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Neurological shoulder disorders Flashcards

Scapular winging suprascapular neurology thoracic outlet syndrome brachial neuritis- parsonnage - turner syndrome quadrilateral space syndrome scapulothoracic dyskinesis

1
Q

What are the types of scapular winging?

A
  • 2 types
    • medial
      • serratus anterior- long thoracic nerve
    • lateral
      • Trapezius - CN XI- spinal accessory n
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2
Q

Describe the normal anatomy and motion of the scapula?

A
  • attachment of 17 muscles
  • function
    • to stabilise the scapula to the thorax
    • provide power to the upper limb
    • synchronise glenohumeral motion
  • ​Motion
    • ​Elevation and upwards rotation= Trapezius
    • scapular protraction (ant/lateral motion)= serratus ant/pect major & minor
    • Scapular retraction ( medial motion)= rhomboid majoir and minor
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3
Q

Dsecribe the anatomy of serratus anterior?

A
  • Origin
    • superolateral surfaces of upper 8-9 ribs at chest wal
  • insertion- vertebral body of scapula
  • action
    • draws scapula forward and upward
    • abducts scapula and rotates it
    • stabilises vertebral border of scapula
  • innervation
    • long thoracic nerve C5,6,7
  • Blood supply
    • circumflex scapular artery
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4
Q

What is the aetiology of medial scapular winging?

A
  • Deficit in Serratus anterior
  • injury to long thoracic nerve C5,6,7
  • by
    • Repetitive stretch injury
      • most common
      • head tilted away from overhead activity
      • e.g. weightlifters, volleyball
    • Compression injury
      • direct from lateral wall from contact sports/trauma
    • Iatrogenic injury
      • Axillary node clearance
    • Scapula fx
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5
Q

What is the presentation of medial scapular winging?

A
  • Shoulder pain and scapular pain
  • weakness when lifting away from body or overhead activity
  • discomfort when sitting against chair

O/E

  • Inferior border of scapula goes medial
  • shoulder girdle elevats
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6
Q

What is the tx of medial scapular winging?

A

non operative

  • Observation, bracing, serratus ant strengthening
    • obs for minimal of 6 months
    • wait for nerve to recover
    • bracing with modified thoracolumbar brace

Operative

  • Pectoralis transfer
    • no spontaneous resolution after 1-2 years
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7
Q

Describe the aetiology of lateral scapular winging?

A
  • Deficit to trapezius due to spinal accessory nerve injury: CN XI
  • often Iatrogenic injury - post neck surgery for nodes
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8
Q

What is the presentation of lateral scapular winging?

A
  • scapular moves lateral
  • shoulder girdle appears depressed or dropped
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9
Q

What is the tx of lateral scapular winging?

A

Nonoperative

  • Observation and trapezius strengthening

Operative

  • Nerve exploration
    • iatrogenic injury
  • Eden-Lange transfer
    • lateralise levator scapulae and rhomboids ( transfer from medial border to lateral border)
  • Scapulothoracic fusion
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10
Q

What is the aetiology of suprascapular neuropathy?

A
  • Suprascapular notch entrapment
    • weakness of supraspinatus and infraspinatus
  • Spinoglenoid notch entrapment
    • weakness of infraspinatus only
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11
Q

Describe the anatomy of the suprascapular nerve?

A
  • C5/C5
  • Emerges off superior trunk C5/6 of brachial plexus
  • travels across post triangle to neck of scapula
  • runs below suprascapular ligament/spinoglenoid ligament
  • innervates
    • supraspinatus
    • infraspinatus
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12
Q

What is the anatomy of the suprascapular ligament/spinoglenoid ligament?

A
  • Suprascapular lig
    • arises from medial base of coracoid & overlies suprascapular notch
    • suprascapular artery runs above it
    • suprascapular n runs below
  • Spinoglenoid ligament
    • ​arises near spinoglenoid notch
      • ​overlies distal suprascapular nerve
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13
Q

What is suprascapular notch entrapment?

A
  • Proximal compression of suprascapular n in the **suprascapular notch **
  • leads to weakness of infraspinatus and supraspinatus
  • compression from
    • ganglion cyst ( often w labral tears)
    • Transverse scapular ligament entrapment
    • fracture callus
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14
Q

Describe the presentation of suprascapular notch entrapment?

A
  • Deep , diffuse , posterolateral shoulder pain

O/E

  • Pain on palpation of suprascapular notch
  • weakness on supraspinatus- jobe test positive
  • weakness on infraspinatus
  • Atrophy of muscle
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15
Q

How is suprascapular notch entrapment evaluated?

A
  • MRI
    • to identify a compressive mass with assoc cyst
  • EMG/NCV
    • diagnostic
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16
Q

What is the tx of suprascapular notch entrapment?

A

Non operative

  • activity modification. organised shoulder rehab
    • minimum 6 months
    • no abnormality on mri

Operative

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17
Q

What is spinoglenoid notch entrapment?

A
  • Distal compression of the suprascapular nerve
  • affects only infraspinatus
  • compression due to
    • posterior labral tears -> cysts
    • spinoglenoid ligament
    • spinoglenoid notch ganglion
    • traction injury ( 45% vollet ball players)
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18
Q

What is the presentation of spinoglenoid notch entrapment?

A
  • Deep , diffuse, posterolateral shoulder pain

0/E

  • Infraspinatus weakness
  • infraspinatus atrophy along posterior scapula
  • supraspinatus normal
19
Q

How is spinoglenoid notch entrapment evaluated?

A
  • MRI
    • to identify any posterior labral lesions with assoc cysts
  • EMG/NCV
    • diagnostic
20
Q

What is the tx of spinoglenoid notch entrapment?

A

Non operative

  • Activity modifcation and organised shoulder rehab programme
    • if no structural lesion on MRI
    • posterior capsule stretching

Operative

  • Arthroscopic cyst decompression & labral repair
    • labral lesion with assoc cyst seen on MRI
  • Spinoglenoid ligament release with nerve decompression
    • ​if no lesion but failure consx tx 1 year
    • post approach to shoulder
    • decompress n in spenoglenoid notch
21
Q

What is thoracic outlet syndrome?

A
  • A neurovascular compressive neuropathy with either a neurogenic or vascular etiology
  • F>M
22
Q

What is the pathophysiology of thoracic outlet syndrome?

A
  1. Neurogenic
    • compression of neurovascular bundle as it passes over 1st rib or thru scalene muscle by
      • scalene muscle abnormalities
      • scapular ptosis
      • clavicle/first rib malunion
      • cervical rib
      • vertebral transverse process
    • ​other causes in athletes
      • ​fibormuscular bands
      • abn pect major
      • reptitive shoulder use
      • extreme arm positions
      • weightlifting, swimming
  2. ​Vascular
    • compression of subclavian vessel or aneursym
    • may lead to emboli at hands
23
Q

What is the assoc condition with thoracic outlet syndrome?

A
  • Paget-Schroetter syndrome
    • thoracic outlet syndrome w compression of subclavian vein in the developed athlete due to scalene muscle hypertrophy
24
Q

What is the presentation of thoracic outlet syndrome?

A
  • Arterial ischaemia
  • Raynaud’s phenomenon
  • venous congestion
  • cold intolerance
  • neurological
    • pain & swelling of upper extremities
    • ulnar nerve parathesias
      • differentiated form more distal compression due to sensory diff in medial brachial and antebrachial cutaneous nerves

O/E

25
Q

What is seen on imaging of thoracic oulet sydrome?

A
  • C spine- rule out cervical rib
  • cxr- rule out pancoast tumour
  • Angiography
    • will subclavian vessel disease/aneurysm
26
Q

What is the tx of thoracic oulet sydrome?

A

non operative

  • Physio, activity modifications
    • fist line
    • shoulder girdle strengthening, proper posture, relaxation techniques

Operative

  • Neurologic decompression
    • adress site of compression
      • repair clavicle malunion
      • transaxillary 1st rib resection = 90% excellent results
      • sclene takedown
      • pectoralis minor tentomy
      • release of fibromuscular anomalous bands
  • Vascular reconstruction ( open bs interventional)
    • for subclavian aneursym
27
Q

What is the complications of thoracic oulet sydrome?

A
  • emboli to the hands
    • tx with heparinisation, embolectomy.
    • 7-10 days of heparin then 3/12 warfarin
28
Q

decribe what is brachial neuritis?

A
  • AKA Pasonage- Turner syndrome
  • 1-30 cases per 100,00
  • any age affected
  • typically middle aged individuals
  • M>F
  • risk factors
    • viral infection
    • immunisation
    • medications
    • extreme stress
    • autoimmune disease
  • effects nerves of lower brachial plexus
29
Q

What is the pathophysiology of brachial neuritis?

A
  • Autoimmune process, probably involving lymphocytes
  • Hereditary form is extremely rare but autosomal dominant
30
Q

What is the presentation of brachial neuritis?

A
  • Sudden onset of pain that subsides in 1-2 wks
    • typically awakens people from sleep
  • Followed by Weakness period of up to 1 yr in muscles supplied by involved nerve

O/E

  • Severe weakness of ER/ Abductors
  • can have decreased sensation - up to 75% pts
    • esp in lateral antebrachial cutaneous n
  • commonly affects >1 nerve
31
Q

What imaging is helpful in brachial neuritis?

A
  • MRI
    • show signal abnormalities in affected muscle bellies
  • EMG
    • abnormalities show acute degeneration w sharp waves and fibrillations
32
Q

What is the tx of brachial neuritis?

A
  • Non operative
    • Observation for resolution and physio
    • follow pts monthly for improvement
    • outcomes
      • 90% pts recover at 3 years
      • only 35% of pt recover in 1 year
33
Q

What is quadrilateral space syndrome?

A
  • Axillary nerve and posterior humeral artery compression in quadrilateral ( quardangular) space
  • rare
  • often misdx as subacromial impingement
  • 20-40 years
  • most commonly affects dominant shoulder
  • risk factors
    • overhead athletes
    • contact throwing sports
34
Q

What is the pathophysiology of quadrilateral space syndrome?

A
  • Compression & reduction of quadrangular space due to
    • Iatrogenic ( tight fibrous bands, muscle hypertrophy)
    • Paralabral cysts ( with inferior labral tears)
    • Trauma ( scap fx, shoulder dislocation)
    • Benign/Malignant masses
  • ​Greatest amount of compression is when arm is in late cocking phase of throwing ( abduction/ER)
35
Q

what is the prognosis of quadrilateral space syndrome?

A
  • Long-standing cases often causes atrophy/weakness of teres minor and deltoid
36
Q

Can you describe the anatomy of the quadrangular space?

A
  • location
    • lateral to triangular space
    • medial to triangular interval
  • Boundaries
    • superior- subscapularis & teres minor
    • inferior- teres major
    • medial - long head of triceps
    • lateral - surgcal neck of humerus
  • contents
    • Axillary nerve (C5 n root, post cord)
    • Posterior circumflex humeral artery
37
Q

What is the presentation of quadrilateral space syndrome?

A
  • Poorly localised pain of posteriolateral shoulder
    • often worse at night
    • worse with overhead activity or late cocking/acceraltion phase of throwing
  • non dermatomal distribution of parathesia
  • shoulder ER weakness

O/E

  • Atrophy teres minor and deltoid
  • point tendereness over quadrangular space
  • ER weakness with arm abducted in throwing position
  • pain exacerbated by active and resisted Abduction & ER of arm
  • neurology - usually normal
38
Q

What is seen on imaging of quadrilateral space syndrome?

A
  • Xray
    • usually normal
  • MRI
    • rule out RC tears
    • may show…
    • atrophy teres minor( axillary innervation)
    • Compression of quadrilateral space
    • inferior paralbaral cyst asso w labral tear
  • Arteriogram
    • lesion in post humeral circumflex artery
  • EMG
    • used to confirm dx
    • show axillary n involvment
39
Q

What is the tx of quadrilateral space syndrome?

A

Non operative

  • NSAIDS, activity restriction, physio
    • first line of tx
    • glenohumeral mobilisation & strengthening
    • posterior capsule stretching
    • massage
    • most pt improve in 3-6 months
  • diagnostic lidnocaine block
    • inject lidnocaine into quadrilateral space
    • starting point is 2-3 cm inferior to standard post shoulder arthroscopy
    • positive if no point tenderness or pain on full rom

Operative

  • nerve decompression
    • open release of quadrilateral space +/- arthroscopic repair of labral tear
40
Q

Describe the technique for quadrilateral space decompression?

A
  • Approach
    • lateral decubitus position
    • 3-4cm incision over quadrilateral space
    • identify post border of deltoid and reflect superiolateral
    • expose fat in quadrilangulr space between teres minor and teres major
  • Technique
    • identify axillary nerve by using the humeral neck as reference
    • avoid cutting the posterior circumflex artery
    • free any fibrous tissue aherence to the nerve
    • ensure n is completely free of compression by moving arm into abduction and ER
  • Post op sling
    • immediate for comfort
    • early pendulum exercises to avoid new adhesions
    • progress to full active rom with supervsiedphysio
41
Q

What is scaphulothoracic dyskinesis?

A
  • Abnormal scapula motion leading to shoulder impingement & dysfunction
  • cause multifactoral
    • neurological injury
    • pathological thoracic spine kyphosis
    • periscapular muscle fatigue
    • poor throwing mechanics
    • secondary to pain
  • seen in athletes
42
Q

Describe the pathoanatomy of scapular dyskinesis?

A
  • Scapulothoracic power imbalance lead to protraction of scapula
  • leads to alteration of mechanics of GH joint
    • excessive stress placed on anterior capsule of shoulder and posterosuperior labrum
  • increase risk of injuring
    • labrum
    • RC
    • Capsule
43
Q

What is the presentation of scapular dyskinesis?

A
  • shoulder pain and dysfunction worse with arm elevation
  • loss of throwing velocity

O/E

44
Q

What is the tx of shoulder dyskinesis?

A
  • NSAIDS, PT local injections
  • main tx
  • physio emphasis on
    • core strengthening
    • scapular stabilisers , serratus ant , trapezius
    • RC muscles
    • core mechanics to throwers

Sport FRCS (26 decks)

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