Nerve lesions around the shoulder

1. Nerve lesions around the shoulder
Puneet Monga

2. Scope of the talk
• Brachial Plexus
• Brachial neuritis
• Birth injuries
• Traumatic BP lesions
• Mono-neuropathies
• Axillary N
• Musculocutanous N
• Suprascapular N

3. Diagnosis
It’s all about Pattern recognition!

4. Brachial Plexus

5. Parsonage Turner
syndrome
• Inflammation of the nerves
• Unknown aetiology
• aka brachial neuritis / neuralgic
amyotrophy/ various
• ? viral / ? post immunization

6. Presentation
• Intense Burning Pain
• Weakness
• Wasting

7. Differentials
• Cervical disc disease
• Adhesive capsulitis
• Calcific tendonitis
• Infection

8. Investigations
• EMGs / NCV
• MRI shoulder and
C spine
Image Courtesy: American family
physician

9. Management
• Principles
• Non operative management
• Pain management
• Maintain range of motion
• Patient education

10. Sequelae of Obstetric
Palsy

11. Types
• Upper Trunk; Erb’s
• Lower Trunk: Klumpke’s
• Complete

12. Erb’s palsy
• Typical posture
• Adducted
• Internally rotated
• Secondary changes
• Soft tissues
• Bony changes

13. Management
• Non operative
• Operative
• Correct deformity
• Restore ER power

14. Traumatic Brachial
plexus injuries

15. Presentation
• Usually high energy injuries
• Grade of Nerve damage mirrors force of
trauma
• Initially appear dense

16. Degree of nerve
damage
Seddon Classification
Sunderland Classification
Outcomes better in lower grade injuries

17. Initial management
• Investigation (EMGs) and timing (3-4
wks)
• Physiotherapy
• Early Referral

18. Definite management
• Allow for early recovery phase
• Maintain ROM
• Maintain the functional groups
• Pain relief

19. Definitive surgery
• Nerve repair, Neurolysis, Nerve transfers
• Tendon transfers
• Joint Fusion
• Orthoses

20. Axillary nerve injury

21. Aetiology
• Trauma
• Fractures
• Dislocations
• Iatrogenic

22. Presentation
• Sensory loss
• Motor loss

23. Initial management
• Identification
• Early EMGs (3-4 weeks)
• Management associated injuries

24. Special Note
• Displaced tuberosities/ cuff tear
associated with Axillary N injury
• Consider EARLY surgery

25. Management
• Maintain ROM
• Close monitoring / early referral

26. Musculo-cutaneous
nerve injury

27. Aetiology
• Commonly Iatrogenic

28. Management
• Tendon transfer
• Orthoses

29. Suprascapular nerve

30. Presentation
• Weakness of Spinatii
• Associated with Cuff tears

31. Aetiology
• Ganglia
• Idiopathic
• ?inflammatory

32. Site of compression
• Suprascapular notch
• Spinoglenoid notch

33. Diagnosis
• High index of suspicion
• Early EMGs

34. Management
• Non operative management in majority
• Suprascapular nerve decompression

35. Suprascapular nerve
decompression
• Arthroscopic suprascapular nerve
release
• Posterior Labral repair / ganglion
drainage
• Timing of surgery

36. Quadrilateral space
syndrome

37. Summary
• Early / Serial EMGs
• Maintain ROM awaiting neurological
recovery
• Early Referral