Custom Shoulder Abduction/Rotation Orthosis in Postoperative Management of Brachial Plexus Injury After Modified L???Episcopo Procedure

In Brief Obstetrical brachial plexus injury is rare, occurring with an incidence of 0.1% to 0.4% of live births. Although many infants recover completely, some go on to permanent injury with muscle imbalance, contracture development, and significant functional limitations. Infants with no recovery until after the third month of life may be candidates for microsurgical or reconstructive treatment. Children with chronic upper trunk plexopathy typically exhibit weakness of external rotators, contractures positioning them in internal rotation with limited external rotation range of motion, and limited shoulder extension. Glenohumeral articulation changes may also develop. A modified L’Episcopo procedure improves range of motion, strength, and overall function. Postoperative management involves positioning in maximal external rotation and approximately 100° shoulder abduction. A shoulder abduction orthosis that allows adjustment of abduction and external rotation must be fabricated to ensure accurate position and intimacy of fit during postoperative activity. The thoracic stabilizing component and total contact upper extremity components are connected with an adjustable rod to allow changes in position of abduction and rotation. Preoperative contracture with decreased range of motion limits accuracy of preoperative molding and fitting. Adjustability of position in anticipation of expected improved postoperative position is a necessary part of the orthosis design. Other design challenges also involve adapting components to reflect the size of the patient (as young as 18 months). Preoperative molding and measurement facilitates immediate fitting after cast removal or, in some cases, immediately after surgery and is vital to a successful postoperative protocol. A custom-molded adjustable shoulder abduction/rotation orthosis is described, as used in the modified L’Episcopo procedure postoperative regimen, for four pediatric patients younger than 29 months. Obstetrical brachial plexus injury is rare; however, it leads to significant functional limitations in children who do not experience spontaneous recovery. A modified L’Episcopo procedure in conjunction with a postoperative protocol that includes a custom adjustable rotation/abduction orthosis can produce an exceptional result with significant functional improvement. The University of Michigan’s Department of Orthopaedic Surgery is performing modified L’Episcopo procedures on children as young as 18 months with continued success and adherence to the postoperative protocol. Use of an appropriately fitting custom orthosis as part of the postoperative regimen for an already well-documented successful surgical procedure produces the optimum clinical success and may eliminate the need for postoperative spica casting, which presents significant benefit to the child and the caregiver.