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CASE REPORT Table of Contents   
Year : 2003  |  Volume : 37  |  Issue : 3  |  Page : 16
Deltoid contracture - A report of five cases


Dr. Dinubhai Patel Orthopaedic Hospital and Research Centre, Ahmedabad, India

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How to cite this article:
Shah V B. Deltoid contracture - A report of five cases. Indian J Orthop 2003;37:16

How to cite this URL:
Shah V B. Deltoid contracture - A report of five cases. Indian J Orthop [serial online] 2003 [cited 2019 Dec 13];37:16. Available from: http://www.ijoonline.com/text.asp?2003/37/3/16/48555

   Introduction Top


The characteristic of the deltoid contracture is the inability of the patient to bring the arm in contact with chest in anatomical position of scapula. When the arm is brought to the side by some force, there is winging of the scapula. It can be congenital or acquired. In acquired cases, fibrosis of the intermediate portion of deltoid muscle is responsible. Patients may have a history of multiple intra­muscular injections in deltoid muscle. This condition can be easily misdiagnosed as an old anterior dislocation of shoulder, serratus anterior paralysis or old injury to proximal humerus epiphysis.Truly known, it is easy to diagnose and its correction gives a reasonably good result. It would be wise to avoid indiscriminate use of the intramuscular injections in deltoid muscle. An accurate diagnosis of the deltoid contracture would help in its correction especially in its early stage.


   Case Reports Top


From 1983 to 2001, five patients with abduction deformity of the shoulder due to deltoid contracture were seen. There were three males and two females patients. Their ages ranged from seven to 19 years. Two patients had the affection on right side, two on left side, and one had bilateral affection. Two patients were brothers; their parents did not suffer from same problem. During childhood, all had a history of multiple intra-muscular injections of unknown drugs for febrile illness in three and, gastroenteritis in two patients. Abduction deformity of the shoulder gradually developed over the course of next three to four years. The interval between the development of deformity and presentation varied from one to 14 years. Three patients came early within 3 years and two came after 5 years of the development of the deformity.

The common complaint of all the patients was inability to bring the arm in contact with lateral chest wall or ugly look of the prominent scapula. A complaint of vague pain was present in one patient. No case had a history of injection abscess. No case had any other associated skeletal muscle contracture. Birth histories of all the patients were quite normal.

On examination, the affected shoulder was found at varying degree of abduction and internal rotation [Figure 1]. The prominent medial border of scapula from the back gave a winging appearance to the scapula, which increased on passive adduction. The tight bands were felt at the intermediate portion of deltoid. These bands extended from the acromion process to the deltoid tuberosity [Figure 2]. External rotation was restricted. Movements of the elbow and forearm were full. There was inability to bring both forearms alongside each other. Above all, there was prominent humerus head anteriorly and the prominence increase on passive adduction. Neurologically, all the patients were normal.

Radiologically, there was overlapping of glenoid by humeral head. Anterior subluxation of shoulder was evident on axial view. Acromion process was prominent and overhanging. CT scan performed in two cases suggested anterior subluxation of the shoulder joint. There was no dislocation.

Under general anesthesia, in lateral position, bands were made more prominent by passive adduction. They were released through a transverse incision in two cases and a vertical incision in three cases. The transverse incision was more useful for subacromial release of tight fibrous bands in intermediate portion, as well as anterior and posterior deltoid region. The subacromial area is safer for release of fibrous band to avoid injury to axillary nerve. Most of the bands were four to six centimeters long and one to two centimeters broad.

Postoperatively, pushing and stretching exercise were started according to the pain tolerence.Night strapping with rib belt were started from fourth day and continued for two to three weeks. Our follow up ranges from one to 17 years. Three cases, which reported within the three years of development of deformity, had good correction in immediate post-operative period. In two cases with long lasting deformity of more than five years, full correction of the winged scapula was not possible. The physiotherapy as continued in the form of pushing and stretching exercises for about four to six months. At the end of six to eight months, all cases had satisfactory correction of abduction deformity and prominent scapula [Figure 3]. Histopathological examinations were suggestive of fibrosis without any evidence of inflammation or ischemia.


   Discussion Top


A contracture of the skeletal muscle from repeated intramuscular injections is uncommon. In world literature, following the original reports by Hnevkovsky [1] , and Fairbank and Barrett [2] of fibrosis of quadriceps muscle, many publications of the same have appeared. In India, the most common cause of the muscle contracture is from residual poliomyelitis. Chung and Nissenbaum [3] described congenital fibrotic bands of the deltoid muscle.

Acquired deltoid contracture was described first in India by Bhattacharya [4] . He described three cases of abduction contracture of shoulder. First two cases had no history of illness. Third case had history of meningitis. Shanmugasundaram [5] described a large series of 169 cases of post injection fibrosis including 78 cases of deltoid fibrosis, 84 cases of quadriceps fibrosis, 6 cases of gluteal fibrosis and one case of triceps fibrosis. Dimple or puckering of the skin over the sites of the contracture has been reported. [4],[5],[6] It was remarkably absent in our series.

Regarding the agents causing the fibrosis of muscle following the repeated injections, no one particular agent could be blamed. Shanmugasundaram found tetracycline injection leading to fibrosis in experimental animals. [4] Race and country of the origin of patients are not significant since, there are reports of intramuscular fibrosis from all over the world. However, perhaps the largest number of reported cases of the skeletal muscle contracture are from India. [4],[5],[6],[7],[8] Intermediate portion of deltoid is having anatomical peculiarity of multiple intramuscular septae. [4] This might be the reason of fibrosis usually occurring in the intermediate portion of deltoid [Figure 4].Pressure ischemia and chemical irritation could be the other causes. Goodfellow and Nade [9] reported a case of the flexion contracture of the shoulder joint. Their patient had a history of injection in the anterior portion of deltoid. In our series only the intermediate portion of the deltoid muscle was involved. Power of deltoid was nearly normal.

Release of the fibrous bands was the preferred technique as it is a simple procedure giving a good cosmetic result. [4],[5],[6] In his latter cases, Shanmugasundaram [5] had reported release of fibrous bands by close fasciotomy method. In severe long lasting deformity, winging of scapula did not corrected fully in immediate post-operative period. This requires prolong pushing and stretching exercise.

 
   References Top

1.Hnevkovsky 0. Progressive fibrosis of the vastus interme-dius muscle in children. A cause of limited knee flexion and elevation of the patella. J Bone Joint Surg [Br] 1961; 43-B: 318-325.  Back to cited text no. 1    
2.Fairbank TJ, Barrett AM. Vastus intermedius contrac­ture in early childhood. Case report in identical twins. J Bone Joint Surg [Br] 1961; 43- B: 326-334.   Back to cited text no. 2    
3.Chung MK, Nissenbaum M. Congenital and developmen-tal defects of the shoulder. Orthop Clin North Am 1975; 6: 389-392  Back to cited text no. 3    
4.Bhattacharya S. Abduction contracture of the shoulder from contracture of intermediate part of the deltoid. Re-port of three cases. J Bone Joint Surg [Br] 1966; 48-B: 127-131.  Back to cited text no. 4    
5.Shanmugasundaram TK. Post-injection fibrosis of skel­etal muscle: A clinical problem. A personal series of 169 cases. Int Orthop 1980; 4: 31-37.   Back to cited text no. 5    
6.Moitra TK, Acharya B, Sen Roy SG, Chowdhury A. Deltoid fibrosis. Ind J Orthop 1991; 25:139-140.   Back to cited text no. 6    
7.Mukherjee PK, Das AK. Injection fibrosis in the quadri­ceps femoris muscle in children. J Bone Joint Surg [Am] 1980; 62-A: 453- 456.  Back to cited text no. 7    
8.Patel DA, Patel BJ. Gluteal maximus contracture. Ind J Orthop 1987; 21: 57-60.  Back to cited text no. 8    
9.Goodfellow JW, Nade S. Flexion contracture of the shoul-der joint from fibrosis of the anterior part of the deltoid muscle. J Bone Joint Surg [Br] 1969; 51-B: 356-­358.  Back to cited text no. 9    

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Correspondence Address:
V B Shah
Dr. DB Patel Orthopaedic Hospital and Research Centre, 41, Nathalal Colony, Naranpura, Ahmedabad, Gujarat. 380013
India
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Source of Support: None, Conflict of Interest: None


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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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