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Introduction: In children with brachial plexus birth injury (BPBI), denervation of the shoulder muscles leads to bony deformity in the first months of life, reducing active and passive range of motion (ROM) and causing activity limitation. The aim of this multicentre randomised controlled trial is to evaluate the effectiveness of botulinum toxin injections (BTI) in the shoulder internal rotator muscles of 12-month-old babies in limiting the progression of posterior subluxation of the glenohumeral joint, compared with a sham procedure mimicking BTI. The secondary aims are to evaluate the effectiveness of BTI in (1) limiting the progression of glenoid retroversion and three-dimensional (3D) deformity and (2) improving shoulder ROM and upper limb function, as well as to confirm the tolerance of BTI., Methods and Analysis: Sixty-two babies with unilateral BPBI and a risk of posterior humeral head subluxation will be included. Only those with at least 7% posterior subluxation of the humeral head compared with the contralateral shoulder on the MRI will be randomised to one of two groups: 'BTI' and 'Sham'. The BTI group will receive BOTOX injections at the age of 12 months in the internal shoulder rotator muscles (8 UI/kg). The sham group will undergo a sham BTI procedure. Both groups will undergo repeated shoulder MRI at 18 months of age to quantify changes in the percentage of posterior migration of the humeral head (primary outcome), glenoid version and 3D bone deformity. Clinical evaluations (passive shoulder ROM, active movement scale) will be carried out at baseline and 15 and 18 months of age. The mini-assisting hand assessment will be rated between 10 and 11 months and at 18 months of age. Adverse events will be recorded at least monthly for each child., Ethics and Dissemination: Full ethical approval for this study has been obtained. The findings will be disseminated in peer-reviewed publications., Trial Registration Number: EudraCT: 2015-001402-34 in European Clinical Trial database; NCT03198702 in Clinical Trial database; Pre-results., Competing Interests: Competing interests: CP reports non-financial support from Biogen, outside the submitted work. SB reports non-financial support from Allergan, outside the submitted work. GLG reports other from Portola Pharmaceuticals, other from Boehringer-Ingelheim, other from Pfizer, other from Bristol-Myers Squibb, other from LEO Pharma, other from Daiichi Sankyo, other from Bayer, other from Bayer, other from Pfizer, other from LEO Pharma, other from Sanofi, other from bioMérieux, outside the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Subject-specific musculoskeletal models can predict accurate joint and muscle biomechanics thereby helping clinicians and surgeons. Current modeling strategies do not incorporate accurate subject-specific muscle parameters. This study reports a statistical shape model (SSM) based method to predict subject-specific muscle attachment regions on shoulder bones and illustrates the concurrent validity of the predictions. Augmented SSMs of scapula and humerus bones were built using bone meshes and five muscle attachment (origin/insertion) regions which play important role in the shoulder motion and function. Muscle attachments included Subscapularis, Supraspinatus, Infraspinatus, Teres Major and Teres Minor on both the bones. The regions were represented by subset of vertices on the bone meshes and were tracked using vertex identifiers. Subject-specific muscle attachment regions were predicted using external set of bones not used in building the SSMs. Validity of predictions was determined by visual inspection and also by using four similarity measures between predicted and manually segmented regions. Excellent concurrent validity was found indicating the higher accuracy of predictions. This method can be effectively employed in modeling pipelines or in automatic segmentation of medical images. Further validations are warranted on all the muscles of the shoulder complex.

In the pediatric shoulder, injury and pathology can disrupt the muscle force balance, resulting in severe functional losses. As little data exists pertaining to in vivo pediatric shoulder muscle function, musculoskeletal data are crucially needed to advance the treatment of pediatric shoulder pathology/injury. Therefore, the purpose of this study was to develop a pediatric database of in vivo volumes for the major shoulder muscles and correlate these volumes with maximum isometric flexion/extension, internal/external rotation, and abduction/adduction joint moments. A methodology was developed to derive 3D shoulder muscle volumes and to divide the deltoid into sub-units with unique torque producing capabilities, based on segmentation of three-dimensional magnetic resonance images. Eleven typically developing children/adolescents (4F/7M, 12.0 ± 3.2 years, 150.8 ± 16.7 cm, 49.2 ± 16.4 kg) participated. Correlation and regression analyses were used to evaluate the relationship between volume and maximum, voluntary, isometric joint torques. The deltoid demonstrated the largest (30.4 ± 1.2%) and the supraspinatus the smallest (4.8 ± 0.5%) percent of the total summed volume of all six muscles evaluated. The anterior and posterior deltoid sections were 43.4 ± 3.9% and 56.6 ± 3.9% of the total deltoid volume. The percent volumes were highly consistent across subjects. Individual muscle volumes demonstrated moderate-high correlations with torque values (0.70-0.94, p<0.001). This study presents a comprehensive database documenting normative pediatric shoulder muscle volume. Using these data a clear relationship between shoulder volume and the torques they produce was established in all three rotational degrees-of-freedom. This study furthers the understanding of shoulder muscle function and serves as a foundation for evaluating shoulder injury/pathology in the pediatric/adolescent population., (Copyright © 2014. Published by Elsevier Ltd.)

Methods based on cutaneous markers are the most popular for the recording of three dimensional scapular motion analysis. Numerous methods have been evaluated, each showing different levels of accuracy and reliability. The aim of this review was to report the metrological properties of 3D scapular kinematic measurements using cutaneous markers and to make recommendations based on metrological evidence. A database search was conducted using relevant keywords and inclusion/exclusion criteria in 5 databases. 19 articles were included and assessed using a quality score. Concurrent validity and reliability were analyzed for each method. Six different methods are reported in the literature, each based on different marker locations and post collection computations. The acromion marker cluster (AMC) method coupled with a calibration of the scapula with the arm at rest is the most studied method. Below 90-100° of humeral elevation, this method is accurate to about 5° during arm flexion and 7° during arm abduction compared to palpation (average of the 3 scapular rotation errors). Good to excellent within-session reliability and moderate to excellent between-session reliability have been reported. The AMC method can be improved using different or multiple calibrations. Other methods using different marker locations or more markers on the scapula blade have been described but are less accurate than AMC methods. Based on current metrological evidence we would recommend (1) the use of an AMC located at the junction of the scapular spine and the acromion, (2) the use of a single calibration at rest if the task does not reach 90° of humeral elevation, (3) the use of a second calibration (at 90° or 120° of humeral elevation), or multiple calibrations above 90° of humeral elevation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: We characterized bilateral shoulder strength and the balance of antagonist/agonist muscle pairs in children with brachial plexus palsy (BPP) and with typical development (TD)., Methods: In 15 children with unilateral BPP and 11 with TD, bilateral maximal isometric shoulder strength in flexion/extension, internal/external rotation, and abduction/adduction was recorded using a hand-held dynamometer. Correlation between strength and active range of motion were evaluated using the Mallet score., Results: Children with BPP had strength asymmetry in all muscles, whereas children with TD had significant strength asymmetry for flexors and abductors. In children with BPP, extensors and external rotators were the weakest muscles, leading to sagittal and transverse plane muscle imbalances. Higher strength values were related to better active range of motion., Conclusions: This study highlights the importance of documenting shoulder strength profiles in children with BPP which may help predict deformity development., (Copyright © 2013 Wiley Periodicals, Inc.)

Shoulder motion has been mainly analysed in children based on thoraco-humeral (TH) joint kinematics, excluding the scapula-thoracic (ST) and gleno-humeral (GH) joints. In order to measure 3D scapulo-humeral motion using an optoelectronic system, we propose a protocol based on an acromion marker cluster (AMC), a functional method to determine the gleno-humeral rotation centre and different Euler sequences. This study investigated the validity of the AMC compared to the palpation of anatomical landmarks with a scapula locator, assessed the intra-session repeatability and the ability to discriminate differences of such a protocol in 10 typically developing children (TD) and 10 children with hemiplegic cerebral palsy (HCP) during 6 different tasks (flexion, abduction, horizontal abduction, hand to head, hand to controlateral shoulder and hand to back pocket). For both populations, the AMC method showed an overall Root Mean Square Error (RMSE) of 5.5°. The AMC method under-estimated the protraction/retraction of the scapula during abduction. The within-session reliability was good to excellent for all tasks except the hand to back pocket task. The YXY recommended Euler sequence for TH and GH joints resulted in gimbal lock for most of the tasks whereas the XZY sequence could be used for most of the tasks and most of the children., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The article presents a study which proves the use of acromion marker cluster (AMC) method to detect three dimensional (3D) scapular motion using palpation and the reliability and accuracy of scapulo-thoracic (ST) kinematics in hemiplegic cerebral palsy (HCP) children. It says that kinematics was examined by assessing the relation between the AMC and palpation recording by scapula locator (SL). Results show that AMC method looks to be reliable and precise method for scapular dynamics tracking.

The article presents a study which assesses the accuracy of single calibration (SC) and double calibration (DC) comparing to the skinmarker-based methods to a scapula palpation procedure. The study used acromion marker method, two-way analysis of variance, and infrared cameras. Results showed that on the two-way analysis of variance, DC measurements were not different from palpation for five axes of rotation, while SC showed differences for five axes.

The article presents a study on a three-dimensional freehand ultrasound to estimate the glenohumeral rotation centre (GHRC) which is compared with medical imaging and functional methods. It discusses how the study was conducted which involved seven individuals without upper extremity disorders and the calibration of the ultrasound system. The results reportedly revealed that the most accurate method in estimating GHRC is the combination of a motion analysis system and the U.S.