UE Disorders, Shoulder, Brachial Plexus

3.47 million

estimated _ UE injuries in 2009

upper extremity prevalence

• Finger- 38.4%

• Shoulder- 16.8%

• Lower arm- 15.3 %

• Wrist- 15.2%

• Elbow- 10.5%

brachial plexus epidemiology

• Traumatic in nature

• Forceful pulling or stretching of arm

‒ Obstetric injury

‒ MVA

‒ Winter Sports

‒ Motorcycle accident

• Typically unilateral

avulsion

Most severe – torn from nerve root & may not be surgically repairable

stretch

Mild injuries which may heal without intervention

rupture

More forceful stretch resultng in partial or full tear

‒ Sometimes able to be repaire

laceration

Usually more distal – Sometimes able to be repaired primarily or with nerve transfers

upper trunk palsy

Occurs when angle between shoulder & neck forcibly widens

‒ Falls onto shoulder & head forced to opposite side

lower trunk palsy

Occurs when angle between arm & chest is forcibly widened

‒ When arm & shoulder are forced upward (falls from tree, ladder)

pan-plexus pasly injury

Most severe – all levels of nerves & trunks are injured

‒ Complete limb paralysis

social determinants of health affected brachial plexus injury

• Socio economic status

• Health Care Access

typical course of recovery brachial plexus injury

Typically a long recovery

• Nerves regenerate at 1mm/day, 1 inch/month

• May not regain full function

typical medical intervention brachial plexus injury

• Evaluation by MD

• Electromyography (EMG)

• Nerve Repair

• Nerve Graft

• Nerve Transfer

OT intervention brachial plexus injury

Custom orthosis

‒ Proper positoning

• Passive ROM to maintain mobility & prevent joint contractures

• Scar mobilization

• Adaptive equipment

• ADL retraining

erb’s palsy (erb-duchenne syndrome)

Obstetric Brachial Plexus injury

• 0.9 to 2.6 per 1,000 live births

• Thought to be caused by the head being moved away from the shoulder in both

vaginal & cesarean deliveries

Risk Factors:

‒ Large baby

‒ Small mother

‒ Low or mid forceps delivery

‒ 2nd stage of delivery more than 60 minutes

erb’s treatment

• OT & PT in the frst 9 months with a watchful wait

• 80 to 90% will experience recovery

• Surgery before a year

thoracic outlet syndrome

Impingement of the brachial plexus &/or blood vessels at the level of the thoracic outlet

Symptoms may include:

‒ Neck pain

‒ Shoulder pain

‒ Arm pain

‒ Numbness/tingling

‒ Decreased circulaton to the extremites

onset of thoracic outlet syndrome

Traumatc: MVA

‒ Extra rib

‒ Muscle or soft tissue bulk (body building or obesity)

Elevated Arm Stress Test (EAST) or Roos test

Touch down positon – 3 minutes – Failure to maintain positon + TOS

specific interventions for thoracic outlet syndrome

Full recovery rare

• Operative treatment

‒ Release scar tssue PRN

‒ Not overly successful --- last resort

• Non-operatve treatment

‒ Diaphragm breathing

‒ Strengthening the scapular musculature

‒ Nerve gliding exercises

‒ Stretching within tolerance

‒ Learn to manage symptoms

common shoulder injuries

• Bursitis

• Tendonitis

• Tendon tears

• Arthritis

• Fracture

• Instability

• Impingement

adhesive capsulitis

Other name: Frozen Shoulder

• Common with axial webbing (post mastectomy), post trauma, insidious onset

adhesive caputilitis primary

idiopathic onset

adhesive capsulitis secondary

post-traumatic onset

adhesive caputilits freezing phase (2-9 months)

WFL ROM with pain causing guarding

adhesive caputilitis frozen phase (up to 1 yr)

Substitution of ST motion for loss of GH motion

adhesive caputilitis thawing phase (up to 26 months)

Gradual return of motion

adhesive caputilitis interventions

Non-operative treatment

‒ Modalities

‒ A/PROM

• TWO APPROACHES

‒ Aggressive

‒ Conservatve

‒ Workstation modifcation

• Operative treatment

‒ Arthroscopic release of the GH capsule

‒ Manipulation under anesthesia

intervention for RTC injuries

Can be age-related degeneration

• Most are partal-thickness tears, progressing to full full-thickness tear

• Non-operatve tx:

‒ Rest

‒ Anti-infammatory medication

‒ Early AAROM exercises

‒ Pendulums

‒ Wand

‒ Strengthening the healthy portion (usually shoulder IR, adduction, extension)

• Operatve treatment protocol:

‒ Often immobilized with only PROM during therapy

rotator cuff tears

Most common cause of shoulder disability

‒ 20.7% of 1,328 partcipants

age of full thickness tears

• < age 50 – 0%

• 50-59 – 10.7%

• 60-69 – 15.2%

• 70-79 – 26.5%

• 80-89 – 36.6 %

etiology of rotator cuff tears

‒ Degeneratve or Acute

‒ Impingement

‒ Tensile overload

‒ Repetitive stress

‒ Poor vascularity

‒ Trauma

social determinats affected rotator cuff tears

socioeconomic status

typical course of recovery rotator cuff tears

Typically a long recovery if surgical intervention is required

• May not regain full function

typical medical intervention for rotator cuff tears

• Evaluation by MD

• Special tests

• MRI

• OT/PT

• Surgical repair