Elsevier

The Journal of Hand Surgery

Volume 36, Issue 12, December 2011, Pages 2017-2023
The Journal of Hand Surgery

Scientific article
Abduction in Internal Rotation: A Test for the Diagnosis of Axillary Nerve Palsy

https://doi.org/10.1016/j.jhsa.2011.09.011Get rights and content

Purpose

To describe and validate the use of a test of abduction in internal rotation for the assessment of axillary nerve injury.

Methods

A total of 14 male patients with a mean age of 29 years (SD ±6 y), with axillary nerve lesions lasting an average of 6 months, participated. We measured their shoulder range of motion. In the upright position, with the trunk bending forward, we asked our patients to actively extend the shoulder (swallowtail test), and then we extended the shoulders and asked each patient to hold them in that position (deltoid extension lag test). For the abduction in internal rotation test, we asked patients to abduct the shoulder in internal rotation. If full abduction compared with the normal contralateral side was not possible, the examiner passively held the affected limb in maximal abduction and internal rotation. The patient was instructed to maintain the position when the examiner released the limb. In each test, any lag compared with the normal side accounted for deltoid palsy.

Results

All patients exhibited abduction beyond horizontal and full external rotation. The swallowtail test and the deltoid extension lag test identified the axillary nerve lesion in 10 of 14 patients. The abduction in internal rotation test recognized the axillary nerve injury in all 14. The average difference in the range of abduction in internal rotation between the normal and affected side was 37° (abduction lag).

Conclusions

Compensatory abduction in axillary nerve palsy has been attributed to the action of the supraspinatus, biceps, coracobrachialis, and pectoralis major. During abduction in internal rotation, compensatory abduction is impaired, clearly indicating deltoid muscle dysfunction.

Type of study/level of evidence

Diagnostic II.

Section snippets

Patients and Methods

In advance of data collection, the local ethics committee approved the protocol of the present study. Patients provided written informed consent before participating, in accordance with the Declaration of Helsinki, which guides biomedical research involving human subjects.

From December 2008 to December 2010, we examined 22 patients with suspected axillary nerve injuries at our hospital. We excluded from the study 4 patients with passive limitation of shoulder abduction and 4 with an associated

Results

All patients reported that initially after the accident their range of motion was incomplete, but that it had improved with time. All patients described fatiguability accompanied by shoulder pain when the affected arm was actively raised above horizontal. This was the main reason for seeking surgical intervention. Two-thirds of the patients were concerned about the shoulder appearance after deltoid atrophy. Eleven patients exhibited 180° of active abduction; the remaining 3 patients exhibited

Discussion

Many surgeons believe that lack of abduction beyond horizontal indicates an axillary nerve lesion.16, 17 We observed that full range of abduction is possible in isolated injuries of the axillary nerve, in accordance with previous case reports.13, 18, 19 Here, we demonstrated abduction above horizontal in a series of 14 patients. All of our patients had isolated axillary nerve palsy without fractures or dislocations. Axonal lesions of the suprascapular nerve have been observed in half of

References (21)

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