Upper Limb Cases- Case 4

Upper Limb Cases- Case 4 Group 4 David Folt, Stephen Smith, Valerie Allen, Amanda Foley

Patient Profile • A 17 year-old male student athlete • Chief complaint: complains of a “bad shoulder” Vital signs: • Blood Pressure: 125/75 • Pulse: 58 bpm • Rhythm: Regular • Temperature: 97.6oF • Respiratory rate: 13 bpm • Height: 6’0” • Weight: 200 lbs. • General: No cutaneous sensory changes were found. No swelling or changes in perfusion were noted. • All other systems: Normal

History of Present Illness • He was performing bench press without a spotter when his left upper limb and shoulder were pushed posteriorily past the bench by the shifting weight. • He states that he felt “an electric shock” inside his left shoulder. • When he was free from the weight bar and was able to stand up, he found that could not raise his left arm away from his body. • Following the incident he went home, took some “pain medicine”, and went to bed. • During the next several days he experienced pain and “stiffness”, especially in his chest and left upper limb.

Musculoskeletal Examination • Left shoulder: • a decrease of muscular tone (firmness) on the posterior scapula • The glenohumeraljoint allows a greater degree of manual movement • Flexion/extension, medial/lateral rotation present but not smooth • Inability to voluntarily abduct the left arm from anatomical position to 90 degrees • Ability to maintain the position of 90 degree abduction if the limb is placed in that position

Question 1 • 1) Which bone(s) and or ligament(s), if any, have been directly damaged?

Answer 1 • Bones: • Probably none involved • Why? • Ligaments: • If any, fibrous joint capsule involved in glenohumeral joint • Heavily involved in glenohumeralstability, possible compromised stability

Question 2 • The function of which muscle/tendon unit(s), if any, has been altered by this event? How has the function been altered?

Answer 2 • Possible muscles involved: • Supraspinatus • Cannot abduct from anatomical position to 30 degrees • Infraspinatus • Weakened lateral rotation • Quick! What nerve innervates supra/infraspinatus? • Deltoid • Possible strain, no innervations affected • ClavicleDeltoid tuberosity connection affected in the incident • Flexion/Extension, lateral/medial rotation are not smooth movements • Pectoralis major • Pain/stiffness, swelling in chest • Hyperextension of muscle during the incident

Question 3 • The function of which peripheral nerve(s), if any, has been altered by this event? How has the function been altered?

Answer 3a Nerves Involved: • Suprascapular • Supraspinatusand infraspinatus • Where does the suprascapular n. come from? • NOT axillary • Deltoid maintains functionality

Answer 3b How has nerve function been altered? • No sensory changes, therefore not severed • Other nerves that are continuous with the upper trunk are not affected (i.e. musculocutaneous, and he has no problems with anterior compartment muscles of arm)

Question 4 • With a working assumption (hypothesis) that a tendon has been torn, when might the patient expect to have a return of function or elimination of symptoms related to his injury?

Answer 4 • Although we have not discussed the specific surgical techniques for repairing tendons, it is our understanding that the tendon will not regain original function unless appropriate medical interventions are used • Depending on the length of time the muscle remains inactive due to the injury, some sort of physical rehabilitation would be necessary

Question 5 • If a nerve were injured (crushed), when might the patient expect to have a return of function or elimination of symptoms related to his injury?

Answer 5 • The patient would require conservative therapy consisting of rest, anti-inflammatory medication, and physical therapy designed to increase muscular tone and strength. (Safran MR: Nerve injury about the shoulder in athletes, part 1: Suprascapular nerve and axillary nerve. Am J Sports Med 2004;32:803.) • Surgical intervention is used if the initial non-invasive treatment is ineffective(Cummins, CA, Schneider DS. Peripheral Nerve Injuries in Baseball Players. Neurologic Clinics 2008; 26:1)

Upper Limb Cases- Case 4