Transcript Clinical Presentation

Peripheral Nerve Injuries
AXILLARY NERVE
A large nerve arising from the posterior cord of the brachial
plexus
Divided:
Posterior branch:
Innervates Teres minor, part of the Deltoideus
&
Anterior branch. Innervates Skin overlying the Deltoideus;
the Deltoideus.
(Some fibers of the nerve also supply the capsule of the shoulder
joint)
Aetiology
Blunt trauma or excessive stress on the nerve over a long period of time
other body structures putting pressure on the axillary nerve, or
trapping it against another body part
a penetrating injury, such as a knife or gunshot wound
exceeding a normal range of motion joint.
high-impact upper body activities (athletes)
perform repetitive tasks using your shoulder
have a certain type of existing bone fracture
improperly use supportive equipment such as crutches
Pathophysiology
most common peripheral nerve injury to affect the shoulder.
It most often is seen after glenohumeral joint dislocation, proximal humerus
fracture, or a direct blow to the deltoid muscle.
Compression neuropathy has been reported to occur in the quadrilateral
space syndrome,
true pathophysiology of this disorder remains unclear.
vulnerable during any operative procedure involving the inferior aspect of
the shoulder and iatrogenic injury (Referring to injuries caused by a doctor.).
The quadrangular
space (or quadrila
teralspace or
Foramen
Humerotricipitale)
is an axillary
space
in the
arm.peripheral nerve injury to affect the shoulder.
most
common
This Itismost
a clinically
often is seen after glenohumeral joint dislocation, proximal
important
humerus fracture, or a direct blow to the deltoid muscle.
anatomic
spaceneuropathy
in
Compression
has been reported to occur in the
quadrilateral space syndrome, although the true pathophysiology of
the arm.
Pathophysiology
this disorder remains unclear. The axillary nerve is vulnerable during
any operative procedure involving the inferior aspect of the shoulder
and iatrogenic injury remains a serious complication of shoulder
surgery. During the acute phase of injury, the shoulder should be
rested, and when clinically indicated, a patient should undergo an
extensive rehabilitation program emphasizing range of motion and
strengthening of the shoulder girdle muscles. If no axillary nerve
recovery is observed by 3 to 6 months after injury, surgical exploration
may be indicated, especially if the mechanism of injury is consistent
with nerve rupture. Patients who sustain injury to the axillary nerve
have a variable prognosis for nerve recovery although return of
function of the involved shoulder typically is good to excellent,
depending on associated ligamentous or bony injury.
Pathophysiology
Nerve Injury
◦ Nerve regeneration takes place at a rate of ~1mm/day
◦ Seddon's Classification of Nerve Injury
◦ Neuropraxia The axon and all 3 connective tissue layers
(endoneurium, perineurium, and epineurium) remain intact with a
decrease in conduction
◦ Axonotmesis Axonal damage is present with preservation of the
endoneurium
◦ Neurotmesis Axonal damage is present
Pathophysiology
Anterior shoulder dislocation is the most common occurring
dislocation at the shoulder.
Men and women 3:1 9-65% involve axillary nerve injury
Traction and compression to the axillary nerve
Blunt trauma
Clinical Presentation
# Variable and can go undetected, as the concomitant dislocation or fracture may mask the symptoms.
Subjective Examination
◦ Generalized mild, dull, and achy pain to the deep or lateral shoulder, with
occasional radiation to the proximal arm
◦ Numbness and tingling of the lateral arm and/or posterior aspect of the
shoulder
◦ In some cases, persisting 2-4 weeks post-injury
◦ Feeling of instability
Clinical Presentation
◦ Weakness, especially with flexion, abduction, and external
rotation
◦ Fatigue, especially with overhead activities, heavy lifting, and/or
throwing
◦ May/or may not reveal a history of trauma to the shoulder region
◦ Easing Factors include: rest, ice, analgesics, and anti-inflammatory
medications
Clinical Presentation
Differential Diagnosis
“Unhappy Triad”
Quadrilateral Space Syndrome (QSS)
Posterior Cord of the Brachial Plexus
Injury
C5-6 Cervical Radiculopathy
Parsonage-Turner Syndrome (PTS)
"Unhappy Triad"
 The “Unhappy Triad” consists of a shoulder
dislocation that results in both a rotator cuff
tear and axillary nerve injury.
 Occurs in 9-18% of anterior shoulder
dislocations
 Risk of an “unhappy triad” with anterior
shoulder dislocation increases after the age of
40.
Clinical Presentation
Quadrilateral space syndrome(QSS)
QSS is an “uncommon condition that involves the compression of the posterior humeral
circumflex artery and the axillary nerve within the quadrilateral space,” secondary to an acute
trauma or from overuse, especially with overhead sports like throwing and swimming.
Symptoms are typically present with the arm in an overhead position, especially in late cocking
or the early acceleration phases of throwing
Parsonage-Turner Syndrome(PTS)
PTS is an uncommon, idiopathic condition.
Characterized by an acute onset of intense pain, without a mechanism of injury, that subsides
within days-weeks, leaving behind residual weakness/paralysis in upper extremity muscles.
Significant Atrophy in left deltoid
Symptoms
Numbness over part of the outer shoulder
Shoulder weakness, especially when lifting the arm up and away from the body
May experience weakness in the shoulders and have problems with normal
physical activities, such as lifting your arms above your head. Difficulty lifting
objects can also be a sign of AND.
Over time, your shoulder muscles may become smaller because they cannot
be worked out regularly.
Medical Management
Examination
Physical examination should begin with a screening consisting of an
evaluation of the head and neck which shouldn’t reveal any
abnormalities.
If the patient presents with a recent shoulder dislocation, presence
of a radial pulse and sensation and movement of the digits should
also be assessed as part of the initial screening
Medical Management
Surgery
Indications for surgery
Suspicion of osteophyte formation or
compression in the quadrilateral space.
No axillary nerve recovery observed by 3 to
4 months following injury.
No improvements seen after 3 to 6 months
of conservative treatment.
No EMG/NCV evidence of recovery by 3 to
6 months after injury.
Surgical Procedures
Neurolysis
Neurorrhaphy
Nerve grafting
Nonsurgical Reduction
 Reduction eliminates the need for surgical
intervention, and is followed by
immobilization and physical therapy
management.
 Immobilization for young adult males 4-6
weeks
 Immobilization for older patients 7-10
days
 Precaution should be taken during
manipulative reduction of a dislocation,
 NSAIDS, rest, ice
Physical Therapy Management
(current best evidence)
Current research encompassing treatment and intervention of axillary nerve injuries following shoulder
dislocation is limited.
Non-Surgical Physical Therapy Treatment
0-2 weeks
Shoulder immobilization via sling after reduction
◦ There is insufficient evidence to support whether physical therapy should be initiated during or after
immobilization.
Isometric Strengthening; Dosing: 10 seconds X 6 repetitions X 2 day within limits of pain
◦ Shoulder(Flex, Ext, Abd, Add, IR)
Joint Mobility
◦ Active Range of Motion(AROM); Dosing 10 repetitions X 2 day
◦ Elbow(Flex, Ext ,Pronation, Supination)
◦ Wrist (Flex, Ext, Radial/Ulnar deviation)
◦ Hand (Opening/Closing Fist)
2-4 week
Joint Mobility
PROM/AAROM); Dosing 10 repetitions X 2 day
Shoulder (Flex, IR, Add)
Avoid end-range ER/Abd until later stages of treatment!
AROM; Dosing 10 repetitions X 2 day
Elbow(Flex, Ext ,Pronation, Supination) Wrist (Flex, Ext, Radial/Ulnar deviation) Hand (Opening/Closing
Fist)
Pendulum Exercises 3 sets x 30 seconds
Postural/Periscapular Muscular Strengthening/Neuromuscular Re-education
Target Muscles
Deltoid
Rhomboid Major/Minor
Serratus Anterior
Upper/Middle/Lower Trapezium
PRECAUTION: against shoulder abduction & flexion beyond 90 degrees, and ER beyond neutral in the first 3 weeks
Older individuals have lower rates of reoccurrence of shoulder dislocation and an increase in incidence of joint
stiffness.
Medical Management
4-6 weeks
D/C sling
Strengthening Program light resistive exercises
Proprioceptive Techniques
PNF diagonals
Closed Chained Activities
Wall push-ups -->Table-->Floor
Weight Shifts
6 weeks-Discharge
Continue ROM, glenohumeral and scapulothoracic stabilization/strengthening exercises,
Proprioception, and joint mobility, while maintaining optimal conditions for tissue healing
Begin to initiate sport/job specific activities, progressing to full return as patient’s
functional status allows
Conclusion
During the acute phase of injury, the shoulder should be rested, and when
clinically indicated, a patient should undergo an extensive rehabilitation
program emphasizing range of motion and strengthening of the shoulder
girdle muscles.
If no axillary nerve recovery is observed by 3 to 6 months after injury, surgical
exploration may be indicated, especially if the mechanism of injury is
consistent with nerve rupture.
Patients who sustain injury to the axillary nerve have a variable prognosis for
nerve recovery although return of function of the involved shoulder typically
is good to excellent, depending on associated ligamentous or bony injury.
References
http://www.merriam-webster.com/medical/axillary%20nerve
http://medical-dictionary.thefreedictionary.com/axillary+nerve
https://www.google.gy/search?q=axillary+nerve+definition&rlz=1C1CHFX_enGY629GY629&espv=2&biw=1242&bih=606&site=we
bhp&source=lnms&tbm=isch&sa=X&ei=VrwLVYO_GYmhyQT29IH4Aw&sqi=2&ved=0CAYQ_AUoAQ&dpr=1.1#imgdii=_&imgrc=tSup
G6p00N1nmM%253A%3B1nKZj2k2ocSGDM%3Bhttp%253A%252F%252Fwww.usra.ca%252Fimages%252Fbp2.jpg%3Bhttp%253A
%252F%252Fwhat-is-this.net%252Ffr%252Fdefinition%252Faxillary%3B420%3B310
https://www.google.gy/search?q=axillary+nerve+definition&rlz=1C1CHFX_enGY629GY629&espv=2&biw=1242&bih=606&site=we
bhp&source=lnms&tbm=isch&sa=X&ei=VrwLVYO_GYmhyQT29IH4Aw&sqi=2&ved=0CAYQ_AUoAQ&dpr=1.1#imgdii=_&imgrc=2rlR
RBWo8cRukM%253A%3BiaN2Ymik8NlmvM%3Bhttp%253A%252F%252Flegacy.owensboro.kctcs.edu%252Fgcaplan%252Fanat%25
2Fnotes%252FImage544.gif%3Bhttp%253A%252F%252Flegacy.owensboro.kctcs.edu%252Fgcaplan%252Fanat%252Fnotes%252Fa
pi%252520notes%252520m%252520%252520peripheral%252520nerves.htm%3B640%3B480
http://www.healthline.com/health/axillary-nerve-dysfunction#Overview1
http://www.physio-pedia.com/Axillary_Nerve_Injury
http://www.ncbi.nlm.nih.gov/pubmed/10613150
http://www.nlm.nih.gov/medlineplus/ency/article/000689.htm