radER Vol 1.2

Case 1.2

A 29-year-old man presents to your ED with left should pain that started immediately after he struck a volley ball during his serve.  On exam, the left arm is held in slight abduction and external rotation.  The patient is unable to touch his uninjured shoulder with the hand from his injured arm.  His radiograph is seen below.

1. What two nerves are at risk for injury?

2. How do you test the integrity of these potential nerve injuries?

3. What is a Hill-Sachs deformity?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

radER is a weekly contest consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

7 Responses

  1. 1/2) The literature I found said you should test for 3 nerves
    1. the axillary nerve before and after reduction by testing both pinprick sensation in the “regimental badge” area of the deltoid and palpable contraction of the deltoid during attempted abduction
    2. radial nerve – Triceps extension and dorsal and lateral part of hand (The area between your thumb and first finger).
    3. musculocutaneous nerve – causes weakness of elbow flexion & supination of the forearm. sensory disturbance is present on the radial side of the forearm.

    3) posterolateral humeral head indentation fracture

  2. 1. axillary nerve, musculocutaneous nerve

    2. test for sensation in the lateral upper arm and palpate for contraction of the deltoid muscle while the patient abducts against resistance. Assess contraction of biceps.

    3. hill-sachs (hatchett) deformity: it is a compression deformity of the humeral head. gleno-humeral dislocation results usually from impact of the postero-lateral aspect of the humeral head against the glenoid. This resulted from a blow to the upper arm while arm was abducted and externally rotated.

  3. 1) Axillary and musculocutaneous/radial
    2) sensory and motor
    3) compression fracture that results in the formation of a groove in the posterolateral aspect of the humeral head

  4. 1) Axillary and radial nerves
    2) To test the axillary, check for sensation over the deltoid; or check for deltoid muscle contraction for motor function. For the radial, check for sensation over the dorsal aspect of the hand or muscle contraction of triceps for motor function.
    3) Hill-Sachs deformity is a compression fracture of the posterolateal portion of the humeral head due to forceful contact with the glenoid rim.

  5. 1. Axillary N. & Musculocutaneous N.
    2. Axillary N. – sensory loss over lateral shoulder and weakness in shoulder abduction. Musculocutaneous N. – weakness of forearm flexors and supinators, sensory loss along dorsal forearm.
    3. Hill-Sachs: compression fx of posterolateral aspect of humeral head due to impact of humeral head on anterior glenoid rim.

  6. 1. Axillary and Radial

    2. Axillary: Can try test of sensation over lateral aspect of deltoid region. Test motor function of deltoid….ask patient to attempt abduction and feel for deltoid muslce contraction

    Radial: Ask patient to extend thumb at MCP, Ask patient to abduct thumb, ask patient to extend fingers at MCP, ask patient to abduct wrist. Any of these should demonstrate intact radial function.

    3. A compression fracture of posterior-lateral aspect of humeral head from impact on anterior lip of glenoid fossa during the dislocation process.

  7. 1. Axillary and brachial plexus
    2. EMG and physical exam (abduction of arm, test for deltoid muscle)
    3. Deformity caused by compression of humeral head on glenoid.

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