Bauer Andrea S, Lucas Justin F, Heyrani Nasser, Anderson Ryan L, Kalish Leslie A, James Michelle A
1Department of Orthopaedic Surgery (A.S.B.) and Clinical Research Center (L.A.K.), Boston Children's Hospital, Boston, Massachusetts 2Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, California 3University of California Davis School of Medicine, Sacramento, California 4Shriners Hospitals for Children-Northern California, Sacramento, California.
J Bone Joint Surg Am. 2017 May 3;99(9):778-783. doi: 10.2106/JBJS.16.00806.
Early detection of posterior shoulder dislocation in infants with brachial plexus birth palsy (BPBP) is essential, but it may be difficult to accomplish with physical examination alone. The aim of this study was to determine the prevalence of shoulder dislocation in patients with BPBP using ultrasound and to identify which physical examination measurements correlated most with dislocation in these patients.
This study was a retrospective review of data obtained in an ultrasound screening program of infants with BPBP born from January 2011 to April 2014. Physical examination included the use of the Active Movement Scale (AMS) and measurement of passive external rotation of the shoulder. Ultrasound measurements included PHHD (percentage of the humeral head displaced posterior to the axis of the scapula) and the alpha angle (intersection of the posterior scapular margin with a line tangential to the humeral head through the glenoid). Shoulder dislocation was defined as both a PHHD of >0.5 and an alpha angle of >30°.
Of sixty-six infants who had undergone a total of 118 ultrasound examinations (mean, 1.8; range, 1 to 5), 19 (29%) demonstrated shoulder dislocation with the shoulder positioned in internal rotation; the dislocation was first detected between 2.1 and 10.5 months of age. Infants with a dislocated shoulder demonstrated significantly less mean passive external rotation in adduction (mean, 45.8° versus 71.4°, p < 0.001) and a greater difference between internal rotation and external rotation AMS scores (mean, 5.5-point versus 3.3-point difference, p < 0.001) than those without shoulder dislocation. Passive external rotation in adduction was a better measure for discriminating between dislocation and no dislocation (area under receiver operating characteristic curve [AUC] = 0.89) than was the difference between internal and external rotation AMS scores (AUC = 0.73). A cutoff of 60° of passive external rotation in adduction (≤60° versus° >60) yielded a sensitivity of 94% and a specificity of 69%.
Shoulder dislocation is common in infants with BPBP; 29% of the infants presenting to our tertiary care center had a dislocation during their first year of life. Ultrasound shoulder screening is appropriate for infants with BPBP. If passive external rotation in adduction is used to determine which infants should undergo ultrasound, ≤60° should be utilized as the criterion to achieve appropriate sensitivity.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
早期发现臂丛神经产瘫（BPBP）婴儿的后肩关节脱位至关重要，但仅通过体格检查可能难以做到。本研究的目的是使用超声确定BPBP患者肩关节脱位的患病率，并确定哪些体格检查测量值与这些患者的脱位最相关。
本研究是对2011年1月至2014年4月出生的BPBP婴儿超声筛查项目中获得的数据进行的回顾性分析。体格检查包括使用主动运动量表（AMS）和测量肩关节被动外旋。超声测量包括肱骨头后移至肩胛轴线后方的百分比（PHHD）和α角（肩胛后缘与通过关节盂的肱骨头切线的交点）。肩关节脱位定义为PHHD>0.5且α角>30°。
在总共接受118次超声检查（平均1.8次；范围1至5次）的66例婴儿中，19例（29%）在肩关节内旋位时显示肩关节脱位；脱位首次在2.1至10.5个月龄时被发现。与无肩关节脱位的婴儿相比，肩关节脱位的婴儿在内收位时平均被动外旋明显更少（平均45.8°对71.4°，p<0.001），内旋和外旋AMS评分差异更大（平均差异5.5分对3.3分，p<0.001）。内收位被动外旋在区分脱位和无脱位方面（受试者操作特征曲线下面积[AUC]=0.89）比内旋和外旋AMS评分差异（AUC=0.73）是更好的指标。内收位被动外旋角度截断值为60°（≤60°对>60°）时，敏感性为94%，特异性为69%。
肩关节脱位在BPBP婴儿中很常见；在我们三级医疗中心就诊的婴儿中，29%在出生后第一年内发生脱位。超声肩关节筛查适用于BPBP婴儿。如果使用内收位被动外旋来确定哪些婴儿应接受超声检查，≤60°应作为标准以获得适当的敏感性。
治疗性四级。有关证据水平的完整描述，请参阅作者指南。
