Level 5: N
Normal
100 %
Full, normal muscle strength
Level 4: G
Good
Approx. 75 %
Medium resistance can be overcome in full range of motion
Level 3: F
Fair
Approx. 50 %
Movement against gravity can be performed in full range of motion
Level 2: P
Poor
Approx. 25 %
Full range of motion possible with exclusion of gravity
Level 1: T
Trace
Approx. 10 %
Trace of tension in the muscle
Level 0: Z
Zero
0 %
No muscle contraction possible
Addition
S
Spasticity
Addition
K
Contracture
Functional Testing
For the function of each muscle see Table 20.2:
Table 20.2
Characteristic muscles and their functions at the shoulder joint
Muscle | Function |
|---|---|
M. supraspinatus | Initiates abduction |
M. infraspinatus | External rotation, adduction |
M. subscapularis | Internal rotation, adduction |
M. deltoideus | Abduction from about 30° |
M. teres minor | External rotation, adduction |
M. biceps | Caput longum: abduction |
Caput breve: adduction | |
M. pectoralis major | Adduction |
M. coracobrachialis | Adduction, internal rotation, anteversion |
M. trapezius pars deszendens and aszendens | Elevation beyond horizontal |
M. serratus anterior | Connects shoulder joint and trunk; pulls the scapula in ventral direction and allows rotation |
M. latissimus dorsi | Adduction |
Anteversion is also denoted flexion, while retroversion can also be called extension. The resistance test is usually done in sitting position. Immediately after surgery, it should be avoided. Isometric strength tests are to be omitted after surgery. In addition to the shoulder joint, flexion and extension and pronation and supination in the elbow joint should always be tested.
To assess the shoulder joint function and document the subjective history of patients, questionnaires can be used:
Constant score: Summarizes subjective (35 %) and objective (65 %) parameters to a total of 100 points; it covers e.g. pain, strength, agility and everyday functionality; it is recommended by the SECEC (European Society of Shoulder and Elbow Surgery) as well as the DVSE (German Society of Shoulder and Elbow Surgery) as a standard tool for the assessment of shoulder function
Oxford Score: Captures the results of shoulder surgery and the influence of shoulder injuries on daily activities and quality of living in 12 points
DASH (Disabilities of Arm, Shoulder and Hand): A subjective score, which measures the ability to carry out everyday activities; the way in which these activities are carried out is not recorded.
SPADI (Shoulder Pain and Disability Index): Subjective score, pain and impairment in activities of daily living are recorded
Neurological Status
A complete examination includes the orientational neurological status of the relevant nerves in the shoulder joint. Indications of motor deficits are already obtained in parallel to the muscle function test. Basically, the innervation is realized via the brachial plexus (segment C4–C6). An overview of the innervation of each muscle is provided in Table 20.3.
Table 20.3
Shoulder muscles and their innervation
Muscle | Innervation |
|---|---|
M. supraspinatus | N. suprascapularis |
M. infraspinatus | N. suprascapularis |
M. subscapularis | Nn. subscapulares (from the fasciculus post. of the Plexus brachialis) |
M. deltoideus | N. axillaris |
M. teres minor | N. axillaris |
M. biceps (caput longum and caput breve) | N. musculocutaneus |
M. pectoralis major | N. pectoralis (from N. suprascapularis) |
M. coracobrachialis | N. musculocutaneus |
M. trapezius pars deszendens and aszendens | N. accessorius and branches of the cervical plexus |
M. serratus anterior | N. thoracicus longus |
M. latissimus dorsi | N. thoracodorsalis |
Due to its location close to the humerus, the radial nerve is often affected in addition to the mentioned muscles in fractures or storage damages. Nerves that are also frequently lesioned are: the axillary nerve, the musculocutaneous nerve and the median nerve.
Radial Nerve
If there is a lesion of the radial nerve in the front third region of the proximal humerus, there will be a paralysis of the triceps (not in case of a lesion at the level of the mid upper arm!), brachialis and all wrist extensors. An extension of the elbow joint is no longer possible, as well as there is a weakness in flexion of the elbow in the middle position. The symptom of the typical “drop hand” occurs, as the active extension of the hand is paralyzed. In addition, no active abduction of the thumb is possible due to the failure of the M. abductor pollicis. The hand is pronated.
Axillary Nerve
The axillary nerve contains fibers from the spinal cord segments C5 and C6. It runs very close to the humerus in the quadrangular space. A lesion of the axillary nerve occurs very frequently in shoulder dislocations, but also in humerus fractures. As a result of a lesion, a functional failure of the deltoid and teres minor will occur, so that the arm can not be lifted up to the horizontal plane. In case of hypo- or atrophy of the deltoid muscle, the symptom of “acute shoulder” will result.
Sensory disturbances will occur at the outside of the proximal shoulder joint.
Musculocutaneous Nerve
The n. musculocutaneus provides motoric innervation to the coracobrachialis, the biceps and the brachialis. In case of lesions, atrophies of the anterior upper arm muscles occur accordingly. This leads to loss of function of flexion and supination of the forearm, which can be compensated by other muscle groups. The failures of the coracobrachialis can also be compensated in case of an isolated lesion. Nevertheless, a misalignment of the humerus head occurs in any type of lesion.
Median Nerve
In case of irritations of the median nerve, the known “monkey hand” occurs when the patient is asked to close his hand to a fist. Fingers I–III remain stretched, while only fingers IV and V can be bent as they are supplied by the ulnar nerve. As the M. opponens pollicis malfunctions, only an incomplete closure of the fist is possible. Typically, a bottle cannot be held anymore. This condition is termed as “positive bottle sign”. Sensory disturbances occur in case of median nerve lesions of the thumb, forefinger and middle finger and partially on the ring finger.
Therapeutic Regimens Overview
A surgeon acting responsibly should also set the guidelines for the treatment, because he knows the intraoperative findings best. Here, he has to predetermine the actually permitted ranges of motion and define details for the load in each case, as well as to define the further increase over time in a regular healing process. The earliest possible mobilization under sufficient analgesia and the degrees of movement and exercise levels set by the surgeon are important in any case. The partially necessary immobilization of 3–4 weeks is already leading to contractures in the capsular-ligament system, whereby the subsequent mobilization is considerably more difficult and delayed. The availability of studies regarding the optimum time interval of immobilization is not satisfactory [1].
General Therapeutic Measures
Positioning and Splint Supply
Postoperative positioning should preferably be comfortable and painless for the patient, as far as possible under the permitted ranges of motion.
The shoulder joint should be stored in a slight internal rotation and abduction. A functionally correct positioning of the elbow joint is flexion of 90–100° and a slight pronation. Pillows, wedge pillows, blankets, foam, roll pillows, sand bags and splints can be used to position the patients.
Congenital or acquired functional limitations must be considered. With the patient lying in an acute stage, slight elevation above heart level is recommended to favor the decongestion. Possible nerve pressure points and exposed wound or scar areas must be padded well.
Depending on the type of surgery and intraoperative situation, the surgeon prescribes 3–6 weeks of immobilization of the shoulder joint. The existing auxiliary devices for this are:
Desault dressing: maximum immobilization, therefore used for no longer than 2–3 weeks; shoulder joint in neutral position and maximum internal rotation, elbow in 90° flexion
Gilchrist dressing: zero position and maximum internal rotation of the shoulder joint, elbow joint in 90° flexion; the hand can and may be moved and used; in case of stable osteosyntheses only necessary for a few days (Fig. 20.1a)
Fig. 20.1
Examples of shoulder ortheses (a) gilchrist, (b) abduction pillow
Abduction pillow: relieves capsular ligaments by 40–60° – abduction position and internally rotated arm; elbow joint in 90° flexion; applied postoperatively usually for 4–6 weeks, especially in case of prosthetic treatment (Fig. 20.1b)
Arm sling/Bronner sling: sometimes used as a transition to relief at the stage of active training or exercise-stable osteosyntheses; rotation of the shoulder joint possible
Analgesia
Modern pain management should be sufficient to counteract peri- and postoperative chronic pain and to allow early mobilization. Through a proactive basic analgesia, better pain relief is achieved at a lower total dose. Centrally, regionally and locally acting analgesics are used. Centrally acting opioids are mainly applied intraoperatively and in the early postoperative phase. The patients have to be monitored sufficiently (respiratory depression). In outpatient surgery, usually no centrally acting substances are used.
In case of very painful procedures (e.g. arthrolysis), the installation of a pain catheter in the supraclavicular plexus or patient-controlled analgesia (PCA) is useful with computer-controlled, need-based administration of opioids. Only in this way, an adequate analgesia for earliest possible mobilization can be achieved. It is important to check the involved nerves for their regular functioning before installing the catheter.
The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is well-established in the further course of treatment because of the additional decongestant and anti-inflammatory compounds of these substances in the first 10–14 postoperative days. Additionally, Novaminsulfon or Tramal can be administered. In principle, treatment is conducted according to the WHO staging system. If pain is occurring during rehabilitation treatment with intensive exercising, a local steroid infiltration therapy can be successful in addition to a reduction of the intensity.
Cooling Applications
To reduce swelling and hyperthermia, cooling applications in the form of ice, cooling pads, quark compresses or alcohol covers etc. are suitable. In addition, cryotherapy is one of the preparatory and accompanying measures of motor-functional treatment methods. Short-term measures of 5–15 s have a rather superficial effect on the sympathetic nervous system. Heat dissipation is accelerated, the tissue tone decreases, the pain is muted and the motor system is activated. Fast rubbing with ice promotes the disposition of a weakened muscle to contract.
Long-term applications of 10–30 min, act further in depth in the sense of a dampening, depending on the fat layer. The pain relief outlasts the time of application about two to three -times. Cold water covers promote the absorption of edema. Cryotherapy can therefore on the one hand reduce pain, on the other hand stimulate muscles. It should be noted that the pain threshold is increased by the application of ice so that pain as a protective function is partially disabled. Patients sometimes allow too intense exercise and in some cases develop increased pain symptoms only hours after treatment. During the first 2 postoperative weeks, only dry ice packs with textile cover should be used for cooling at the surgical site until removal of the suture.
The cooling system should be rather mild and carried out in an interval principle. The ice-swab technique is also proven. Ice compression bandages should only be applied in exceptional circumstances and under supervision. If cold pain occurs, the patient must have an opportunity to remove the cooling cover immediately, otherwise there is a risk of ice burns. Injuries associated with sensory loss are particularly at risk.
Heat Applications
In the acute state, the application of heat in the injured shoulder is absolutely contraindicated because it intensifies the stimulus sensitivity and inflammatory responses and leads to increased edema. Under certain circumstances, even bleeding or rebleeding can be triggered or at least strengthened.
It makes sense, however, to use the heat in some remote regions as relaxing and circulation-enhancing measure, for example, to the strained neck muscles. Typical application forms are the classic mud pack and hay flower sachets and the so-called “hot roll”. In this case, a rolled up hand towel is soaked with boiling water. The towel roll is just as hot as tolerated by the patient (approximately 45 to a maximum of 65 °C) and is repeatedly pressed and unrolled at different points in the treatment area. After cooling, the procedure is repeated. The treatment takes 10–20 min. Advantage over the Fango treatment is the individualized dose of warmth and prevent heat build-up.
In the chronic stage, heat is well-suited for the treatment of contractures. Under heat used therapeutically in the range of 40–45 °C, collagen fibers do not completely reverse back to their original length after increasing strain. A partial extension remains even after the stretching stimulus is removed. The treatment is less strength-consuming for the therapist, because the resistance to movement is reduced by the application of heat and the maximum passive movement speed increases.
Massages
Manual Lymphatic Drainage
Manual lymph drainage is a special form of massage. By particularly soft, tissue-sparing techniques, intra- and extravascular tissue fluid is tried to be mobilized and drained to relieve the accumulated body region. Depending on the surgical incision, small lymphatic vessels will be interrupted so that there are perifocal lymphedema. Through the lymph drainage, the own motor function of the wall muscle is stimulated in the transport vessels and promotes the formation of new lymphatic vessels.
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