Clinical Cases: Upper Limb

Clinical Cases test your anatomical and clinical knowledge. Each case comes with a list of
questions followed by a detailed discussion on findings and treatment to emphasize the
clinical significance of a structure and highlight how injury or disease affects it. High-yield
facts are also included to pin-point important information.

Select a clinical case from the list below

Case 1: A 28-Year-Old Volley Ball Player Fell on Her Right Outstretched Arm During a
Game

Case 2: A 4-Year-Old Girl Is Brought to the Emergency Room by Her Father After Some
Horseplay in Her Backyard Left Her Holding Her Elbow and Unable to Move Her Hand

Case 3: A 28-Year-Old Man was Horseback Riding When the Horse He was Riding
Stumbled, Throwing Him From the Saddle

Case 4: A 21-Year-Old Collegiate Swimmer Goes to Her Doctor with a Complaint of

Shoulder Pain

Case 5: A 28-Year-Old Woman in Her Eighth Month of Pregnancy Comes to Her Physician’s
Office with a Complaint of Numbness, Tingling, and Slight Pain in Both Hands

Case 6: The Goalkeeper in a Soccer Match Fell Heavily on His Outstretched Left Arm
Blocking a Kick
Case 1: A 28-Year-Old Volley Ball Player Fell on Her Right Outstretched Arm During a
Game

Part A: The Case

History
A 28-year-old volley ball player fell on her right outstretched arm during a game. She felt an
immediate pain in her wrist. She was taken to the emergency room of the local hospital at the
end of the game, where you examine her.

Physical Exam
Except for the painful wrist, you find that the patient is in excellent health and taking no
regular medication. Vital signs are normal. On examination, you note that in comparison to
her left wrist, the right wrist has a deformity that resembles a dinner fork. All her wrist
movements are extremely painful.

Test Results
You order a plain radiograph; it reveals a transverse fracture of the distal end of the radius,
which was tilted posteriorly and radially. You diagnose a Colles’ fracture.

Questions

• What bones may fracture as a result of someone’s fall on an outstretched hand?

• Which muscle tendon is more likely to be injured in Colles’ fracture?
• What would be the complication if such a fracture takes place in young children?
• Why is this the most common fracture in women older than age 50 years?
Case 1: A 28-Year-Old Volley Ball Player Fell on Her Right Outstretched Arm During a
Game

Part B: The Answer

Topic
Colles’ Fracture

Discussion

• The patient has a fracture of the distal end of the radius, called a Colles’ facture,
which is a common result of falling on an outstretched hand (Plate 439).
• This usually presents as a dinner fork deformity because the distal end of the radius is
displaced posteriorly and tilted.
• The extensor pollicis longus tendon may be injured in a Colles’ fracture ( Plate 444 ).
• Other bones that can be fractured in such a fall are the scaphoid, lower end of the
radius, ulnar styloid, lower end and surgical neck of the humerus, and clavicle.
• Such a fall in children may result in a separated epiphysis with a crushed growth
plate.
• In this case differential radial and ulnar growth may result.
• A Colles’ fracture is the most common fracture in people older than age 50 years in
general but especially in women because their bones may be weakened by
osteoporosis.

Findings

• A Colles’ fracture is a complete transverse fracture of the distal end of the radius,
resulting from forced dorsiflexion of the hand, usually from a fall on an outstretched
upper limb.
• The radius fractures because it projects further distally than the ulna, and the posterior
projection of the fractured radial end creates a bump in the forearm just proximal to
the wrist, the so-called dinner fork deformity.

Treatment

• Treatment may range from simple immobilization with a splint and sling to a
lightweight fiberglass cast for 6 to 8 weeks.
• There is a rich blood supply to the distal end of the radius, and union of the fractured
ends is usually good.
• If casting is necessary, traction is applied after a local hematoma block and parenteral
pain medication to align the fracture pieces and reduce the fracture.
• Then the palm is flexed, wrist firmly pronated, and the distal radius pressed while
casting to maintain the reduction.
• If cast immobilization is insufficient to repair the fracture, surgery may be necessary
and the break may need to be fixed with a plate and screws.
• Older people with Colles’ fractures often fail to regain full mobility of the wrist joint,
and carpal tunnel syndrome may occur as a late complication.
More High-Yield Facts

• Although the radius is shorter than the ulna, the radial styloid process is larger than
the ulnar styloid process and extends further distally (Plate 439). This is why a fall on
an outstretched hand usually results in a Colles’ fracture.
• The distal end of the radius and the articular disc in the radioulnar joint articulate with
the proximal row of carpal bones, with the exception of the pisiform.
• A radial collateral ligament attaches the radial styloid process to the scaphoid bone.
Plate 444:Upper Limb-Elbow and Forearm-Muscles of Forearm (Superficial Layer):
Posterior View
Case 2: A 4-Year-Old Girl Is Brought to the Emergency Room by Her Father After Some
Horseplay in Her Backyard Left Her Holding Her Elbow and Unable to Move Her Hand

Part A: The Case

History
A 4-year-old girl is brought to the emergency room by her father after some horseplay in her
backyard left her holding her elbow and unable to move her hand without pain. Her father
reports that he had picked up his daughter by her hand and started swinging her around in a
circle. When he put her down, she was giggling, but when she tried to move her arm, she
cried out in pain.

Physical Exam
The girl’s vital signs are normal. You notice that she is holding her arm in a partially flexed
and pronated position, and when you ask her to supinated her hand, she refuses to do so,
saying that it hurts a lot. When you palpate her elbow, you find that the joint is tender,
especially on the lateral side, but all of the bony landmarks were in their normal locations.
She is able to move her fingers without difficulty. You suspect that the head of the radius had
slipped out of the anular ligament and you order a radiograph.

Test Results
The radiograph is inconclusive.

Questions

• What is the anular ligament and where is it located?

• What are the bony landmarks that are readily palpable at the elbow?
• Why might the radiographs have been unhelpful in this situation?
• What nervous structure is particularly vulnerable in elbow injuries and where is it
located?
• What other types of elbow dislocations are common and how do they present?
Case 2: A 4-Year-Old Girl Is Brought to the Emergency Room by Her Father After Some
Horseplay in Her Backyard Left Her Holding Her Elbow and Unable to Move Her Hand

Part B: The Answer

Topic
Subluxation of the Head of the Radius

Discussion

• Subluxation (incomplete or partial dislocation) of the head of radius from its

encircling anular ligament is a common elbow injury among young children, and is
most common in children younger than age 6, when the radial head is spherical and
smaller, compared to the size of the anular ligament, and is composed mainly of
cartilage (Plate 436).
• It generally results from a sudden pull on the upper limb, such as that exerted by an
adult to prevent the child from falling or, in this case, swinging the child around by
the hand.
• The radial head is traumatically subluxated with forceful pulling on the hand when the
child’s elbow extended and the forearm pronated.
• As a result, the ligament becomes interposed between the radial head and capitulum
of the humerus.
• This condition is also called “Nursemaid’s Elbow,” undoubtedly because long ago it
was seen in small children raised by nursemaids who swung their young charges
around by the arms.
• The annular ligament is a circular ligament that forms a collar around the head of the
radius, holding it firmly in place without directly attaching to the radius.
• This allows relatively free rotary movement of the radius at its proximal articulation
with the capitulum of the humerus.
• The anular ligament is attached to the anterior and posterior margins of the radial
notch on the ulna.
• The bony landmarks of the elbow that can be readily palpated include the olecranon
process of the ulna, lateral, and medial epicondyles of the humerus, and the head of
the radius.
• The three-dimensional relationships of these landmarks are important in diagnosing
injuries to the elbow joint.
• The radiographs in this case were not helpful because this injury is not likely to tear
the joint capsule and as a result, the head of the radius may not be obviously displaced
on films.
• Furthermore, obtaining them was likely difficult in itself because of the age of the
patient and the severity of pain caused by manipulation of the elbow.
• The ulnar nerve, which passes behind the medial epicondyle and crosses the medial
ligament of the elbow, is particularly vulnerable in elbow injuries.
• The ulnar nerve is often crushed in elbow injuries, which may lead to sensory loss and
muscle weakness or paralysis in regions of ulnar distribution.
• Symptoms may appear immediately or after some delay.
• The effects of ulnar nerve damage are noticed particularly in the hand.
• Other common injuries to the elbow include:
o Posterior dislocation of the elbow:
 ▪ These are common in children and generally result from falling on an
outstretched hand with the elbow flexed.
▪ These are easily recognized by unusual protrusion of the olecranon
posteriorly along with displacement of the distal end of the humerus
anteriorly, disrupting normal articulation with the forearm at the radial
head and trochlear notch.
o Avulsion of the medial epicondyle:
▪ Also common in children, this injury results from a fall that causes
severe abduction of an extended elbow.
▪ The ulnar collateral ligament, which is stronger than the fusion of the
diaphysis and epiphysis of the humerus at the medial epicondyle, pulls
the medial epicondyle away from the humerus.
▪ This epiphyseal plate does not usually fuse until around 20 years of
age.
o Separation of the proximal radial epiphysis:
▪ This injury again happens only in children and is a displacement of the
radial head following a fall that places a compression and abduction
force on the elbow.
▪ This epiphysis usually fuses around 14 to 17 years of age.
▪ In adults, fractures of the elbow tend to occur more frequently than
dislocations.

Findings

• The anular ligament, together with the radial notch, completely encircles the head of
the radius.
• Preschool children are very vulnerable to subluxation (an incomplete dislocation) of
the head of the radius from its encircling ligament.
• When this happens, the limb is held with a flexed elbow and pronated forearm.

Treatment

• This injury is treated by reduction (realignment of the bones).

• The head of the radius is repositioned by supinating the forearm fully and then flexing
the elbow.
• A small pop can be felt on the lateral side of the cubital fossa as the head of the radius
slips back into position, and within a few moments the pain disappears.
• Immobilization is not necessary for the first episode of subluxation, but if treatment is
delayed for more than 12 hours, the upper limb should be immobilized for several
days in a long-arm posterior splint with the elbow in 90 degrees of flexion and the
forearm in full supination.
• Recurrent episodes of subluxation may require surgical repair of the annular ligament.
• If the anular ligament is torn, the limb should be placed in a sling for 2 weeks to allow
for healing.

More High-Yield Facts

• The proximal radioulnar joint is a pivot type of synovial joint in which the head of the
radius articulates with the radial notch of the ulna and is held in place by the anular
ligament.
• A fibrous capsule encloses the joint and is continuous with the capsule of the elbow
joint.
• A synovial membrane lines the deep surface of the anular ligament, and the head of
the radius rotates within it, allowing pronation ad supination of the forearm.
Case 3: A 28-Year-Old Man was Horseback Riding When the Horse He was Riding
Stumbled, Throwing Him From the Saddle

Part A: The Case

History
A 28-year-old man was horseback riding when the horse he was riding stumbled, throwing
him from the saddle. In order to break his fall, he stretched out his right hand, injuring his
wrist. He remounted his horse and continued to ride, but his wrist continued to hurt. When
the ride was finished, he went to the local emergency room to have his wrist examined. The
emergency room was crowded that afternoon and the staff was extremely busy. When the
resident came in, he gave the patient a quick examination, decided that the wrist was
sprained, wrapped it in a bandage and prescribed a pain killer. For 2 weeks following the
injury, the patient experienced little pain and assumed that his sprain was healing. After the
medication ran out, however, he began to experience more pain and a loss of movement in
the injured wrist. He then went to see his own doctor.

Physical Exam
Except for the painful wrist, you find that the patient is otherwise healthy and taking no
regular medication. Vital signs are normal. You then press in various regions of the hand and
wrist to assess point tenderness and pain, and when you come to the region of the anatomical
snuffbox, the patient yells and pulls away his hand, saying that he feels severe pain in that
area.

Test Results
You order radiographs of the wrist, which show that your patient had suffered a fracture of
one of the bones in the wrist. You diagnose a fracture of the scaphoid bone.

Questions

• What is the anatomical snuffbox?

• What bone did your patient break? (Hint: It is palpable in the anatomical snuffbox.)
• What are some of the possible anatomic reasons that this bone failed to heal?
• Why might the resident have missed the diagnosis initially?
Case 3: A 28-Year-Old Man was Horseback Riding When the Horse He was Riding
Stumbled, Throwing Him From the Saddle

Part B: The Answer

Topic
Scaphoid Fracture

Discussion

• The patient has a fracture of the scaphoid bone, which can be palpated in the
anatomical snuffbox (Plate 421).
• The anatomical snuffbox is the triangular depression observed on the dorsum of the
hand when the thumb is fully extended.
• It is bounded by the tendons of the extensor pollicis longus on the medial side and the
extensor pollicis brevis on the lateral side.
• The scaphoid is the most frequently fractured of the carpal bones.
• There are three basic reasons why the patient’s fracture may have failed to heal:
a. The blood supply to the scaphoid frequently enters the bone only from its
distal end; therefore, a fracture may deprive the proximal fragment of blood,
interfering with healing and possibly leading to necrosis of the proximal
fragment.
b. The fracture line may enter a joint with one of the other bones of the wrist,
leading to leakage of synovial fluid into the space. The presence of synovial
fluid may prevent healing of the fracture. The scaphoid is not easily
immobilized to promote healing, due to its small size and its location.
c. Scaphoid fractures produce symptoms that are similar to strains and sprains
(synovial effusion, joint pain, and limitation of movement), and thus can easily
be confused with a strain or sprain if a careful examination is not performed.

Findings

• The patient has a fracture of the scaphoid bone, a common result of a hard fall onto
the hand.

Treatment

• Treatment of a scaphoid fracture depends on the type of fracture, the presence of any
associated ligament damage, and the severity of the ligament damage.
• The location of the fracture in the bone is also important since fractures of some parts
of the bone statistically heal better in a cast than others.
• Placement of a cast with thumb immobilization is the treatment of choice for those
patients who have a fracture that is incomplete or does not extend all the way across
the bone. Nondisplaced fractures treated in a cast within 28 days after the injury have
a good chance of healing, with an average time in the cast of 3 months.
• A fresh fracture of the scaphoid (less than 2 to 4 weeks old) that is displaced or
unstable can be treated with an operation to reduce and/or stabilize the fracture with
the fixation device.
 • If it is not stabilized, the bone usually will not heal in a cast; and if it does, the wrist is
stiff and usually develops traumatic arthritis leading to pain and loss of use.
• A nonunion of the scaphoid bone in an older fracture requires a bone graft to
stimulate union. For this, a small piece of bone may be taken from the patient's pelvis.

More High-Yield Facts

• Other injuries common with a fall on an outstretched hands include:

o Dislocation of the lunate bone
o Posterior displacement of the distal radial epiphysis (in children)
o Fracture of the clavicle (in adolescents)
o Fracture of the distal radius (Colles’ fracture—usually in older adults)
Case 4: A 21-Year-Old Collegiate Swimmer Goes to Her Doctor with a Complaint of
Shoulder Pain

Part A: The Case

History
A 21-year-old collegiate swimmer goes to her doctor with a complaint of shoulder pain and a
reduced range of motion in the shoulder joint.

Physical Exam
On examination, the patient was able to achieve approximately 165 degrees of shoulder
flexion/arm abduction, with pain between approximately 70 and 120 degrees of abduction.
With more than 120 degrees of abduction, she did not feel any pain. Shoulder abduction
against resistance yielded pain only during the first 35 degrees of movement. All other
resisted movements were painless. Palpation of the shoulder only produced pain on the
superior surface of the greater tubercle of the humerus. Pressure at this location also produced
pain that radiated down the lateral side of her arm. You suspect a problem with the
swimmer’s rotator cuff.

Questions

• What muscles, along with their tendons, compose the rotator cuff?
• Where do these muscles insert?
• Based on the preceding information, which tendon specifically was inflamed?
• Why did the pain radiate down the patient’s arm?
• When the arm was abducted without resistance, pain was felt between 70 and 120
degrees of abduction; however, abduction against resistance produced pain only
during the first 35 degrees. How would you explain this?
• When abducting the arm fully through 180 degrees, how much of the elevation is
because of movement of the glenohumeral (shoulder) joint, and how much is because
of rotation of the scapula?
Case 4: A 21-Year-Old Collegiate Swimmer Goes to Her Doctor with a Complaint of
Shoulder Pain

Part B: The Answer

Topic
Torn Rotator Cuff

Discussion

• Rotator cuff injuries are fairly common, especially in people performing repetitive
arm movements done overhead, such as in swimming.
• Other causes of the injury may include falling and lifting.
• The muscles of the rotator cuff (Plate 420, Plate 421, and Plate 425) are as follows:
o Supraspinatus inserts:
▪ Into the upper facet of the greater tubercle of the humerus
▪ Into the capsule of the shoulder joint
o Infraspinatus inserts:
▪ Into the middle facet of the greater tubercle of the humerus
▪ Into the capsule of the shoulder joint
o Teres minor inserts:
▪ Into the lower facet of the greater tubercle of the humerus
▪ Into the capsule of the shoulder joint
o Subscapularis inserts:
▪ Onto the lesser tubercle of the humerus
• From the physical exam and the information provided by the patient, it appears that
the supraspinatus tendon is inflamed (Plate 425).
• The results of the motion tests, and especially the location of pain on palpation, are
the key indicators suggesting supraspinatus tendonitis.
• The supraspinatus muscle is innervated by the suprascapular nerve, which contains
nerve fibers from C5.
• The lateral surface of the arm contains part of the C5 dermatome.
• Thus the pain on the lateral side of patient’s arm was likely referred pain.
• The pain from abduction against resistance directly results from the action of the
supraspinatus muscle, which initiates abduction.
• The pain felt between 70 and 120 degrees with no resistance is probably caused by
compression of the supraspinatus tendon between the greater tubercle of the humerus
and the acromion process.

Abduction of the Arm

• Abduction of the arm is actually a fairly complex process.

• During the first 30 degrees of abduction, only the glenohumeral joint (Plate 423) is in
motion, caused first by the supraspinatus primarily (0 to15 degrees) and then by the
deltoid.
• From approximately 30 to 120 degrees, both the glenohumeral joint and the scapula
are moving such that for every 3 degrees of abduction, 2 degrees are contributed by
glenohumeral movement, and 1 degree by scapular rotation.
 • From 120 to 180 degrees, abduction results exclusively from rotation of the scapula
(the greater tubercle of the humerus bumps against the acromion at approximately 120
degrees).

Findings

• The patient was informed that she had tendonitis in her rotator cuff, specifically her
supraspinatus muscle.

Treatment

• Anti-inflammatory medication was prescribed, along with ultrasound therapy and rest.
• If the pain had been severe, a corticosteroid injection might have been administered to
relieve the symptoms.

More High-Yield Facts

• Increasingly after age 40 years, normal wear and tear on the rotator cuff can cause a
breakdown of collagen in the cuff’s tendons and muscles, making them more prone to
degeneration and injury.
• Calcium deposits or arthritic bone spurs also can develop within the cuff with age and
can pinch or abrade the muscle tendons.
• Tears of the rotator cuff are uncommon in young patients, but chronic abrasion in
older patients can lead to tears.
• The supraspinatus is the most frequently torn of the rotator cuff muscles, possibly
because of its relative lack of a vascular supply.
• Surgery to repair a tear can be done through a 6- to 10-cm incision, but usually is
done arthroscopically, with the aid of a small camera inserted through a smaller
incision.
• During this surgery, bone spurs or calcium deposits can be scraped and removed.
Case 5: A 28-Year-Old Woman in Her Eighth Month of Pregnancy Comes to Her Physician’s
Office with a Complaint of Numbness, Tingling, and Slight Pain in Both Hands

Part A: The Case

History
A 28-year-old woman in her eighth month of pregnancy comes to her physician’s office with
a complaint of numbness, tingling, and slight pain in both hands, which are worse during the
night, often waking her, and in the morning when she gets up. Recently, she has experienced
some weakness in her grasp, and notes that most of her symptoms seem to be limited to her
thumb and index and middle fingers.

Physical Exam
The patient’s vital signs are normal. After her weight is taken, you note that she has gained
45 pounds during her pregnancy. She tells you that recently her ankles have begun to swell.
On examination, you determine that she has impaired appreciation of light touch and pin
pricks to the thumb, index, middle, and lateral side of her ring finger, but sensation to her
palm is not affected. You also find that there is a loss of strength in certain movements of the
thumb. Pressure and tapping over the flexor retinaculum causes tingling (Tinel’s sign). You
make a diagnosis of carpal tunnel syndrome

Questions

• What is the carpal tunnel? What is contained in it?

• Two muscles that are affected by carpal tunnel syndrome are the abductor pollicis
brevis and the opponens pollicis. How would you test their function?
• Physicians used to think this kind of pain was caused by a deficiency in the brachial
plexus. If this was the case, what roots or trunks would have to be involved and why
is this unlikely to be the cause of the problem? (Consider both sensory and motor
deficiencies that this patient has.)
• What causes the symptoms of carpal tunnel syndrome?
Case 5: A 28-Year-Old Woman in Her Eighth Month of Pregnancy Comes to Her Physician’s
Office with a Complaint of Numbness, Tingling, and Slight Pain in Both Hands

Part B: The Answer

Topic
Carpal Tunnel Syndrome

Discussion

• Carpal tunnel syndrome affects approximately 3% of adults in the United States and is
approximately three times more common in women than in men.
• Twenty-eight percent of all pregnant women will experience this syndrome.
• The carpal tunnel is a canal at the wrist made up of the carpal bones and flexor
retinaculum. The tunnel houses the tendon of the flexor pollicis longus in its synovial
sheath, the tendons of the flexor digitorum superficialis, and profundus in their
common synovial sheath and the median nerve (Plate 461).
• The two muscles of the thumb that are affected by carpal tunnel syndrome are the
abductor pollicis brevis and the opponens pollicis.
• The abductor pollicis brevis pulls the thumb away from the palm at a right angle.
• One way to test this muscle is to ask the patient to place her forearm on a table, palm
up and ask her to point their thumb toward the ceiling.
• The opponens pollicis pulls the thumb across the palm toward the base of the little
finger. Ask the patient to do this against resistance.
• If this patient's symptoms were caused by a deficiency in the brachial plexus,
practically all roots from C6 to T1 would have to be involved.
• The sensory dermatome of that region comes from the ventral rami of C6 and C7,
which compose part of the upper and the entire middle trunk of the brachial plexus.
• The motor supply to the muscles involved come from segments of C8 and T1.
• Such a widespread lesion, however, would be unlikely to have such limited
symptoms.
• Carpal tunnel syndrome is caused by a compression of the median nerve.
• Alterations in fluid balance may predispose some pregnant women to develop carpal
tunnel syndrome.
• Symptoms are typically bilateral and first noted during the third trimester.
• High prevalence rates of unilateral carpal tunnel syndrome have been reported in
persons who perform certain repetitive wrist motions.
• This appears to be a result of the inflammation of the common flexor tendon sheath
after strain and overexertion.
• Patients often feel an increase in symptoms at night because of venous stasis. Venous
stasis contributes to the compression of the nerve.

Findings

• This patient has developed carpal tunnel syndrome as a result of her pregnancy.
• Alternations in fluid balance have led to swelling of her extremities, with compression
of the median nerve as it travels through the carpal tunnel.
 • The function of her abductor pollicis brevis and opponens pollicis are particularly
effected, and there is a partial loss of sensation to those areas of the hand supplied by
the median nerve:
o Thumb
o Index
o Middle
o Lateral side of her ring finger

Treatment

• In this case, conservative measures are appropriate, because symptoms resolve after
delivery in most women with pregnancy-related carpal tunnel syndrome.
• Patients with carpal tunnel syndrome should avoid repetitive wrist and hand motions
that may exacerbate symptoms.
• If possible, they should not use tools that vibrate (e.g., floor sanders, drills), because
the vibration can make their symptoms worse.
• Ergonomic measures to relieve symptoms depend on the motion that needs to be
minimized. Patients who work on computers, for example, may benefit from
improved wrist positioning or the use of wrist supports.
• Wrist splints may be helpful for patients in other professions that require repetitive
wrist motion.
• In addition to wrist splinting, conservative treatments include oral corticosteroid
therapy and local corticosteroid injections.
• Approximately 80% of patients with carpal tunnel syndrome initially respond to
conservative treatment; surgery should be considered when carpal tunnel syndrome
does not respond to conservative measures.

More High-Yield Facts

• If conservative treatment of nonpregnancy-related carpal tunnel syndrome fails,

surgery can decompress the median nerve and relieve the symptoms.
• However, structures superficial to the flexor retinaculum might be endangered by
open surgery and need to be avoided:
o The superficial palmar vascular arch formed by the superficial branch of the
ulnar artery
o The superficial branch of the radial artery
o The palmar cutaneous branches of the median and ulnar nerves
o The recurrent motor branch of the median nerve
• Median nerve decompression is now frequently done laparoscopically, needing only a
small incision in the palm and another about 1 cm above the wrist.
• These incisions heal more rapidly than the larger one of an open surgery.
Case 6: The Goalkeeper in a Soccer Match Fell Heavily on His Outstretched Left Arm
Blocking a Kick

Part A: The Case

History
The goalkeeper in a soccer match fell heavily on his outstretched left arm blocking a kick. He
felt an immediate pain in the shoulder region and was unable to move his arm. He was
brought to the emergency room 20 minutes later.

Physical Exam
At the hospital, you note that the keeper’s arm is slightly abducted, he is supporting his
injured arm with his other hand, and the injured arm appears longer than the uninjured one.
When the patient is asked to move his arm, he has intense pain. You order a radiograph.

Test Results
A plain film of the shoulder region shows that humeral head lying below the glenoid labrum
but no fracture of the humerus. You diagnose an anterior dislocation of the head of the
humerus.

Questions

• What neurovascular structures are liable to be injured in such a condition? How do

you examine the patient to rule that out?
• What other structures are usually damaged in such an injury?
• What is the anatomical principle in reducing a dislocation of this type?
Case 6: The Goalkeeper in a Soccer Match Fell Heavily on His Outstretched Left Arm
Blocking a Kick

Part B: The Answer

Topic
Anterior Dislocation of the Humeral Head

Discussion

• The shoulder is the most commonly dislocated joint in the body, accounting for
approximately 85% of all dislocations, and of these, the majority involved a
dislocation at the glenohumeral joint (Plate 423).
• The combination of abduction, extension, and external rotation with posteriorly
directed force applied to the arm will produce anterior inferior dislocation of the
humeral head.
• The head of the humerus impacts the weakest part of the joint capsule and usually
tears it and possibly the glenoid labrum as well.
• This injury frequently involves injury of the axillary and musculocutaneous nerves.
• The Axillary nerve injury may be assessed clinically by examining skin sensation
over the deltoid region, which is supplied by the upper lateral brachial cutaneous
branch (C5) of the axillary nerve.
• A musculocutaneous nerve injury can be assessed preliminarily by testing for
sensation over the lateral aspect of the forearm.
• Determining whether either of these muscles are functioning is difficult with
dislocated shoulders.
• To reduce (realign) an anterior dislocation of the humeral head, the elbow must be
flexed under traction, humerus laterally rotated, adducted and then the head pushed
back into position.

Findings

• The patient has an anterior dislocation of the head of the humerus as the result of
falling on the posterior aspect of his abducted, extended arm.
• His affected arm appears longer than the uninjured one and is in a slightly abducted
position.
• The musculocutaneous and axillary nerves may be injured in this dislocation.

Treatment

• There are many named procedures for reducing an anterior dislocation of the humeral
head, and some that are specific for children and the elderly.
• Prior to any reduction, a numbing agent may be injected into the joint area.
• One of the more common procedures is the Milch technique.
• In this technique, the patient lies in a supine position.
• The physician stands on the same side as the injury (in this case the left side) and
places his left hand on the patient’s shoulder, so that the fingers firmly support the top
of the shoulder and the thumb is braced against dislocated humeral head.
 • With his right hand he gently abducts the arm into the overhead position and laterally
rotates it, continuing to support the head of the humerus so that it cannot move from
its dislocated position.
• Once the arm is in complete abduction, the humeral head can be gently pushed over
rim of glenoid and back into place with the left thumb
• A radiograph is then taken to ensure proper reduction.
• Axillary nerve function is then assessed by asking the patient to abduct his arm.
• Musculocutaneous nerve function is assessed by having the patient supinate his
forearm and flex at the elbow against resistance.
• A substantially weakened ability to do this would indicate a musculoskeletal nerve
injury (the actions of the brachioradialis and supinator muscles make these
movements still possible).

More High-Yield Facts

• Because of the coracoacromial arch (acromion, coracoid process, and coracoacromial

ligament) and the rotator cuff, upward dislocation of the glenohumeral joint is rare.
• The rotator cuff is composed of the tendons of the supraspinatus, the infraspinatus, the
subscapularis, and the teres minor muscles, which surround the joint and blend with
the joint capsule.
• Repetitive use of the rotator cuff muscles can lead to muscle tears and inflammation,
producing shoulder pain.