Trauma Lecture 7

Upper limb injuries
Traumatology
RHS 231
Dr. Einas Al-Eisa
Pain in the limbs:
May be classified under 4 headings:
1. Joint pain
2. Soft tissue pain
3. Neurogenic pain
4. Orthopaedic causes (fractures,
dislocations, tumors, infections)
Brachial plexus lesions
• Most common in young men thrown from

their motorcycles or during difficult
deliveries
Closed injuries:
Can occur in 2 ways:
1. Violent lateral flexion of the neck with

depression of the shoulder, or forced
abduction of the arm
2. At birth during difficult deliveries

Open injuries:
• Rare
• Caused by falling objects such as glass

or steel
Patterns of brachial plexus lesions
Supraclavicular Infraclavicular
lesions lesions
Supraclavicular lesions
Trauma:
• Mechanism of injury: blows to the head

and shoulder cause violent lateral flexion
of the cervical spine and depression of the
shoulder tear the upper cords
• Example: motorcyclists landing on the

head and shoulder
Supraclavicular lesions
Obstetric palsy:
• When the upper cords are damaged at
birth
weak deltoid, elbow flexors, wrist
extensors, supinator
“waiter’s tip” position of the arm
(Erb’s palsy)
Erb’s palsy
Erb’s palsy
Infraclavicular lesions
Trauma:
Mechanism of injury:
– When the arm is violently abducted
– Anterior dislocation of the shoulder
injury to the lower part of the brachial plexus

Infraclavicular lesions
Birth injury:
• Damage to the lower cords (C7, C8, T1):
Klumpke’s palsy (weakness of finger
flexors and intrinsics)
Erb’s palsy:
C5/6 paralysis (particularly
following a breech delivery)
paralysis of the deltoid,

external rotators of the
shoulder, & biceps
the baby's arm is held in

adduction, internal rotation
and with the elbow extended
(waiter's tip position)
Klumpke's palsy:
C7, C8 and T1 palsy
flexed elbow & paralyzed hand

Assessment
• The roots, trunks, or branches can be torn,

or the roots avulsed from the spinal cord
• The more distal the lesion, the better the

prognosis
Assessment
• Preganglionic lesions:
¾between the spinal cord and the distal
root ganglion
¾never recover
• Postganglionic lesions:
¾distal to the ganglion
¾can recover sometimes
Assessment
• To determine the site of the lesion
clinically, assess muscle function
• Check scapular elevation (because the

first branches of the plexus are motor
nerves to the rhomboids and levator
scapulae)
Assessment
• Check the activity of the autonomic
nervous system
• If Horner’s syndrome is present, the lesion

is close to the cord (preganglionic)
Horner’s syndrome
• Caused by lesion of the cervical
sympathetic trunk:
¾Pupil constriction (paralysis of the dilator

pupilae muscle)
¾Ptosis = drooping of the upper eyelid

(paralysis of the levator palperae
superioris)
Horner’s syndrome
¾Sinking of the eye (paralysis of the
smooth orbitalis muscle in the floor of
the orbit)
¾Vasodilatation and absence of sweating

in the face and neck (lack of
sypmathetic vasoconstrictive nerve
supply to the blood vessels and sweat
glands)
Treatment (brachial plexus lesions)
• If the roots are torn out of the spinal cord,
nothing can be done to restore continuity
• If the lesions are distal to the ganglion, or

there is a clean cut across the nerves,
surgical repair or grafting may be possible
Impingement syndromes
• A common cause of shoulder pain is

impingement of the soft tissues in the
subacromial space with loss of the normal
gliding movement
• The most common structures to be

entrapped are:
¾The supraspinatus tendon
¾Subacromial bursa
¾The biceps tendon
Most common causes include:
• Prominent anterior acromion
• Bony spurs from under the acromion or

arising from the acromioclavicular joint
Most common:
• In young athletes, or those whose
activities involve repeated overhead
actions (e.g., swimming, throwing, tennis)
• In more elderly people working with their

arms repeatedly in horizontal position
during abduction and elevation
Symptoms
• Oedema and inflammatory changes in the

supraspinatus tendon (the biceps tendon
may also be involved)
• Rotator cuff degeneration
• Pain on shoulder movement
• Stiffness and weakness
Symptoms
• The painful arc: impingement of the

supraspinatus felt in the middle range of
abduction
(as the greater tubercle approaches the
acromion, structures between those two
bony prominences are impinged producing
pain)
Management
• Early or mild cases may respond to

conservative therapy:
¾Rest from activities known to aggravate
pain
¾Non-steroidal anti-inflammatory drugs
¾Injection of local anaesthetic and
corticosteroid into the subacromial
space
Management
• Ice, heat, and ultrasound
• Mobilization techniques to restore passive
range of motion and scapulohumeral
rhythm
• Strengthening exercises in a pain-free
range
• Surgery is indicated in patients with
recurrent or chronic pain, cuff tears, or
biceps tendon involvement
Lesions of the
supraspinatus tendon
• Supraspinatus tendinitis
• Subacromial bursitis
• Complete or incomplete rupture of the

tendon
• Calcification
Supraspinatus tendinitis
• Impingement or overuse
wear and tear with friction of the tendon in
the subacromial space
degeneration of the tendon collagen fibers
Supraspinatus tendinitis
• Pain is felt over the outer aspect of the
shoulder, and may radiate to the region of
deltoid insertion
• Pain may disturb sleep
• Pain may be reproduced on isometric

contraction of the supraspinatus muscle
Bicipital tendinitis
• Inflammation of the biceps tendon in the
bicipital groove is the 2nd most common
cause of shoulder tendinitis
• Due to impingement of the tendon against

the acromial arch and overuse
Bicipital tendinitis
• Associated with tenosynovitis:
inflammation of its synovial sheath
• Pain in the shoulder is usually localized

anteriorly, but may radiate down the arm
• Pain is reproduced by stretching the

biceps tendon
Shoulder dislocation
• The shoulder is mechanically unstable
• The head of humerus is held against the

relatively flat glenoid cavity by muscles
1. Anterior Dislocation
• The most common
• The head of humerus slips off the front of

the glenoid when the arm is abducted and
externally rotated
• When the arm is lowered, the head slips

medially
• The shoulder has a flatter appearance
than usual and the elbow points outwards
• Hamilton’s ruler test: the shoulder is

dislocated when the tip of the acromion
and the lateral epicondyle can be joined by
a straight line
• Complications:
¾ Damage to the axillary nerve (partial or
complete paralysis of the deltiod)
¾ Damage to the axillary artery by

traction (pressure from the humeral
head)
• Complications:
¾ If reduction is not undertaken within a
few days of dislocation, reduction may
then be impossible
¾ Stiffness and loss of movement

(adhesions or fibrosis in the rotator
cuff)
Treatment
• Reduction:
¾Manipulation under general anaesthesia
¾Hanging arm technique
¾Hippocratic method
¾Kocher’s method
Old untreated
fracture/dislocation of the
head and neck of the
humerus of 10 months’
duration in a 34 year old
man.
The shoulder was stiff and

painful, and the axillary nerve
had been damaged with
paralysis of the deltoid.
Anterior shoilder
dislocation:
• associated with paralysis of the
deltoid and flattening of the
muscle due to damage to the
axillary nerve
1. Posterior Dislocation
• Less common
• Caused by a direct blow to the shoulder in

internal rotation or after an epileptic
seizure
• Characteristic “light bulb” appearance

Recurrent dislocation of the
shoulder:
the use of a Huckstep titanium
staple and screw
Inferior dislocation of the shoulder: due
to paralysis of the deltoid (rare)
Acromioclavicular
joint dislocation:
• treated in most cases by a
triangular sling
• occasionally operative
repair may be indicated if
cosmetic appearance is
important
Myositis (traumatic) ossificans:
• common around the hip and elbow

• due to calcification and new bone
formation following a dislocation or
fracture
• often initiated by too early active or
passive movements of the joint
following injury resulting in repeated
tearing of the muscles and capsule
•Note the solid blocks of bone on the

front and the back of the elbow in this
X-ray which was preventing all
movement
• This was treated by excising the
new bone
• Following excision the elbow was

rested in a plaster back slab for 3
weeks
• The optimum prevention of

myositis ossificans is rest in the
acute stage.

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Upper limb injuries

• Most common in young men thrown from

1. Violent lateral flexion of the neck with

2. At birth during difficult deliveries

• Caused by falling objects such as glass

• Mechanism of injury: blows to the head

• Example: motorcyclists landing on the

injury to the lower part of the brachial plexus

paralysis of the deltoid,

the baby's arm is held in

flexed elbow & paralyzed hand

• The roots, trunks, or branches can be torn,

• The more distal the lesion, the better the

• Check scapular elevation (because the

• If Horner’s syndrome is present, the lesion

¾Pupil constriction (paralysis of the dilator

¾Ptosis = drooping of the upper eyelid

¾Vasodilatation and absence of sweating

• If the lesions are distal to the ganglion, or

• A common cause of shoulder pain is

• The most common structures to be

Most common causes include:

• Prominent anterior acromion

• Bony spurs from under the acromion or

• In more elderly people working with their

• Oedema and inflammatory changes in the

• The painful arc: impingement of the

• Early or mild cases may respond to

• Complete or incomplete rupture of the

• Pain may disturb sleep

• Pain may be reproduced on isometric

• Due to impingement of the tendon against

• Pain in the shoulder is usually localized

• Pain is reproduced by stretching the

• The head of humerus is held against the

• The head of humerus slips off the front of

• When the arm is lowered, the head slips

• Hamilton’s ruler test: the shoulder is

¾ Damage to the axillary artery by

¾ Stiffness and loss of movement

¾Hanging arm technique

The shoulder was stiff and

• Caused by a direct blow to the shoulder in

• Characteristic “light bulb” appearance

• common around the hip and elbow

•Note the solid blocks of bone on the

• Following excision the elbow was

• The optimum prevention of

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