Hands
Tor Wo Chiu in Stone’s Plastic Surgery Facts, 2018
Move Test motor power (MRC, M2 is movement with gravity eliminated) at shoulder, elbow, wrist, fingers and thumb.Winging of the scapula suggests a preganglionic injury (see above).Test trapezius – SAN may be used for nerve transfer.Nerve screening.Axillary nerve (shoulder abduction).RN (wrist extension – low, elbow extension – high).Musculocutaneous nerve (elbow flexion).Median and ulnar nerve (finger and wrist flexion).Passive and active ROM of all joints.
Neuroanatomy
Ibrahim Natalwala, Ammar Natalwala, E Glucksman in MCQs in Neurology and Neurosurgery for Medical Students, 2022
The following diagram is a schematic representation of the brachial plexus. It shows the roots C5-T1; note the contribution to the phrenic nerve that innervates the diaphragm (‘C 3,4, 5 keep the diaphragm alive’). The dorsal scapular nerve supplies the rhomboid muscles and levator scapulae muscle. The suprascapular nerve supplies supraspinatus and infraspinatus (two of the rotator cuff muscles; teres minor is supplied by the axillary nerve and subscapularis by the upper and lower subscapular nerves). The long thoracic nerve of Bell innervates the serratus anterior muscle and a lesion of this nerve results in winging of the scapula (‘C 5, 6, 7 bells of heaven’). The axillary nerve supplies the deltoid muscles; this nerve is commonly injured in shoulder dislocations; always check the sensation over the ‘regimental badge area’ before attempting shoulder reduction to assess if damage has already occurred.
Capsular release
Andreas B. Imhoff, Jonathan B. Ticker, Augustus D. Mazzocca, Andreas Voss in Atlas of Advanced Shoulder Arthroscopy, 2017
Plain radiographs are an essential diagnostic study prior to consideration of capsular release. We have seen cases of heterotopic ossification, greater tuberosity fracture, loose incarcerated anchors, and even chronic locked glenohumeral dislocation all in patients that were receiving aggressive therapy for presumed routine postoperative stiffness after rotator cuff repair. We do not typically recommend any advanced diagnostic testing unless there is reasonable concern of an underlying cause for the post-surgical stiffness. If there is a concern for an axillary nerve injury after 6 weeks of no improvement with conservative management, then an electromyography (EMG) study is indicated. Certainly, any concerns for infection are assessed with inflammatory marker and white blood cell count blood labs. We very rarely request a repeat magnetic resonance imaging (MRI) study after a RCR unless there is a history of significant injury following surgery.
Salvage of cervical motor radiculopathy using peripheral nerve transfer reconstruction
Published in British Journal of Neurosurgery, 2019
Fardad T. Afshari, Taushaba Hossain, Caroline Miller, Dominic M. Power
The mechanism of recovery following nerve transfer is not fully understood but is likely to be due to reinnervation of dennervated muscle. In first case reported in this article, the nerve transfer procedure was undertaken at 6 months after no clinical evidence of improvement in shoulder abduction or external rotation. The pre-operative EMG findings demonstrated poor re-innervation of muscles and there was no evidence of clinical improvement on sequential assessments despite physiotherapy. The axillary nerve was intraoperatively transected for nerve transfer and therefore the recovery in deltoid is likely to be due re-innervation following nerve transfer. In the second case in this case series, it may be argued that chemotherapy contributed to the recovery through tumour shrinkage. However there was no improved motor function during the period of pre-operative assessment despite physiotherapy treatment and the functional recovery pattern and MRI findings post operatively argue against this as despite chemotherapy, improvement in motor function was only seen in elbow flexion (target of nerve transfer) and not in shoulder abduction. In addition MRI findings 8 months post nerve transfer demonstrated that chemotherapy had no effect on tumour shrinkage despite improvement in elbow flexion and had only arrested the progression of the disease and the level of nerve compression remained unchanged.
Stemless total shoulder arthroplasty in elderly patients with primary osteoarthritis of shoulder – a developing country experience
Published in Expert Review of Medical Devices, 2021
Vishwajeet Singh, Sanjay S Desai
All the patients were operated in beach chair position once regional block was given followed by Sedation or GA (general anesthesia). The incision starts above the coracoid process and terminates above the insertion of the pectoralis major on the shaft of the humerus. The cephalic vein is mobilized laterally with deltoid muscle, and conjoint tendon is protected. A retractor is placed under CA (coracoacromial ligament) to protect it and provide exposure to superior aspect of subscapularis, and the humerus. Subscapularis is cut at 5 mm from insertion over lesser tuberosity and secured using number 2 fiberwire. Capsular release is done at anterior and inferior levels. The axillary nerve is secured and protected. The humerus is gently dislocated from the glenoid. The arm is held in 90° of external rotation, 20° −30° of extension, and adducted against the operating room table.
Percutaneous peripheral nerve stimulation for treatment of shoulder pain after spinal cord injury: A case report
Published in The Journal of Spinal Cord Medicine, 2018
Daniela Mehech, Melvin Mejia, Gregory A. Nemunaitis, John Chae, Richard D. Wilson
The single percutaneous electrode stimulation system was implanted as described previously.21,33 The skin overlying the subject's affected shoulder was prepared and sterilized prior to the procedure. To stimulate the axillary nerve, investigators inserted monopolar needle electrodes perpendicular to the skin surface at the locations where the axillary nerve innervated the middle and posterior deltoids (i.e. the motor points) and iteratively stimulated and repositioned until a strong contraction occurred at each muscle. A third monopolar needle electrode was placed at the midpoint between the 2 motor points of the middle and posterior deltoid muscles. Stimulation was applied to the single mid-point electrode and the position was adjusted until strong contraction of both the middle and the posterior deltoid muscles was achieved. The depth of the third needle electrode was recorded. A 20-gauge, insulated introducer loaded with a percutaneous lead was then inserted perpendicular to the skin surface to the depth and location indicated by the third needle electrode. The introducer was withdrawn, leaving the electrode in place. Stimulation was delivered through the lead to the axillary nerve to ensure stimulation produced comfortable contraction of the middle and posterior deltoid, confirming proper placement. A dry sterile dressing was placed over the lead, and an occlusive dressing was applied.
Related Knowledge Centers
- Brachial Plexus
- Quadrangular Space
- Axilla
- Nerve
- Upper Trunk
- Dorsal Ramus of Spinal Nerve
- Posterior Cord
- Cervical Spinal Nerve 5
- Cervical Spinal Nerve 6
- Posterior Humeral Circumflex Artery