肩关节前、后路手术治疗产瘫肩关节内旋挛缩伴盂肱关节后脱位

Surgical treatment of shoulder joint posterior dislocation secondary to internal rotation contracture deformity in brachial plexus birth palsy

目的观察肩关节前路松解复位、后路关节囊紧缩治疗产瘫肩关节内旋挛缩畸形伴肩关节后脱位的临床效果。方法19例产瘫并发肩关节内旋挛缩畸形患者，经X线和CT检查确诊为盂肱关节半脱位伴假盂形成或完全脱位。男14例，女5例，年龄2．5～8．5岁，平均5岁。盂肱关节畸形按照改良的Water的标准进行分型，Ⅳ型15例，V型4例。19例均行肩关节前路挛缩软组织松解、复位，同时行后路剥离关节囊与假盂的粘连并紧缩后下方关节囊。肩关节外旋0。位石膏固定4周。结果术后随访12．36个月，平均20个月。肩关节Mallet评分由术前平均（11．4±1．7）（7～16）分至术后（15．5±1．8）（13。19）分，两者差异有统计学意义（P〈0．05）；术后盂肱关节达到中心性复位的有16例；3例肱骨头仍向后脱位。结论对于产瘫肩关节内旋挛缩导致的肩关节脱位，前路松解复位、后路剥离关节囊与假盂粘连、紧缩后下侧关节囊，不但使脱位的盂肱关节达到中心复位，同时明显改善其肩关节的功能。

Objective To observe the functional recovery of shoulder joint and the reduction of posterior dislocated humeral head in children with shoulder joint internal rotation contracture and humeral head posterior dislocation secondary to brachial plexus birth palsy treated by a modified surgical procedure through the anterior combined posterior approach of the shoulder. Methods Ninteen patients, ranging in age from 2.5 to 8.5 years （average 5 years） , suffered posterior dislocation of the shoulder joint secondary to internal rotation contracture in brachial plexus birth palsy. The gleno-humeral joint deformity was confirmed by X-ray and CT examination and classified as type IV in 15 cases and type V in 4 cases according to the modified water＇s criteria. The surgical procedure was as follows： the contracture soft tissue around the anterior of shoulder joint was released firstly through the anterior approach, and the posterior-inferior capsule of the shoulder was exposed and separated with the pseudoglenoid through the posterior approach, the humeral head was reduced by external rotation the arm, then the posterior-inferior capsule was retighten. A piaster cast was used to fix the shoulder at the neutral position of 0° for 4 weeks. Results After 12 to 36 months follow up（average of 20 months）, the Mallet score of the shoulder was from 11.4 ± 1.7 （range 7-16）preoperative to 15.5 ± 1.8 （range 13-19） postoperative, the difference was significantly （P 〈 0.05）. The central relocation of humeral head was achieved in 16 patients, but the humeral head was still dislocated to posterior in 3 cases. Conclusions The posterior-inferior capsule was separated with the pseudo-glenoid and retighten through the posterior approach, and reduction of the humeral head by soft tissue releaseing through the anterior approach can recover the concentric relationship of gleno-humeral joint and improve the function of shoulder joint with posterior dislocation secondary to internal rotated contracture deformity in brachial plexus birth palsy.