Nerve lesions about the shoulder.

The shoulder is the most mobile joint in the body. Because it serves as a way station for the nerves supplying the upper limb, it creates a potential for nerve lesions that may be caused or significantly influenced by the complex dynamics of the shoulder girdle. This article presents the most commonly encountered lesions as well as an algorithm for their diagnosis and treatment.

Thoracic outlet syndrome. Results of 282 transaxillary first rib resections.

Thoracic outlet syndrome may follow trauma but also may be seen as a result of postural abnormalities of the shoulder girdle. Cervical ribs and other anatomic variations are not prerequisites for the diagnosis, although they may be more common in patients with thoracic outlet syndrome. The diagnosis is made by history and physical examination. There is no reliable laboratory diagnostic test to confirm or exclude the diagnosis. Proper selection of candidates for surgery can produce excellent and good results in a high percentage of cases. The transaxillary approach to first rib resection is tolerated well, and serious complications should be unusual when the procedure is performed by an experienced surgeon. Postoperative attention to shoulder girdle mechanics is important in the prevention of recurrence of symptoms and treating them should they occur.

Clavicle malunion.

The clavicle fracture that has united with deformity or shortening may have an adverse effect on normal shoulder girdle function. We report on 4 patients in whom a malunited fracture of the clavicle was believed to be a contributing factor to shoulder girdle dysfunction. In each patient, the functional status of the involved limb was improved after corrective osteotomy at the site of deformity, realignment, and plate fixation.

Results of transfer of the pectoralis major tendon to treat paralysis of the serratus anterior muscle.

BACKGROUND: Paralysis of the serratus anterior muscle can be functionally disabling. As a result of the scapular winging associated with such paralysis, the scapula does not remain apposed to the thorax when the upper extremity is elevated forward at the shoulder. This produces functional disability associated with pain and loss of a stable base for movement of the upper extremity. METHODS: We reviewed the results of transfer of the pectoralis major tendon with the addition of a fascial graft in sixteen patients who had paralysis of the serratus anterior. The average age of the patients at the time of the operation was thirty-three years (range, twenty to fifty-five years). Electrodiagnostic studies confirmed the presence of an isolated injury of the long thoracic nerve. The index operation was performed sixteen months to eleven years after the onset of pain and weakness. The etiology of the paralysis was idiopathic in two patients, traumatic in seven, and secondary to operative intervention in seven. All patients had pain in the shoulder on the side of the paralysis. RESULTS: The result was excellent for eight patients, good for five, and fair for one at an average of four years and three months (range, two years and one month to nine years) postoperatively. There were two failures, both of which occurred after a traumatic event. Of the fourteen patients in whom the procedure did not fail, eight were asymptomatic and had normal function, five had intermittent mild discomfort, and one had frequent mild pain without any winging of the scapula. The average Constant and Murley score for the fourteen patients in whom the procedure did not fail increased from 36 points preoperatively to 92 points postoperatively. CONCLUSIONS: The index procedure successfully alleviated the functional disability caused by paralysis of the serratus anterior muscle.

Direct injury to the axillary nerve in athletes playing contact sports.

We performed long-term followup (31 to 276 months) of 11 contact athletes who had sustained isolated injuries to their axillary nerves during athletic competition. There were no known shoulder dislocations. Electromyographs were taken of 10 patients, and all patients had confirmation of clinically defined injuries that were confined to their axillary nerves. Nine injuries were sustained while tackling opposing players in football; two were sustained in hockey collisions. In seven athletes, the mechanism of injury was a direct blow to the anterior lateral deltoid muscle. In four athletes, there were simultaneous contralateral neck flexion and ipsilateral shoulder depression. At followup, all patients had residual deficits of axillary sensory and motor nerve function. There had been no deltoid muscle improvement in three patients, moderate improvement in two patients, and major improvement in six patients. However, shoulder function remained excellent, with all athletes maintaining full range of motion and good-to-excellent motor strength. Axillary nerve exploration and neurolysis in four patients did not significantly affect the outcomes. Although no patient had full recovery of axillary nerve function, 10 of 11 athletes returned to their preinjury levels of sports activities, including professional athletics.

Thoracic outlet syndromes.

TOS may arise in a variety of circumstances including trauma, but it may also be seen as a result of postural abnormalities that may be induced by different factors. Cervical ribs and other congenital anomalies are not necessary prerequisites for either the causation or diagnosis of TOS, although they are more common in the TOS population. More important than diagnostic tests are the history and physical examination of the patient. Double crush syndrome can complicate the diagnosis and treatment; however, proper selection of candidates for surgery can produce excellent and good results in a high percentage of cases. Perioperative complications can be significant, so that surgery should be restricted to only those patients who find their symptoms intolerable.

Clinical diagnosis, testing, and electromyographic study in brachial plexus traction injuries.

A system for evaluation of patients with brachial plexus injury is based on careful observation, including the patient's history and a physical examination, a radiographic assessment, and electrodiagnosis. The clinical history and physical examination remain the cornerstone of this evaluation and their documentation is vital. Traction injuries, wherein there is a possibility of root avulsion, were examined myelographically and electromyographically at one month. Although they must be considered, the limitations of these methods of evaluation do not vitiate their usefulness. Modification of the evaluation procedures should be made according to the requirements imposed by specific causal agents and circumstances.

Massive allograft replacement of hemiarticular traumatic defects of the elbow.

Four elbow osteoarticular allografts were done for four patients as salvage procedures for unreconstructable elbow fracture malunions. With a mean follow-up of 60 months (range, 12 to 72 months) all elbows were stable, free of pain, and had mean motion of 130 degrees active flexion and 27 degrees of flexion deformity, 67 degrees pronation and 62 degrees supination (preoperative mean: 104 degrees flexion, 42 degrees flexion contracture, 20 degrees pronation, and 34 degrees supination). Complications occurred in two elbows. One had a deep infection necessitating graft removal and subsequent regrafting. The second had an olecranon osteotomy nonunion. Elbow allografting is recommended as a salvage procedure for massive posttraumatic articular defects, bone loss, or malunion when neither arthrodesis nor conventional arthroplasty is indicated.

Tendon transfers for brachial plexus injury.

Brachial plexus injuries result in severe functional deficits in the upper limb. The authors review a group of 74 patients with brachial plexus injuries who underwent 160 tendon transfer operations, as well as 94 additional procedures, in an attempt to augment lost function. Following evaluation of functional recovery, 58 percent of the patients were rated Good, 34 percent Improved, and 8 percent Unimproved. The authors conclude that significant benefit can be obtained by peripheral reconstruction and tendon transfers in patients with brachial plexus injuries.

Rehabilitation of the patient with a brachial plexus injury.

The rehabilitation of patients with brachial plexus injury is a complex process that is dependent upon the understanding by the physician, and others involved in providing care, of the nature of the nerve injury, its natural history, and what measures are available to lessen the disability of such patients. In addition, the patients themselves must understand these same facts so that they can maximize the treatment they receive.

The relationship between dead arm syndrome and thoracic outlet syndrome.

A relationship exists between anterior shoulder subluxation and thoracic outlet syndrome that is responsible for the more florid symptoms of dead arm syndrome (DAS) in some patients. This relationship was demonstrated in eight of 27 patients (30%) in a consecutive series of Bankart operations for treatment of subluxation. The mechanism is associated with a disturbance in the kinesiology of the shoulder-joint complex that alters the position of the scapula relative to the rib cage and neurovascular supply to the upper limb. Therapy is directed toward restoration of the stability of the glenohumeral joint so that normal biomechanics can be reestablished. In advanced stages of thoracic outlet syndrome, however, DAS may initially require surgical decompression of the nerves and vessels. Careful attention to postural mechanics is essential for rational diagnosis and treatment of DAS.

Massive neurofibromatosis of the upper extremity with paralysis.

Tendon transfer and bulk reduction procedures are an alternative to amputation of the elephantoid enlarged limb with neurofibromatosis and paralysis. A patient with this progressive disease has been followed-up for 10 years and retains sufficient function to work as a computer operator.

Non-union of the clavicle. Associated complications and surgical management.

Twenty-three patients who had a clavicular non-union were treated operatively at the Massachusetts General Hospital from 1974 to 1985. Twenty-one non-unions were the result of fracture and two, secondary to osteotomy. Twenty non-unions were located in the middle third of the clavicle, while three were in the lateral third. Radiographically, eighteen non-unions were atrophic and three, hypertrophic. Two non-unions resembled pseudarthrosis. Of the etiological factors that were reviewed the extent of displacement of the original fracture was the most significant. Associated complications of the non-union included limited mobility of the shoulder in fourteen, neurological symptoms in eight, thoracic outlet syndrome in four, and arterial ischemia in one. Of the nineteen patients who were treated to obtain union, seventeen had a successful result at an average length of follow-up of 23.8 months. In sixteen (93.7 per cent) of the seventeen patients union was achieved by fixation with a plate; one patient required two procedures. Ancillary bone graft was used in eighteen patients, with three requiring a sculptured bicortical graft from the iliac crest to span a defect. Of the four other patients three were treated with a partial clavicular resection and one, with complete clavicectomy.

The frozen shoulder.

The clinical entity of frozen shoulder has been the subject of considerable controversy concerning pathogenesis and treatment. This is a review and interpretation of the literature against the background of my personal experience and a formulation of a treatment algorithm based on a practical synthesis of these sources. The separate stages of the disease are clearly definable and must be considered in prescribing treatment for the purpose of compressing the natural history and morbidity of this self-limited though disabling condition.

Thoracic outlet syndrome and the shoulder.

Thoracic outlet syndrome may be the cause of symptoms wrongly attributed to shoulder pathology, or it may accompany or result from shoulder injury. If misdiagnosed, it may leave the physician wondering why relevant shoulder therapy fails to result in a return to full potential, but if correctly diagnosed, it can be cured or ameliorated.

Hand difficulties among musicians.

We describe our experience with 100 musicians in whom occupation-related difficulties developed. The majority, pianists, experienced hand difficulties in midcareer (average age, 31 years). These were described as "pain, tightening, or weakness" of the right hand or arm or drooping of the fourth or fifth fingers. These difficulties led to loss of control (34%) or diminished facility (18%), endurance (18%), or speed (18%) while playing trills, arpeggios, or octaves requiring fast, forte finger movements. Most commonly found were inflammatory disorders of tendon or joint (45%) or disorders of motor control (24%). Less likely were entrapment of peripheral nerves and noninflammatory tendon or joint disorders.

The treatment of upper extremity reflex sympathetic dystrophy with prolonged continuous stellate ganglion blockade.

Twenty-nine consecutively treated patients over a 5-year period with upper extremity reflex sympathetic dystrophy were admitted to Massachusetts General Hospital for prolonged continuous stellate ganglion blockade. Diagnosis was based on the presence of pain, decreased joint motion, trophic changes, and vasomotor disturbances. Selection for blockade was made on the failure to improve with outpatient physical therapy, tranquilizers, and mild analgesics. Treatment consisted of indwelling-catheter injections of bupivacaine hydrochloride every eight hours to the stellate ganglion for an average of 7 days, supplemented with vigorous physical therapy. Improvement during treatment was documented in all but two patients with regard to pain and decreased joint motion and in two-thirds with regard to trophic and vasomotor changes. Long-term follow-up demonstrated a relapse rate of 25%, but marked improvement persisted in the rest and normal status was attained in four of 26 patients at an average of 3 years later.