Shoulder Examination and the
Brachial Plexus
Structure of the Session
Teaching – 30 minutes
Shoulder Examination and the Brachial
Plexus
Move into small groups
with Tutor
• Pt. history
• Shoulder examination
• SAQs
Debrief and Feedback
• Tutor feedback
• Student feedback
Shoulder Examination
Preparation
•Same thing every examination
• Introduction
• “Hello, my name is Rob. I’m a second year medical student at Leicester medical
school”
• Consent and explanation
• “Would it be okay for me to perform a shoulder examination on you? It will involve
me looking at, feeling, and moving your shoulder”
• Wash hands
• Position
• Standing
Look
• Front, side, back
• Say what you’re looking for:
• Posture
• Muscle wasting
•Supra/infraspinatus wasting would suggest
chronic tear of their tendons
• Scars
• Skin changes
• Swelling
•Will be seen in dislocations, inflammatory
disorders, proximal fractures of the
humerus
• Symmetry
•Are there any obvious differences?
• The above list can be found in your consultation
skills book
Feel
•Before you touch the patient ask them to tell you if they feel pain at any point!
•They may not tell you if they’re in pain, so look at their face whilst doing it!
• Check the temperature of the shoulder and compare with other side (using the dorsum
(back) of your hand)
• NB: Cardinal signs/symptoms of inflammation
• Dolor (pain)
• Calor (heat)
• Rubor (redness)
• Tumor (swelling)
• Loss of function
Feel (2)
•Start at the Sternoclavicular joint
•Between the clavicle and manubrium of
the sternum
•Feel along the Clavicle to the
Acromioclavicular joint
•Between the clavicle and acromion of
the scapula
•Acromion process
•Coracoid process
•Inferior to the acromioclavicular joint
•Be careful as it can be painful for the
patient
Feel (3)
•Scapula
•Spine of the scapula
•Medial border
•Inferior angle
•Lateral border
•Head of the humerus
•Joint line
•Muscle bulk
•Deltoid
•Supraspinatus
•Infraspinatus
•You will be feeling for swelling, and
checking for tenderness (say you are
doing this!)
Move
Flexion
Muscle
Nerve
Biceps Brachi
Musculocutaneous
Coracobrachialis
Musculocutaneous
Deltoid (Anterior
fibres)
Axillary
• BRACHIALIS DOES NOT FLEX THE ARM AT
THE GLENOHUMERAL JOINT
Move (2)
Extension
Muscle
Nerve
Triceps Brachi
Radial
Latissimus Dorsi
Thoracodorsal
Deltoid (posterior
fibres)
Axillary
Move (3)
Abduction
Muscle
Nerve
Supraspinatus
Suprascapular
Deltoid (Lateral
fibres)
Axillary
• Supraspinatus initiates abduction
(first 15°)
• Deltoid continues it.
• Pain between 10° and 120° (but
with full range of passive
movements)  Painful arc (rotator
cuff lesion/tendonitis)
• Between 50 and 70% of abduction
occurs at the glenohumeral joint,
the rest occurs with the movement
of the scapula on the chest wall –
Macleod’s Clinical Examination 12th
edition
Move (4)
Adduction
Muscle
Nerve
Teres Major
Lower Subscapular
Pectoralis Major
Medial and Lateral
pectoral
Triceps Brachi
(long head)
Radial
Latissimus Dorsi
Thoracodorsal
Coracobrachialis
Musculocutaneous
Move (5)
Internal (medial) rotation
Muscle
Nerve
Subscapularis
Upper and Lower
Subscapular
Teres Major
Lower Subscapular
Pectoralis Major
Medial and Lateral
Pectoral
Deltoid (anterior
fibres)
Axillary
Latissimus Dorsi
Thoracodorsal
Move (6)
External (lateral) rotation
Muscle
Nerve
Infraspinatus
Suprascapular
Teres Minor
Axillary
Deltoid (Posterior
fibres)
Axillary
Move (7)
Passive movements
•Flexion, extension, abduction, adduction, internal and external rotation need to be
preformed passively whilst palpating the glenohumeral joint for crepitus.
•Passive – You move it for them
•Crepitus – “A crackling sound or grating feeling produced by bone rubbing on bone or
roughened cartilage, detected on movement of an arthritic joint” – Oxford concise medical
dictionary – 7th edition
Function
•Ask patient to put their hands behind their head, and behind their back
•Tests their ability to dress, comb hair ect.
Pause for shoulder examination
demonstration
The Brachial Plexus
Mnemonic
• Real
• Teenagers
• Drink
• Cold
• Beer
Roots
Trunks
Divisions
Cords
Branches
The Brachial Plexus
- A few key points
•Formed from the union of the anterior rami of C5-T1
•Trunks of the brachial plexus divide into anterior and posterior divisions
• Anterior divisions: Go on the supply the anterior compartments of the upper limb
• Posterior divisions: Go on to supply the posterior compartments of the upper limb
• Posterior divisions of all 3 trunks unite to from the posterior cord
• Anterior divisions of superior and middle braches unite to form the lateral cord
• Anterior division of inferior branch goes on to become the medial cord
•Cords are named based on their anatomical relationship to the axillary artery
• A lot of nerves come from the brachial plexus. Focus mainly on the terminal branches.
The Brachial Plexus
- Injuries
Injuries to the superior parts of the brachial plexus (C5 and C6)
Erb-Duchenne palsy (palsy is a paralysis of part of the body)
• Usually occur due to a person being thrown off a horse or motorcycle
•The landing results in an increased angle between the neck and shoulder
• Results in “waiter’s tip position” – Arm hangs at the person’s side in medial rotation
• Hangs by side
• C5 and C6 supply Suprascapular nerve, and Axillary nerve
• These nerves innervate Supraspinatus and Deltoid
• These muscles Abduct the arm
• Medial rotation
• C5 and C6 supply Suprascapular nerve, and Axillary nerve
• These nerves innervate Infraspinatus , Deltoid (Posterior fibres)
and Teres Minor
•These muscles Laterally rotate the arm
The Brachial Plexus
- Injuries
Injuries to the inferior parts of the brachial plexus (C8 and T1)
Klumpke paralysis
• Less common than Erb-Duchenne’s palsy
• Occur when:
• Arm is suddenly pulled superiorly
• e.g. Somebody grabbing a branch to stop them falling from
a tree.
• A baby’s arm is pulled excessively during delivery.
• Results in a “Claw hand”
• All intrinsic muscles of the hand are supplied by the ulnar nerve
• Except: 1st and 2nd Lumbricals; Opponens pollicis; Abductor pollicis brevis; Flexor
pollicis brevis (superficial head) – Median nerve.
• Meat LOAF
The Brachial Plexus
- Injuries
http://en.wikipedia.org/wiki/File:Ulnar_claw_hand.JPG
The Brachial Plexus
- Injuries
• Lumbricals:
• Flex metacarpophalangeal joints
• 4th and 5th not functioning  hyperextension of these joints
• Extend interphalangeal joints
• 4th and 5th not functioning  flexion of these joints (weak)
• Medial part of flexor digitorum profundus:
• Flexes interphalangeal joints 4 and 5
• Not functioning  weak flexion of this joint
• Interphalangeal joint remains in flexed position, but flexion is weak
•Flexor carpi ulnaris:
• Adducts hand at wrist
• Not functioning  Radial deviation
The Brachial Plexus
- Injuries
• Same presentation if you
had a distal ulnar nerve
compression (Ulnar canal
syndrome)
• However, there would be
no weakness of flexion and
no radial deviation due to
no anterior forearm
weakness
http://en.wikipedia.org/wiki/File:Ulnar_claw_hand.JPG
The Brachial Plexus
- Injuries
Compression of the cords of the brachial plexus
•Due to prolonged hyperabduction (e.g. From painting a ceiling)
•Cords are compressed between the coracoid process of the scapula and pectoralis minor
tendon.
•Presents as pain radiating down the arm, numbness, and paresthesia (Tingling)
Questions?
Clinical Correlates of the Upper Limb:
Pectoral Girdle to Elbow
SESSION 4
9th March 2011
This is not a substitute to self study
I have intentionally not given you all
the details
You will need to go away and think
about what is discussed
Please don’t tell me this falls
upon deaf ears…
Winged Scapula
• Damage to the Long Thoracic N.
• Results in paralysis of Serratus Anterior
• Often a stab wound to the lateral thorax
• Ask patient to place hands flat against
wall
• If one of the scapula protrudes further
than the other = winged
Winged Scapula
http://www.sciencephoto.com/images/downloa
d_lo_res.html?id=773500123
Brachial Plexus:
Terminal Branches
• You should know:
• Axillary N. damage
• Paraesthesia over ‘Regimental Badge’ area – why?
• Loss of abduction – why?
• Musculocutaneous N. damage
• Very weak flexion of forearm at elbow. Not complete loss – why?
• Loss of sensation of lateral forearm – why?
• Radial N. damage
• Wrist Drop – why?
• Loss of sensation over most of posterior aspect of Upper Limb
• Is extension of forearm at elbow always completely lost?
• Median N. damage
• Hand of Benediction (if damage at elbow or above) – why?
• Ape Hand (if damage distal to elbow) – why?
• Sensation over palmar aspect of digits 1-3 – why?
• Ulnar N. damage
• Claw Hand – why?
Signs in the Hand
http://www.flickr.com/photos/subvert/545135749/
http://clogginsart.blogspot.com/2009/01/blessthis-blog.html
http://www.wesnorman.com/clinicalconsiderations.
htm
Fractures
• You should know:
• Clavicular Fx.
• Subclavian vessels run inferiorly, between the clavicle and the 1st rib
• Obvious deformity?
• Inability to support the upper limb – supporting arm at the elbow?
• Surgical Neck of Humerus
• Axillary N. damage
• Musculocutaneous N. damage
• Spiral Fx. of Humerus
• Radial N. damage
• What else runs in this groove?
• Transverse Humeral Fx.
• Radial N. damage
• Intercondylar/Olecranon Fx.
• Ulnar N. damage
Fractures
If you have a good grasp of anatomy,
you can work out what nerves might
be damaged
Glenohumeral Joint Injuries
• Dislocation of the Glenohumeral Joint
• ~90% anterior, ~10% posterior – why?
• Easiest when arm is extended, abducted and
externally rotated – why?
• Axillary nerve compression possible
• Loss of contour of the shoulder
• Adhesive Capsulitis (‘Frozen Shoulder’)
• Caused by fibrosis in the joint capsule
• The arm can still be abducted, to ~45 degrees – why?
• What would you see if you looked at their scapula
during abduction?
Glenohumeral Joint Injuries
•Tear of Supraspinatus tendon
• Inability to abduct arm, unless starting above 15
degrees
• Pt’s will lean to the affected side to get themselves
started
• Subacromial Bursitis
• ‘Painful Arc’ syndrome, due to tendon of
Supraspinatus moving under the bursa
• Glenoid Labrum Tears
• Common in those who have unstable shoulder joints
• Causes pain, sublaxation and ‘snapping’ feeling
in joint
Rotator Cuff Injuries
You need to know about these, too…