Neurological shoulder disorders Flashcards
Scapular winging suprascapular neurology thoracic outlet syndrome brachial neuritis- parsonnage - turner syndrome quadrilateral space syndrome scapulothoracic dyskinesis
What are the types of scapular winging?
- 2 types
-
medial
- serratus anterior- long thoracic nerve
-
lateral
- Trapezius - CN XI- spinal accessory n
-
medial

Describe the normal anatomy and motion of the scapula?
- 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
Dsecribe the anatomy of serratus anterior?
- 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

What is the aetiology of medial scapular winging?
- 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
-
Repetitive stretch injury
What is the presentation of medial scapular winging?
- 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

What is the tx of medial scapular winging?
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

Describe the aetiology of lateral scapular winging?
- Deficit to trapezius due to spinal accessory nerve injury: CN XI
- often Iatrogenic injury - post neck surgery for nodes
What is the presentation of lateral scapular winging?
- scapular moves lateral
- shoulder girdle appears depressed or dropped

What is the tx of lateral scapular winging?
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

What is the aetiology of suprascapular neuropathy?
-
Suprascapular notch entrapment
- weakness of supraspinatus and infraspinatus
-
Spinoglenoid notch entrapment
- weakness of infraspinatus only
Describe the anatomy of the suprascapular nerve?
- 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

What is the anatomy of the suprascapular ligament/spinoglenoid ligament?
-
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
- arises near spinoglenoid notch
What is suprascapular notch entrapment?
- 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
Describe the presentation of suprascapular notch entrapment?
- 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
How is suprascapular notch entrapment evaluated?
- MRI
- to identify a compressive mass with assoc cyst
- EMG/NCV
- diagnostic
What is the tx of suprascapular notch entrapment?
Non operative
- activity modification. organised shoulder rehab
- minimum 6 months
- no abnormality on mri
Operative
-
Surgical decompression at suprascapular notch
- if structural lesion on mri or no response 1 yr consx
- http://www.orthobullets.com/video/view?id=116
What is spinoglenoid notch entrapment?
- 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)
What is the presentation of spinoglenoid notch entrapment?
- Deep , diffuse, posterolateral shoulder pain
0/E
- Infraspinatus weakness
- infraspinatus atrophy along posterior scapula
- supraspinatus normal

How is spinoglenoid notch entrapment evaluated?
- MRI
- to identify any posterior labral lesions with assoc cysts
- EMG/NCV
- diagnostic

What is the tx of spinoglenoid notch entrapment?
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
What is thoracic outlet syndrome?
- A neurovascular compressive neuropathy with either a neurogenic or vascular etiology
- F>M
What is the pathophysiology of thoracic outlet syndrome?
-
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
- compression of neurovascular bundle as it passes over 1st rib or thru scalene muscle by
- Vascular
- compression of subclavian vessel or aneursym
- may lead to emboli at hands

What is the assoc condition with thoracic outlet syndrome?
-
Paget-Schroetter syndrome
- thoracic outlet syndrome w compression of subclavian vein in the developed athlete due to scalene muscle hypertrophy
What is the presentation of thoracic outlet syndrome?
- 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
-
Wright
- abduction, ER with neck rotated away from head to loss of pulse and reproduction of symptoms
- http://www.orthobullets.com/video/view?id=903
What is seen on imaging of thoracic oulet sydrome?
- C spine- rule out cervical rib
- cxr- rule out pancoast tumour
- Angiography
- will subclavian vessel disease/aneurysm
What is the tx of thoracic oulet sydrome?
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
- adress site of compression
-
Vascular reconstruction ( open bs interventional)
- for subclavian aneursym
What is the complications of thoracic oulet sydrome?
-
emboli to the hands
- tx with heparinisation, embolectomy.
- 7-10 days of heparin then 3/12 warfarin
decribe what is brachial neuritis?
- 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
What is the pathophysiology of brachial neuritis?
- Autoimmune process, probably involving lymphocytes
- Hereditary form is extremely rare but autosomal dominant
What is the presentation of brachial neuritis?
-
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
What imaging is helpful in brachial neuritis?
- MRI
- show signal abnormalities in affected muscle bellies
- EMG
- abnormalities show acute degeneration w sharp waves and fibrillations
What is the tx of brachial neuritis?
- 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
What is quadrilateral space syndrome?
- 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
What is the pathophysiology of quadrilateral space syndrome?
-
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)
what is the prognosis of quadrilateral space syndrome?
- Long-standing cases often causes atrophy/weakness of teres minor and deltoid
Can you describe the anatomy of the quadrangular space?
- 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

What is the presentation of quadrilateral space syndrome?
- 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
What is seen on imaging of quadrilateral space syndrome?
- 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

What is the tx of quadrilateral space syndrome?
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
Describe the technique for quadrilateral space decompression?
- 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
What is scaphulothoracic dyskinesis?
- 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

Describe the pathoanatomy of scapular dyskinesis?
- 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
What is the presentation of scapular dyskinesis?
- shoulder pain and dysfunction worse with arm elevation
- loss of throwing velocity
O/E
- scapulothoracic crepitus
- affected scapula may be lower and protected
- symptom relieved with scapula stabilisation
- http://www.orthobullets.com/video/view?id=627

What is the tx of shoulder dyskinesis?
- NSAIDS, PT local injections
- main tx
- physio emphasis on
- core strengthening
- scapular stabilisers , serratus ant , trapezius
- RC muscles
- core mechanics to throwers