Fix Shoulder Haikal

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Anatomy Neurovascular of

Shoulder
• The suprascapular nerve originates from the
upper trunk of the brachial plexus

• Innervates the supraspinatus and


infraspinatus muscles and provides sensation
to the glenohumeral and acromioclavicular
joints.

• The suprascapular notch, making a sharp turn


around the scapular spine.
There the nerve travels within

scapular notch or scapular

incisura a fibroosseous tunnel

bridged superiorly by the

scapular ligament.
What is the “Unhappy or Terrible
Triad” in regard to the shoulder?
A shoulder dislocation along with rotator cuff tear and peripheral nerve injury.
Dislocations should be considered as a clinical spectrum that includes

1) Isolated dislocations,

2) Injuries producing either detachment of the rotator cuff or neurologic deficit


alone, and ;

3) Combined injuries.
DO NOT GET CONFUSED ENTRAPMENT OF NERVE WITH ROTATOR CUFF PROBLEM!!
A) Suprascapular Nerve
Compression
Chronic or repetitive compression of the

suprascapular nerve and its branches is much more

common than is generally recognised. The peculiar

anatomy of the nerve makes it unusually vulnerable

to both traction and entrapment (compression).


What are the common sites of entrapment
of the suprascapular nerve?
The suprascapular nerve courses from nerve roots C5 and C6 and runs

posterolaterally to the suprascapular notch beneath the transverse

scapular ligament. The nerve is commonly injured at the suprascapular

notch by ganglia or tumor. Injury at the suprascapular notch affects

both the supraspinatus and the infraspinatus muscles and mimics

rotator cuff pathology.


What are the Clinical features for this
entrapment?
• unexplained pain in the suprascapular region or at the back of the
shoulder,

• Weakness of shoulder

• wasting of the supraspinatus muscle and diminished power of


abduction and external rotation.
Physical Exam

• atrophy along the posterior scapula

• pain with palpation of suprascapular notch

• weakness of supraspinatus

• weakness of infraspinatus

• weakness to external rotation with elbow at side


Physical Exam (Cont.)

• weakness seen with shoulder abduction to 90 degree, 30 degrees


forward flexion, and with internal rotation (Jobe test positive)
What diagnostic tests are available to help
confirm suprascapular nerve injury?
Electromyography and measurement of nerve conduction velocity may

help to establish the diagnosis. Ultrasonography and MRI are useful in

excluding a soft-tissue mass.


Treatment
• Stop any type of activity which might stress the suprascapular nerve;

after a few weeks, graded muscle strengthening exercises can be

introduced.

• Within 3 to 6 months. If there is no improvement, or if imaging

studies reveal a soft-tissue mass, operative decompression is justified.


B) Thoracic Outlet Syndrome
• Thoracic outlet syndrome (TOS) refers to the compression of the

neurovascular structures between the neck and axilla.

• May be produced by compression of the lower trunk of the brachial

plexus (C8 and T1) and subclavian vessels between the clavicle and

the first rib.


Thoracic outlet syndrome (TOS) is a broad term that sometimes also

refers as Scalenus syndrome where there is a compression of the

neurovascular structures in the area just above the first rib and behind

the clavicle that results in upper extremity symptoms.


B) Thoracic Outlet Syndrome (cont.)
TOS can be subdivided into vascular or neural compression symptoms,

or both, depending on which specific structures within the

cervicoaxillary canal are compromised.


How to evaluate a patient suspected of
having TOS
Typically a woman in her thirties, complains of pain and paraesthesia

extending from the shoulder, down the ulnar aspect of the arm and

into the medial two fingers. Symptoms tend to be worse at night and

are aggravated by bracing the shoulders


What are the Clinical features for this
entrapment?
In most cases, the physical examination findings of thoracic outlet
syndrome (TOS) are completely normal. Other times, the examination is
difficult because the patient may guard the extremity and exhibit
giveaway-type weakness. The sensory examination is often unreliable.
Physical examination

a) inspection

note specific postures, can increase loading on the brachial plexus, rounded
shoulders, increased thoracic kyphosis, downward rotation or depression of the
scapula

At skin we may see cyanosis, congestion, pallor, distal ulcerations, signs of


microembolic events (rare), muscle atrophy.

b) palpation

over the supraclavicular area , may reveal tenderness and/or masses and skin
temperature.
TOS Special test.
In Adson’s test the patient’s neck is extended and turned towards the

affected side while he or she breathes in deeply; this compresses the

inter scalene space and may cause paraesthesia and obliteration of the

radial pulse.
TOS Special test (cont)

In Wright’s test the arms are abducted and externally rotated; again the

symptoms recur and the pulse disappears on the abnormal side.


TOS Special test (cont)
In Roos test by asking the patient to hold his or her arms high above

their head and then open and close the fingers rapidly; this may cause

cramping pain on the affected side.

Unfortunately, these tests are neither sensitive nor specific enough to clinch the diagnosis.
What diagnostic tests are helpful in
diagnosing TOS?
Klaassen describes one of the issues with TOS as a lack of a
gold standard for definitive diagnosis. Radiographs, CT scans,
and MRIs provide for detection of cervical ribs and fibrous
bands for identification of potential factors causing TOS.
What diagnostic tests are helpful in
diagnosing TOS? (Cont.)
Confirmation of a vascular abnormality is aided by the use of duplex
ultrasound, which has been found to be 92% sensitive and 95% specific.
In addition, electrophysiologic testing is valuable for differential
diagnosis and determining the presence of additional abnormalities
such as cervical nerve root or distal peripheral nerve pathology.
Treatment for TOS
By conservative treatment for TOS treatment, exercises can be done to strengthen

the shoulder girdle muscles, postural training and instruction in work practices and

ways of preventing shoulder droop and muscle fatigue. Analgesics may be needed

for pain.

Operative treatment is indicated if pain is severe, if muscle wasting is obvious or if

there are vascular disturbances.

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