DEFINITION

Trapezius palsy results from a disruption of cranial nerve (CN) XI, also known as the spinal accessory nerve.

Because the trapezius is innervated exclusively by CN XI, any disruption causes trapezius palsy. The most common cause of trapezius palsy is iatrogenic.12

The trapezius plays an integral part in stabilization of the scapula, and dysfunction can lead to painful

shoulder disability.

Nonoperative treatment, including strengthening of the functioning thoracoscapular muscles, does not typically provide satisfactory clinical results.2,5

Transfer of the levator scapulae, rhomboid major, and rhomboid minor (Eden-Lange procedure or triple transfer) is an accepted technique for this difficult problem.19

The procedure was first described by Eden6 in 1924 and then corroborated by Lange10 in 1951 and Francillon8 in 1955, all reporting satisfactory short-term results. Further modifications have improved on the initial procedure.1

Lateral transfer of the insertions of the three muscles allows the scapula to be stabilized in a position of abduction and anterior flexion.20

 

ANATOMY

 

The trapezius muscle is broad, superficial, and divided into superior, middle, and inferior fibers. Its origin is from the eternal occipital protuberance and medial third of the superior nuchal line, the ligamentum nuchae, and the C7-T12 spinous processes. It inserts on the acromion, clavicle, and spine of the scapula (FIG 1A).

 

The upper portion consists of descending fibers and functions as an aid to suspension of the shoulder girdle, allowing shrugging of the shoulder. The middle portion consists of transverse fibers and contributes to abduction and rotation of the inferior angle of the scapula. The ascending fibers of the lower portion (along with the serratus anterior) anchor the scapula to the chest wall.

 

Given its function to elevate and rotate the scapula, absence of the trapezius leads to drooping of the shoulder girdle and lateral winging of the scapula.

 

The blood supply is variable, but typically, the dorsal scapular and transverse cervical arteries supply the trapezius muscle.

 

In the posterior cervical triangle, CN XI is located in the subcutaneous tissue; this superficial location renders it susceptible to damage during procedures such as cervical lymph node biopsy.

 

Scapular winging occurs in both trapezius and serratus anterior palsy. In serratus palsy, the inferior angle of

the scapula is noted to rotate medially (FIG 1B). This is the most common type of scapular winging. In trapezius palsy, the scapula rotates laterally (FIG 1C,D). Rarely, mild lateral scapular winging can occur in

rhomboid palsy as a result of injury to the dorsal scapular nerve.18

 

PATHOGENESIS

 

The most common cause of CN XI palsy is iatrogenic. It is a rare but well-described complication of cervical lymph node biopsy and cervical mass excision.12,20,21

 

Other causes include trauma (including traction injuries) or injuries from other surgical procedures such as radical neck dissection.1

 

In one instance, a CN XI palsy was reported to have occurred after a viral infection.15

 

 

 

FIG 1 • A. Schematic of the three parts of the normal trapezius muscle: upper, middle, and lower. (continued)

 

 

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FIG 1 • (continued) B. Schematic of trapezius palsy, demonstrating lateral scapular winging and shoulder drooping. C. Schematic of serratus anterior palsy, demonstrating medial scapular winging.

 

 

Idiopathic CN XI paralysis also has been reported.7

 

Patterson13 reported trapezius palsy after acromioclavicular and sternoclavicular dissociation.

 

 

Even rarer causes include postcarotid endarterectomy and postcatheterization of the internal jugular vein.3 In most cases, patients report pain and present with visible deformity and dysfunction of the shoulder girdle.

NATURAL HISTORY

 

Trapezius palsy most often results from iatrogenic causes, as noted earlier, and, if left untreated, will lead to progressive worsening of the shoulder's biomechanics and pain of the shoulder girdle.

 

Typically, the initial presentation is acute shoulder pain without palsy, with weakness of anterior elevation, and abduction appearing after a few days (with slow diminution of pain). Atrophy of the trapezius becomes clinically apparent after a few weeks.19

 

Radiating arm pain is thought to be the result of traction on the brachial plexus caused by drooping of the shoulder girdle.15

 

Although nonoperative management can provide reduction of pain, it does not lead to return of function, and patients treated without surgery usually go on to progressive shoulder dysfunction.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Altered mechanics of the entire shoulder girdle are possible with trapezius palsy.

 

The classic winging of the scapula seen in CN XI palsy is characterized by downward and lateral translation of the scapula.

 

The patient should be observed from behind so comparison can be made with the contralateral side.

 

Signs unique to CN XI palsy include lateral winging of the scapula (FIG 2A), an asymmetric neckline, wasting anteriorly due to involvement of the sternocleidomastoid muscle, drooping of the affected shoulder, pain,

weakness of shoulder abduction, and forward elevation.16 Visible atrophy of the trapezius muscle should be noted19 (FIG 2B).

 

Symptoms include weakness made worse by prolonged use of the arm, a feeling of a heavy arm, and a dull pain radiating from the scapula to the forearm (and occasionally with radiation to the hand). The radiation of pain is described as mimicking thoracic outlet syndrome (medial aspect of the

 

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upper limb). Pain typically is made worse by abduction of the shoulder as well as forward elevation.19 Some patients also reported paresthesias in the distribution of the auricular nerve (posterolateral side of the neck).19

 

 

 

FIG 2 • A. Patient with a trapezius palsy demonstrating characteristic scapular winging. B. Anterior sternocleidomastoid muscle wasting due to the CN XI palsy.

 

 

Patients also often state that the arm feels difficult to control.15

 

Occasionally, patients are pain free and present only with winging and drooping of the scapula.

 

 

Range of motion is decreased in elevation as well as abduction and typically is limited to 90 degrees.15 Teboul

et al19 report average active abduction of 78 degrees (range 30 to 140 degrees), and active forward flexion of 110 degrees (range 50 to 180 degrees). As a result, overhead activity is not typically possible nor is shrugging of the shoulder.

 

External rotation of the shoulder and elbow flexion are not affected by CN XI lesions.19

 

Reports of stiffness and passive range of motion are somewhat contradictory in the literature. Romero and Gerber15 state that patients did not always present with a stiff shoulder but passive range of motion typically

was decreased. On the other hand, Teboul et al19 report that patients often presented with stiffness but with no deficit in passive range of motion.

 

Often, the diagnosis of CN XI dysfunction is one of exclusion, and it is not until an unsuccessful trial of physical therapy that a patient is referred for an electrodiagnostic study and CN XI palsy is confirmed.

 

The necessity for electrodiagnostic testing is an issue of debate in the literature. Romero and Gerber15 state that this testing is not necessary to establish the diagnosis of CN XI palsy but that it can be a valuable tool if

other nerve lesions are suspected. Setter et al16 advocate electrodiagnostic testing as part of the initial workup.

 

 

Evaluate the scapula for signs of lateral translation by asking patient to perform a wall push-up. CN XI palsy also affects the sternocleidomastoid muscle.

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

A standard five-view shoulder series (including true anteroposterior [AP] views of the glenohumeral joint in neutral, external, and internal rotation as well as a scapular Y and axillary view) is required for every patient, although osseous pathology typically is not associated with CN XI palsy.

 

Magnetic resonance imaging (MRI) is not necessary, although it could be useful to assess the degree of fatty atrophy of the trapezius muscle as well as to help rule out any associated pathology such as rotator cuff injury.

 

Electrodiagnostic testing is recommended in every case, according to Setter et al.16 Not only will an electromyography (EMG) help confirm the diagnosis of CN XI palsy but it also will serve as confirmation that the muscles to be used in the transfer procedure are functioning normally.

 

Although electrodiagnostic testing is helpful in determining muscle involvement and detecting improvement and reinnervation, initial denervation is not a predictor of possible recovery. In addition, improvement on

electrodiagnostic testing does not necessarily correlate with clinical outcome.12

 

 

DIFFERENTIAL DIAGNOSIS

Missed diagnosis of CN XI palsy is the rule,15 most likely owing to the rare nature of the condition.

Because shoulder motion is possible due to the complex coupling of the glenohumeral, sternoclavicular, acromioclavicular, and scapulothoracic articulations, it can be difficult to distinguish between

diagnoses.21

Other possible types of shoulder dysfunction that may confuse the issue include serratus palsy, multidirectional glenohumeral instability, impingement syndrome, cervical radiculopathy, thoracic outlet syndrome, and rotator cuff pathology.

In children especially, trapezius absence or hypoplasia and Poland syndrome should be considered.22

It is crucial to be able to differentiate between CN IX (trapezius) palsy and long thoracic nerve (serratus) palsy. In serratus palsy, the inferior angle of the scapula rotates medially. This is the most common type of scapular winging. In trapezius palsy, the inferior angle of the scapula rotates laterally.

 

 

NONOPERATIVE MANAGEMENT

 

Typically, if the injury is not detected within 6 months (after which point nerve repair usually is not recommended), a 12-month trial of nonoperative treatment is recommended.16

 

Due to possible compensation by the levator scapulae, the impact of injury to the CN XI must be determined individually for each patient.20

 

Maxillofacial surgeons have reported that 30% to 49% of patients do not exhibit any clinical symptoms after

radical neck dissection where the CN XI is sacrificed.11

 

If the CN XI palsy is symptomatic, pain sometimes can be relieved after a course of nonoperative treatment, but satisfactory return to function cannot be achieved.

 

Strengthening of the remaining scapulothoracic muscles does not compensate for the trapezius deficit, and, in one study, patients who elected nonoperative management could not elevate their arms above the

horizontal.15

 

One study has reported favorable results with nonoperative management in sedentary or elderly persons because discomfort was alleviated.14

SURGICAL MANAGEMENT

 

Nerve exploration with neurolysis, microsurgical repair, or sural nerve grafting can be successful for some injuries if performed early.18 Timing of the repair attempt is controversial; some authors believe that repair should only be attempted if diagnosis is confirmed within 6 months of injury,16 whereas other surgeons

advocate repair up to 20 months from the time of the nerve insult.19 It is not indicated for patients with chronic scapular winging.

 

In patients with spontaneous spinal accessory palsy for whom nonoperative treatment has not been helpful, some authors advocate proceeding directly to muscle transfer reconstruction because nerve procedures have produced poor results.20

 

Patients who have failed nerve repair attempt or nonoperative therapy should be considered surgical candidates for the Eden-Lange procedure, the current procedure of choice for stabilization of the scapula after CN XI palsy. This dynamic, reconstructive operation has evolved from prior static procedures, such as

scapulothoracic arthrodesis, initially used to treat chronic trapezius paralysis due to poliomyelitis.9,21

 

The first dynamic procedure for trapezius palsy was described by Dewar and Harris,4 who transferred the levator

 

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scapulae insertion laterally and created a fascial sling between the medial border of the scapula and the vertebral spinous processes. This procedure failed, due to the inability of the small levator scapulae to substitute for the trapezius. Eden first described the lateral transfer of the insertions of the rhomboids and the

levator scapulae for treatment of trapezius palsy in 1924.9,21

 

Timing of the Eden-Lange procedure is controversial. Typically, however, reconstructive surgery is recommended if more than 12 months has elapsed since the injury.21

 

The goal of the Eden-Lange procedure is to reconstruct the three parts of the trapezius muscle. Because the rhomboid major and minor and levator scapulae have medial insertions, they are not capable of stabilizing the

scapula unless they are transferred laterally.19

 

Preoperative Planning

 

It is imperative to have appropriate preoperative discussions with the patient so that he or she understands the procedure, the postoperative rehabilitation program, and the time frame within which improvement should be expected.

 

Consider that nonoperative management may be the most appropriate management for the elderly, more

sedentary patients, and for patients with minimal symptoms.

 

In addition, it is important to identify any preexisting shoulder pathology and create an inclusive treatment plan. As an example, patients with concurrent multidirectional shoulder instability may have difficulties rehabilitating postoperatively if both procedures are performed at the same time. It is important to achieve scapular

stabilization, then subsequent procedures aimed at glenohumeral stabilization are less likely to fail.18

 

Furthermore, scapular stabilization may allow patients with preexisting instability or rotator cuff disease to effectively participate in physical therapy and avoid further operative intervention in the future.17,18

Positioning

 

The patient is placed in the lateral decubitus position with thoracic, pubic, and sacral supports.19,20 The entire upper extremity, including the shoulder girdle, should be draped free (FIG 3). Head above bed should be

elevated 15 degrees.9

 

 

 

FIG 3 • The patient is placed in the lateral decubitus position with the entire extremity draped free.

 

TECHNIQUES

• Exposure

A 10-cm incision is made between the medial border of the scapula from the superior to inferior edge and the spinous processes8 (TECH FIG 1A).

The trapezius is then divided midway through its muscle belly and retracted, and the three muscles of interest (the levator scapulae, rhomboid major, and rhomboid minor) are identified, dissected, and marked with vessel loops (TECH FIG 1B). The tendons can be taken directly off the medial border of the scapula

or taken attached to a small piece of osteotomized bone.8

 

 

 

 

TECH FIG 1 • A. The major incision is made between the medial border of the scapula and spinous processes, extending superiorly to allow exposure to the levator scapula, rhomboid minor, and rhomboid major for their planned transfers. B. The levator scapula, rhomboid minor, and rhomboid major are identified and individually released from their scapular attachment sites for lateral transfer. C. The supraspinatus and infraspinatus are elevated at least 5 cm medially to allow appropriate exposure of the scapula.

 

 

Draping the entire arm freely allows for manipulation of the extremity, which facilitates exposure to the levator scapulae and the rhomboids major and minor.8

 

The supraspinatus and infraspinatus must be elevated 5 to 6 cm to expose their respective fossae for transfer of the rhomboids8,19 (TECH FIG 1C). They are not elevated beyond the neurovascular bundle.8

 

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• Rhomboid Transfer

   

  A series of transosseous mattress sutures are placed in anticipation of transferring the rhomboids. At least four mattress sutures are used in the infraspinous fossa (TECH FIG 2A) and two in the supraspinous fossa.

   

  The rhomboids are advanced laterally and attached to the scapula with heavy, nonabsorbable transosseous sutures (TECH FIG 2B). The arm is abducted at this time to reduce the scapula while the

  muscles are sutured down.8

   

   

   

  TECH FIG 2 • A. A series of drill holes are made, and transosseous sutures are placed in preparation for securing the transferred muscles. B. The rhomboid minor and major are transferred to the supra- and infraspinous fossae, respectively.

   

   

   

  TECH FIG 3 • A. Normal position of the levator scapula, rhomboid minor, and rhomboid major on the medial border of the scapula. B. Lateral transfer of the levator scapula, rhomboid minor, and rhomboid major. This modification includes transfer of the rhomboid minor to the supraspinatus fossa.

  Modification

   

   

  Bigliani et al1 proposed a modification of the procedure in which the rhomboid minor is transferred cephalad to the scapular spine, thereby closing the gap between the rhomboid minor and the levator scapulae (TECH FIG 3).

   

   

  In this modification, the new position of the rhomboid minor more efficiently substitutes for the middle part of the trapezius.

   

• Levator Transfer and Wound Closure

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A second incision 3 cm in length is made about 5 to 7 cm from the posterolateral corner of the acromion for transfer of the levator scapulae (TECH FIG 4A).

 

The trapezius, deltoid, and supraspinatus are elevated off to allow for three drill holes to be placed in the spine of the scapula.8

 

Care must be taken to ensure that the levator has been dissected laterally enough to allow tension-free excursion to the scapular spine (TECH FIG 4B). The levator is then transferred subcutaneously and affixed to the scapular spine with a series of heavy, nonabsorbable sutures.

 

TECH FIG 4 • A. The second incision is made 5 to 7 cm medial to the posterolateral corner of the acromion for transfer of the levator scapula muscle. B. Excursion of the levator is confirmed before the muscle is subcutaneously tunneled to the planned transfer site.

The infraspinatus muscle is then sutured over the new rhomboid muscle insertions. The incisions are closed in a layered fashion.

Consider drain placement to minimize the risk of postoperative seroma formation.20

 

 

 

PEARLS AND PITFALLS
	Rhomboid ▪ Separate the rhomboid minor from the rhomboid major so they can be transferred transfer separately. The infraspinatus and supraspinatus are elevated from their respective fossae for approximately 5 cm. This modification of the original procedure permits the rhomboid minor to be transferred to a position that better substitutes for the action of the middle trapezius. Care should be taken to prevent injury to the suprascapular nerve, which lies on the deep surface of the supraspinatus muscle.     Levator ▪ Dissect the levator scapula far enough laterally to allow tension-free transfer to the transfer scapular spine. Avoid iatrogenic injury to the transverse cervical artery and the dorsal scapular nerve, which run superficial and deep, respectively, to the levator scapulae and then terminate into the deep surface of the rhomboids near their insertion onto the scapula. A tunnel is created through the atrophied trapezius, in line with its upper fibers, for passage of the tagged levator scapulae. The levator should not be transferred too far laterally because this can cause a

 

	web-like deformity in the neck. A good position is 5-7 cm from the posterior lateral corner of the acromion.

 

 

 

POSTOPERATIVE CARE

 

Most authors advocate immobilization for 6 weeks postoperatively, followed by initiation of physical therapy (passive and active).15,16,19

 

Romero and Gerber15 prefer an abduction splint, whereas Teboul et al19 suggest securing the arm to the chest with an elastic bandage.

 

Our routine postoperative protocol is to use a foam abduction wedge or orthosis for the first 4 weeks, keeping the arm in 60 to 70 degrees of abduction. We encourage early passive range of motion above the wedge or orthosis to prevent stiffness (forward elevation to 140 degrees and external rotation to 40 degrees in the first 4

weeks).9

 

At 4 weeks, the wedge is discontinued, and gentle strengthening exercises are added. We have designed a progressive strengthening program that uses rubber tubing, free weights, and medicine ball throws to achieve dynamic scapular stability and improve scapulothoracic rhythm. All of the exercises in the protocol are designed to strengthen the transferred levator scapula and rhomboids.

 

 

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OUTCOMES

The Eden-Lange procedure produces satisfactory results for the difficult problem of trapezius palsy.

In a study in which 16 patients were reviewed at a mean follow-up of 32 years, clinical outcomes were noted to be excellent in 9 patients, fair in 2 patients, and poor in 1 patient (as determined by Constant

score).15 Some patients with outcomes that were less than satisfactory also had dorsal scapular and long thoracic lesions.

Romero and Gerber15 describe a radiographic outcomes measure that uses an AP radiograph to measure the angle between a line drawn between the cranial and caudal ends of the glenoid with a vertical axial line. This measurement was compared to the contralateral side, and no statistical differences were found.

Teboul et al19 concluded that muscle transfer should be performed only after previous nerve repair surgery had failed or when more than 20 months has elapsed since the injury was incurred. In this series of 7 patients treated with the Eden-Lange procedure (the other 20 patients were treated with nerve surgery), results were excellent in 3 patients, good in 1 patient, and poor in 3 patients. It was concluded that two factors are most predictive of a poor result following reconstructive surgery: if the patient is older than 50 years or the lesion is caused by radical neck dissection, penetrating injury, or spontaneous palsy.

In a recent study at our institution, the mean American Shoulder and Elbow Surgeons (ASES) scores were improved for the patients who underwent the Eden-Lange procedure. Average forward elevation improved from 141.7 degrees preoperatively to 151.0 degrees postoperatively. Visual analog scores improved from a mean of 7.0 preoperatively to 2.3 postoperatively. No patients who underwent the Eden-

Lange procedure had residual winging.9

 

 

 

COMPLICATIONS

Complications associated with the Eden-Lange procedure, in addition to the usual surgical risks, include failed integration of the transferred muscles with resultant continued dysfunction. Such a complication is

discussed rarely, and we were only able to find one report of a failure of muscle integration.19

Patient compliance with strict immobilization after surgery is important to avoid pullout of the transferred muscles, especially the rhomboids, which, unlike the levator scapulae, are not attached to their new scapular insertion with the tendo-osseous interface intact.

Initial complications do not seem to be the problem with the Eden-Lange procedure; rather, the primary complication appears to be later effects of functional outcome falling short of expectations.

Iatrogenic dysfunction resulting from no longer having a physiologic levator scapula or rhomboids is not, to our knowledge, discussed in the literature. However, because the origin of these muscles is merely being transposed more laterally, it does not appear that the Eden-Lange procedure creates a new problem while fixing the old one.

In cases of failure of the procedure, where pain and dysfunction continue, scapulothoracic arthrodesis can be performed as a salvage procedure.

 

REFERENCES

1. Bigliani LU, Compito CA, Duralde XA, et al. Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius. J Bone Joint Surg Am 1996;78:1534-1540.

    

    

2. Bigliani LU, Perez-Sanz JR, Wolfe IN. Treatment of trapezius paralysis. J Bone Joint Surg Am 1985;67:871-877.

    

    

3. Burns S, Herbison GJ. Spinal accessory nerve injury as a complication of internal jugular vein cannulation. Ann Intern Med 1996;125:700.

    

    

4. Dewar FP, Harris RI. Restoration of function of the shoulder following paralysis of the trapezius by fascial sling fixation and transplantation of the levator scapulae. Ann Surg 1950;132(6):1111-1115.

    

    

5. Dunn AW. Trapezius paralysis after minor surgical procedures in the posterior cervical triangle. South Med J 1974;67:312-315.

    

    

6. Eden R. Zur behandlung der trapeziuslahmung mittelts muskelplastik. Deutsche Zeitschr Chir 1924;184:387-397.

    

    

7. Eisen A, Bertrand G. Isolated accessory nerve palsy of spontaneous origin. A clinical and electromyographic study. Arch Neurol 1972; 27:496-502.

    

    

8. Francillon MR. Zur Behandlung de Accesoriuslahmung. Schweiz Med Wochenschr 1955;33:787-788.

    

    

9. Galano GJ, Bigliani LU, Ahmad CS, et al. Surgical treatment of winged scapula. Clin Orthop Relat Res 2008;466:652-660.

    

    

10. Lange M. Die Behandlung der irreparablen Trapeziuslahmung. Langenbecks Arch Klin Chir 1951;270:437-439.

     

     

11. Leipzig B, Suen JY, English JL, et al. Functional evaluation of the spinal accessory nerve after neck dissection. Am J Surg 1983;146:526-530.

     

     

12. Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med 2008;1(1):1-11.

     

     

13. Patterson WR. Inferior dislocation of the distal end of the clavicle: a case report. J Bone Joint Surg Am 1967;49(6):1184-1186.

     

     

14. Pelissier J, Lopez S, Herisson C, et al. Shoulder pain and trapezius paralysis: Evaluation of a rehabilitation protocol [in French]. Rev Rhum Mal Osteoartic 1990;57:319-321.

     

     

15. Romero J, Gerber C. Levator scapulae and rhomboid transfer for paralysis of trapezius. The Eden-Lange procedure. J Bone Joint Surg Br 2003;85(8):1141-1145.

     

     

16. Setter KJ, Voloshin I, Bigliani LU. Operative treatment of spinal accessory nerve palsy. Techniques in Shoulder and Elbow Surgery 2004;5:25-36.

     

     

17. Skedros JG, Kiser CJ. Modified Eden-Lange procedure for trapezius paralysis with ipsilateral rotator cuff-tear arthropathy. J Bone Joint Surg Am 2011;93:e131.

     

     

18. Skedros JG, Knight AN. Treatment of scapular winging with modified Eden-Lange procedure in patients with pre-existing gleno-humeral instability. J Shoulder Elbow Surg 2012;21:e10-e13.

     

     

19. Teboul F, Bizot P, Kakkar R, et al. Surgical management of trapezius palsy. J Bone Joint Surg Am 2004;86-A(9):1884-1890.

     

     

20. Teboul F, Bizot P, Kakkar R, et al. Surgical management of trapezius palsy. J Bone Joint Surg Am 2005;87(suppl 1):285-291.

     

     

21. Wiater JM, Bigliani LU. Spinal accessory nerve injury. Clin Orthop Relat Res 1999;(368):5-16.

     

     

22. Witbreuk MM, Lambert SM, Eastwood DM. Unilateral hypoplasia of the trapezius muscle in a 10-year-old boy: a case report. J Pediatr Ortho B