583 Shoulder and Elbow

Where does the brachial begin and extend to?

Brachial plexus:
The 5 roots merge to form which three trunks?

Brachial plexus:
supplies anterior (flexor) compartments of the upper limb

Brachial plexus:
supplies posterior (extensor) compartments.

Brachial Plexus:
What are the 3 cords?

Brachial plexus:
It is divided into 2 nerves.

Brachial plexus:
The following nerves are derived from which nerve path?
Dorsal Scapular - Long Thoracic- Nerve to subclavius- Suprascapular

Brachial plexus:
The following nerves are derived from which nerve path?
Lateral pectoral
Musculocutaneous
Median
Median Pectoral
Medial brachial cutaneous
Medial antebrachial cutaneous
Ulnar
Upper Subscapular
Thoracodorsal
Lower Subscapular
Axillary
Radial

Injuries to the brachial plexus can affect?

What can cause brachial plexu injuries?

What are signs and symptoms of brachial plexus injury?

How can you test for degree of paralysis from brachial plexus injury?

How can you test for anesthesia from brachial plexus injury?

Where is the injury?
Usually results from an excessive increase in the angle between the neck and the shoulder. This stretches or tears the superior part of thebrachial plexus.

Injury e.g. being thrown from a motorcycle or horse, wrestling
New born babies when excessive stretching of the neck occurs during delivery.
“waiter’s tip position”

Brachial plexus injury:
What has the following clinical presentation? (4 conditions)
adducted shoulder
medially rotated arm
extended elbow
loss of sensation

Brachial plexus injury:
Produces motor and sensory deficitsin the distribution of themusculocutaneous and radial nerves.This may result in muscle spasmsand be very disabling.

Brachial plexus injury:
Sudden onset of severe pain usually around the shoulder. Pain begins at night and is followed by muscle weakness and sometimes atrophy.

Brachial Plexus Injury:
May resultfrom prolonged hyper abductioneg. Overhead activities such as painting or plastering a ceiling.Cords impinged or compressed between the coracoid processof the scapula and the pectoralis minor tendon.

Brachial Plexus Injury:
Common neurologicalsymptoms are:
Pain runningdown the arm
Numbness
Paresthesia (tingling)
Erythema (redness of the skin caused bycapillary dilation) Weaknessof the hands.

Brachial Plexus Injury:
May occur when the upper limb is suddenly pulled superiorly – e.g. grasping something to prevent afall or breech birth

These events injure the inferior trunk of the brachial plexus (C8 andT1) and may pull (avulse) the dorsal and ventral roots of the spinal nerves from the spinal cord. The short muscles of the hand are affected and claw hand results.

Which nerve?
May beinjured when the GH jointdislocates because of itsclose relation of theinferior part of thearticular capsule of thehead of the humerus intothe quadrangular spacedamages the nerve.
Result: paralysis of thedeltoid and loss ofsensation in a small areaof skin covering thecentral part of the deltoid.

Which nerve?
injury to thisnerve in the axilla resultsin paralysis ofcoracobrachialis, biceps,and brachialis. Flexion ofthe elbow joint andsupination of the forearmare greatly weakened.
Loss of sensation on the lateral surface of the forearm supplied by thelateral antebrachial cutaneous nerve.

Which nerve?
Injuries superior to the origin of its branches to the Triceps brachii results in paralysis of the triceps, brachioradialis,supinator, and extensor muscles of the wrist and digits
Results in an inability to extend the wrist upward when the hand is palm down and inability to straighten the fingers.
Loss of sensation in areas ofskin supplied by this nerve also occurs ( numbness of the back of the hand and wrist).

Radial nerve injury:
Name the condition:
Results from falling asleep with one’s arm hanging over the arm rest of achair, compressing the radial nerve at the spinalgrove.

Radial Nerve Injury:
Name the condition:
Results from another individual sleeping on and compressing one’sarm overnight.

Radial Nerve Injury:
Name the condition:
Rrom tight handcuffs compressing the superficial branch of the distal radial nerve

Which nerve is injured?
Commonly occurs where the nerve passes posterior to the medial epicondyle of the humerus
The injury results when the lateral part of the elbow hits a hard surface, fracturing the medial epicondyle (“funny bone”).

Which nerve is injured?
An injury to the nerve in the distal part of the forearm denervates most intrinsic handmuscles. Power of adduction is impaired and when an attempt is made to flex thewrist, the hand is drawn to the lateral side by the flexor carpi radialis

Which nerve is injured?
Patients have difficulty making a fist because they can’t flex their 4th and 5th digits at the DIP joints. This results in claw hand deformity.This is due to atrophy of the interosseous muscles of the hand supplied by the this nerve. The claw is produces by the opposed action of the entensors and flexor digitorum profundus muscles.

Which nerve is injured?
Flexion of the PIP joints of digits 1 to 3 is lost and flexion of digits 3 to 5 is weakened
Flexion of the DIP joints of the 2nd and 3rd digits is also lost The 4th and 5th are not affected
Flexion of metacarpopharangeal joints of the 2nd and 3rd digits will beaffected

Median Nerve Injury:
When a patient attempts to make a fist, digits 2 and 3 remain partiall extended.

Median Nerve Injury:
Caused by compression of the median nerve near theelbow. The nerve may be compressed between the heads of the pronatorteres. Symptoms follow activities that involve repeated elbow movements

Treatment for Median Nerve Injury in elbow region

Which Syndrome?
Pain out ofproportion to the eliciting event.
Disease that develops from an initialnoxious/painful event.
Spontaneous pain (pain with lighttouch) occurs. Hyperesthesia(increased sensitivity with touch)occurs beyond the territory of a single peripheral nerve and isdisproportionate to the inciting event

Which type of CRPS is this?
Disease that develops from an initial noxious event. Cannot be linked to any pathologic process.

Which type of CRPS is this?
Associated with an identifiablenerve injury

Pain state maintained bysympathetic efferent innervation,circulating catecholamines, orneurochemical action. Patients have apositive response to sympatheticblockade.

Pain state in which patients donot respond to sympathetic blocs.

After fracture of the ______, the sternocleidomastoid muscle elevates the medial fragment of the bone. Because the trapezius muscle is unable to hold the lateral fragment up because of theweight of the upper limb, the shoulder drops.

The following are symptoms of what?
Sagging shoulder (down and forward)
Inability to lift the arm because of pain
A grinding sensation if an attempt is made to raise the arm
A deformity or “bump” over the break
Bruising, swelling and/or tenderness over the area

These injuries are common in elderly people, especially those with osteoperosis.
Are often the result of a minor fall on the hand

Usually results from a fall on the hand when the arm is abducted

_________ fractures of the body of the humerus frequently result from a direct blow to the arm. The pull of the deltoid carries the proximal fragment of the fractured humerus laterally.

_____ fractures are the result of an indirect injury resulting from a fall on the outstretched hand (rotational component).

______ fractures of the humerus result from a severe fall on the “point” of elbow flexion. The olecranonof the elbow is driven like a wedge into the condyle ofthe humerus, separating one or both parts from the humeral body.

The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
Surgical neck

The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
Radial groove

The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
Medial epicondyle

The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
Distal end of humerus

Which joint?
• ball and socket joint
• wide range of movements
• relatively unstable

Name the rotator cuff muscles.

What is the function of the glenohumeral ligaments?

What is the function of the coracohumeral ligament?

What is the function of the transverse humeral ligament?

Deposition of calcium in thesupraspinatus tendon is common.inflammation and calcification of the subacromial bursa results in pain,tenderness and limitation of movement of the glenohumeral joint

The calcium deposit in the supraspinatus tendon may also irritate the overlying subacromail bursa producing andinflammatory condition called ________ ________
The pain usually develops in males 50 yearsor older after unusual or excessive use of the shoulder (e.g., during atennis game).

The pain from subacromial bursitis occurs during 50-130 degrees of abduction because during this arc the supraspinatus tendon is in intimate contact with the inferior surface of the acromion. This is called the ...

Commonly injured during repetitive use of the upper limb above the horizontal (e.g.,during throwing or racquet sports, swimming and lifting weights).

Common cause of shoulder pain

Rotator Cuff Injuries:
positive when the subjectcannot hold the arm elevated against gravity.

What are the 3 clinical signs of rotator cuff injury?

Rotator Cuff Injury:
Pain with elevation of the arm between 70 and 120 degrees of abduction

What are 3 treatments for rotator cuff injuries?

What direction are most dislocations of the humeral head?

Occurs most often in young adultscaused by excessive extension and lateral rotation of the humerus.

Occurs in athletes who throw a baseball or football or in those who have shoulder instability and partial dislocation (subluxation) of the glenohumeral joint.
Results in sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum. Usual symptom is pain while throwing, especially during the deceleration phase, but a sense of catching or snapping may be felt in the GH joint during abduction and lateral rotation of the arm.

Adhesive fibrosis and scarringbetween the inflamed articular capsule of the GH joint, RC, subacromialbursa and deltoid. Patient will have difficulty abducting arm. They can obtain an apparent abduction of up to 45° by elevating and rotating the scapula.
Conditions that may initiate acute ______ _____are glenohumeral dislocation, calcific supraspinatus tendinitis, partial tearing ofthe rotator cuff and bicipital tendinitis.

True or false?
Isolated fractures of the radius or ulna may occur, but are rare.
True False

True or false?
Fractures of the distal end of theradius are common in adults older 50 + years, more women than men (osteoporosis).
True False

the most common fracture of the forearm and results from forced dorsiflexion of the hand.

The subcutaneous olecranon bursa is exposed to injury after a fall on the elbow and to infection from abrasions of the skin covering the olecranon. Repeated excessive pressure and friction may cause this bursa to become inflamed

Known as “student’s elbow”, “miners elbow” or dart thrower’s elbow.

May occur when children fall on their hands with their elbows flexed.
Results from hyperextension or a blow that drives the ulna posterior or posterolateral.
The distal end of the humerus is driven through the weak anterior part of thefibrous capsule as the radius and ulna dislocate posteriorly.
The ulnar collateral ligament is often torn and an associated fracture ofthe head of the radius, coronoid process or olecranon may occur resulting in numbness of the little finger and weakness flexion and adduction of the wrist.

Results when the child is lifted bythe upper limb while the forearm is pronated (e.g. lifting a child into a bus)
The child may refuse to use the limb.
Tears the distal attachment of the anular ligament where it is loosely attached to the neck of the radius.
Preschool children are at risk for incomplete dislocation of the head of the radius

What condition is the following treatment for?
Treatment consists of supinationof the child’s forearm with theelbow in a flexed position andusually heals in a sling in 2 weeks.

Caused by overuse. It is the inflammationof the tendons that join the forearms muscles on the outside of the elbow. Forearm muscles and tendons become damaged from repeating the same motions over and over again.
Pain and tenderness on the outside of the elbow and may have a weak grip.

Like tennis elbow but onthe medial aspect of the elbow leads tomedial epicondylitis in trailing arm.

True or false?
Majority of spinal cord injuries are complete.
True False

Where is the lesion?
Upper limbs more profoundly affected. There is oftenflaccid weakness of the arms, due to the lower motor neuron (LMN) lesionsand spastic patterning in the arms and legs due to upper motor neuron(UMN) injury.

Where is the lesion?
Upper limb is weak or flaccid.
Nerve conduction studies used to determine if brachial plexus lesion exists ,only an intact nerve will produce muscle contraction. It is important to identify such a lesion at the earliest opportunity in order to facilitate a primary repair 

Characterized by progressive andirreversible deterioration of upper anlower motor neurons, resulting in bothupper and lower motor signs.Degeneration within the corticospinaland corticobulbar tracts gives rise toupper motor weakness andhypertonia. The hardening of thetracts as the degenerated neurons arereplaced by gliosis explains the term“lateral sclerosis”.

Leads to lower motor weakness, wasting and involuntary flickering of muscle fibres, which is known as fasciculations. The atrophyof denervated muscle fibres leads to the use of term Amyotrophy

What is a classical amyotrophic lateral sclerosis?

What are the signs of classical amyotrophic lateral sclerosis?

What is the principle member of a group of disorders known as demyelinating diseases.These diseases have animmune-mediated destructionof myelin as the primarypathological finding.

What are 2 symptoms of MS?

An accident with rapidly developing clinical signs of focal or global disturbance of cerebral function with symptoms lasting 24 hours or longer or leading to death with no apparent cause other than of vascular origin.
May have motor and/or sensory impairments in the upper limb.

Symptom of stroke:
loss of detection to touch sensation, proprioception loss,vibration, light touch and loss of pin prick sensation.

Symptom of stroke:
shoulder subluxation, spasticity,frozen shoulder, rotator cuff injury, complex regional pain syndrome and altered sensitivity.

Symptom of stroke:
Is caused by a lack of adequate support of the shoulder while the patient is in the upright position causing overstretchingof the joint capsule as a result of the gravitational pull on the weak/inactive arm.

True or false?
Swelling of the hand is a symptom of stroke.
True False

What condition?
Broken pieces of cartilage in joint
Common in the capitullum
Gradual onset (1 to 2 years), throwingcurveballs, gymnastics, wrestling, trauma
Limited ROM, clicking, locking,
Treatment: Rest from stress.
Good prognosis if diagnosed early
Surgery for severe cases.

Which condition?
Disruption of biceps from attachment (usuallydistal)
Pain at area of biceps
Quick forceful biceps contraction
Discontinuity of biceps with bulge
Loss of elbow flexion strength
May need surgical intervention

Which condition?
One-third of all elbow fractures males > females 30 to 40 years old, pain overthe radial head.
Stiff joint, unable to fully flex or extend, pain with supination-pronation.
Immobilization for short period, ROM once fracture is stable, progressive strengthening.

Which condition?
Calcification of muscle
From Trauma
Decreased ROM. Palpation of mass.
Treatment is Rest, Gentle ROM and medical management of symptoms.

Which condition?
Parasthesia in thumb, index finger, middle fingerthat is aggravated with activity, also have pain on thevolar aspect of the forearm.
Symptoms include weakness in the muscles of theforearm and hand innervated by the median nerve(FCR, PL, FD).

Which condition?
Median nerve compression
Sudden severe arm pain that resolves in a fewhours, no loss of sensation
Weakness of FPL, PQ, FDP; unable to pinchtip to tip.
Treatment: relative rest, splinting

Pain over the lateral humeral epicondyle,tender radial head, numb radial nerve.
Resisted middle finger extension.

Radial nerve compression at arcade of Frohse.
Tender to palpation distal from lateralepicondyle.
Symptoms with resisted wrist extension,unable to extend thumb or fingers at MCP.
Treatment: relative rest, splinting

True or false?
Pain is a part of healing.
True False