Shoulder Examination and the Brachial Plexus

Structure of the Session

Teaching – 30 minutesShoulder Examination and the Brachial

Plexus

Move into small groups with Tutor

• Pt. history• Shoulder examination• SAQs

Debrief and Feedback• Tutor feedback• Student feedback

Shoulder Examination

Preparation•Same thing every examination

• Introduction• “Hello, my name is Rob. I’m a second year medical student at Leicester medical

school”

• Consent and explanation• “Would it be okay for me to perform a shoulder examination on you? It will involve

me looking at, feeling, and moving your shoulder”

• Wash hands• Position• Standing

Look• Front, side, back

• Say what you’re looking for:• Posture• Muscle wasting

• Supra/infraspinatus wasting would suggest chronic tear of their tendons

• Scars• Skin changes• Swelling

• Will be seen in dislocations, inflammatory disorders, proximal fractures of the humerus

• Symmetry • Are there any obvious differences?

• The above list can be found in your consultation

skills book

Feel

•Before you touch the patient ask them to tell you if they feel pain at any point!

•They may not tell you if they’re in pain, so look at their face whilst doing it!

• Check the temperature of the shoulder and compare with other side (using the dorsum (back) of your hand)• NB: Cardinal signs/symptoms of inflammation

• Dolor (pain)• Calor (heat)• Rubor (redness)• Tumor (swelling)• Loss of function

Feel (2)

•Start at the Sternoclavicular joint• Between the clavicle and manubrium of

the sternum

•Feel along the Clavicle to the Acromioclavicular joint• Between the clavicle and acromion of

the scapula

•Acromion process

•Coracoid process• Inferior to the acromioclavicular joint• Be careful as it can be painful for the

patient

Feel (3)

•Scapula• Spine of the scapula• Medial border• Inferior angle• Lateral border

•Head of the humerus

•Joint line

•Muscle bulk• Deltoid• Supraspinatus• Infraspinatus

•You will be feeling for swelling, and checking for tenderness (say you are doing this!)

MoveFlexion

• BRACHIALIS DOES NOT FLEX THE ARM AT THE GLENOHUMERAL JOINT

Muscle Nerve

Biceps Brachi Musculocutaneous

Coracobrachialis Musculocutaneous

Deltoid (Anterior fibres)

Axillary

Move (2)Extension

Muscle Nerve

Triceps Brachi Radial

Latissimus Dorsi Thoracodorsal

Deltoid (posterior fibres)

Axillary

Move (3)Abduction

• Supraspinatus initiates abduction (first 15°)• Deltoid continues it.• Pain between 10° and 120° (but with full range of passive movements) Painful arc (rotator cuff lesion/tendonitis)

• Between 50 and 70% of abduction occurs at the glenohumeral joint, the rest occurs with the movement of the scapula on the chest wall – Macleod’s Clinical Examination 12th edition

Muscle Nerve

Supraspinatus Suprascapular

Deltoid (Lateral fibres)

Axillary

Move (4)

Adduction

Muscle Nerve

Teres Major Lower Subscapular

Pectoralis Major Medial and Lateral pectoral

Triceps Brachi (long head)

Radial

Latissimus Dorsi Thoracodorsal

Coracobrachialis Musculocutaneous

Move (5)

Internal (medial) rotation

Muscle Nerve

Subscapularis Upper and Lower Subscapular

Teres Major Lower Subscapular

Pectoralis Major Medial and Lateral Pectoral

Deltoid (anterior fibres)

Axillary

Latissimus Dorsi Thoracodorsal

Move (6)

External (lateral) rotation

Muscle Nerve

Infraspinatus Suprascapular

Teres Minor Axillary

Deltoid (Posterior fibres)

Axillary

Move (7)Passive movements

•Flexion, extension, abduction, adduction, internal and external rotation need to be preformed passively whilst palpating the glenohumeral joint for crepitus.

•Passive – You move it for them

•Crepitus – “A crackling sound or grating feeling produced by bone rubbing on bone or roughened cartilage, detected on movement of an arthritic joint” – Oxford concise medical dictionary – 7th edition

Function

•Ask patient to put their hands behind their head, and behind their back• Tests their ability to dress, comb hair ect.

Pause for shoulder examination demonstration

The Brachial Plexus

Mnemonic• Real Roots• Teenagers Trunks• DrinkDivisions

• ColdCords• BeerBranches

The Brachial Plexus- A few key points

•Formed from the union of the anterior rami of C5-T1

•Trunks of the brachial plexus divide into anterior and posterior divisions• Anterior divisions: Go on the supply the anterior compartments of the upper limb• Posterior divisions: Go on to supply the posterior compartments of the upper limb

• Posterior divisions of all 3 trunks unite to from the posterior cord• Anterior divisions of superior and middle braches unite to form the lateral cord• Anterior division of inferior branch goes on to become the medial cord•Cords are named based on their anatomical relationship to the axillary artery

• A lot of nerves come from the brachial plexus. Focus mainly on the terminal branches.

The Brachial Plexus- Injuries

Injuries to the superior parts of the brachial plexus (C5 and C6)Erb-Duchenne palsy (palsy is a paralysis of part of the body)• Usually occur due to a person being thrown off a horse or motorcycle• The landing results in an increased angle between the neck and shoulder

• Results in “waiter’s tip position” – Arm hangs at the person’s side in medial rotation

• Hangs by side • C5 and C6 supply Suprascapular nerve, and Axillary nerve• These nerves innervate Supraspinatus and Deltoid • These muscles Abduct the arm

• Medial rotation• C5 and C6 supply Suprascapular nerve, and Axillary nerve• These nerves innervate Infraspinatus , Deltoid (Posterior fibres)

and Teres Minor• These muscles Laterally rotate the arm

The Brachial Plexus- Injuries

Injuries to the inferior parts of the brachial plexus (C8 and T1)Klumpke paralysis• Less common than Erb-Duchenne’s palsy• Occur when:• Arm is suddenly pulled superiorly

• e.g. Somebody grabbing a branch to stop them falling from a tree.

• A baby’s arm is pulled excessively during delivery.• Results in a “Claw hand”

• All intrinsic muscles of the hand are supplied by the ulnar nerve• Except: 1st and 2nd Lumbricals; Opponens pollicis; Abductor pollicis brevis; Flexor

pollicis brevis (superficial head) – Median nerve.• Meat LOAF

The Brachial Plexus- Injuries

http://en.wikipedia.org/wiki/File:Ulnar_claw_hand.JPG

The Brachial Plexus- Injuries

• Lumbricals: • Flex metacarpophalangeal joints

• 4th and 5th not functioning hyperextension of these joints• Extend interphalangeal joints

• 4th and 5th not functioning flexion of these joints (weak)

• Medial part of flexor digitorum profundus:• Flexes interphalangeal joints 4 and 5

• Not functioning weak flexion of this joint

• Interphalangeal joint remains in flexed position, but flexion is weak

•Flexor carpi ulnaris:• Adducts hand at wrist

• Not functioning Radial deviation

The Brachial Plexus- Injuries

http://en.wikipedia.org/wiki/File:Ulnar_claw_hand.JPG

• Same presentation if you had a distal ulnar nerve compression (Ulnar canal syndrome)• However, there would be no weakness of flexion and no radial deviation due to no anterior forearm weakness

The Brachial Plexus- Injuries

Compression of the cords of the brachial plexus•Due to prolonged hyperabduction (e.g. From painting a ceiling)

•Cords are compressed between the coracoid process of the scapula and pectoralis minor tendon.

•Presents as pain radiating down the arm, numbness, and paresthesia (Tingling)

Questions?

Clinical Correlates of the Upper Limb:Pectoral Girdle to Elbow

SESSION 49th March 2011

This is not a substitute to self study

I have intentionally not given you all the details

You will need to go away and think about what is discussed

Please don’t tell me this falls upon deaf ears…

Winged Scapula

• Damage to the Long Thoracic N.• Results in paralysis of Serratus Anterior • Often a stab wound to the lateral thorax

• Ask patient to place hands flat against wall• If one of the scapula protrudes further than the other = winged

Winged Scapula

http://www.sciencephoto.com/images/download_lo_res.html?id=773500123

Brachial Plexus: Terminal Branches

• You should know:• Axillary N. damage

• Paraesthesia over ‘Regimental Badge’ area – why?• Loss of abduction – why?

• Musculocutaneous N. damage• Very weak flexion of forearm at elbow. Not complete loss – why?• Loss of sensation of lateral forearm – why?

• Radial N. damage • Wrist Drop – why? • Loss of sensation over most of posterior aspect of Upper Limb• Is extension of forearm at elbow always completely lost?

• Median N. damage• Hand of Benediction (if damage at elbow or above) – why?• Ape Hand (if damage distal to elbow) – why? • Sensation over palmar aspect of digits 1-3 – why?

• Ulnar N. damage• Claw Hand – why?

Signs in the Hand

http://clogginsart.blogspot.com/2009/01/bless-this-blog.html

http://www.flickr.com/photos/subvert/545135749/

http://www.wesnorman.com/clinicalconsiderations.htm

Fractures• You should know:

• Clavicular Fx. • Subclavian vessels run inferiorly, between the clavicle and the 1st rib• Obvious deformity? • Inability to support the upper limb – supporting arm at the elbow?

• Surgical Neck of Humerus• Axillary N. damage• Musculocutaneous N. damage

• Spiral Fx. of Humerus• Radial N. damage• What else runs in this groove?

• Transverse Humeral Fx. • Radial N. damage

• Intercondylar/Olecranon Fx.• Ulnar N. damage

Fractures

If you have a good grasp of anatomy, you can work out what nerves might

be damaged

Glenohumeral Joint Injuries• Dislocation of the Glenohumeral Joint

• ~90% anterior, ~10% posterior – why?• Easiest when arm is extended, abducted and externally rotated – why? • Axillary nerve compression possible• Loss of contour of the shoulder

• Adhesive Capsulitis (‘Frozen Shoulder’)• Caused by fibrosis in the joint capsule• The arm can still be abducted, to ~45 degrees – why?

• What would you see if you looked at their scapula during abduction?

Glenohumeral Joint Injuries•Tear of Supraspinatus tendon

• Inability to abduct arm, unless starting above 15 degrees• Pt’s will lean to the affected side to get themselves started

• Subacromial Bursitis• ‘Painful Arc’ syndrome, due to tendon of Supraspinatus moving under the bursa

• Glenoid Labrum Tears• Common in those who have unstable shoulder joints• Causes pain, sublaxation and ‘snapping’ feelingin joint

Rotator Cuff Injuries

You need to know about these, too…