Post- operative Physiotherapy after MOD QUAD Procedure
Description
MOD QUAD is a surgical procedure to rebalance the muscles around the shoulder in brachial plexus injury (C5,c6 or C5,c6, c7) to improve shoulder movement.
In brachial plexus injury, imbalances develop as some groups of muscles overact and some get weak or paralysed. [1]The most common secondary deformity in obstetric brachial palsy, Erb's palsy, is seen at shoulder which is deficiency of shoulder abduction and/or external rotation. [2]
Brachial plexus nerve root c5,c6 are most frequently stretched in newborns and some may restore function spontaneously with physiotherapy. Children who do not recover fully within the first few months are likely to develop secondary deformities, especially at the shoulder, with most common at the site being shoulder abduction and external rotation. Poor recovery of neurological function in obstetric brachial palsy results in muscle weakness and imbalances around shoulder affecting its movement and functions. [2]
Indication
- Patient with obstetrics brachial palsy with C5,6 involvement. [2]
- Revision procedure for obstetric brachial plexus with poor outcomes of previous surgeries like exploration, nerve transfer, nerve graft, neurolysis and Botox [3]
- Untreated adult obstetric Brachial Plexus suing compensatory strategy to achieve loss of shoulder abduction. [4]
Clinical Presentation
- Poor or lack external rotation and persistent internal rotation [2]. On clinical assessment, there is shoulder adductor and internal rotator contracture and weakness of shoulder external rotators.
- Secondary bony changes that included glenohumeral dysplasia, subluxation of the humeral head. [2]
Diagnostic Tests
CT Scan/MRI, myelogram: evaluate nerve root avulsion and identify pre-ganglionic or post-ganglionic injury.
EMG and NCV to identify muscle and nerve function [5]
Operative Procedure
The procedure has four components:
- Latissimus dorsi muscle transfer to restore external rotation and abduction
- Teres major muscle transfer to restore scapular stabilisation and external rotation
- Subscapularis muscle release facilitates abduction of shoulder
- Axillary nerve decompression and neurolysis). Depending on the individual child, other nerve decompressions or muscle/tendon transfers (such as pectoralis muscle releases) might be performed at the same time (the modified quad or "Mod Quad" procedure). [6]
Post-Operative Management
Post-surgery arm upper limb is immobilised in the POP slab with the shoulder in abduction .Later,the slab is replaced by a splint with shoulder in abduction and external rotation( statue of liberty splint) for four weeks .[7]The splint is used for night time for a further 6 weeks.
After 3 weeks, mobilisation of the shoulder is started. So, the child is encouraged to abduct the shoulder above the level of splint. Full shoulder abduction is permitted after 4 weeks (2015). Do not encourage any internal rotation or adduction of the shoulder. [1]
Precautions: All compensatory movement is to be discouraged. Compensatory movements are bending the body backwards, sideways, hiking the shoulder and hip hiking .
0 to 03 weeks: Immobilisation in cast or splint; active hand movements are encouraged.
03 to 08 weeks: Active movements are encouraged in abduction above splint. Scar massage and mobility techniques are followed. Gradually, around 6 weeks, the splint is taken off and encouraged to perform active abduction. In order to avoid fatigue and damage to the transferred muscle, the patients are advised to move slowly. The patient is instructed to wear an orthosis during the day at home and take it off only for exercises.
08 to 16 weeks: Gradually, active movements in functional patterns are encouraged, hand to mouth, hand to back of head, hand to lower back. young patients Play way methods for overhead abduction is encouraged, like overhead clapping , butterfly wing movement, touching the hair clip etc.
16 weeks onwards: In-cooperating abduction and external rotation movements in functional activities, e.g., playing with a ball, putting a hairclip, eating with a spoon, etc.
This is the guideline of the protocol followed after Mod Quad surgery, but it may vary based on the operative surgeon guidance or post surgical complication.
Outcome Measures
Mallet score[8]
Active range of motion
Results/Prognosis
MOD quad is a secondary reconstruction procedure that results in significant improvement in shoulder abduction, external rotation. [3][9]
The procedure results in improvement of shoulder abduction and external rotation in adults with neglected or poor outcomes of previous surgeries obstetric brachial plexus injury. [4]
References
- ↑ 1.0 1.1 G. Kartikayan. Manual of reconstructive hand surgery-page 264. JP medical .
- ↑ 2.0 2.1 2.2 2.3 2.4 Nath RK, Somasundaram C. Comparing the Results of External Rotational Humeral Osteotomy in Older Children to the Mod Quad and Triangle Tilt Procedures in Adults with Obstetric Brachial Plexus Injury. Eplasty. 2022 Feb 8;22:e2. PMID: 35651582; PMCID: PMC9128834.
- ↑ 3.0 3.1 Nath RK, Somasundaram C. Improvements after mod Quad and triangle tilt revision surgical procedures in obstetric brachial plexus palsy. World J Orthop. 2016 Nov 18;7(11):752-757. doi: 10.5312/wjo.v7.i11.752. PMID: 27900273; PMCID: PMC5112345.
- ↑ 4.0 4.1 Nath RK, Goel D, Somasundaram C. Clinical and functional outcome of modified Quad surgery in adult obstetric brachial plexus injury patients: Case reports. Clin Pract. 2019 Sep 23;9(3):1140. doi: 10.4081/cp.2019.1140. PMID: 31579492; PMCID: PMC6763706.
- ↑ Nath RK, Kumar N, Somasundaram C. Modified Quad surgery significantly improves the median nerve conduction and functional outcomes in obstetric brachial plexus nerve injury. Ann Surg Innov Res. 2013 May 28;7:5. doi: 10.1186/1750-1164-7-5. PMID: 23714699; PMCID: PMC3668219.
- ↑ DR. Rahul K. Nath, Mod QUAD procedure.
- ↑ Nath RK, Avila MB, Melcher SE, Nath DK, Eichhorn MG, Somasundaram C. Birth weight and incidence of surgical obstetric brachial plexus injury. Eplasty. 2015 Apr 28;15:e14. PMID: 25987939; PMCID: PMC4415516.
- ↑ Al-Qattan MM, El-Sayed AA. Obstetric brachial plexus palsy: the mallet grading system for shoulder function--revisited. Biomed Res Int. 2014;2014:398121. doi: 10.1155/2014/398121. Epub 2014 Jan 5. PMID: 24527447; PMCID: PMC3909974.
- ↑ Ozkan T, Aydin A, Onel D, Ozkan S. [Reconstruction of shoulder abduction and external rotation in obstetric brachial plexus palsy]. Acta Orthop Traumatol Turc. 2004;38(3):161-9. Turkish. PMID: 15347915.