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Time Completed: 01:42:54

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154
26

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Anatomy

Upper Limb

Question 11 of 180

A 28 year old man is brought to ED with a severely painful arm after being involved in a collapsed scrum during a rugby match. An x-ray of his arm is shown below. Which of the following nerves is most commonly injured in this type of injury:

By Hellerhoff (Own work) [CC BY-SA 3.0 , via Wikimedia Commons

(Image by Hellerhoff (Own work) [CC BY-SA 3.0 , via Wikimedia Commons)

Answer:

The x-ray shows an anterior shoulder dislocation - the axillary nerve is the most commonly injured nerve in this type of injury where it wraps around the surgical neck of the humerus.

Shoulder Joint Dislocation

Dislocation of the shoulder joint most commonly occurs in an anterior direction.

Clinical Features

  • Severe shoulder pain
  • All movements limited and painful
  • Affected arm supported by unaffected arm
  • Loss of normal contour of deltoid (flattened shoulder)
  • Step-off deformity at acromion (with palpable gap inferior to acromion)
  • Humeral head palpable anteriorly and below the coracoid process

Anterior Shoulder Dislocation. (Image by Hellerhoff [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)], from Wikimedia Commons)

Complications

Common complications of anterior shoulder dislocation include:

  • Axillary nerve damage (paralysis of the teres minor and deltoid with weakness of lateral rotation and abduction, and loss of sensation over 'regimental badge' area on lateral arm)
  • Posterior humeral circumflex vessel damage
  • Bankart lesion (avulsion of the glenoid labrum at the insertion of the inferior glenohumeral ligament)
  • Rotator cuff damage
  • Shoulder joint instability
  • Injury to brachial plexus

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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