Medial Approach for Humeral Rotational Osteotomy in Children with Residual Brachial Plexus Birth Palsy

Residual brachial plexus birth palsy often results in an internal rotation contracture. The constant position of internal rotation leads to glenohumeral joint deformity that progresses over time. In the older child, the glenohumeral joint deformity is advanced, and the joint cannot be reduced. Humeral osteotomy can reposition the limb into external rotation, which improves appearance and enhances activities of daily living, such as eating, washing hair, and grooming. This article discusses my preferred technique for humeral osteotomy using a medial approach along with its advantages and disadvantages. The technique involves a medial incision along the arm. The internervous plane is between the median and ulnar nerves. The intermuscular septum is traced to the medial aspect of the humerus. The periosteum is incised and provisional fixation is obtained. A transverse osteotomy is performed, and the humerus is rotated into the desired position. Rigid plate and screw fixation is applied. Postoperative immobilization is nominal, although the osteotomy is protected until union. Improvement in function of activities of daily living, such as dressing, washing, self-cleaning, and feeding is obtained. An added benefit is better limb appearance with improved symmetry.

Keywords: humeral rotation, brachial plexus, birth palsy, glenohumeral joint, transverse osteotomy, technique