Surgical Science, 2013, 4, 15-21
http://dx.doi.org/10.4236/ss.2013.49A003 Published Online September 2013 (http://www.scirp.org/journal/ss)
Comparing the Surgical Outcomes of M odified Quad and
Triangle Tilt Surgeries to Other Procedures Performed in
Obstetric Brachial Plexus Injury
Rahul K. Nath*, Juan-Carlos Pretto, Chandra Somasundaram
Texas Nerve and Paralysis Institute, Houston, USA
Received June 20, 2013; revised July 21, 2013; accepted July 29, 2013
Copyright © 2013 Rahul K. Nath et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Purpose: To compare results from our surgical treatment experiences in children with obstetric brachial plexus injuries
(OBPI), to those who have had other surgical treatments. Methods: We conducted a retrospective study in our medical
records consisting of two groups of OBPI patients. Group 1: 26 OBPI children (16 girls and 10 boys), age range be-
tween 2.0 and 12.0 (mean age 6.9), who have undergone surgical treatments at other institutions between 2005 and
2010. Group 2: 45 OBPI children (20 boys and 25 girls), age between 0.7 and 12.9 (mean age 3.7), who have had
modified Quad and triangle tilt surgical treatment between 2005 and 2010 at our institution. In both groups Mean modi-
fied Mallet scores and radiological scores were measured and compared. All measurements were made at least one year
post surgery in both groups. Results: Post-operative mean modified Mallet score was 11.8  2.4 in group 1 patients,
whereas post-mean modified Mallet score was 20  2.7 (P < 0.0001) following modified Quad and triangle tilt surgeries
in group 2 patients. Further, their radiological scores such as posterior subluxation, and glenoid version were 13.4 
21.3 and −30.2  19.1 in group 1, whereas 32.1 13.5 (P < 0.0004), and −16.3  11.5 (P < 0.008) in group 2 patients,
when compared to normal values of 50, and 0 respectively. Co nclusion: Patients who have had mod Quad and triangle
tilt for OBPI obtained significantly better functional outcomes in modified total Mallet score as well as in radiological
scores, when compared to those OBPI children, who underwent other procedures such as posterior glenohumeral cap-
sulorrhaphy, biceps tendon lengthening, humeral osteotomy, anterior capsule release, nerve transfer/graft, botox and
muscle/tendon transfer and release.
Keywords: Obstetric Brachial Plexus Injury; Triangle Tilt Surgery; Modified Quad Surgery; Modified Mallet;
Radiological Score
1. Introduction
Obstetric brachial plexus injuries (OBPI) occur during
the delivery process, and the incidence has been reported
to vary between 0.38 and 5.8 for every 1000 live births
[1-4]. The most frequent pattern of nerve injury occurs in
the upper C5-C6 roots (Erb’s palsy). Many of these inju-
ries are transient, and therefore several patients recover
spontaneously within the first three months of life. How-
ever, a significant proportion of these children tend to
retain persistent limb deficits, never recover full function
and develop permanent injuries [1,5,6].
Inadequate recovery of neurological function in these
patients lead to long-term morbidity by causing muscle
imbalances and weakness around the shoulder (the del-
toid and external shoulder rotators) [7-10], and bony de-
formities (glenohumeral dysplasia and joint incongruity)
[5,11,12]. Early surgical interventions have been shown
to improve the limb functions in this group of patients
[13,14].
We and other investigators have demonstrated that soft
tissue procedures such as muscles release and tendon
transfers [15-22] including the modified Quad procedure
first described by Narakas and modified by the senior
author (RKN) lead to better shoulder abduction and flex-
ion through releasing the existing contractures. However,
this procedure does not realign the deformed glenohu-
meral joint (GHJ). The triangle tilt surgery, developed by
the senior author and the surgeon (RKN) has been shown
to effectively address these bony deformities, which great-
ly improves overall functions of the shoulder [23-33]. In
*Corresponding author.
C
opyright © 2013 SciRes. SS

R. K. NATH ET AL. 16
addition, we have previously demonstrated that this sur-
gical procedure improves shoulder function in OBPI pa-
tients with SHEAR deformity [30], and is a salvage pro-
cedure in failed humeral osteotomy patients [23,31-33].
2. Patients and Methods
A retrospective study was conducted on children diag-
nosed with OBPI who came to our clinic with a history
of prior operative procedures in other hospitals to correct
their deformities before presenting to our institute (group
1), and OBPI children who came to our institute without
prior surgeries and undergone triangle tilt and mod Quad
surgery to correct their deformities (group 2).
Group 1: 26 OBPI children (16 girls and 10 boys), age
range between 2.0 and 12.0 (mean age 6.9), who have
undergone surgical treatment at other institutions be-
tween 2005 and 2010.
Group 2: 45 OBPI children (20 boys and 25 girls), age
between 0.7 and 12.9 (mean age 3.9), who have had
modified Quad and triangle tilt surgical treatment be-
tween 2005 and 2010 at our institution.
The nerve involvement in group 1 was C5-6 (n = 6),
C5-7 (n = 7), and total (n = 13): and in group 2 C5-6 (n =
16), C5-7 (n = 20) and total (n = 9). Prior surgical pro-
cedures that the patients in group 1 have undergone at
other clinics are included posterior glenohumeral capsu-
lorrhaphy (N = 2), biceps tendon lengthening (N = 1),
humeral osteotomy (N = 5), and anterior capsule release
(N = 3), nerve transfer/graft (N = 13), botox (6) and mus-
cle/tendon transfer and release (N = 7). We compared
statistically the results from other procedures performed
in other institutes to the results from our procedures at
least with a follow up of one year. In addition, their ra-
diological scores such as posterior subluxation, and gle-
noid version were measured from CT scans and Mag-
netic resonance imaging in both groups and compared.
2.1. Clinical Assessment
Patients were evaluated with a physical exam, and through
the modified Mallet clinical assessment with video re-
cordings of patients performing the following move-
ments pre- and post-operatively: external rotation, hands
to mouth, hands to neck, hands to spine, and supination.
For each functional Mallet parameter, patients were
scored on a scale of 1 - 5 with 5 as normal function and 1
denoting lack of any movement.
2.2. Radiological Evaluation
CT or MRI images were used to measure the posterior
humeral head subluxation (PHHA), glenoid version [34],
and SHEAR deformity [35], which evaluate the bony
deformities of the patients’ shoulder joint before and
after triangle tilt surgery. Posterior subluxation of the hu-
meral head, expressed as percentage of humeral head
anterior to the glenoid (normal value = 50), was calcu-
lated from the ratio of the distance between the scapular
line to the anterior aspect of humeral head and the great-
est diameter of the head multiplied by 100. The scapular
deformity, also referred to as SHEAR deformity, was
measured from the 3D reconstructions of the CT images.
The area of the scapula visible above the clavicle was
measured and divided with the total area of the scapula
for both affected and normal sides. The ratio of the af-
fected side was subtracted from that of the normal side
and multiplied with 100 to obtain SHEAR deformity
(normal value = 0).
2.3. Operative Technique
Group 2 patients have undergone the triangle tilt surgery.
This was developed by the lead author, and this proce-
dure has been shown to have successful outcomes in
OBPI patients [23-33]. The operative technique includes
clavicle osteotomy at the intersection of its middle and
distal third, acromion osteotomy at its intersection with
the scapular spine and osteotomy of the scapula followed
by splinting of the limb in adduction [23-33]. Group 2
patients have also undergone the transfer of the latis-
simus dorsi and teres major muscles, release of contrac-
tures of subscapularis pectoralis major and minor and
axillary nerve decompression and neurolysis (the modi-
fied Quad procedure) [17,36]. The surgeon and the lead
author (RKN), who has over 17 years of experiences in
this field with several thousand OBPI patients performed
all surgical procedures.
2.4. Statistical Analysis
The Student’s t test statistic was applied to compare the
mean Mallet scores and bony parameters between the
both groups using the “Analyse it” plugin (Leeds, UK)
for Microsoft Excel 2003. A value of P < 0.05 was con-
sidered to be statistically significant.
3. Results and Discussion
The 26 OBPI patients from group 1 in our present study
have had one or multiple surgical treatments with other
surgeons before visiting our clinic (Table 1). These pa-
tients have undergone at least one of the following tradi-
tional approaches that are aimed to treat OBPI such as
nerve transfer, contracture release, axillary nerve decom-
pression, and external derotational osteotomy of the hu-
merus.
Conventional surgical approaches fail to address the
scapular hypoplasia, elevation and rotation (SHEAR)
deformity [35] associated with most OBPI cases. There-
fore, these patients had poor functions (mean modified

R. K. NATH ET AL. 17
Table 1. Surgical outcome of other surgeons.
Patient Gender Age Surgeries
at other clinic
Modified
Total
Mallet
1 F 2.5 Humeral head reposition 13
2 M 6.5
Nerve graft, Shoulder
capsular release 11
3 F 4.1 Nerve transfer 13
4 F 12 Nerve graft 11
5 F 2.0 Nerve graft 12
6 M 12 Nerve graft 11
7 M 10.5 Nerve transfer 5
8 F 7.1 Nerve graft 11
9 M 5.5
Humeral osteotomy,
coracoacromion release 14
10 F 10.5 Humeral osteotomy 8
11 F 9.0 Humeral osteotomy 14
12 M 11.2 Muscle transfer & release 10
13 F 5.0 Nerve graft 10
14 M 3.5 Botox 12
15 M 1.9 wrist capsular release 12
16 F 2.0 Neurolysis 11
17 F 12.3 Nerve graft 9
18 F 8.5 Capsular release 12
19 F 12.0 Acromionclavicular release 14
20 M 4.3
Tendon transfer &
Neurolysis 13
21 F 4.5 Brachial Plexus Exploration 17
22 F 6.7 Nerve transfer 11
23 F 6.8 Tendon transfer 14
24 M 7.9 Muscle transfer & release 15
25 M 2.0 Brachial Plexus Exploration 13
26 F 10.0
Muscle & tendon
transfer & release 12
Mean: 11.8; STD: 2.4.
Mallet score was 11.8  2.4 (Table 1, Figures 1 and 2),
and anatomical structures (mean PHHA 13.4  21.3, ver-
sion −30.2  19.1, and SHEAR 15.5  15.1; Table 2,
Figures 3 and 4). Normal values are PHHA 50, glenoid
version 0 and SHEAR 0.
In group 2 all the patients had poor shoulder abduc-
tion and flexion due to C5 injury present in all patients
prior to surgery. The mod Quad procedure addresses
these deformities, yet it does not address the SHEAR,
and does not realign the deformed glenohumeral joint
(GHJ). Therefore, the triangle tilt surgery was performed
on these patients. This procedure has been shown to ef-
fectively address these bony deformities, and improves
overall functions of the shoulder [23-33]. The functional
benefits of mod Quad [17], and triangle tilt surgeries
have been extensively discussed in our previous publica-
tions [23-33]. After undergone these two surgical proce-
Figure 1. Modified Mallet functions performed by OBPI
children, who have had surgeries at other clinic before pre-
senting to us.
Figure 2. Statistical comparison of modified total Mallet of
OBPI patients, who have had surgeries at other clinic with
OBPI patients, who have had modified Quad and triangle
tilt surgeries at our clinic.

R. K. NATH ET AL. 18
Figure 3. Comparison of CT images of OBPI patients, who
have had surgeries at other clinic with OBPI patients, who
have had modified Quad and triangle tilt surgeries at our
clinic.
Figure 4. Statistical comparison of radiological scores of
OBPI patients, who have had surgeries at other clinic with
OBPI patients, who have had modified Quad and triangle
tilt surgeries at our clinic.
dures with us, the group 2 patients have better results
(mean Mallet score was 20  2.7; Table 3, Figures 2 and
5), which is statistically significant (P < 0.0001), when
compared to the group 1 patients (mean Mallat score
11.8  2.4; Table 1, Figures 1 and 2).
There was statistically significant improvement ana-
tomically in group 2 patients, who have undergone train-
Figure 5. Modified Mallet functions performed by OBPI
children, who have had modified Quad and triangle tilt sur-
geries at our clinic.
Table 2. Anatomical outcome (radiological scores) of other
surgeries in OBPI.
Patient GenderAge
at TT
Surgeries
at other
clinic
PHHA
affected
Version
affected
SHEAR
affected
1 M 6.5NG 8 −47
2 F 2.0NG −7 −62 8
3 M 12NG 34 −20 0
4 M 10.5NT 33 −16 15
5 M 5.5NG −12 −51 30
6 F 10.5HO 13 −20 7
7 M 9.0HO 39 0 9
8 F 5.0NG 38 −10 0
9 M 3.5BO −8 −38 11
10 F 2.0NL −14 −33 25
11 F 12NG 0 −45 32
12 F 12ACR −11 −53 48
13 M 3.0NL 33 −18 1
Mean  STD 11.2  21.3 −31.8  19.115.5  15.1
gle tilt (mean PHHA, and glenoid version were 32.1 
13.5 and −16.3  11.5 respectively; Table 2 and Figures
3 and 4) than those who have undergone other proce-
dures (mean PHHA and glenoid version were 13.4  21.3
and −30.2  19.1 respectively; Table 4, Figu res 3 and 4).
There was no significant difference in the outcome of
SHEAR deformity between these two groups.
4. Conclusion
We have demonstrated in this report, the triangle tilt and
modified Quad surgeries resulted in significantly better
glenohumeral congruity and shoulder abduction respect-

R. K. NATH ET AL. 19
Table 3. Surgical outcome of triangle tilt.
No Gender Age at TT Post-TT Total Mallet
1 F 1.3 23
2 F 2.8 21
3 M 7.5 18
4 F 1.5 21
5 F 3.0 19
6 M 12.9 16
7 F 2.5 23
8 F 1.3 23
9 M 2.2 21
10 M 7.3 19
11 F 0.8 23
12 F 9.3 17
13 M 1.7 19
14 F 1.9 22
15 M 3.0 23
16 F 1.3 22
17 F 3.6 20
18 M 0.7 21
19 M 11.6 16
20 F 1.5 15
21 M 3.5 21
22 F 3.8 19
23 F 2.3 16
24 M 1.6 23
25 F 3.2 18
26 M 1.3 23
27 F 0.9 16
28 M 3.8 16
29 F 2.5 23
30 F 1.8 23
31 F 7.5 21
32 F 2.8 22
33 F 8.5 19
34 M 1.1 18
35 F 3.0 22
36 F 1.8 17
37 M 2.0 22
38 M 7.9 21
39 F 5.8 16
40 M 2.8 23
41 M 1.3 21
42 M 7.3 13
43 M 2.8 21
44 M 1.7 22
45 F 7.9 22
Mean  STD: 20  2; P value: <0.0001.
Table 4. Anatomical outcome (radiological scores) of train-
gle tilt.
NoGender Age
at TT
Post-op
PHHA-
affected
Post-op
version
affected
Post-op
SHEAR-
affected
1 F 9.39 29 −22 24
2 M 1.7231 −12 29
3 F 1.90 38 −2 6
4 F 5.90 43 −6 9
5 F 1.87 46 −13 23
6 M 7.3715 −45 37
7 M 2.8238 −7 0
8 M 8.02−10 −41 18
9 M 3.8117 −30 3
10 F 2.8050 −4 21
11 M 2.2138 −7 0
12 M 3.0827 −16 17
13 F 3.8242 −11 5
14 F 2.3546 −12 6
15 F 1.5034 −10 −1
16 M 1.3350 −5 23
17 M 1.1134 −20 11
18 F 1.3421 −39 18
19 F 2.5836 −19 7
20 M 1.6527 −19 12
21 F 0.7826 −10 9
22 F 2.5314 −27 40
23 F 1.3644 −14 8
24 M 1.2845 −10 7
25 F 3.2949 −31 30
26 F 3.6833 −26 12
27 M 13.1028 −23 11
28 F 2.8844 −13 17
29 M 1.6651 −3 3
30 M 1.9228 −20 25
Mean 32.1 −16.3 14.1
STD 13.5 11.5 10.9
P value 0.0004 0.008 0.76
ively, and thus overall shoulder functions, when com-
pared to the results obtained in those OBPI patients who
have had other traditional surgeries at other institutes.
REFERENCES
[1] J. B. Adler and R. L. Patterson Jr., “Erb’s Palsy.
Long-Term Results of Treatment in Eighty-Eight Cases,”
The Journal of Bone and Joint Surgery (American Vol-
ume), Vol. 49, No. 6, 1967, pp. 1052-1064.
[2] A. F. Hoeksma, H. Wolf and S. L. Oei, “Obstetrical Bra-
chial Plexus Injuries: Incidence, Natural Course and
Shoulder Contracture,” Clinical Rehabilitation, Vol. 14,
No. 5, 2000, pp. 523-526.

R. K. NATH ET AL. 20
doi:10.1191/0269215500cr341oa
[3] S. L. Foad, C. T. Mehlman and J. Ying, “The Epidemiol-
ogy of Neonatal Brachial Plexus Palsy in the United
States,” The Journal of Bone and Joint Surgery (Ameri-
can Volume), Vol. 90, No. 6, 2008, pp. 1258-1264.
doi:10.2106/JBJS.G.00853
[4] E. D. Gurewitsch, E. Johnson, S. Hamzehzadeh and R. H.
Allen, “Risk Factors for Brachial Plexus Injury with and
without Shoulder Dystocia,” American Journal of Obstet-
rics & Gynecology, Vol. 194, No. 2, 2006, pp. 486-492.
doi:10.2106/JBJS.G.00853
[5] R. Birch, G. Bonney and C. B. Wynn Parry, “Birth Le-
sions of the Brachial Plexus,” In: R. Birch, G. Bonney
and C. B. Wynn Parry, Eds., Surgical Disorders of the
Peripheral Nerves, Churchill Livingstone, New York,
1998, pp. 209-233.
[6] A. Gilbert and J. L. Tassin, “Surgery Repair of the Bra-
chial Plexus after Obstetric Paralysis,” Chirurgie, Vol.
110, No. 1, 1984, pp. 70-75.
[7] R. Birch, “Late sequelae at the shoulder in obstetrical
palsy in children,” In: M. Randelli and J. Karlsson, Eds.,
Surgical Techniques in Orthopaedics and Traumatology,
Elsevier, Paris, 2001, pp. 55-200-E-210.
[8] D. S. Kon, A. B. Darakjian, M. L. Pearl and A. E. Kosco,
“Glenohumeral Deformity in Children with Internal Rota-
tion Contractures Secondary to Brachial Plexus Birth
Palsy: Intraoperative Arthrographic Classification,” Radi-
ology, Vol. 231, No. 3, 2004, pp. 791-795.
doi:10.1148/radiol.2313021057
[9] J. A. van der Sluijs, W. J. van Ouwerkerk, A. de Gast, P. I.
Wuisman, F. Nollet and R. A. Manoliu, “Deformities of
the Shoulder in Infants Younger than 12 Months with an
Obstetric Lesion of the Brachial Plexus,” The Journal of
Bone & Joint Surgery (British Volume), Vol. 83, No. 4,
2001, pp. 551-555. doi:10.1302/0301-620X.83B4.11205
[10] R. K. Nath, S. E. Mackinnon, J. N. Jensen and W. C.
Parks, “Spatial Pattern of Type I Collagen Expression in
Injured Peripheral Nerve,” Journal of Neurosurgery, Vol.
86, No. 5, 1997, pp. 866-870.
doi:10.3171/jns.1997.86.5.0866
[11] R. Birch, “Obstetric Brachial Plexus Palsy,” Journal of
Hand Surgery (British Volume), Vol. 27B, No. 1, 2002,
pp. 3-8.
[12] P. M. Waters, “Obstetric Brachial Plexus Injuries: Eval-
uation and Management,” Journal of the American Acad-
emy of Orthopaedic Surgeons, Vol. 5, No. 4, 1997, pp.
205-214.
[13] S. M. Shenaq, J. Y. Kim, A. H. Armenta, R. K. Nath, E.
Cheng and A. Jedrysiak, “The Surgical Treatment of Ob-
stetric Brachial Plexus Palsy,” Plastic and Reconstructive
Surgery, Vol. 113, No. 4, 2004, pp. 54E-67E.
doi:10.1097/01.PRS.0000110215.61220.72
[14] R. K. Nath, C. Somasundaram and F. Mahmooduddin,
“Comparing Functional Outcome of Triangle Tilt Surgery
Performed before versus after Two Years of Age,” The
Open Orthopaedics Journal, Vol. 5, 2011, pp. 59-62.
doi:10.1097/01.PRS.0000110215.61220.72
[15] M. M. Al-Qattan, “Latissimus Dorsi Transfer for External
Rotation Weakness of the Shoulder in Obstetric Brachial
Plexus Palsy,” Journal of Hand Surgery (British Vol-
ume), Vol. 28, No. 5, 2003, pp. 487-490.
doi:10.1097/01.PRS.0000110215.61220.72
[16] T. A. El-Gammal, W. R. Saleh, A. El-Sayed, M. M. Kotb,
H. M. Imam and N. A. Fathi, “Tendon Transfer Around
the Shoulder in Obstetric Brachial Plexus Paralysis: Cli-
nical and Computed Tomographic Study,” Journal of Pe-
diatric Orthopaedics, Vol. 26, No. 5, 2006, pp. 641-646.
doi:10.1097/01.PRS.0000110215.61220.72
[17] R. K. Nath and M. Paizi, “Improvement in Abduction of
the Shoulder after Reconstructive Soft-Tissue Procedures
in Obstetric Brachial Plexus Palsy,” The Journal of Bone
& Joint Surgery (British Volume), Vol. 89, No. 5, 2007,
pp. 620-626. doi:10.1097/01.PRS.0000110215.61220.72
[18] A. Pagnotta, M. Haerle and A. Gilbert, “Long-Term Re-
sults on Abduction and External Rotation of the Shoulder
after Latissimus Dorsi Transfer for Sequelae of Obstetric
Palsy,” Clinical Orthopaedics and Related Research, Vol.
426, 2004, pp. 199-205.
doi:10.1097/01.PRS.0000110215.61220.72
[19] Y. Safoury, “Muscle Transfer for Shoulder Reconstruc-
tion in Obstetrical Brachial Plexus Lesions,” Handchi-
rurgie Mikrochirurgie Plastische Chirurgie, Vol. 37, No.
5, 2005, pp. 332-336. doi:10.1055/s-2005-872818
[20] J. A. van der Sluijs, W. J. van Ouwerkerk, A. de Gast, F.
Nollet, H. Winters and P. I. Wuisman, “Treatment of In-
ternal Rotation Contracture of the Shoulder in Obstetric
Brachial Plexus Lesions by Subscapular Tendon Length-
ening and Open Reduction: Early Results and Complica-
tions,” Journal of Pediatric Orthopaedics B, Vol. 13, No.
3, 2004, pp. 218-224. doi:10.1055/s-2005-872818
[21] P. M. Waters and D. S. Bae, “The Early Effects of Ten-
don Transfers and Open Capsulorrhaphy on Glenohu-
meral Deformity in Brachial Plexus Birth Palsy,” The
Journal of Bone and Joint Surgery (American Volume),
Vol. 90, No. 10, 2008, pp. 2171-2179.
doi:10.2106/JBJS.G.01517
[22] P. M. Waters and D. S. Bae, “Effect of Tendon Transfers
and Extra-Articular Soft-Tissue Balancing on Glenohu-
meral Development in Brachial Plexus Birth Palsy,” The
Journal of Bone and Joint Surgery (American Volume),
Vol. 87, No. 2, 2005, pp. 320-325.
doi:10.2106/JBJS.G.01517
[23] R. K. Nath, M. B. Avila and P. Karicherla, “Triangle Tilt
Surgery as Salvage Procedure for Failed Shoulder Sur-
gery in Obstetric Brachial Plexus Injury,” Pediatric Sur-
gery International, Epub Ahead of Print, 2010.
[24] R. K. Nath, A. Amrani, S. E. Melcher, M. J. Wentz and
M. Paizi, “Surgical Normalization of the Shoulder Joint
in Obstetric Brachial Plexus Injury,” Annals of Plastic
Surgery, Vol. 65, No. 4, 2010, pp. 411-417.
[25] R. K. Nath, A. Amrani, S. E. Melcher and M. G. Eich-
horn, “Triangle Tilt Surgery in an Older Pediatric Patient
with Obstetric Brachial Plexus Injury,” Eplasty, Vol. 9,
2009, p. e26.
[26] R. K. Nath, A. Amrani, S. E. Melcher, M. J. Wentz and
M. Paizi, “Surgical Normalization of the Shoulder Joint
in Obstetric Brachial Plexus Injury,” Annals of Plastic
Surgery, Vol. 65, No. 4, pp. 411-417.

R. K. NATH ET AL. 21
doi:10.1097/SAP.0b013e3181e1335b
[27] R. K. Nath, M. B. Avila, P. Karicherla and C. Soma-
sundaram, “Assessment of Triangle Tilt Surgery in Chil-
dren with Obstetric Brachial Plexus Injury Using the Pe-
diatric Outcomes Data Collection Instrument,” Open Or-
thopaedics Journal, Vol. 5, No. 12, 2011, pp. 385-388.
[28] R. K. Nath, X. Liu, S. E. Melcher and J. Fan, “Long-
Term Outcomes of Triangle Tilt Surgery for Obstetric
Brachial Plexus Injury,” Pediatric Surgery International,
Vol. 26, No. 4, 2010, pp. 393-399.
doi:10.1007/s00383-010-2550-4
[29] R. K. Nath and F. Mahmooduddin, “Triangle Tilt Surgery:
Effect on Coracohumeral Distance and External Rotation
of the Glenohumeral Joint,” Eplasty, Vol. 10, No. 11, 2010,
p. e67.
[30] R. K. Nath, S. E. Melcher, A. B. Lyons and M. Paizi,
“Surgical Correction of the Medial Rotation Contracture
in Obstetric Brachial Plexus Palsy,” The Journal of Bone
& Joint Surgery (British Volume), Vol. 89, No. 12, 2007,
pp. 1638-1644. doi:10.1302/0301-620X.89B12.18757
[31] R. K. Nath, S. E. Melcher and M. Paizi, “Surgical Cor-
rection of Unsuccessful Derotational Humeral Osteotomy
in Obstetric Brachial Plexus Palsy: Evidence of the Sig-
nificance of Scapular Deformity in the Pathophysiology
of the Medial Rotation Contracture,” Journal of Brachial
Plexus and Peripheral Nerve Injury, Vol. 1, No. 12, 2006,
p. 9. doi:10.1302/0301-620X.89B12.18757
[32] R. K. Nath, C. Somasundaram and F. Mahmooduddin,
“Triangle Tilt and Steel Osteotomy: Similar Approaches
to Common Problems,” The Open Orthopaedics Journal,
Vol. 5, No. 2011, pp. 124-133.
doi:10.1302/0301-620X.89B12.18757
[33] R. K. Nath, C. Somasundaram, S. E. Melcher, M. Bala
and M. J. Wentz, “Arm Rotated Medially with Supination
—The Arms Variant: Description of Its Surgical Correc-
tion,” BMC Musculoskeletal Disorders, Vol. 10, No. 3,
2009, p. 32. doi:10.1186/1471-2474-10-32
[34] R. J. Friedman, K. B. Hawthorne and B. M. Genez, “The
Use of Computerized Tomography in the Measurement of
Glenoid Version,” The Journal of Bone and Joint Surgery
(American Volume), Vol. 74, No. 7, 1992, pp. 1032-1037.
[35] R. K. Nath and M. Paizi, “Scapular Deformity in Obstet-
ric Brachial Plexus Palsy: A New Finding,” Surgical and
Radiologic Anatomy, Vol. 29, No. 2, 2007, 133-140.
doi:10.1007/s00276-006-0173-1
[36] R. K. Nath and C. Somasundaram, “Successful Outcome
of Modified Quad Surgical Procedure in Preteen and Teen
Patients with Brachial Plexus Birth Palsy,” Eplasty, Vol.
12, No. 12, 2012, p. e54.