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Deltoid Fibrosis Treatment & Management

  • Author: Brian G Cothern; Chief Editor: S Ashfaq Hasan, MD  more...
 
Updated: Jun 22, 2016
 

Approach Considerations

Surgical treatment focuses on the release of the contracted, fibrous bands. The most commonly indicated cases for surgical treatment are those in which the abduction contracture at rest is greater than or equal to 25°. Patients should be at least 5 years old and should show evidence of progressive deformity during growth or changes in bony anatomy (eg, head flattening, changes in acromial morphology, widening of the acromioclavicular joint, scoliosis, narrowing of the thoracic cage). Most of these bony abnormalities may be exaggerated or underestimated, depending on the radiographic imaging method used and whether the bones are positioned adequately.

Fluoroscopy or computed tomography (CT) may be required to appreciate fully the specific deformity. Ogawa reported that the humeral head deformity remained in juvenile cases, despite surgical resolution of the abduction contracture.[7]  Therefore, deltoid contracture in the young patient should be treated surgically when the patient is at an age that allows spontaneous correction of the bony deformity with growth. This decreases the risk of late arthritic changes due to humeral head incongruence.

Indications for surgical treatment in adults should be based on symptoms of neck or shoulder girdle pain, as well as limitations in activities of daily living. A derangement of shoulder mechanics occurs when a deltoid contracture and concomitant scapular winging is present. An increased winging angle of the glenoid alters the natural coordination between the deltoid and the rotator cuff, leading to mechanical consequences such as impingement and, possibly, rotator cuff tendinopathy and rotator cuff tears.

In a study by Huang et al,[27]  the relationship between deltoid contracture and rotator cuff tears was evaluated. In patients with deltoid contracture, they found that age and the winging angle of the glenoid were predisposing factors for rotator cuff injury. They suggested that early surgery is necessary in older patients and in patients with an increased winging angle. Surgical release of the deltoid contractures aims to restore natural scapulothoracic kinematics to avoid rotator cuff injury or worsening of rotator cuff pathology and impingement.

A series by Yin et al supported simultaneous treatment of deltoid contractures and concomitant rotator cuff tears.[14]

The usual contraindications for surgery apply, such as general health considerations that would make the patient unsuitable for general anesthesia. Local problems with the skin and soft tissues preclude surgical treatment. There are no other specific contraindications.

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Medical Care

Medical treatment has involved observation, stretching, nonsteroidal anti-inflammatory agents, and some forms of physical therapy. However, none of these treatments has been shown to be an effective form of treatment for deltoid contracture.

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Surgical Care

Preparation for surgery

In managing contractures, it is important to know the specific area of contracture to plan the appropriate approach. A single band may be approached via either a proximal or a distal incision. Fibrosis of more than one portion of the deltoid is best approached through a distal incision.[21]  Some predisposing indicators for surgical treatment include the following[8, 22] :

  • Contracture of 25° or greater
  • Patient aged 5 years or older
  • Progression of contracture or appearance
  • Pain and discomfort

Operative details

In most reports, proximal incisions have been used to expose the acromial attachment of the bands. Incisions may be transverse or longitudinal and are typically about 5-10 cm in length. Incisions must be made with caution to avoid the axillary nerve.

Transverse incisions have been associated with keloid formation and unattractive scars. Longitudinal incisions may not allow adequate exposure of the entire deltoid area and may necessitate multiple incisions to perform adequate releases. Proximal release or resection of bands may leave large gaps in the deltoid muscle, causing loss of the natural shoulder contour and a stair-step–like deformity.

Minami et al transferred a portion of the posterior deltoid to fill in gaps, returning the shoulder to a more normal shape.[8]  They reported no failures with this technique. Groves and Goldner transferred the conjoined tendon of the coracobrachialis and the short head of the biceps to fill the defect in the deltoid by attaching the tendons to the remaining anterior deltoid and to the anterior acromion (limited Ober procedure).[6]

Following release or resection of the fibrous bands, shoulder range of motion (ROM) should be assessed. Ensuring adequate adduction is important. Occasionally, further release of smaller secondary bands or gentle manipulation of the shoulder is necessary to regain full motion.

When the bands involve more than one portion or all of the deltoid, simple band release or excision is not always a good option. Manske reported on a case involving fibrosis dispersed throughout the entire deltoid.[19]  Instead of a proximal release, he used a distal incision about the deltoid tubercle, releasing the entire deltoid tendon from the tubercle. This approach yielded an excellent result.

Subsequently, Chen et al and Ko et al reported larger studies using distal release.[13, 22]  They noted excellent results as well, with fewer complications than previous proximal releases.

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Postoperative Care

With proximal release, Minami et al advised using a stockinette to stabilize the arm across the body in an adducted position for 10 days following surgery.[8]  Ater this 10-day period, the patient should be advised to start movement and therapy to regain motion. Bhattacharyya also advocated this approach.[28]

Manske advocated the use of a plaster dressing to keep the arm adducted for 5 weeks, followed by an active exercise program.[19] Hang and Miller reported on multiple individuals without a postoperative immobilization period.[26] These patients showed full ROM at 2 years following surgical release.

With distal release, Chen et al used immediate postoperative ROM exercises, encouraging forced adduction.[13] Ko et al also used early ROM exercises, as well as a triangular sling for comfort.[22] From a review of these studies, it appears that neither a short period of immobilization nor early immediate mobilization provides a better result than the other. Prolonged immobilization does not appear to be required for a successful outcome.

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Complications

Proximal resection of the deltoid has been associated with multiple complications, including failure to release the deltoid contracture, keloid formation, and cosmetic deformities of the shoulder contour.

Patients undergoing distal release surgery experience fewer complications with good clinical results.[22] Owing to the high vascularization of the deltoid muscle, postoperative hematomas may form in proximal, distal, and intrasubstance releases. Careful hemostasis through electrocauterization is used to try to prevent hematoma formation and blood loss.[13]

Neurovascular injury, infection, or other significant complications have not been reported.

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Contributor Information and Disclosures
Author

Brian G Cothern Wright State University, Boonshoft School of Medicine

Brian G Cothern is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Jedediah H May, MD Resident Physician, Department of Orthopedics, Wright State University, Boonshoft School of Medicine

Jedediah H May, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Matthew J DiPaola, MD Assistant Professor of Orthopedics, Wright State University, Boonshoft School of Medicine; Director, Shoulder and Elbow Service and Orthopedic Surgical Simulation Laboratory, Dayton Veterans Affairs Medical Center

Matthew J DiPaola, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Association of American Physicians and Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Mark Brodersen, MD Assistant Professor, Department of Orthopedic Surgery, Mayo Medical School

Mark Brodersen, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Clinical Orthopaedic Society, Florida Medical Association, and Mid-America Orthopaedic Association

Disclosure: Nothing to disclose.

References
  1. Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2012 Jun. 20(6):364-72. [Medline].

  2. Scott DA, Alexander JR. Relapsing and Remitting Scapular Winging in a Pediatric Patient. Am J Phys Med Rehabil. 2010 Mar 30. [Medline].

  3. Wolbrink AJ, Hsu Z, Bianco AJ. Abduction contracture of the shoulders and hips secondary to fibrous bands. J Bone Joint Surg Am. 1973 Jun. 55(4):844-6. [Medline].

  4. Mir NA, Ahmed SM, Bhat JA. Post-Injection Gluteal Fibrosis: A Neglected Problem. JK Science. Jul-Sept 2002. 4(3):144-6.

  5. Chatterjee P, Gupta SK. Deltoid contracture in children of central Calcutta. J Pediatr Orthop. 1983 Jul. 3(3):380-3. [Medline].

  6. Groves RJ, Goldner JL. Contracture of the deltoid muscle in the adult after intramuscular injections. J Bone Joint Surg Am. 1974 Jun. 56(4):817-20. [Medline].

  7. Ogawa K, Yoshida A, Inokuchi W. Deltoid contracture: a radiographic survey of bone and joint abnormalities. J Shoulder Elbow Surg. 1999 Jan-Feb. 8(1):22-5. [Medline].

  8. Minami M, Yamazaki J, Minami A. A postoperative long-term study of the deltoid contracture in children. J Pediatr Orthop. 1984 Sep. 4(5):609-13. [Medline].

  9. Ogawa K, Inokuchi W, Naniwa T. Subacromial impingement associated with deltoid contracture. A report of two cases. J Bone Joint Surg Am. 1999 Dec. 81(12):1744-6. [Medline].

  10. Chen HC, Huang TF, Chou PH, Chen TH. Deltoid contracture: a case with multiple muscle contractures. Arch Orthop Trauma Surg. 2007 Oct 25. [Medline].

  11. Banerji D, De C, Pal AK, Das SK, Ghosh S, Dharmadevan S. Deltoid contracture: A study of nineteen cases. Indian J Orthop [serial online]. 2008. 42:188-91. [Full Text].

  12. Chen SS, Chien CH, Yu HS. Syndrome of deltoid and/or gluteal fibrotic contracture: an injection myopathy. Acta Neurol Scand. 1988 Sep. 78(3):167-76. [Medline].

  13. Chen WJ, Wu CC, Lin YH. Treatment of deltoid contracture in adults by distal release of the deltoid. Clin Orthop. 2000 Sep. (378):136-42. [Medline].

  14. Yin TC, Chen JM, Huang CC, Wang CJ, Wang FS, Chou WY, et al. Surgical results of concomitant treatment of deltoid contracture and rotator cuff tear. Injury. 2011 Apr. 42(4):397-402. [Medline].

  15. Hogendoorn S, van Overvest KL, Watt I, Duijsens AH, Nelissen RG. Structural changes in muscle and glenohumeral joint deformity in neonatal brachial plexus palsy. J Bone Joint Surg Am. 2010 Apr. 92(4):935-42. [Medline].

  16. Chen CK, Yeh L, Chen CT, Pan HB, Yang CF, Resnick D. Contracture of the deltoid muscle: imaging findings in 17 patients. AJR Am J Roentgenol. 1998 Feb. 170(2):449-53. [Medline].

  17. Cozen LN. Pentazocine injections as a causative factor in dislocation of the shoulder. J Bone Joint Surg Am. 1977 Oct. 59(7):979. [Medline].

  18. Davidson LT, Carter GT, Kilmer DD, Han JJ. Iatrogenic axillary neuropathy after intramuscular injection of the deltoid muscle. Am J Phys Med Rehabil. 2007 Jun. 86(6):507-11. [Medline].

  19. Manske PR. Deltoid muscle abduction contracture. Clin Orthop. 1977 Oct. (128):165-6. [Medline].

  20. Weber PC, Capello W, Brandt KD. Fibrous replacement of the deltoid muscle: a remediable cause of abduction contracture of the shoulder in scleroderma. Clin Orthop Relat Res. 1977. 164-9. [Medline].

  21. Ngoc HN. Fibrous deltoid muscle in Vietnamese children. J Pediatr Orthop B. 2007 Sep. 16(5):337-44. [Medline].

  22. Ko JY, An KN, Yamamoto R. Contracture of the deltoid muscle. Results of distal release. J Bone Joint Surg Am. 1998 Feb. 80(2):229-38. [Medline].

  23. van Gelein Vitringa VM, van Kooten EO, Mullender MG, van Doorn-Loogman MH, van der Sluijs JA. An MRI study on the relations between muscle atrophy, shoulder function and glenohumeral deformity in shoulders of children with obstetric brachial plexus injury. J Brachial Plex Peripher Nerve Inj. 2009 May 18. 4:5. [Medline]. [Full Text].

  24. Hill NA, Liebler WA, Wilson HJ. Abduction contractures of both glenohumeral joints and extension contracture of one knee secondary to partial muscle fibrosis. J Bone Joint Surg Am. 1967 Jul. 49(5):961-4. [Medline].

  25. Reinold MM, Macrina LC, Wilk KE, Fleisig GS, Dun S, Barrentine SW, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007 Oct-Dec. 42(4):464-9. [Medline].

  26. Hang YS, Miller JW. Abduction contracture of the shoulder. A report of two patients. Acta Orthop Scand. 1978 Apr. 49(2):154-7. [Medline].

  27. Huang CC, Ko SF, Ko JY, Wan YL, Cheng YF, Wang CJ. Imaging factors related to rotator cuff tear in patients with deltoid contracture. J Formos Med Assoc. 2006 Feb. 105(2):132-8. [Medline].

  28. Bhattacharyya S. Abduction contracture of the shoulder from contracture of the intermediate part of the deltoid. Report of three cases. J Bone Joint Surg Br. 1966 Feb. 48(1):127-31. [Medline].

 
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