Shoulder Paralysis Research Articles

Shoulder Pain, Paralysis and Fever: Dog Attack or Infection?

Correspondence: Dr Mark A Miller, Division of Infectious Diseases, Sir Mortimer B Davis Jewish General Hospital, 3755 Cote-Ste-Catherine #G-139, Montreal, Quebec H3T 1E2. Telephone 514-340-8294, fax 514-340-7546, e-mail mmiller@lab.jgh.mcgill.ca CASE PRESENTATION A 22-year-old homosexual male presented to the Infectious Diseases clinic with a one-week history of fever and muscle pains. He had no significant past medical history and was on no medications except for narcotic analgesics prescribed for back pain two months earlier. At that time, a dog had jumped on his back while working at his job as an animal technician in a research laboratory, causing him to turn suddenly and experience sudden mid-back pain. He was seen by the occupational health office and prescribed shortterm narcotics and bed rest. His social history was significant as he had recent unprotected anal sex with an anonymous male approximately one week before the work accident. Over the eight weeks following the dog ‘attack’, the patient gradually developed severe fatigue, muscle aches and pains in areas not related to his back injury (ie, arms, legs), sweats and fevers up to 39.5°C. He attributed these symptoms to his back injury and to side effects of the narcotics. He presented to the clinic after two weeks of fever and myalgias because his fever persisted and he felt that his shoulder and arm pains were worse. He denied any sore throat, diarrhea, abdominal pain, headache, urinary symptoms or other problems. On examination, he complained of mid-back and bilateral shoulder pain and looked obviously ill. He was diaphoretic, but warm. His temperature was 39.0°C, his pulse was 90 beats/min and his respiratory rate was normal. The oropharynx was normal and there was no adenopathy. Chest and cardiovascular exam were both normal. Abdominal exam revealed moderate splenomegaly but no hepatomegaly and no masses or tenderness. There were no rashes. A limited neurological examination was normal but muscle tenderness was present. Laboratory studies showed mildly elevated levels of alanine aminotransferase (139 U/L), aspartate aminotransferase (83 U/L) and lactate dehydrogenase (481 U/L) with normal levels of bilirubin and creatine kinase. The hemogram showed normal red cell indices and platelets but an elevated white blood cell count of 11.5×109/L and 12% atypical lymphocytes. Serological markers for hepatitis B, hepatitis A Immunoglobulin M, hepatitis C, Toxoplasma gondii, HIV and Epstein-Barr virus (EBV) (heterophile antibodies) were negative. In addition, HIV p24 antigenemia was absent. A presumptive diagnosis of mononucleosis due to either EBV or cytomegalovirus (CMV) was made and the patient was told to rest at home. The patient returned to the clinic ten days later, complaining of severe upper arm and shoulder pain, and an inability to “move” his left arm. He attributed this problem to his back injury and had increased his analgesic intake. The physical examination was unchanged from the first visit, except that he was unable to abduct his left arm, however strength was intact in the hand and forearm. An urgent same-day neurology consultation disclosed normal symmetric reflexes in the upper extremities but the patient was unable to abduct, raise or externally rotate his left arm. There was wasting of the left deltoid, supraspinatus and infraspinatus muscles. Nerve conduction studies of the upper and lower extremities were normal. An electromyogram of the left infraspinatus, supraspinatus and deltoid muscles was remarkable for an absence of activity at rest and the inability to recruit motor units in any of these muscles, indicating dysfunction of the left axillary and suprascapular nerves consistent with an acute brachial neuritis.

Palliative surgery in paralytic shoulder multiple motor transfers (trapezius, rhomboid and levator scapulae for abduction; latissimus dorsi transfer for rotation)

Palliative surgery in paralytic shoulder multiple motor transfers (trapezius, rhomboid and levator scapulae for abduction; latissimus dorsi transfer for rotation)

Shoulder fusion and free-functioning gracilis transplantation in patients with elbow and shoulder paralysis caused by poliomyelitis.

Six children between 7-16 years of age presented with flail shoulder and elbow caused by poliomyelitis. Shoulder fusion was followed by free-functioning gracilis transplantation to replace the atrophied biceps muscle. The transplanted muscle was reinnervated by either the spinal accessory or phrenic nerve. Follow-up averaged 44 months (range, 56-23 months). All cases developed at least grade 3 power of elbow flexion and were able to place their hands to their mouths. Five out of 6 cases were able to flex their elbow against resistance. One case required tension readjustment, and elbow flexion contracture of 45 degrees developed in another case. On average, the transplanted gracilis started to contract 3 months after transplantation, and muscle power reached grade 2 at 5-6 months and grade 3 at 9-12 months. Muscles supplied by the spinal accessory nerve were earlier to contract and ultimately attained more power than those supplied by the phrenic nerve, probably because of easier rehabilitation. Shoulder fusion and free-functioning gracilis transplantation for biceps replacement provide a solution for restoration of function in children with flail shoulder and elbow, as caused by poliomyelitis. The procedure can be useful in other neuromuscular conditions, such as late-presenting Erb's palsy, especially when no other muscles are available for local transfer.

Shoulder fusion and free‐functioning gracilis transplantation in patients with elbow and shoulder paralysis caused by poliomyelitis

Shoulder fusion and free‐functioning gracilis transplantation in patients with elbow and shoulder paralysis caused by poliomyelitis

Trapezius transfer for shoulder paralysis. 6 patients with brachial plexus injuries followed for 1 year.

We transferred the trapezius with its bone insertion to the proximal humerus in 6 patients for treatment of a paralytic shoulder secondary to traumatic lesions of the brachial plexus. After 1 year, the shoulder abduction was improved from average 13 degrees (0 degrees-30 degrees) preoperatively to 76 degrees (50 degrees-100 degrees) postoperatively, and the shoulder flexion from 18 degrees (0 degrees-40 degrees) to 78 degrees (45 degrees-110 degrees) postoperatively. All the patients were satisfied with the outcome. We consider that transfer of the trapezius in a paralytic shoulder after brachial plexus injury gives a better outcome than shoulder fusion.

The role of shoulder fusion in the era of arthroplasty.

The indications, surgical techniques, results and complications of shoulder fusion are described. The indications are bacterial infection, paralytic disorders in infancy, combined deltoid and rotator cuff paralysis, post-traumatic brachial plexus lesions, inflammatory arthritis with severe rotator cuff involvement, failed arthroplasty, recurrent dislocation, after resection of tumours, irreparable rotator cuff tear, painful arthritis in a patient whose activities require power but not movement, the immunocompromised patient, and tuberculosis. Satisfactory results are achieved in children with isolated shoulder paralysis, but in adults loss of glenohumeral movement is associated with about 50% loss of function. The best results are obtained in cases of isolated shoulder paralysis with a normal arm and hand distally. The most frequent complications are nonunion (5-20%), fracture of the ipsilateral humerus (10-15%) and infection (3-5%). Other causes of failure are functional limitation, fusion in malposition, functional involvement of the distal joints, acromioclavicular dislocation, suprascapular traction neuritis, failure or migration of an internal fixation device, epiphyseal problems, and the complications of using an allograft. Shoulder replacement is most likely to be chosen for most destructive shoulder disorders, but fusion is useful in certain cases.

The Clinical and Neurological Study of Non-Traumatic Shoulder Paralysis

The Clinical and Neurological Study of Non-Traumatic Shoulder Paralysis

The clinical and neurological study of nontraumatic shoulder paralysis

The clinical and neurological study of nontraumatic shoulder paralysis

A Comparison of Ropivacaine 0.5% and Bupivacaine 0.5% for Brachial Plexus Block

This study compared the effectiveness of 0.5% ropivacaine and 0.5% bupivacaine for brachial plexus block. Forty-eight patients received a subclavian perivascular brachial plexus block for upper-extremity surgery. One group (n = 24) received ropivacaine 0.5% (175 mg) and a second group (n = 24) received bupivacaine 0.5% (175 mg), both without epinephrine. Onset times for analgesia and anesthesia in each of the C5 through T1 brachial plexus dermatomes did not differ significantly between groups. Duration of analgesia and anesthesia was long (mean duration of analgesia, 13-14 h; mean duration of anesthesia, 9-11 h) and also did not differ significantly between groups. Motor block was profound, with shoulder paralysis as well as hand paresis developing in all of the patients in both groups. Two patients in each group required supplemental blocks before surgery. Ropivacaine 0.5% and bupivacaine 0.5% appeared equally effective in providing brachial plexus anesthesia.

Facial Reanimation by Cranial Nerve Substitution Without Tongue or Shoulder Paralysis

Facial reanimation using the sternocleidomastoid branch of the spinal accessory nerve (XI) was the subject of a paper presented by William R. Panje, MD, and Thomas J. Dobleman, MD, University of Chicago (Ill) Pritzker School of Medicine, at the Fifth International Symposium on Plastic and Reconstructive Surgery of the Head and Neck in Toronto, Canada, on June 21, 1989. This selective nerve XI-VII anastomosis avoids the problem of speech and swallowing dysfunction, or shoulder weakness that can occur with a hypoglossal or spinal accessory nerve transposition. In a previous cadaver study the authors had identified three types of innervation patterns to the sternocleidomastoid muscle. Each of these branching patterns afforded enough length after mobilization to be approximated to the pes anserinus. In this paper, the authors reported their experience in five patients, some of whom had long-standing paralysis greater than 2 years. A microneural suture technique was used, as well

Facial reanimation by XI-VII anastomosis without shoulder paralysis.

Transposition of the spinal accessory (XI) and facial (VII) nerves has been used successfully in reanimation of facial paralysis, but because of the severity of symptoms associated with denervation of the trapezius muscle, this technique has largely been abandoned. Hypoglossal-facial (XII-VII) nerve anastomosis has now become a more favored procedure; however, the resultant hemiglossal atrophy carries some morbidity. Transposition of the sternocleidomastoid (SCM) branch of the accessory nerve as a way to avoid shoulder paralysis was reported more than 20 years ago with initially excellent results, yet few follow-up studies have been done. Twenty-one fresh cadaver dissections of the accessory nerve-SCM branch and facial nerve were performed to determine if adequate numbers of fascicle groups and sufficient proximal nerve length are available for an adequate end-to-end anastomosis without nerve interposition grafting. This paper presents our anatomic and histologic findings to support the use of proximal SCM nerve anastomosis to distal facial nerve in facial reanimation. When feasible, the use of this technique to correct facial paralysis is encouraged rather than hypoglossal-to-facial nerve anastomotic repair.

Facial Reanimation Using Cranial Nerves XI to VII Anastomosis Without Shoulder Paralysis

Drs Dennis S. Poe, Burlington, Mass; Natan Scher, San Antonio, Tex; and William R. Panje, Chicago, Ill, reported at the recent meeting of the Eastern section of The Triological Society in Toronto, Canada, on January 27, 1989, on a feasibility study to determine if the 11th cranial nerve could be used in lieu of the 12th cranial nerve for reanastomosis with the seventh cranial nerve to restore facial function. Twenty-one neck dissections were performed on cadavers to determine the distribution and length of the 11th cranial nerve. They also transected the seventh cranial nerve at the stylomastoid foramen. The nerve sections were taken from both the seventh and the 11th cranial nerves for light microscopy and histologic examination. In those dissections, they were able to anatomically define the 11th cranial nerve and its relationships to the sternocleidomastoid muscle, the auricular nerve, and the cervical plexus. They noted that, when necessary, they

Biomechanical Basis of Transfers for Shoulder Paralysis

Elevation of the scapulohumeral joint can be executed by two different and distinct systems, both capable of separately performing this movement. The deltoid muscle is composed of several parts contracting independently, sometimes antagonistically between them and providing elevation in different directions. Parts two and three (Fick) of the deltoid are essential because they are lateral to the centers of rotation and work in the plane of the scapula. The supraspinatus and adjacent muscle system can produce compensatory movements with full elevation in the plane of the scapula. Lateral rotation is absolutely necessary for abduction in the coronal plane. Rotatory muscles inserted on the tuberosities of the proximal part of the humerus are more efficient than those inserted on the humeral diaphysis. Vertical and horizontal stabilization of the humeral head in the glenoid fossa is the result of a complex balance between several muscles and passive factors. Trapezius and serratus anterior are essential for the rotation of the scapula around its centers of rotation.

Electromyographical Study of Shoulder Paralysis due to Peripheral Nerve Injury

Electromyographical Study of Shoulder Paralysis due to Peripheral Nerve Injury

Tendon Transfers for Shoulder Paralysis in Children

The treatment of shoulder paralysis in children is discussed and a new classification system is presented. The importance of treating contracture before considering tendon transfers is emphasized, especially for internal rotation contracture where subscapularis release alone results in the return of active external rotation is 47 per cent of patients. Specific transfers for external rotation, internal rotation and abduction are discussed.

肩関節固定後の上腕骨骨折

The arthrodesis is very effective for the functional reconstruction of the paralytic shoulder joints. But humeral shaft fractures are the most embarrassing complications. We experienced two such cases. These cases are presented. We thought that it would be better for these patients to make contracture with preserving some passive movement than to fuse completely their paralytic shoulder joints.

Shoulder Paralysis due to Peripheral Nerve Injuries

Shoulder Paralysis due to Peripheral Nerve Injuries

Shoulder arthrodesis for paralysis and arthrosis.

Twenty-three patients with a mean age of 35 years (11 males and 12 females) were reexamined 6 years after shoulder fusion. Indication for the operation was shoulder paralysis in 14 cases and arthrosis in 9. In 4 patients the operation had to be repeated because of nonunion. Eighteen patients had improved function, particularly in bringing the hand to the midline of the body, to the face, and to the side pocket. However, bringing the hand to the back and the anal region often deteriorated. One third of the patients, mainly those with arthrosis, had considerable shoulder pain at the follow-up.

Tendontransference of Paralytic Shoulder Joint in Children

Tendontransference of Paralytic Shoulder Joint in Children

Treatment of paralysis of the flexors of the elbow.

1 . Twenty-one cases of poliomyelitis and twenty cases of brachial plexus injury in which muscle transplantations had been performed to restore elbow flexion have been reviewed. The average follow-up period was four and a half years. 2. The results were graded objectively and subjectively. They were better when passive extension of the elbow was limited; such limitation always occurs after Steindler's operation, but infrequently after pectoral transplantation. 3. The results of pectoral transplantation are good when there is no significant shoulder paralysis; if there is shoulder weakness arthrodesis of the joint may be required to control medial rotation and adduction of the shoulder on flexion of the elbow. In brachial plexus lesions the results of pectoral transplantation may be marred by simultaneous contraction of the triceps. This can be overcome by transplanting triceps into the flexor apparatus. Triceps transplantation is rarely indicated because loss of active extension of the elbow is a grave disability. 4. Subjective results tended to be worse than objective results in brachial plexus lesions because impairment of sensibility in the hand often limited the usefulness of the limb. In striking contrast the subjective results were in general far better than the objective in patients who had had poliomyelitis. In them the smallest gain can be of functional value.