by other surgical groups were unsuccessful and therefore the patient came to our clinic for further treatment. She had triangle tilt surgery with us, as a salvage procedure. Conclusion. The OBPI patient in this study clearly showed noticeable clinical and functional improvements after triangle tilt surgical management. The posture of the arm at rest was greatly improved to a more normal position, and hand to mouth movement was improved as well. Triangle tilt surgery should be conducted as a first choice treatment for medial rotation contracture of the shoulder in OBPI patients.
... A maioria incluiu pequenas amostras (57% com amostras ≤ 30 doentes), enquanto seis estudos apresentaram resultados de grandes amostras[ 29,34,36,45,52,56 ].A idade média ponderada na altura na data da cirurgia foi 4,3 anos (entre 0,3 e 19,8 anos). A maioria dos estudos avaliou os resultados de uma técnica cirúrgica em doentes com um espectro de idades alargado.Os diagnósticos mais frequentes foram a CORI, défice de abdução e/ou rotação externa e, por último, instabilidade/incongruência gleno-umeral (66,7%, 23,8% e 9,5%, respetivamente).Em 76% dos estudos foi avaliada a gravidade da lesão segundo a classificação de Narakas: 8 estudos[27,34,38,39,50,53,63,59 ] não incluíram doentes com parésias completas (GIII ou IV de Narakas) e num estudo[ 22 ] apenas se incluíram doentes parésias completas.A avaliação das alterações da morfologia da glenoide e congruência articular foi realizada de vários modos: em 12 estudos[ 2,7,11,12,20,21,29,30,39,40,41,43 ] foi utilizada a classificação de Waters; a descrição em congruente/não congruente foi realizada em 10 estudos[26,31,36,40,43,49,52,53,54,59 ]; a descrição morfológica foi realizada em 10 estudos[24,31,35,37,40,44,48,49,57,58 ]; e dois estudos[ 38,39 ] fizeram a avaliação segundo a GDS. Seis estudos incluíram doentes sem alterações ou com alterações morfológicas ligeiras e ombros estáveis[ 26,28,35,37,52,63 ] (todos utilizaram técnicas de partes moles) enquanto 9 estudos incluíram doentes com alterações moderadas a graves da morfologia e/ou instabilidade gleno-umeral (2 com técnicas de partes moles45,49 , 6 com técnicas ósseas[ 42,43,48,59,61,58 ] e um[ 33 ] com combinação de transferências tendinosas com glenoplastia). ...
Que técnica paliativa para as sequelas gleno-umerais das lesões obstétricas do plexo braquial? Rev Port Ortop Traum 22(1): XXX-XXX, 2014 RESUMO Objetivo: a lesão obstétrica do plexo braquial está presente em 1-4 em cada 1000 partos. Apesar da maioria recuperar, até 19% vão apresentar sequelas definitivas, mesmo após cirurgias de reparação primária do plexo braquial, sendo o ombro a região anatómica mais afetada. As cirurgias paliativas do ombro foram desenvolvidas para aumentar a função e qualidade de vida destes pacientes, no entanto não há consenso quanto ao timing cirúrgico e indicações de cada técnica. Avaliamos sistematicamente toda a evidência disponível nos últimos 10 anos com o objetivo de determinar quais as melhorias na função e quais os fatores que influenciam o resultado destas técnicas. Determinar a capacidade de remodelação gleno-umeral foi um objetivo secundário .
... The most common sequelae following OBPI may include posterior subluxation or dislocation of the humeral head, winging of the scapula, forearm deformities as pronation or supination contractures, hand deformities, and hypoplasia of the bones in the upper extremity resulting in limb length discrepancy problems5678 . Two well-described secondary deformities are the medial rotation contracture of the arm and the fixed supination deformity of the forearm [9] . The medial rotation contracture is a major cause of shoulder deformity in children with OBPI, requiring surgery in more than one third of patients whose injury did not resolve spontaneously [10]. ...
Many children who sustain birth injuries to the brachial plexus suffer significant functional limitations due to various sequelae affecting the shoulder and elbow or forearm. The aim of this study was to test the feasibility of a treatment program based on the elements of the modified constraint induced movement therapy (MCIMT) to encourage use of the affected arm of a child with obstetric brachial plexus injury (OBPI). Thirty children with OBPI from both sexes ranging in age from three to five years were assigned into two groups of equal number. The control group (group A) who received the exercise program which focused on improving the arm function as well as shoulder abduction and external rotation and the study group (group B) received MCIMT in addition to the same exercise program given to the control group. The arm function was evaluated by the Mallet score system, while active abduction and external rotation range of motion were measured by a standard universal goniometer. The results revealed no significant difference when comparing the pretreatment mean values of the two groups (study and control), while a significant improvement was observed in measuring variables of the two groups when comparing their pre and post treatment mean values. A significant difference was also observed when comparing the post treatment results of the two groups in favor of the study group (group B). The modified constraint movement therapy is an effective method on improving the arm function in children with OBPI.
... However, these procedures may not address the glenohumeral dysplasia and joint incongruity, which impair the bone growth and development [12]. The triangle tilt surgery was developed by the surgeon (RKN) to mainly correct this bony deformity and shown to have a high success rate [13][14][15][16][17][18][19][20][21][22][23]. ...
... The triangle tilt operative technique includes osteotomies of the clavicle, neck of the acromion and scapula in order to release the distal acromioclavicular triangle and allow it to reorient itself in a more neutral position into the glenoid [13][14][15][16][17][18][19][20][21][22][23]. The lead author and surgeon, who has over 17 years of experience with obstetric brachial plexus injury, performed all the surgical procedures, and evaluated the pre-and postoperative shoulder functions of these patients in the clinic. ...
... Modified Quad procedure releases the soft tissue contractures, which greatly improves the shoulder abduction and flexion, but does not correct the glenohumeral joint incongruence. In order to address this, the triangle tilt [13][14][15][16][17][18][19][20][21][22][23], a unique bony surgical intervention has been performed on these patients. This procedure realigns the glenohumeral joint, and improves the other upper extremity functions such as external rotation, hand to mouth, and neck [13][14][15][16][17][18][19][20][21][22][23]. ...
We evaluated the "extended" long-term (5 years) functional outcomes in obstetric brachial plexus injury (OBPI) patients, who underwent triangle tilt surgery between February 2005 and January 2008.
Twenty two children (9 girls and 13 boys, mean age at surgery was 5.8 years; ranging 2.1-11.8 years old), who initially presented with medial rotation contracture and scapula deformity secondary to obstetric brachial plexus injury were included in this study. Functional movements were evaluated pre-operatively, and 5 years following triangle tilt surgery by modified Mallet scale.
Here, we report long-term (5 years) follow-up of triangle tilt surgery for 22 OBPI patients. Upper extremity functional movements such as, external rotation (2.5±0.6 to 4.1±0.8, p<0.0001), hand-to-spine (2.6±0.6 to 3.4±1.1, p<0.005), hand-to-neck (2.7±0.7 to 4.3±0.7, p<0.0001), hand-to-mouth (2.3±0.9 (92º±33) to 4.2±0.5 (21º±16), p<0.0001), and supination (2.6±1.1 (-8.2º ±51) to 4.1±0.7 (61±32)) were significantly improved (p<0.0001), and maintained over the extended long-term (5 years). Total modified Mallet functional score was also shown to improve from 14.1±2.7 to 20.3±2.5.
The triangle tilt surgery improved all shoulder functions significantly, and maintained over the extended long-term (5 years) in these patients.
