Magnetic resonance (MR) imaging has been known as a useful tool for imaging the musculoskeletal system, especially spinal lesions, avascular necrosis, and tumors of the bone and soft tissues. However, there are few reports on MR imaging around the shoulder joint. To our knowledge, there has been no report on MR imaging of the shoulder in Japan. Because the shoulder poses several unique difficulties for imaging with MR, we have examined 24 shoulders with three different coils of MR imaging since August 1987. Scanning was performed on a Yokogawa Medical RESONA 0.5-T magnetic imaging system by using a spin-echo pulse sequence. Axial scan was used as a scout for the scapular plane. The arm was placed across the abdomen. The first two cases were scanned with a body coil, which resulted in difficulties in evaluating the images. In the next 15 cases we utilised a disc surface coil. Although MR appearance of the shoulder joint is better with the Ti-weighted sequence, some difficulties arise when evaluating the MR appearance of the joint with the T2-weighted sequence. We used a special surface coil for the neck in the last 5 cases. The MR appearance of the shoulder joint is excellent with the Ti-weighted and T2-weighted sequence.
The electromyographic activity of the shoulder girdle muscle was studied in three dimensional motion with a new apparatus. The apparatus is composed of four portions as follows: 1. The mechanical part: This part is made up of a gimbal, sliding tubes and a tripod. Displacement of the gimbal and the tubes are detected by three optical rotary encoders. 2. EMG amplifiers: 8 channels of EMG amplifiers are available in the appar a tus. EMG signals are amplified, filtered, rectified full-wave and detected to obtain envelopes of the EMG signals. Envelope signals of the EMG are sampled every 20 msec and on average,10 data of each channel for 200 msec are employed to avoid the fluctuation of EMG signals. 3. A computer system: A personal computer (NEC PC9801VM2) with digital input and analogue input interface board has been used for signal processing of the motion and the EMGs of the shoulder complex. Loci of the end tip of the tube are calculated and presented on three planes on the graphic display in real time. 4. Holding gears: The head, thorax and pelvis are held by a standing frame. The elbow is placed at 0° with neutral rotation of the fore-arm in a posterior splint. The splint is connected to the end of the sliding tube. EMG signals were recorded of 8 d ifferent muscles. EMG signals of the supraspinatus and intraspinatus muscles were recorded by Basmajian's bipolar fine-wire electrodes. Other muscles, which were the upper fibers of the trapezius, anterior, middle and posterior fibers of the deltoideus, the sternal part of the pectoralis major and the biceps brachii, were recorded by skin electrodes. The conventional five ROM (flexion, abduction in the scapular plane, abduction, forward motion in the horizontal plane and backward motion in the horizontal plane) were also measured.
The clavicular movement during active elevation of the upper limb was analyzed in this study. Sixty right shoulders in normal sugjects were investigated by using “ Chneradiography” and the “ personal image analysis system”. The lateral lower margin and the conoid tubercle of the clavicle were measured as the points which demonstrate clavicular movement. During elevation of the upper limb in the scapular plane, the elevated ang l e s of the clavicle were calculated with the scapular movement in the following stages; “ setting phase”, the “ hanging joint” prase, “ transit zone”, and the “ joint needing support” phase. The results were as follows: 1. The elevated angles of the clavicle increased gradually during elevation of the upper limb. Finally the average of maximum elevated angles of the clavicle was 41.5 degrees at 150degrees of the arm-trunk angle. We noticed the clavicular movement for every 10 degrees was uneven in this study. 2. No remarkab l e elevation was noted in the “ setting phase”. The elevated angles of the clavicle reached 4.22 degrees during the setting phase. Clavicular movement is similar to scapular movement, however, it was slightly irregular and unstable. 3. In the “ hanging joint” phase, the elevated angle of the clavicle was 3.69 degrees forevery 10 degrees. 4. In “ transit zone”, the elevated angle of the clavicle was 4.02 degrees for every 10degrees. The ratio of clavicular movement was closest to the scapular movement in this phase. And this movement was the most characteristic. 5. In the final stage, in the “ joint needing support” phase, the elevated angle of the clavicle increased 4.22 degrees of the elevation of the upper limb. 6. The absolute relationship between scapular and clavicu l a r movements were obtained from these results.
Rotational movements synchronized with abduction, flexion, extension, horizontal flexion and horizontal extension of the shoulder complex were analysed. Materials and methods. Forty three normal shoulders and twenty five contracted shoulders were measured using the apparatus which we developed for measuring three dimensional motion and rotation of the shoulder complex using a personal computer system. In measuring abduction, flexion and extension, the starting position was that in which the arm hangs vertically with the thumb facing anteriorly. This position was defined as the 0°rotation. On the other hand, in measuring horizontal flexion and horizontal extension, the starting position was that in which the arm abducted 90° with the thumb facing upward. Subjects actively moved their arms in each of the three planes. The angles of rotation and each of the five movements were calculated by the personal computer system. The data were stored in diskets. Results Normal shoulders During the first 90° of abduction, external rotation of the shoulder increased gradually. From 90° to 135° abduction, external rotation increased rapidly. At maximum abduction, the average angle of external rotation was 93° ± 23°. During flexion, the arms rotated internally slowly. At maximum flexion, the average angle of internal ratation was 25° ± 17°. During extension, the arms ratated externally in 22shoulders and internally in 21 shoulders. During the early stages of horizontal flexion internal rotation increased slowly but during the final stages, internal rotation increased rapidly. At 135° horizontal flexion, the average angle of internal rotation was 46°± 28°. During horizontal extension, the arms rotated externally in 21 shoulders and internally in 9 shoulders. Contracted shoulders The patterns of change of rotation were similar to those in normal shoulders, but the degrees were less than in normal shoulders.
Since 1934, although scapulohumeral rhythm has been studied by a number of investigators, little is known about glenohumeral rhythm. In this study, we measured the extent of a ball roll (B), the rotational movement of the humeral head, and gliding (G), its parallel translation by sliding on the glenoid cavity, observed in normal individuals during elevation of the arm. Sixty healthy subjects made active elevations on the scapular plane in the sitting position, and the joint kinetics during the movement were recorded with an image intensifier and a video recorder. From the records obtained, images were extracted at every 10° between 0° and 150° arm-trunk angle using an image analyzing system (PIAS LA-500), and B and G values were calculated between the successive images. B +G values and the | G | / B ratio were also determined for comparison of the two values. The elevation process was analyzed by dividing it into 4 phases, namely the setting phase, the hanging joint phase, the transit phase, and the phase of joint needing support. The results were as follows: (1) B and G values: B value reached the maximum at an arm-trunk angle of 0-10° and G value at 10-20°. As the arm was elevated, G value decreased and B value tended t o gradually stabilize after some decrease. (2) B+G value: This value reached the maximum in the early range of elevation, and superior migration of the humeral head was most notable during this period. Although the value decreased until an arm-trunk angle of 40° was reached, the humeral head continued to rise. Until this point, B value was always greater than | G | value. The value alternated between positive and negative after 30°, and the amplitude of t he fluctuation increased after 90°. (3) | G | /B ratio: It was always below 1.0 between 0° and 30° and remained about 1.0 until 90°, but the rhythm was disturbed above 90°. (4) Glenohumeral movement was divided into 3 phases by B +G value and | G | / B ratio, as follows: 1st ( 0°-30°): Ball Roll>Gliding 2nd (30°-90°): Stable phase 3rd (90°-150°): Unstable phase
A fifteen-year-old boy had pain and snapping of the bilateral sternoclavicular joint, for two months after slipping. He was mentally retarded and had hypothyroidism and his mother had also suffered from Hashimoto's disease. Physical examination showed anterior subluxation of the bilateral sternoclavicular joint at the position of 90° flexion,90° abduction, and a slight extention of the shoulder, but reduction at the neutral position. The range of motion of the shoulder was full and he had generalized joint laxity. A computed tomographic scan revealed anterior s ubluxation of the medial end of the clavicule at the positions mentioned above, and a large joint cavity was demonstrated in the arthrography. In order to stabilize the sternoclavicular joint, we performed an operation was performed by means of a fascial loop, as described by Speed, on both sides, because of his generalized joint laxity and mental retardation, We initially planned immobilization of the arm for eight weeks. However, the right side was immobilized for two more weeks, because of a tendency of recurrence of the subluxation. One week after physical therapy was started, he regained his preoperative range of motion of the shoulders. Three months after the operation, in his left side a recurrence of the subluxation was seen, but its degree was mild and no particular treatment was performed. One year after the operation, he had no pain but a slight subluxation was observed in his left side. Recurrent subluxation of the sternoclavicular joint is rare, and only eight cases have been reported in Japan. The operative treatment includes stabilization of the sternoclavicular joint, arthrodesis, resection of the medial end of the clavicule and resection of the disk. Speed's method is a stabilization of the sternoclavicular joint by means of a fascial loop. In this method, the joint is stabilized by using a free fascial graft. Therefore, recurrence due to stretching or loosening of the graft several months after surgery is great concern. The operative stabilization is very difficult, especially when complicated with generalized joint laxity and mental retardation exist as in the case reported here.
In one of the reconstruction surgeries for acromio-clavicular dislocation which is represented by Weaber's procedure, the coraco-acromial ligament is detached at the acromial end and transfered to the clavicle for reconstructing the damaged coraco-clavicular ligament. The procedure seems to be biomechanically reasonable in respect with the direction of the ligamentous course. However, the coraco-acromial ligament is thin compared to the coracoclavicular ligament, and it is uncertain whether the former is strong enough to compensate the loss of the latter. In the present study we performed a tension study of the coracoacromial ligament, the coraco-clavicular ligament and the acromio-clavicular ligament in five shoulders obtained from four fresh cadavers (13-68, average 43.3 years of age). Each ligament was prepared in the form of a bone-ligament-bone complex and the ultimate failing strength (maxmum tolerable load) was obtained for each ligament using an Instron universal testing instrument. The maximum loads tolerated were 20.8-44.7 (average 31.0) kgf for the coraco-acromial ligament,53.2-85.9 (average 64.5) kgf for the coraco-clavicular ligament and 46.7-79.2 (average 59.1) kgf for the acromio-claviclar ligament. The coraco-acromial ligamnt failed with only half the force compared to the coraco-clavicular ligament. Clinically, we suggest that the procedure should be carefully applied, especially in the cases of athletes and heavy laborers.
Treatment of acromiocravicular dislocation is controversial. Open reduction is usually indicated for grade 3 injury in young patients and athletes. We have previously reported that modified Phemister procedure (P method) produced satisfactory results. We also performed modified Bosworth procedure (B method) in 15 cases. In this study, we assessed the clinical and roentgenographical results of B method compared with P method. All 15 patients treated by B method were men, their average age at time of operation was 27 years. The length of follow-up averaged 3 years and 9 months. Clinically we evaluated pain, deformity, range of motion, and fatigability. Radiographically we clasified the results as reduction, subluxation, and dislocation. The patients treated by P method were evaluated in the same way as in B method. The clinical results of B method were as good as those of P method. There were 5 cases of subluxation in patients treated by B method,3 of which were caused by displacement of the screw. Osteoarthritic changes were obseved in 2 patients, the incidence being about the same as in the P method group. It is very important to insert the screw in the proper position of the coracoid process to achieve a stable fixation.
Since 1975, modified Weaver procedure without resection of the distal end of the clavicle has been performed in our university hospital.27 cases were operated on by modified Weaver procedure,18 cases of which were evaluated in follow-up studies.15 of these cases were male and 3 were female. The age at the time of operation ranged from 18 to 56 years, with an average of 32 years. The follow-up period ranged from 4 months to 13 years and 3 months and the average follow-up time is 2 years and 7 months. In the modified Weaver procedure, the coracoacromial ligament is detached with a small piece of bone from the acromial portion and the ligament is transfered and fixed to the clavicle using suture wire. The follow-up res u lts were excellent with little shoulder pain and without any disturbance of the affected joint. In X-ray findings, osteoarthritic change was seen in 5 cases, and slight redislocation was found in 8 cases, while there are many cases without any osteoarthritic changes in the long term follow-up cases. Therfore, the midified Weaverprocedure is extremely useful for reconstruction of complete dislocation of the acromioclavicular joint.
Although the incidence of new cases of tuberculosis of all types has decreased dramatically, tuberculosis is still a major cause of infections. The rarity of bone and joint tuberculosis has lowered the index of suspicion in the medical field, which often results in unfortunate delays in diagnosis. Shoulder joints are not common sites of articular tuberculoses. We reviewed a series of 9 cases with histologically-proven tuberculosis of gleno-humeral joints. There were 3 females and 6 males. The right shoulder was affected in 5 cases, an d left side was affected in 4 cases. All patients were treated surgically. The age at the time of operation ranged from 21 years old to 67 years old. Associated tuberculous lesions were present in 6 patients. The lung was involved in 6 cases, and 2 had other joint lesions. The time between onset of symptom and diagnosis was from 6 months to 23 years. Six patients had not been diagnosed properly on their first visit, and three patients had not been diagnosed properly on their first visit, and three patients had steroidal injections. All patients had painful swelling and stiffness of the affected joints. Four patients had fistulas. Radiography revealed advanced stages of joint destruction in all patients, who had been diagnosed late. Curettage alone was performed in 4 cases, but 5 cases required arthrodesis after curettage. A drug regimen of 3 drugs continued for one year postoperatively. The average postoperative follow-up period was 4.5 years. Five cases with arthrodesis gained solid fusion. Considerably good active motion was preserved in two patients with great tuberosity left after curettage. There have been no local recurrences. We emphasize the importance of early d iagnosis and adequate local and general treatment.
Neuropathic joint diseases have been considered to be caused by various lesions of the nerve. Syphilitic tabes dorsalis and diabetes melitus are common causes which lead the lower extremities to this condition. Neuropathic art h ropathy of the upper extremities caused by syringomyelia is rarely seen. The purpose of this paper is to report on a case of neuropathic arthropathy of the shoulder joint due to syringomyelia. The patie n t was a 69-year-old woman who complained of persistent swelling of the right shoulder and proximal part of the arm. There was no past history of trauma, abuse of alcohol or corticosteroid therapy. She had a history of removal of the subacromial bursa one year previously. There were no roentgenographical changes at the time of operation. However, swelling of the shoulder recurred and a tumorous mass developed at the proximal arm. Roentgenograms revealed flattening of the humeral head with distal subluxation. The inferior part of the glenoid fossa had collapsed and bony fragments were noted. Neurological examination demonstrated segmental sensory loss and intrinsic muscle atrophy of the right arm. The Wasserman test was negative in blood and spinal fluid, as was the blood sugar test. As the Magnetic Resonance Image revealed a low intensity band in the cervical spinal cord, arthrodesis was performed.
Haemophilic arthropathies are common in ankle, elbow and knee joints. However, intra-articular bleeding in shoulder joints rarely occur. Bleeding incidences follow in the fourth position of the ankle, elbow or knee joint. Arthropathies of the shoulder are often progressive, however, the performance of surgical or orthotic therapy are uncommon. North Kyushu Haemophilia Center was established in November 1984, and orthopedic surgeons have played a significant role in the management of this center. By June,1988,82patients had been registered in this center,80 male and 2 female. The patients ages ranged from 3 to 59 years old. There are 67 heamophilia A,10 heamophilia B,2 von Willebrand disease,1 7th factor deficiency,1 13th factor deficiency and 1 unknown case, (which is still being investigated). Roentgenographical findings of the shoulder were found in 20 cases (24.4%). In severe cases (the 8th factor activity is less than 1%) and inhibiter-positive cases, the incidence of intra-articular bleeding occurs more often, as it does, too, in patients in their twenties. No bleeding occured in those less than 10 years old. According to DePalma's classification, th e X-ray findings were as follows; grade 1: 8, grade 2: 1, grade 3: 14, grade 4: 11 shoulders. The progressive patients, such as g rade 3 or grade 4, often have difficulties of A. D. L. It is difficult to apply braces on their shoulder or to decide on the course of surgery in these cases. We would like to present some cases on slides and discuss them.
Hemarthrosis in hemophiliacs is very common and results in the functional disorder of the joint. Although there are many reports concerning hemophilic arthropathy of the knee, ankle, and elbow joint, little has been written about the shoulder problems. The purpose of our study is to clarify the clinical status of the shoulder joint in hemophiliacs. We are currently following 309 hemophiliac cases and have experienced 19 cases (23joints) with bleeding in the shoulder joints for 3 years. Their ages range from 2 to 41 with an average of 23 years old. These cases consisted of 17 with hemophilia A, and 2 with hemophilia B. The 18 cases were severe hemophilia. The site of arthropathy was bilateral in 4 cases, right in 7 and left in 8 including two left-handed cases. Most of them had arthropathy of the elbow joint on the same side. First bleedings in the shoulder joints occured in patients aged between 2 and 28 with an average age of 16 years old. The extent of arthropathic changes were classified according to the system proposed by the World Federation of Hemophilia. Pain was not all that apparent, although the radiological changes were severe. The more these changes were severe, the more the range of motion decreased. It is noteworthy that all cases with a destruction at the upper half of the humeral head had a decreased range of motion. Roentgenographically, acute hemarthrosis showed inferior subluxation. The dominant portions of destructive changes were classified into three and are the anatomical neck, the contact area at 90° elevation, and the whole of the joint surface. Finally, osteosclerosis and osteophyte formations were pronounced. These changes led to a decreased range of motion, and then the bleeding frequency lowered. In hemophiliacs, arthropathy of the shoulder joint was characterized as follows: lateonset hemarthrosis is rare, and they do not have severe pain.
There are few reports on posterior lesions of the shoulder joint in baseball injuries, but anterior lesions of the joint are well known. In 1941, Bennett reported the exostosis in the posterior inferior region of the glenoid in groups of professional baseball pitchers. This lesion is the so-called Bennett's lesion. Then Lombardo reported four cases of posterior shoulder lesion in 1977. He said these patients had posterior capsule ossification and chronic inflammation of the capsule. After which Barnes reported on the posterior lesion problems in baseball players. Recently, we treated a baseball pitcher with this sort of lesion, by using a partial resection of the posterior labrum, arthroscopically. A twenty-year-old amateur baseball pitcher visited our clinic with a six-year history of the right shoulder pain. He could not throw a ball because of sharp pains and always had a dull pain for months. On physical-examination the posterior joint space was tender. Roentgenographically the exostosis in the posterior inferior region of the glenoid was present. Arthrographical examination revealed an hypertrophied posterior labrum. Partial resection of the posterior labrum was performed arthroscopically after conservative therapy had failed. Ten months after the operation, his shoulder was no longer sore in ADL, but he still had some pains when he threw a ball for a long time.
Osteochondritis dissecans is a rare disorder in the shoulder joint. We found only 4 cases involving the articular surface of the humeral head when we reviewed publications. In this report, we wish to present a case of this disease. The final diagnosis of osteochondritis dissecans was made on the basis of radiographic findings, because of its unique appearance. As there are similarities in radiographic appearances, differentiation must be made between osteochondral fracture, avascular necrosis and spontaneous osteonecrosis.
Degenerative lesions in the glenohumeral joint are relatively uncommon when compared to those in weight-bearing joint, such as the hip and knee. However, the incidence of osteoarthritis in the glenohumeral joint increases with age, and the disease may be an occasional source of significant pain and disability. Four patients with glenohumeral os t eoarthritis were treated by arthroplasty. The patients were a 46-year-old man, a 31-year-old man, a 52-year-old man and a 56-year-old woman. All the patients suffered from severe shoulder pain with restriction of movement and loss of upper limb function. Surgically, the approach is made through the deltopectoral groove. The marginal osteophytes of the humeral head and glenoid are removed. The irregular articular surface is shaved smoothly by surgical airtome. The coraco-acromial ligament and the coraco-humeral ligament are excised. And the shoulder joint is manipulated. A plaster cast is applied to hold the arm at zero position after operation. Five days after the operation, passive shoulder movements are started. The follow-u p ranged from four months to three years, with a mean of one year and nine months. The results were computed according to the shoulder evaluation sheet of the J.O. A.. The results showed relief of pain and an increase in range of motion in all patients. Roentgenograms after operation showed an increase of glenohumeral movements and normalization of the glenohumeral joint space. We believe that this procedure should be considered prior to undertaking prosthetic replacement and total arthroplasty.
The infraspinatus is the most important muscle of the external rotators of the shoulder. We investigated four athletes with disturbed external rotation of the shoulder due to neurogenic and myogenic disorders. The suprascapular nerve is apt to be injured by traction. Suprascapular entrapment neuropathy at the scapular notch has been frequently reported, but, in some sports injuries, it may occur at the spinoglenoid notch, as well. Definite diagnosis for this neuropathy can be determined by electrophysiological examination, particularly in verifying delays in motor latency. On the other hand, there are some cases in which muscular atrophy does not only recover after decompression, but is also even aggravated, subsequently, by the same sports activities. In these situations, muscular damage is supposed to be due to specific shoulder motion in sports. The infraspinatus muscle is believed to sustain an eccentric contraction at “followthrough”stage in pitching, spiking, serving and so on. Eccentric contractions, however, reportedly bring about muscular damage more than do concentric contractions. Therefore, the serious problem, that this muscular damage is not only due to overuse, must not be overlooked. Several points, such as the so-called infraspinatus test as a method of early diagnosis, the operative treatment and its prevention, are discussed by presenting four cases with disturbances of external rotation of the shoulder, either due to neurogenic or myogenic disorders producing infraspinatus muscle atrophy.
It is sometimes difficult for surgeons to diagnose neurological lesions of the shoulder, with which some patients visit the division of shoulder sugery. The purpose of this paper is to present the characteristics of physical and other examinations of neurological lesions among shoulder disfunctions. The clinical materials are twelve cases with dissociated motor loss syndrome, two neuralgic amyotrophy, one suprascapular entrapment neuropathy and one accessory nerve lesion. Diagnosis of these conditions is sometimes very complicated and over-looked, because these neurological lesions demonstrate only motor weakness and muscular waste, and do not manifest sensory disturbances. In dissociated motor loss syndrome, eleven out of twelve cases showed motor weakness of the biceps humeri muscle combined with disturbance of shoulder motion. One of them, who had a combined massive cuff tear, underwent simultaneous operations of cervical spine and cuff repair. Surgeons must be careful of this combined condition because these two diseases mostly occur in the same generation. The clinical course of neuralgic amyotrophy is characterized by a severe pain which appeared suddenly, however, rotator cuff tear and cervical lesions should be differentiated from it. Not only needle electromyogram but also conduction studies were very helpful in identifying the impaired levels and degrees in cases with peripheral nerve lesions of the shoulder girdle, suprascapular nerve entrapment and accessory nerve injury. The authors emphasize that electrophysiological studies should be utilized more often in diagnosing shoulder disfunctions.
We have experienced two cases of entrapmentneuropathy of the suprascapular nerve in three accessory nerve palsy. CASES. Three patients were refered to our clinic because of a dropped shouldor, inability to abduct the shoulder, and wasting of the upper trapezius. Among those, two cases showed moderate to severe pain in the shoulder region which was inproportionally strong as part of the symptoms of accessory nerve palsy. Case 1: A 28-year-old woman had a biopsy of the neck which was followed by increasing pain in the shoulder region. Five menths after the biopsy, an abduction support was employed to prevent dropping of the shoulder girdle. The symptoms gradually alleviated within five months after the abduction support had been applied. Case 2: A biopsy in the neck of a 23-year-old woman was followed by severe pain in the shoulder region. Five months after the biopsy, an accessory nerve was sutured, and the suprascapular transverse ligament was excised to decompress the suprascapular nerve. Five days after the operation, the pain in the shoulder was decreased dramatically. Discussion: On the basis of our experiences, entrapment neuropathy of the suprascapular nerve occurs at the scapular notch, having been presumably caused by insufficiency of the upper trapezius due to accessory nerve palsy. We conclude that this is one of the pathogenesis of the unexplained pain in the shoulder region caused by accessory nerve palsy.
Infraspinatus muscle atrophy is recognized in various shoulder diseases. It is especially most common in suprascapular nerve disorders. Post reported that cases with suprascapular nerve disorder had severe posterior shoulder pain, but with little or no infraspinatus muscle atrophy, and that measurement of the distal latency was the most useful method of diagnosis. We measured the distal latency of the suprascapular nerves in cases with posterior shoulder pain and infraspinatus muscle atrophy. Inalmost all of the cases, we measured the degree of supra and infraspinatus muscle atrophy by echography. There were 18 cases: 12 males: 6females: average age 31.9. Almost all of the young cases were athletes (baseball: volleyball: rugby: football etc). Only three cases had delayed distal latency. During the operation of one case, we found the suprascapular nerve was pressed by a ganglion on the basis of the scapular spine. Two other cases were treated conservatively. Other cases had slightly delayed in distal latency but had no laterality. The average distal latency: disordered side (supraspinatus 3.20 ± 0.39 msec: infraspinatus 3.79 ± 0.73 msec. ) normal side (supraspinatus 3.12 ± 0.30 msec: infraspinatus 3.69 ± 0.70 msec. ) We could not prove suprascapular nerve disorder in most cases by measuring distal latency. But the clinical features lead us to suspect suprascapular nerve disorder, therefore we must follow those cases up.
Compensatory function of shoulder muscles was studied in cases with shoulder paralysis due to peripheral nerve injury by electromyographical means. Seven paralysed shoulders consisting of five axillary nerve palsies, one accessory nerve and one long thoracic nerve palsy were examined. Three normal contralateral shoulders were also examined as controls. Electromyograms of shoulder muscles were obtained through newly developed electromyography with eight channels, in which the amount of EMG was represented by root-meansquare values (RMS). MRS of EMG in seven muscles, i. e. the upper trapezius, supraspinatus, infraspinatus, three parts of the deltoid and the biceps brachii, participating in shoulder movement were recorded simultaneously using wire electrodes at several shoulder positions during isometric exercise with or without a load. In the normal shoulder the amount of c ontraction increased extremely in the upper trapezius with the shoulder abducted. The tendency for the RMS to increase in the upper trapezius with increasing degrees of shoulder abduction was more remarkable under a load. In axillary nerve palsies the relative contribution to shoulder abduction increased in the infraspinatus at almost each degree of abduction and in the biceps at more than 90 degrees of abduction as compared with normal shoulders. On the other hand, in a long thoracic nerve palsy a remarkable increase of the relative amount of RMS was found in the anterior deltoid at each degree of abduction and in the biceps at more than 90 degrees.
We have performed arthodeses of shoulder joints for reconstructing shoulder functions so as to make upper extremities recover their functions such as flexion, abduction, and adduction. These operations showed that appropriate setting of fusion positions was vitally important, and that, in whole- and upper-plexus injuries, ranges or reconstructed motion differed depending on the remaining functions of the serratus anterior and the pectoralis major before operations. We tried to analyze shoulder joint movements after the arthrodeses by dynamic electromyographic method, in order to investigate how shoulder joint functions differed depending on the remaining muscle functions. In the first step, electromyographies of the trapezius (upper, middle, and lower fibers) and, in addition, the pectoralis major (clavicular and sternal parts) and serratus anterior were recorded. A 12-channel EEG recorder with disc surface electrodes was used for the investigation. Although the serratus anterior and the pectoralis major did not function in whole preganglion lesions categorized as whole-plexus injuries as a matter of course, some contraction of these muscles was often observed on electromyographic in C5 postganglionic and C6,7,8, Ti preganglionic lesions. In 14 abduction cases of the upper extremities out of 16 cases, contraction of the upper trapezius was stronger than that of the lower. On the other hand, in only 6 cases of adduction out of 16, was contraction of the lower trapezius stronger than that of the upper. When functions of the upper extremities were in good control, contraction of the pectoralis major and the serratus anterior was observed. That is to say, movements of the upper extremities are influenced, not only by independant movements of the upper, middle, and lower fibers of the trapezius, but by the remaining muscles to some extent.
Shoulder-hand syndrome is characterized by juxta-articular demineralization and synovial proliferation, edema and fibrosis which are caused by hyperemia associated with vasomotor instability. These changes account for arthralgia and diminished motor function of the involved shoulder and hand. We have examined 20 pat i e nts with shoulder-hand syndrome, using nerve block techniques: three median nerve blocks at carpal tunnels, nineteen ulnar nerve blocks at Guyon canals, one epidural block and seven stellate ganglion blocks. The median nerve block could only slightly flex the index and middle fingers in limited flexion, but the ulnar nerve block fully flexed every digit except in three cases exhibiting joint contracture. E. M. G. revealed intrinsic spasm of the interossei at rest and at work of attempted flexion of the digits. These modalities of study have confirmed the pathogenesis of limited flexion of the affected digits, i. e., intrinsic spasm of the interossei and have demanded early recognition and treatment before joint contracture has developed. Epidural block was preferred to elim i nate pain in one case which showed cocontracture of synergists and antagonists of the shoulder at abduction, because the cocontracture was temporarily extinguished by subacromial infiltration of procaine.
Patients with paralyzed shoulders due to brachial plexus injuries were followed over a 5-year period. Seventeen patients were surgically treated (except for neurolysis): fifteen patients were operated on by nerve reconstruction. Seven patients were operated on by functional reconstruction (multiple-muscle transfers). Fifteen patients had brachial plexus injuries due to traffic accidents. Patients with brachial plexus injuries were classified into two groups infra- and supra-clavicular injuries. Ten of the patients were classified as having supra-clavicular injuries, while five of the patients were classified as having infra-clavicular injuries. Patients with infra-clavicular injuries denote those patients who have nerve injuries of both axillary nerve (or the posterior cord) and the supra-scapular nerve simultaneously. These patients with infra-clavicular injuries were treated by nerve suture or nerve grafting. Later their shoulder function recovered. Most of the supra-clavicula r injuries accompanied root avulsion injuries. In those cases which had root avulsion injuries, the remaining nerves were reconstructed with long nerve grafts. However the results were not satisfactory and later needed multiple muscle transfer surgery in order to regain their shoulder function. The trapezius, the levator scapuli, the latissimus dorsi and the serratus anterior muscles were available for those operations. If a patient's C8 and Thl roots were in functional condition, and his latissimus dorsi and pectoralis major were also functional, the results of multiple muscle transfer surgery were successful. In paralysis involving a whole brachial plexus with avulsion of the roots, we attempted to restore the elbow flexion using intercostal nerves. But in these cases, multiple muscle transfers were not successful due to a lack of available muscles.
The axillary nerve can easily be damaged by trauma in the area covered by following boundaries: the quadrilateral space are superior, the lower border of the capsul e of the shoulder joint; lateral, the lateral border of the scapula, medial, the long head of the triceps; and, anterior, the upper border of the teres major. Some cases of axillary nerve entrapment neuropathy were resistant to conservative treatment. We wish to present a study of the surgical treatment of axillary nerve entrapment in this region. Between 1981 and 1988 we operated seventeen shoulders with quadrilateral space syndrome. The seventeen cases were male with an average age of 31.1 years (range 16 to 61 years). All the patients had been injured in traumatic accidents. There were 10 cases of contusion of the infra-posterior glenoid region and sprained shoulders,2 cases of glenohumeral dislocation,1 humerus fracture case and 4 cases of sports injury. RESULTS: 1) Quadrilateral space syndrome is defined as an injury of both the axillary nerve and the radial nerve upper branch, however, in almost all of the cases the radial nerve was not affected.2) All the results were good.3)In two cases with complete deltoid paralysis, the patients could abduct their shoulder joints. As reported previously, we suspect that this phenomenon was caused by the power of the shoulder girdle muscles, except for the deltoid muscle.4) In cases with Bennett lesion, it is essential to evaluate and investigate the axillary nerve lesion.5) In cases associated with the suprascapular nerve injury, glenohumeral inferior subluxation may occur and it should be distinguished from brachial plexus nerve injury.6) When conservative treatments fail, neurolysis should be selected.7) In the management of shoulder girdle trauma, we should consider quadrilateral space syndrome.
In the last year, we have treated ten patients with paresis consisting of two with suprascapular nerve paresis, five with axillary nerve paresis, one with hyperabduction syndrome and two with accessory nerve paresis. The following cases were particularly interesting. [Case 1] A 40-year-old man with left suprascapular nerve paresis. We resected the transverse scapular ligament, but as subsequent therapy was ineffective, a resection of the spinoglenoid notch was performed. Biceps brachii muscle long head tendinitis and sn a p ping shoulder occurred secondarily. [Case 2] A 46-year-old man with left axillary nerve paresis. There was marked pain on exertion and tenderness on the quadrilateral space. Neurolysis of the axillary nerve was carried out, and the symptoms mentioned above improved. [Case 3] A 64-year-old woman with impingement syndrome and hyper-abduction syndrome. She felt pain on exertion, and a sense of coolness and numbness from the lef t shoulder to the arm. During the operation, we confirmed that the tendon of them. pectorali s minor ran in a groove formed on the coracoid process and entered into the shoulder joint. Peripheral neuropathy around the shoulder is not as uncommon as reported pre v iously. Careful observation is necessary for diagnosis, and suitable, treatment and pathogenesis of each cause are essential.
Functional disturbances of the shoulder are caused, not only by bone or muscle injuries, but also by peripheral nerve injuries. Clinical findings of functional disturbances vary depending on the injured nerve. The authors experienced 180 cases of shoulder dysfunction caused by peripheral nerve injuries, during a 25-year-period from April 1963 to March 1988. The nerves involved were the brachial plexus (115 cases), the axillary nerve (52 cases), the suprascapular nerve (4 cases), the long thoracic nerve (2 cases), and the accessory nerve (7cases). (Case 1) Brachial plexus injury: A 35-year-old male had had a knife thrust at his neck. He had disturbances of abduction and external rotation of the shoulder because of C5,6 root injuries. In two years, satisfactory abduction was obtained after neurorraphy. (Case 2)Axillary nerve injury: An 18-year-old male, had a severe contusion on the shoulder caused by a motorcycle accident. He showed limited abduction with deltoid atrophy. Improvement of abduction of the shoulder was obtained in seven months by neurolysis. (Case 3) Suprascapural nerve injury: A 19-year-old male, a volleyball player, noticed atrophy of the infraspinatus when continuously exercising spiking. He also noticed weakness of external rotation of the shoulder. The operation showed impingement of the suprascapular nerve at the base of the spina scapula. (Case 4) Long thoracic nerve injury: A 12-year-old male, a gymnast, had severe contusion on the lateral chest and gradually, he felt dullness of the shoulder with a winged scapula. (Case 5) Accessory and suprascapular nerve injuries: A 39-year-old female, who had a lymph node resection, felt wekaness at initial motion of flexion and abduction with muscle atrophy of the shoulder. When examining shoulder injuries, it is important to investigate the neurological deficits by neurological tests including electromyography, in addition to the routine diagnostic procedure.
Six patients, five with brachial palsy and one with poliomyelitis, had transplants of the complete latissimus dorsi muscle to restore elbow flexion, by rotating it on its neurovascular pedicles and attaching the tendon to the coracoid process and the muscle origin to the tuberosity of the radius. When the resu l ts were evaluated according to the criteria of Segel (1959), three were excellent, one was good, one was fair and one was a failure. One procedure failed due to erroneous pre-operative evaluation of the strength of the latissimus dorsi muscle. The relationship between control of the shoulder joint and elbow f unction is very important. Strong elbow-flexion and favorable hand-to-mouth function result, if the shoulder is stabilized.
Shoulder arthrodesis is a valuable procedure for the reconstruction of the paralytic shoulder. The authors added an external fixator using methyl-methacrylate to glenohumeral fusion with AO cancellous screws. The results were quite satisfactory. [Materials and methods] Since 1985, sh o ulder arthrodesis has been performed in seven out of 23 brachial plexus injuries. All cases were total paralysis, seven men had an average age of 25 years. Details of our procedure are as follows: The glenohumeral joint was fixed with AO cancellous screws, and an iliac bone graft was inserted between the acrominon and the humeral head as in Hara and Tsuyama's technique. For the external fixation, four cancellous screws were inserted, one was placed in the clavicule, one in the scapular spine and two in the humeral shaft. They were bound up and fixed with methyl-methacrylate. The angle of shoulder fusion was 20° abduction,10° flexion and 30° internal rotation. Follow-up ranged from 8 months to 4 years 1 month, with an average of 1 year 10 months. [Results] Solid union was achieved in all cases. The fused position of the glenohumeral joint did not deteriorate after surgery, nor were there any complications. The duration of the external fixator ranged from 8.5 weeks to 21 weeks, with an agerage of 13.6 weeks. However, in 3recent cases, the external fixator was removed at 8.5 weeks,9 weeks and 10 weeks after operation. [Conclusions] The advantages of this procedure are as follows: 1) early exercise is possible 2) less discomfort than abrace or cast 3) less of an hygienic problem 4) ease of lying in bed 5) inexpensive
Most lesions of the accessory nerve are iatrogenic. In order to clarify the functional prognosis of accessory nerve injury after nerve repair and non surgical treatment, we studied 24 of our own cases with accessory nerve injury. The causes of injury was a superficial lymph-node biopsy in 14 cases, resection of the neck tumor in 8 cases and 2 other cases. Associated injuries were injury of the sensory nerve to the face and head in 10 cases and incomplete injury of the brachial plexus in 1 case. The complaints on the first visit were dynfunction of the shoulder in 24 cases, shoulder pain in 18 cases, a dull feeling in the shoulder and neck in 14 cases and paresthesia of the neck and occipital region in 11 cases. Atrophy of the trapezius was present in all cases, limitation of active elevation of the shoulder in 23cases and drooping of the shoulder in 17 cases. 17 cases were followed up for more t han 8 months.10 out of 17 cases were treated conservatively. In the conservatively treated group, the dull feeling and hypesthesia did not improve. However, pain and dysfunction of the shoulder improved in half of these cases. In 7 cases treated surgically, nerve suture was performed in 2 cases, nerve graft in 3 cases and neurolysis in 2 cases. Resection of the neuroma or neurolysis of the sensory nerve were combined in 4 cases. In the surgically treated group, subjective complaints disappeared in all cases, but hypesthesia or contracture of the shoulder persisted in 2 cases. Surgical treatment of the accessory nerve is recommended in new cases with complete paralysis and in old cases in which the injury in no older than one year and nerve function has not improved.
Entrapment of the suprascapular nerve is one cause of shoulder pain, but very few papers concerning this syndrome have been published. The purpose of this paper is to describe the syndrome resulting from entrapment of the suprascapular nerve and to report a personal series of 7 operated cases. Our own material consists of 7 operated patients. They were all males, with a mean age of 32 (18-61) years. The causes of the symptoms were related to the ganglion in 2 cases, to trauma in 4 cases and to overuse in 1 case. The clinical features are fatigue, dullness, weakness and atrophy of the spinati muscles. The suprascapular nerve is liable to be compressed at the scapular notch and the spinoglenoid notch, and the disordered muscle is usually the infraspinatus muscle. Treatment was external neurolysis, excision of the ganglion and partial removal of the lateral margin of the scapularspine. During the follow-up period, on an average of 41 (16-76) months, all the cases had diminished preoperative pain and they had recovered from atrophy. Entrapment of the suprascapular nerve may occur as a se q uel to a ganglion cyst, overuse and trauma. The nerve is stretched by rotating the scapula, Therefore, we conclude that suprascapular nerve entrapment should be considered as a possible diagnosis in a patient with pains in the shoulder region.
Since 1984, we have surgically treated 21 cases. All the cases were male,13 to 49years-old, and all but three were motorcyclists.19 cases were operated on within 4 months. Bone and joint injuries around the shoulder were recognized in 7 cases, but we only found one case of shoulder dislocation. Operative procedures for the axillary nerve were free sural nerve grafts in 18 cases, and neurolysis in 3 cases. Treatments for suprascapular nerve were free sural nerve grafts in 13cases, neurolysis in one case, conservative treatment in 6 cases but in first experienced case, we could not perform grafting, because the operation was done in supine position. In all cases the lesions of the axillary nerve extended from the division of the posterior cord to the quadrilateral space. In the suprascapular nerve, the lesions distributed themselves from the scapular notch proximally to near the motor point of the infraspinatus distally, and multiple injured sites were found in 5 cases. The results of 13 cases, foll owed up for more than one year, were as follows: The MMT of the deltoideus muscle was more than (3) in 11 cases, and that of the infraspinatus muscle, more than (3) in 9 cases (graft 5, conservative 4), and less than (2) in 4 cases. In the latter 4cases, even though the deltoideus muscle had recovered well, shoulder abduction was less than 90 degrees. Should a denervated pattern be recognized 1 month after trauma, it necessitates exploration. The saber-cut incision is convenient as it offers good operative fields when repairing the suprascapular nerve. It is important to check the status of the suprascaplar nerve as far as the insertion to the infraspinatus muscle, because shoulder abduction relies on its good recovory.
A total of 29 cases have been treated for traumatic brachial plexus palsy. Of these,18cases displayed disorders in the functions of shoulder-joints. The 18 palsy cases were divided into upper type in 12 cases, upper and middle type in 4 cases, and total type in 2 cases. The follow-up period ranged from 6 months to 13 years, with a mean of 5 years. The results showed 14 cases as good,3 cases fair, and 2 cases poor. Conservative therapy or surgical therapy was decided by care f ul observation of the progress and the results of tests on sensitivity, muscle tests and chronaxie tests at the injured sites. Those cases showing improvement in the above mentioned tests were continuously treated with conservative therapy and their progress was observed. Two problems arose from the above conservative thera p y, and were as follows: 1) Time and reason for deciding on conservative therapy or surgical therapy. 2) In conservative therapy, some of those cases which took more than 10 months to elevate their arm to shoulder level showed insufficient recovery of muscle-power thereafter, even in possible state to elevate their arms.
Axillary nerve paralysis in the quadrilateral space is usually treated non-operatively. However, the results are sometimes unsatisfactory, since the recovery period is long and marked atrophy of the deltoid muscle and inferior subdislocation of the humeral head are inevitable. In cases of complete electrophysiological nerve degeneration, neurotmesis cannot be ruled out without surgery. Therefore, early surgery is preferable, especially for active patients so that they may return to their activities quickly. This is a report of the results of microsurgical neurolysis of the axillary nerve in this affection. Thirteen patients (12 men and 1 woman) have been treated by this procedure from 1977to 1988. Their age distribution was from 17 y/o to 62 y/o (mean 29.3 y/o). The main cause of the injuries was blunt trauma to the back of the shoulder after falling from a motorcycle. No sensory deficit was found in one case. Triceps brachii muscle paralysis was found in one case (so-called “quadrilateral space syndrome” after Bateman). The time interval from the injury to the operation was from 2 weeks to 9 months (mean 3 months). Neurolysis of the axillary nerve was performed microsurgically with posterior approach in the prone position under general anesthesia. Adhesion around the nerve was found in 11 cases (3 cases inside of the quadrilateral space; 6 cases at the distal part of the space; 2 cases distal to bifurcation of the branches). There were no cases of neurotmesis. Post-operative treatment was begun from the 5th post-op. day. Shoulder abduction was regained 3 days to 2.5 months post-op. (mean 41 days post-op. ). Sensibility was recovered more quickly and better than the deltoid. Vulnerability of the axillary nerve in the quadrilateral space seems to be due to the short and curved course of the nerve and tension on bifurcation of the branches. The initial injury of the nerve and the entrapment by adhesion caused by bleeding seem to have caused the nerve paralysis. We conclude that surgery is recommended for axillary nerve paralysis in the quadrilateral space in the cases of no recovery within one month after the injury.
Irreversible dysfunction of the shoulder joint often occurs after combined injuries to the axillary nerve and suprascapular nerve (SSN) amongst plexus injuries. We used to carry out neurolysis and nerve graft in new cases, and reconstruction of the deltoid muscle by transfer of the latissimus dorsi (J Bone Joint Surg 69-B,647,1987) in old injuries. However, there several recoveries of SSN injuries were poor, even after nerve grafts. In addition, there were also persisting dysfunctions of the shoulder joint after reconstruction of the deltoid alone. Therefore, we developed and carried out a new combined muscle transfer technique on old and some new cases, and obtained good results.
Shoulder imping ement syndrome encompasses aspectrum of diseases that results from an impingementon the rotator cuff, the underlying subacromialbursa and occasionally the long head of thebiceps againstthe anterior edge of the acromionand its associated coracoacromial arch. The disorderis often due to repetitious trauma caused byvigorous overhead athletic activities. It is a frequentoccurence in the swimmer, thrower and racquetsport enthusiast. Its frequency is also agerelated.