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AXILLARY NERVE PALSY

Definition It is characterized by trauma to the axillary nerve from either a compressive force or traction injury following anterior dislocation of the shoulder.

Figure 1- Depiction of the axillary nerve stretched across the humeral head during dislocation.

Anatomy The axillary nerve originates from the spinal cord at the C5 and C6 levels with occasional contribution from C4.

Epidemiology

Anterior shoulder dislocation is the most common occurring dislocation at the shoulder. However, axillary nerve injuries are uncommon in sports and, in general, represent less than 1% of all nerve injuries. Men and women 3:1 9-65% involve axillary nerve injury - 23% have combination neuropathies, all involving the axillary nerve[8] The incidence of brachial plexus and axillary nerve injury increases dramatically following shoulder dislocation in patients 50 years of age, if fracture is associated with the dislocation, and if the duration of the dislocation lasts >12 hours Incidence of nerve injury doubled with the presence of an associated fracture.

Symptoms Surprisingly, many athletes with axillary nerve injury may be asymptomatic, with complete or incomplete lesions. Often, however, when affected athletes exercise, they may fatigue quickly, especially with overhead activity and heavy lifting. Generalized mild, dull, and achy pain to the deep or lateral shoulder, with occasional radiation to the proximal arm Numbness and tingling of the lateral arm and/or posterior aspect of the shoulder Feeling of instability Fatigue, especially with overhead activities, heavy lifting, and/or throwing May/or may not reveal a history of trauma to the shoulder region History of dislocation with soreness persisting ~1week post-injury Easing Factors include: rest, ice, analgesics, and anti-inflammatory medications

Signs Weakness or paralysis of deltoid muscles (MOST COMMON SIGN) Atrophy of deltoid and teres minor May avoid 90 degrees of external rotation Sensation maybe normal or demonstrate a loss at the lateral deltoid region Weakness, especially with flexion, abduction, and external rotation +VE sulcus test, apprehension test, anterior release test, deltoid extension lag

Treatment

The patient should be referred to a neurologist. An EMG may be taken to confirm the diagnosis. In most cases, treatment is not necessary as the symptoms will gradually clear on their own as the nerve heals. Anti-inflammatories may be prescribed to ease pain and swelling around the nerve, which helps to reduce compression. Physical therapy may be recommended to maintain muscle strength as much as possible. Timescales vary massively for recovery from this injury. It could be anywhere from 6 weeks to 6 months or more. If symptoms do not clear or the problem gets worse, surgery may be required to further investigate the problem.