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130 The Open Orthopaedics Journal, 2014, 8, 130-134

Open Access
Humeral Rotational Osteotomy for Shoulder Deformity in Obstetric
Brachial Plexus Palsy: Which Direction Should I Rotate?
Amr A. Abdelgawad* and Miguel A. Pirela-Cruz

Department of Orthopedic Surgery, Paul L. Foster School of Medicine, Texas Tech University Health Science Center at
El Paso, TX, USA

Abstract: Shoulder internal rotation contracture is the most common deformity affecting the shoulder in patients with
Obstetric Brachial Plexus Palsy. With progression of the deformity, the glenohumeral joint starts to subluxate and then
dislocates. This is accompanied with bony changes of both the humerus and the glenoid. Two opposite direction humeral
osteotomies have been proposed for this condition (internal rotation osteotomy (IRO) and external rotation osteotomy
(ERO)). This fact of different direction osteotomies has not adequately been explained in the literature. Most orthopedic
surgeons may not be able to fully differentiate between these two osteotomies regarding the indications, outcomes and
effects on the joint. This review explains these differences in details.
Keywords: Erb's Palsy, external rotation, glenohumeral joint, humeral osteotomy, internal rotation, internal rotation deformity,
obstetric brachial plexus palsy (OBPP), shoulder dislocation.

INTRODUCTION The purpose of this article is to clarify these two opposite

direction humeral osteotomies in cases of shoulder deformity
Obstetric brachial plexus palsy (OBPP) is an injury to the as a result of OBPP, compare between these two types in
nerves of the upper extremity of the newborn that happens regard to the indications, concepts and outcomes and to help
during labor. Erb’s palsy (C5,6) is the most common type of the orthopedic surgeons identify the difference between
OBPP. Most of the infants with Erb’s palsy will show these two osteotomies. Articles describing osteotomies for
spontaneous full recovery [1, 2]. However, some of them obstetric brachial palsy have been reviewed. Pubmed search
will have residual weakness of shoulder’s external rotation has been conducted using “Erb’s palsy”, “obstetric brachial
which will result in an internal rotation deformity of the plexus palsy” together with osteotomy. Cross reference has
affected shoulder in these children. If this internal rotation also been used. In addition, pediatric orthopedic book
deformity is not repaired, it may progress to posterior chapters have been reviewed for their description of humeral
dislocation of the shoulder joint with bony deformity of the osteotomies in cases of OBPP.
glenoid [3].
The shoulder internal rotation deformity is treated DISCUSSION
surgically either by soft tissue release or by bony osteotomy.
Traditionally, the osteotomy was done for older children Shoulder Pathology in Erb’s Palsy
with dislocated shoulders. The direction of the osteotomy
Internal rotation contracture is the most frequent and
was external rotation osteotomy. The purpose of the surgery
important secondary deformity of the shoulder in children with
was to improve the cosmetic and the function of the upper
Erb’s palsy. It occurs due to weakness of the external rotators
extremity. This osteotomy would ignore the deformity in the
(teres minor and infraspinatus) muscles compared to the internal
glenohumeral joint as it will actually result in more posterior
dislocation of the humeral head in relation to the glenoid. rotators (teres major, pectoralis major, latissimus dorsi) muscles.
Because of the lack of external rotation and persistence of
Recently, there have been articles describing internal internal rotation, chronic posterior shoulder dislocation develops
rotation osteotomy for children who have Erb’s palsy with [4, 5]. Children with Erb’s palsy will develop secondary bone
internal rotation deformity and posterior shoulder dislocation. changes in the glenoid. Several authors have studied the
The aim of this osteotomy is to reduce the glenohumeral joint. shoulder pathology in cases of Erb’s palsy [6-9]. Pearl et al. in
Articles and book chapter which described the 2003 [7], classified the glenoid deformity in patients with Erb’s
osteotomies for shoulder deformity in Erb’s palsy did not palsy using MRI, arthroscopy, and arthrography. According to
emphasize on the fact that there are two opposite direction their classification, the deformity of gleno-humeral articulation
osteotomies for the same condition which can cause great progressed from concentric, concentric posterior, flat, biconcave
confusion among readers. and pseudo glenoid (the latter is further subdivided into mild,
moderate and severe). Waters et al. [9] classified the gleno-
humeral deformity with OBBP into seven grades (type I:
*Address correspondence to this author at the Department of Orthopedic normal articulation; type II: more than 5 retroversion of the
surgery, Texas Tech University Health Science Center at El Paso, TX, 4801
Alberta Ave, El Paso, TX 79905, USA; Tel: 915-215-5407;
glenoid with no subluxation; type III: posterior subluxation;
Fax: 915-545-6704; E-mail: amr.abdelgawad@ttuhsc.edu type IV: progressive posterior humeral subluxation into a false

1874-3250/14 2014 Bentham Open

Humeral Rotational Osteotomy for Shoulder Deformity The Open Orthopaedics Journal, 2014, Volume 8 131

glenoid; type V: severe flattening of the humeral head and correlation between the occurrence of dislocation and the
glenoid, with progressive or complete posterior dislocation of type of initial neurological deficit.
the head; type VI: dislocation of the glenohumeral joint in
infancy and type VII: growth arrest of the proximal aspect of the External Rotational Osteotomy (ERO)
humerus).
This type of osteotomy has been reported by many authors
The humeral shape is also affected by the internal
[13-20] and also described in the pediatric orthopedic textbooks
rotation deformity. Over time the humeral head becomes
[21, 22]. It is usually performed in older children with advanced
retroverted, which Zancolli [5] describes as a posterior
shoulder deformity. The osteotomy is performed to increase the
epiphysiolysis of the proximal humerus.
range of external rotation of the affected shoulder. The effect of
osteotomy on the glenohumeral joint is that it actually increases
Posterior Shoulder Dislocation in Infancy the posterior dislocation of the humeral head. The head of the
humerus sits at a more posterior dislocated position.
Some of the children with Erb’s palsy will develop
This osteotomy has been the standard of treatment in older
posterior dislocation early in their course of disease. This
children. The results of this osteotomy have been very satisfying
condition was thought to be rare, however, in the last two
decades many publications about infantile posterior shoulder with improvement of both external rotation and, to a lesser
degree, abduction of the shoulder joint. Improvement of
dislocations were made and have suggested that the onset of
abduction has been attributed to a better mechanical alignment
glenoid dysplasia which accompanies obstetric brachial
of the deltoid muscle. On the other hand, there is always some
plexus palsy occurs at an earlier age than what has been
loss of internal rotation with this procedure (manifested by the
previously recognized and that the prevalence of this
child not able to reach his/her abdomen by his/her hand).
problem may have been underestimated [10-12].
The osteotomy is usually performed proximal to the level
Moukoko et al. in 2004 [10], studied 134 consecutive
of deltoid tuberosity to improve the alignment of the deltoid.
infants with neonatal brachial plexus palsy over a period of 2
Some authors have recommended adding flexion of the distal
years. Specific clinical signs associated with subluxation and
part of the humerus to cause an increase in elevation of the
dislocation were recorded. A rapid loss of passive external
arm [14]. Others have recommended adding varus
rotation between monthly examinations indicated a posterior
shoulder dislocation. This was the main sign upon which component to repair the abduction contracture [18]. External
immobilization is usually not needed if the osteotomy is
they depended to diagnose posterior shoulder dislocation in
fixed with plates and screws. Tables 1 and 2 show pre and
infants with OBPP. Apparent shortening of the humeral
ostoperative range of motion for some studies which used
segment of the involved extremity combined with
ERO. Fig. (1) is an example of ERO.
asymmetrical skin folds indicates dislocation of the affected
shoulder. The infants who were identified as having these
clinical signs were evaluated with ultrasonographic imaging Internal Rotation Osteotomy (IRO)
studies. Eleven (8%) of the 134 infants had a posterior
Internal rotation osteotomy has rarely been reported in
shoulder dislocation. The mean age at the time of diagnosis
the literature [23, 24]. It is described in young children who
was six months (range, three to ten months). There was no
develop posterior dislocation of the shoulder early in their

Table 1. Results of ERO by degrees of ROM.

External Rotation Abduction

Study Remarks
Pre Post Gain Pre Post Gain

Al-Zahrani [14] 32 61 Combined Sever release and derotation osteotomy

Kirkos and Papadopoulos [19] -41 24.5 65.5 93 120 27
Waters and Bae [18] -14 16 64
Abzug et al. [13] 43.2
Abdelgawad [20] -27 28 55 132 140 8

Table 2. Showing the results of preoperative and postoperative Mallet score [26] for the studies using ERO.

Preoperative Postoperative
Abd Ext Rot Hand to Nape Hand to Mouth Abd Ext Rot Hand to Nape Hand to Mouth

Waters and Bae [18] 2 3 3 4 4 4

Abzug et al. [13] 3.5 2.4 2.5 2.6 3.7 3.3 3.1 3.6
Abdelgawad [20] 4 1.1 1.9 2 4 3.1 3 3.6
132 The Open Orthopaedics Journal, 2014, Volume 8 Abdelgawad and Pirela-Cruz

Fig. (1). Shows a 12 years old boy with severe right shoulder internal rotation deformity. A: Severe internal rotation deformity with the
patient having to put his elbow above the shoulder level in order for the hand to reach the mouth. B: 6 weeks postoperative AP and LAT
radiographs of ERO fixed with plates and screws. C: 6 months follow up; notice the improvement of the upper extremity position when the
child puts his hand over the mouth.

course of disease. The internal rotation osteotomy is soft tissue procedures and then checked the arc of motion. In
performed to reduce the glenohumeral joint. However, this cases where humeral head was dislocated in internal rotation,
osteotomy is likely to result in more loss of external rotation the IRO of proximal humerus was done to improve joint
(loss of external rotation associated with internal rotation stability. Ten patients out of 25 needed the IRO. They found
contracture in addition to loss of external rotation associated that active internal rotation difference in children treated
with the internal rotation osteotomy). In order to restore the with IRO was significantly higher than that in those treated
external rotation of the shoulder in these children, this without osteotomy. The other movements (including external
procedure has to be combined with process of release of the rotation) were similar before and after surgery in both
internal rotators muscles and the anterior capsule (Sever’s groups. The authors concluded that the addition of IRO to
operation [25]) with the possible need for transfer of internal soft tissue procedures around the shoulder allows better
rotators to act as external rotators. internal rotation and maintains stable reduction without
compromising other movements.
Sibinski and Synder [23] described internal rotation
osteotomy (IRO) with tendon transfer. They started first with
Humeral Rotational Osteotomy for Shoulder Deformity The Open Orthopaedics Journal, 2014, Volume 8 133

Table 3. The difference between ERO and IRO.

External Rotation Osteotomy (ERO) Internal Rotation Osteotomy (IRO)

Indication Deformed glenoid (Waters VI, V, VI Posterior dislocation of the shoulder with relatively
or Pearls “pseudoglenoid”) normal glenoid
Increase humeral retroversion
Unstable shoulder joint after reduction of the
glenohumeral joint and performing anterior shoulder
release
Patient Older children with dislocated Young children with dislocated shoulder
shoulder
Effect on the glenohumeral joint Increase the deformity of the joint Reduce the dislocated joint
Effect of humeral retroversion Increase the humeral retroversion Decrease the humeral retroversion
Effect on the range of shoulder external rotation Increase Decrease
Effect on the range of shoulder internal rotation Decrease Increase
Frequency Commonly performed procedure Rarely done procedure
Need of release of anterior capsule and internal No need, sometime added Has to be combined with internal rotator release +/-
rotator muscles tendon transfer

Similarly, Kambhampati et al. [24] prospectively studied for primary care physicians. Abdelgawad A and Naga O, Eds.
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Received: December 15, 2013 Revised: April 11, 2014 Accepted: May 29, 2014

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