You are in: eMedicine Specialties > Orthopedic Surgery > SHOULDER Deltoid FibrosisArticle Last Updated: Jun 5, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Mark Brodersen, MD, Assistant Professor, Department of Orthopedic Surgery, Mayo Medical School Mark Brodersen 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 Editors: Cato T Laurencin, MD, PhD, University Professor, Lillian T Pratt Distinguished Professor and Chairman, Department of Orthopaedic Surgery, The University of Virginia; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Pekka A Mooar, MD, Associate Professor, Department of Orthopedic Surgery, Temple University School of Medicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania Author and Editor Disclosure Synonyms and related keywords: deltoid contracture, scapula winging, scapular winging, scoliosis, Dramamine, penicillin, pentazocine, streptomycin, tetracycline, antipyretic, myoischemia, denervation, myotoxicity, needle injection disorders, injection injury INTRODUCTIONSection 2 of 10
  Deltoid fibrosis is a disorder marked by intramuscular fibrous bands within the substance of the deltoid muscle. These bands lead to secondary contractures that affect the function of the shoulder joint. Scapular winging and secondary scoliosis may also be related to this condition. Deltoid fibrosis has been associated with fibrous contractures of the gluteal and quadriceps muscles and is likely a similar process. History of the ProcedureSignificant documentation of deltoid fibrosis began in the early 1960s. Isolated reports of the condition had been made before then, but not in the English-language medical literature. Following World War II, parenteral administration of antibiotics, antipyretics, and other drugs became increasingly common. Along with the increased use of intramuscular injections came the appearance of deltoid fibrosis and contractures, as well as problems in other muscle groups. ProblemDeltoid fibrosis is part of a spectrum of fibrotic conditions that affect both upper and lower extremities. Such fibrotic conditions may involve 1 extremity or, in rare cases, may involve all 4 extremities. Contracture of a muscle may limit limb function or appearance, which may also cause significant social unease. Deltoid fibrosis is seen in people of all ages, but it has been reported primarily in children. FrequencyIncidence in the United States has been low. Reports on small groups of patients with deltoid fibrosis have been made, but no large series has been reported in the U.S. All of the large series on this condition are from abroad. In certain areas of the world, contractures have become endemic. This has caused significant social problems, resulting in litigation in some districts in Japan. In Taiwan, where the condition is endemic, the prevalence rate is 10% in some areas. EtiologyDeltoid fibrosis has most commonly been related to postinjection changes. Numerous drugs have been implicated as causative agents, including Dramamine, iron, penicillin (crystalline and oily), lincomycin, pentazocine/Talwin, hypodermoclyses, streptomycin, tetracycline, vitamins, and antipyretics.1, 2 Why some children and adults develop deltoid fibrosis is unknown. Most siblings of children with deltoid fibrosis do not develop this condition, even if they have had a similar number of injections. Chen reported on a series in which there was a 30% incidence in siblings.3 Chatterjee and Gupta reported on 17 patients with deltoid fibrosis who belonged to a certain segregated patriarchal ethnic group in Calcutta.4 They noted that children from other communities in central Calcutta did not develop deltoid fibrosis. These findings, as well as those from Taiwan and Japan, suggest the existence of constitutional and/or predisposing factors in the etiology of contractures. PathophysiologyThe deltoid muscle has 3 areas of origin: the clavicle, the acromion, and the scapular spine. There is 1 site of insertion, the deltoid tubercle on the humerus. The anterior and posterior portions converge directly into the insertion site, whereas the middle portion is multipennate. The middle portion has 4 intramuscular septa that extend distally from the lateral acromion. They interdigitate with 3 septa that arise from the deltoid tubercle. The main action of the deltoid is abduction of the arm. The anterior deltoid also assists in forward flexion and internal rotation. The posterior portion assists with extension and external rotation. Contractures of the deltoid have been reported in all 3 portions. They are seen most commonly in the middle portion. The second most common site for contracture is the posterior portion. These areas are involved most commonly because injections are placed there to avoid the cephalic vein anteriorly. Anterior bands occasionally are seen. Two portions, or even all 3 portions, have been reported to be involved with contracture.4, 5, 6, 7, 8, 9, 10, 11 Electromyelogram (EMG) findings have shown no activity in the involved muscle, but nerve conduction studies have been normal. Chen has shown that EMG abnormalities are observed not only in the involved muscle but also in the uninvolved muscles.3, 12 This suggests that the muscle initially is abnormal and is especially susceptible to injury and development of fibrosis. Chen has proposed 3 possible mechanisms for the development of deltoid contractures.3, 12 These mechanisms are as follows:
Repeated injection injuries and/or myotoxicity are believed to trigger fibrotic deltoid contracture by causing focal myositis and subsequent myopathic degeneration. Denervation occurs simultaneously from fibrotic compression or ischemia. Also, it is likely that injury occurs in connective tissue as well as in muscle. This could be caused by an enzyme deficiency in collagen degradation, an increased rate of collagen synthesis, genetic defects in the regulation of collagen biosynthesis, or an enzymatic defect in fibroblasts. Some or all of these factors are undoubtedly at work, independent of muscle injury, as almost all series of deltoid fibrosis include patients who do not have a history of deltoid injections. ClinicalHistory
Physical examination
The contracted portion of the deltoid determines the problems encountered by the patient. The shoulder is abducted when only the middle portion is involved. If the anterior portion is involved, the arm assumes a flexed and abducted position. If the posterior portion is involved, the arm is extended and abducted. As the arm is progressively extended or flexed, subluxation of the humeral head may occur. Most contractures are full thickness. However, a small group of individuals with only undersurface bands has been reported. These individuals experienced impingement and rotator cuff tears. Individuals in this group were skeletally mature. Recurrent dislocation has been reported, as well as chronic labral injury. Radiologic evaluation of glenohumeral joint stability may be difficult because of changes in scapular position causing a relative overlap of the glenoid and humeral head. CT scanning may be required to adequately evaluate the status of the glenohumeral articulation. In patients who are skeletally immature, flattening of the humeral head and changes in acromial morphology (drooping) may be seen. As the abduction contracture increases,13 the weight of the arm causes the inferior border of the scapula to rotate medially, resulting in winging of the scapula. Frequently, the skin may dimple, and a fibrous band may be palpable. Muscle aching about the shoulder girdle frequently accompanies the winging. Scoliosis secondary to more severe abduction contracture has been reported. Individuals usually present with inability to move the arm across the body. Abduction of the arm releases the tension of the fibrous band and allows cross-body movement. INDICATIONSSection 3 of 10
Surgical treatment centers 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. Fluoroscopic radiographs or CT scans 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.5 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. No significant bony abnormalities were reported in adults. Hypertrophy of the deltoid tuberosity and cystic lesions of the acromion have been reported, but no specific bone or joint abnormalities have been identified. 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. CONTRAINDICATIONSSection 4 of 10
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. WORKUPSection 5 of 10
Lab Studies
Imaging Studies
Other Tests
Diagnostic Procedures
Histologic Findings
TREATMENTSection 6 of 10
Medical therapyMedical treatment has involved observation only, stretching, nonsteroidal agents, and some forms of physical therapy. None of these treatments has been shown to be effective. Preoperative detailsIn managing contractures, it is important to know the specific area of contracture to plan the appropriate approach. A single band may be approached from a proximal or distal incision. Fibrosis of more than 1 portion of the deltoid is best approached through a distal incision.15 Intraoperative detailsIn most reports, proximal incisions have been used to expose the acromial attachment of the bands. Incisions may be transverse or longitudinal. 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 roundness of the lateral shoulder, and a cosmetic stairsteplike deformity. Minami described transferring a portion of the posterior deltoid anteriorly and laterally to fill such gaps.6 He reported no failures with this technique. In dealing with anterior contractures, Groves reported transferring the conjoined tendon of the coracobrachialis along with the short head of the biceps to fill the defect in the deltoid.7 The tendons were attached to the anterior acromion (limited Ober procedure). Following release or resection of the fibrous bands, testing of shoulder motion should be performed. Occasionally, further release of smaller secondary bands is required, or gentle manipulation of the shoulder is necessary to regain full motion. When the bands involve more than 1 portion or all of the deltoid, simple band release or excision is not an option. Manske reported on a case involving the entire deltoid.16 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, Ko and Chen reported larger studies using distal release.12, 17 They noted excellent results as well. Postoperative detailsWith proximal release, Minami advises using a stockinette on the arm and tying the hand to the opposite shoulder to keep the arm in an adducted position postoperatively.6 Exercises to regain motion are initiated after 10 days. Bhattacharyya also advocates this approach.18 Manske advocates the use of a plaster dressing to keep the arm at the side for 5 weeks, followed by an active exercise program.16 Hang reported on the use of early motion without immobilization; full shoulder motion was seen at 2-year follow-up.19 With distal release, Chen uses immediate postoperative range-of-motion (ROM) exercises, encouraging forced adduction.12 Ko also uses early ROM exercises, as well as a sling for comfort.17 In reviewing these studies, it seems that a short period of immobilization, to allow for skin healing, and early mobilization do equally well. Prolonged immobilization does not appear to be required. COMPLICATIONSSection 7 of 10
Keloid formation from proximal transverse incisions is the most common problem reported. Neurovascular injury, infection, or other significant complications have not been reported. OUTCOME AND PROGNOSISSection 8 of 10
Several series have reported about a 6% incidence of recurrence. With distal release, Chen reported good outcomes in 100% of patients, and Ko reported good ROM and pain relief in 96%.12, 17 Patients who had distal release were evaluated with a Cybex dynamometer and were found to have no loss of strength as compared with the contralateral side. Function returned to normal within 3 months. In general, the degree of preoperative contracture does not correlate with postoperative results. Whether the shoulder is treated with proximal or distal release, it appears that the rate of complications is low and that the great majority of patients can expect a return to close-to-normal ROM, excellent pain relief, and a resolution of scapular winging. Proximal release can be used if there is one band, but if more than one portion of the deltoid is involved, distal release is recommended. As the results of distal release are as good as those of proximal release, distal release perhaps should be considered routinely. Distal release avoids the stairstep deformity associated with a proximal approach. FUTURE AND CONTROVERSIESSection 9 of 10
Deltoid fibrosis is an uncommon problem. In children, it may be related to congenital or developmental defects20 or to intramuscular injections. Patients who develop contractures following injection probably have an inherent predisposition for development of fibrosis. In adults, contractures seem to be related to injections. In Japan, Ogawa reported that, with the exception of a few adult cases, no new cases of deltoid contracture have been documented since the risks of intramuscular injection were publicized in 1975. Therefore, except for a few isolated cases, deltoid fibrosis may become a problem primarily of historical interest. REFERENCESSection 10 of 10
Article Last Updated: Jun 5, 2008 |
