Deltoid Fibrosis Treatment & Management
- Author: Brian G Cothern; Chief Editor: S Ashfaq Hasan, MD more...
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. 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, 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.
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.
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.
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. 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
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. 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).
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. 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.
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. Ater this 10-day period, the patient should be advised to start movement and therapy to regain motion. Bhattacharyya also advocated this approach.
Manske advocated the use of a plaster dressing to keep the arm adducted for 5 weeks, followed by an active exercise program. Hang and Miller reported on multiple individuals without a postoperative immobilization period. 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. Ko et al also used early ROM exercises, as well as a triangular sling for comfort. 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.
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. 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.
Neurovascular injury, infection, or other significant complications have not been reported.
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