Study On Basic And Clinic Of Both Brachial Plexus Injury And Rotator Cuff Tear In The Adult

BackgroundRotator cuff tear is a common and frequently encountered disease of senile patient and athletes.The disease incidence is 17-41%.Rotator cuff tear seriously affects patients' life and athletes' performance.Brachial plexus injury is another critical trauma,which causes traffic accident and brings serious affect to family and society.If the patient suffered from both,rotator cuff tear and brachial plexus injury at the same time,the patient would suffer much more anguish.In the past,ten years ago,the reports about bothrotator cuff tear and brachial plexus injury increased into the international medicine but they have not been up to these days reported in China.It occasionally happens in our clinical experience but doctors do not pay enough attention to these diseases.Our team has done some initial research about both rotator cuff tear and brachial plexus injury and we feel that the diagnosis and therapeutic tools have to be improved.It is not enough to diagnose and to manage the diseases by clinical research,neuroelectricity physiology,modem imageology and modem microsurgical technology and therefore sometimes to delay the diagnosis and the treatment.The topic applies anatomy,modern imageology,modern microsurgical technology in order to combine rotator cuff tear with brachial plexus injury so that intradisciplinary and multidisciplinary research.It is important to examine the anatomy of rotator cuff tear and brachial plexus injury,to research their relationship and surrounding issues,to get their three-dimensional reconstruction images and arthroscopic images,to analysis the mechanism of action and predilection site and to explore the possibility of treating rotator cuff tear and brachial plexus injury simultaneously under arthroscopy.All of those can develop a new way how to improve the diagnosis and management,how to relieve the patient's anguish,to improve their shoulder's joint function,to lower multilation,to reduce complication, to promote orthopedics and sport medicine and image department combination.It is very important to develop the arthroscopy as a new field.Objectives1.To research the anatomy base of brachial plexus and rotator cuff tear and to analyze the internal mechanism,to offer an anatomic proof for clinical diagnosis and management.2.To research various kinds of imageology examinations for brachial plexus injury and rotator cuff tear,to compare their reliability and suitable object,to explore the best way how to diagnose and to manage them.3.To research extrinsic mechanism of rotator cuff tear and brachial plexus injury by analysis of the patient's history,to explore the diagnosis and management,to develop a new operative way to treat the rototar cufftear and brachial plexus injury.Materials and methods1.AnatomyAnatomical study was on 32 sides of upper extremities of adult cadavers performed,which had been processed by antisepsis.The number,origin,course and distribution of auxiliary nerve in shoulder joint and their relationship to rotator cuff was observed as well as its length,and distance of all branches were measured. Anatomical study was on 44 sides of upper extremities of adult cadavers performed, which had been processed by antisepsis.The number,origin,course and distribution of suprascapular nerve in shoulder joint and their relationship to rotator cuff were observed as well as its length,and distance of all branches were measured.2.Imageology2.1 CTM of brachial plexus injury:10 patients with brachial plexus injury were admitted,including all males,aging from18-52years(mean,38.3years).Machine traction injury includes 2 cases,traffic accident injury 6,shoulder crush injury 2.All cases were by Simens somatom sensation 4 CT machine scanned.CTM was from C₁ to T₂ with 2mm axial slice obtained and the scan images were paralled to the cervical disc with the patient on supine position.Voltage 120kv,electric current 150mAs,2mm scanned and 1 mm reconstruction.2.2 MRI of brachial plexus injury:15 patients with brachial plexus injury were admitted,including 12 males and 3 females,aging from 20-58 years(mean,31.6 years).Machine traction injury includes 3 cases,traffic accident injury 8,shoulder crush injury 1 cases.upper air injury 1 case,shoulder cut injury 2 cases.2.3 MRI of rotator cuff tear:23 patients with rotator cuff tear were admitted, including 17 males and 6 females,aging from 17 -65 years(mean,33.4 years).Before operation,they complained of shoulder joint pain and move limitation,especially superduct,abduction and extemal rotation disable.2.4 MR Arthrography of rotator cuff tear:20 patients with rotator cuff tear were admitted,including 16 males and 4 females,aging from 18-59 years(mean,35.6years), Before operation,they complained of shoulder joint pain and move limitation, especially superduct,abduction and external rotation.All patients accepted MR arthrography before operation.After routine MRI,under fluoroscopic guidance,the glenohumeral joints were punctured and injected with 15 ml of mixed contrast and then the MR imaging was performed again within 45 minutes.2.5Ultrasonography of rotator cuff tear:22 patients were with rotator cuff tear diagnosed,including 13 males and 9 females,aging from 28-67 years(mean,42.5 years),right shoulder 15,left 8,one patient with 2 shoulder injured.Their clinical situation showed trauma,light injury or no reason to feel shoulder's pain.Disease stage from 2 weeks to 8 years,most of them have supraspinatus muscular atrophy, greater tubercle tenderness,drop arm test positive and then got ultrasonograpy, supraspinatus muscle tendon and caput longum musculi bicipitis brachii were observed and measured.2.6 Arthroseopic of rotator cuff tear:16 patients with rotator cuff tear and under arthroscopic operation,including 12 males and 4 females,aging from 18-63years (mean,56.5years),left 5,right 11,they accepted X rays and MRI before operations, the diagnosis were definite.3.Clinic application:25 patients were admitted,16 males,9 females,aging from 42-74years(mean,61.6years),21 patients were injured and 4 patients were not injured, which included 15 shoulder joint dislocation,1 greater tuberosity of humerus fracture, 6 patients upper extremity abduction fall down.Active forward elevation and external rotation average 50°and 70°respectively.Passive forward elevation averaged125°and full elevation limited by pain,strength testing revealed significant weakness in all patients,forward elevation and external rotation muscle testing averaged grade 2,2 patient graded at 4 and 5 patients achieving a grade 3,21patients had evidence of significant atrophy of the deltoid muscle.Decreased sensation over the involved shoulder was only in four patients detected.All patients underwent EMG and arthrography,X rays,shoulder CT and MRI. Results1.axillary nerve anatomy:The localization of axillary nerve in quadrilateral zone locates at inferior 5.0±1.5(3.8—7.2)cm of acromion and in front of the posterior border of deltoid muscle 4.0±1.4(2.7—5.6)cm.The branch to the teres minor muscle was 1.64±0.8(0.8—2.6)cmbefore it entered into the muscle and it innervated the teres minor muscle.The posterior branch of axillary nerve was 2.5±1.5(1.0—4.2)cm and it innervated posterior part of the deltoid muscle and the skin around the long head of triceps.The anterior branch of axillary nerve was 3.1±0.8(2.0—4.2)cm,it innervated anterior part of the deltoid muscle and the skin of inferior part of the deltoid zone.2.Supraseapular nerve anatomy:The suprascapular nerve not only has its starting point and entering-muscle points but also has two limit-points,it has turn-angle about 50°at spinoglenoid notch,supraspinatus muscle branch 44,infra-spinatus muscle branch 44,upper articular branch 42,lower articular branch 53,and sensory branch 37.The branches innervate supraspinatus muscle,infraspinatus muscle and the shoulder joint.The Suprascapular nerve is close to superior transverse scapular ligment at suprascapular hole,close to inferior transverse scapular at subscapular hole. The movement space is limited,the nerve tension is increased when the shoulder abducts,the fascia separates the suprascapular nerve from the rotator cuff.3.CTM of braehial plexus injury:2 patients with brachial plexus tension injury whose CTM showed total root avulsion of brachial plexus,6 patients showed nerve root injury position clearly,2 patients without nerve root avulsion but operation showed that the branches of brachial plexus were injured.4.MRI of brachial plexus injury:3 patients with upper trunk of brachial plexus injured,10 patients total root avulsion of brachial plexus,2 patients inferior trunk injured. 5.MRI of rotator cuff tear:7 patients with rotator cuff full-thicknesse tear,13 patients with rotator cuff partial tear,3 patients normal and then all patients were confirmed by arthroscopic operation.6.MRA of rotator cuff tear:8 cases with full-thickness rotator cuff tears,the MRA appeared as:the intraarticular contrast solution filled the cuff defect,the contrast solution extravasated into the subacromial-subdeltoid bursa through the cuff defect. In 12 patients with partial-thickness rotator cuff tears,the MRA appeared as:the supraspinatus tendon was thinner than normal,an unsmooth inferior surfaced of supraspinatus tendon and a contrast solution filled crater on the inferior surface of this tendon was found.No contrast media leaked into the subacromial-subdeltoid bursa.7.Ultrasonography of rotator cuff tear:22 patients were admitted ultrasonography, including 18 patients with rotator cuff tear and 4 normal,5 patients injured with biceps brachii,11 with supraspinous muscle,2 with subscapular and tendon injury with hydrops articuli 13cases,6 patients with shoulder dislocation.The Brandt diagnosis standard is:focal defect invisibility of the rotator cuff,focal abnomal echogenicity within the cuff,focal thinned rotator cuff,each part can confirm the diagnosis.8.Arthroenfloscopy of rotator cuff tear:according to Gerber typing,8 patients with small rotator cuff tear,5 middle and 3 large.All patients got MRI before operation, all patients were available follow-up for 3--22months,the average follow-up period is being 7 months.Bases on the scale of UCLA(the rating scale of the University of California at Los Angeles)shoulder grading standard,9 were graded excellent,6 good,1 fair,the overall excellent and good rate was 93.8%.9.Clinical research of rotator cuff tear and brachial plexus injury:25 patients were available follow-up from 15 months to 30 months,(average22.4 months) Significant pain relief was achieved in all patients treated surgically.4 patients,who elected for non-operative treatment required of therapy,before achieving significant pain relief.Bases on the scale of UCLA shoulder grading standard,according to shoulder pain,function,active superduct anger,muscle strength and patient satisfaction,whole scale is 35,pain 10,function 10,motion range 5,muscle strength 5, satisfaction degree 5 and excellent 34-35,good 28-33,fair 21-27,bad≤20,average scale,before operation is 23.1(21.1±3.4),the last average scale is 28.5 (31.4±4.7).Our patients excellent 7,good 11,fair 7,90%patients pain relieved,the overall excellent and good rate was 72%.No complication happened.Conclusions1.Brachial plexus injury and rotator cuff tear can act in the body at the same time,it is caused by many factors.Local anotomy is a basic factor,then age and vocational factor are intrinsic premise,exterior violence and chronically traction injury are an immediate cause.2.The imageology to diagnose both brachial plexus injury and rotator cuff tear are various,every way has its advantages and disadvantages,properly examination is decided by patient' s condition and indication,CTM is the reliable indicator for assessing brachial plexus nerve root avulsion,MR is the main examination method at present.Ultrasound can observe rotator cuff dynamic state and repeatability. arthroscopy can diagnose and manage rotator cufftear at the same time.3.We should pay enough attention to those patients so as to preventing missed diagnosis.â‘ shoulder injury history;â‘¡shouler joint pains,especially at night;â‘¢shoulder joint function limited;â‘£Electromyogram or MR abnormal.4.If the patient with brachial plexus injury and rotator cuff tear is acutely injured, operation is suitable in most cases,and brachial plexus and rotator cuff are repaired at the same operation;if chronic lesion,the brachial plexus injury maybe caused by block injury or traction injury,so regular expectant treatment is available,if failed and then operation treatment.but chronic rotator cuff tear need to be repaired by operation.