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Dr. A. Mortazavi MD
Occupational Medicine Specialist
• Musculoskeletal problems :
• 10–20% of outpatient visits
•
traumatic (injury-related) or atraumatic( degenerative or
overuse syndromes)
• acute or chronic
• most helpful part of the history in determining the diagnosis
mechanism of injury
• With acute traumatic injuries, patients typically seek
medical attention within 1–6 weeks of onset.
Symptoms and Signs
• Nonspecific
• pain (most common)
• instability, or dysfunction around the joints
• “locking” or “catching,” internal derangement in joints
• “instability” or “giving way” suggest ligamentous injury
• these symptoms may also be due to pain causing muscular inhibition
• fever or weight loss, swelling with no injury, or systemic illness
suggest medical conditions (such as infection, cancer, or
rheumatologic disease)
.
•
• Physical examination :
• inspection, palpation, and assessment of range of motion and
neurovascular status
Shoulder examination
Imaging
• Radiography:
• Bony pathology, soft tissue findings
• CT scans:
• most effective for bony pathology
• Nuclear bone scans:
• less commonly used (stress injuries, infection, malignancy, or
multisite pathology)
• Positron emission tomography (PET) scans:
• metastatic malignant lesions.
• MRI:
• ligaments, cartilage, and soft tissues
• Gadolinium contrast:
• internal derangements in joints such as labral Injuries
• Musculoskeletal ultrasound:
• superficial tissue problems, including tendinopathies and synovial
problems
Special Tests:
• Arthrocentesis:
• acute knee pain with effusion and inflammation
(rule out an infection)
• Joint fluid should be sent for cell count, crystal analysis, and culture.
• EMG-NCV:
• neurologic concerns; prognostication in chronic conditions.
• Markers of inflammation:
CBC,ESR and C-reactive protein, and rheumatologic tests
Treatment:
• most musculoskeletal problems:
• treated conservatively,
• the first consideration:
• whether there is an immediate surgical need.
conservative treatment:
• “MICE”:
• modification of activities, ice, compression, and elevation.
• Controlling pain:
• analgesics (nonsteroidal anti-inflammatory drugs [NSAIDs],
acetaminophen, or opioids).
• muscle relaxants for neuropathic pain [eg, gabapentin or tricyclic
antidepressants).
• Topical medications:
• capsaicin cream or patch( lidocaine , NSAID)
• Immobilization by casting, slings, and braces for an injured limb.
• Crutches :reduce weight bearing.
• Rehabilitation and physical therapy, chiropractic manipulation, massage
therapy, and osteopathy.
When to Refer
1- emergency referral (immediate)
 Neurovascular injury
 Fractures (open, unstable)
 Unreduced joint dislocation
 Septic arthritis
2- urgent referral (within 7 days)
 Fractures (closed, stable)
 Reduced joint dislocation
 “Locked” joint (inability to fully extend a joint due to mechanical
derangement, usually a loose body or torn cartilage)
3- Indications for early orthopedic assessment (2–4 weeks)
 Motor weakness (neurologic)
 Constitutional symptoms (eg, fever not due to septic arthritis, weight loss)
 Multiple joint involvement
4- Indications for routine orthopedic assessment (for further
management)
 Failure of conservative treatment (persistent symptoms > 3 months)
 Persistent numbness and tingling in an extremity
DEFINITIONS OF COMMON ORTHOPEDIC CONDITIONS
Strain:
• A strained muscle or tendon has been pushed or pulled to its
extreme by exposing it to an extreme load.
• results from an unexpected external force, such as a fall.
• The symptoms of strain should resolve within a few days to several
weeks.
Sprain
•
ligament has been stretched beyond its limit, causing tears or disruption
in fibers.
• edema and local venous congestion develops over hours to days.
•
A complete tear of a ligament is sometimes called a third-degree sprain.
Peripheral Neuropathies
•
The peripheral nerves crosses a joint or is in a tunnel external compression,
•
vibrating hand tools, repeated forceful hand exertions, or sustained posture
extremes (eg, overhead work)
adequate intensity and duration exposures
compresses the nerve
paresthesias and pain
denervation and weakness.
INJURIES OF THE SHOULDER
•
Impingement Syndrome, Rotator Cuff Tendinosis or Tears,
Supraspinatus Tendinitis, Saubacromial Bursitis
•
repetitive-motion work activities, especially overhead position in forward
flexion or abduction
•
•
subacromial bursitis→ irritation of the supraspinatus tendon or tendonitis →
beginning of ulceration (partial-thickness tear) of the tendon → full-thickness
discontinuity or rupture of the rotator cuff
long head of the biceps may be damaged
•
•
Acromion develops osteophytic
.
• Posttraumatic impingement syndrome
• minor injury to the arm or shoulder:
• painful inhibition of normal motion :
self-imposed immobilization of the shoulder → imbalanced rotator
cuff muscle function → impingement syndrome
Clinical Findings
• Pain:
• anterior shoulder pain may be gradual or acute
• pain is limited to the lateral arm about the deltoid insertion on the
humerus.
• Occasionally, pain is referred to the distal arm, elbow, and rarely, to the
hand.
• severe pain at rest caused by a tense subacromial bursa
• Night pain is a common complaint
• shoulder pain:
• when the arm is abducted to 30–40 degrees or flexed forward to 90
degrees or more.
• internal rotation.
significant disruption of the rotator cuff↠ no active elevation past 90
degrees of flexion or weakness to external rotation.
• full-thickness tears of the rotator cuff :lost motion.
• Point tenderness anterior to the acromion over the subacromial
bursa is common.
• Two common tests for impingement are the supraspinatus isolation
test (empty can test), and the Hawkins-Kennedy test.
supraspinatus isolation test:
downward resistance is applied to the arm after the shoulder is abducted to
90 degrees and forward flexed 30 degrees and the straight arm is rotated
so that the thumb is pointing to the ground. Weakness, when compared to
the opposite side, indicates disruption of the supraspinatus tendon.
Hawkins-Kennedy test:
the arm is passively flexed forward to 90 degrees and the elbow is flexed to 90
degrees. When the examiner internally rotates the shoulder, pain indicates
impingement of the supraspinatus tendon
Differential Diagnosis
 Angina
 Cervical radiculopathy
 Acute shoulder sepsis
(quite rare, systemic signs: elevated ESR and WBC)
 Osteoarthritis of the glenohumeral joint (plain radiographs)
 degenerative arthritis of the acromioclavicular joint
With progressive age:
increasing incidence of asymptomatic partial or full-thickness cuff tears
( after 70 years of age, most people will have cuff tears).
Imaging & Diagnostic Studies
 x-rays
 (AP) in internal and external rotation and an axillary and an outlet view
 sclerotic change at the greater tuberosity or evidence of (AC) joint
degenerative arthritis
 in massive disruptions of the cuff, humeral head elevate in relationship to
the glenoid cavity.
 MRI
Prevention
• Avoidance of prolonged or repeated overhead work
rotator cuff strengthening exercises
• Treatment
resolve the patient’s pain and restore normal function and muscle
balance
• anti-inflammatory medications, pendulum exercises (reduces the
pressure, increase the circulation)
• Resistance exercises such as with an elastic band (Thera-Band), with
the arm at the side, elbow flexed 90 degrees, applying force in internal
and external rotation.
fastest way in treatment:
 inject the subacromial space( corticosteroid and local anesthetic (eg,
triamcinolone 40 mg and 1% lidocaine 4 cc).
 then started on progressive resistance exercises
The diagnosis is made when the patient’s symptoms are relieved
immediately after injection
 surgery or arthroscopic surgery:
1- respond temporarily to the injection
2- recurrence after two or three injections and who have participated in
proper exercises
(removal of acromion and AC joint, bursectomy, and cuff debridement,….)

Bicipital Tendinosis
 anterior shoulder pain that is often worse with overhead activity
 point tenderness in the area of the intertubercular groove anteriorly
over the humerus.
Differential Diagnosis:
 impingement or rotator cuff pathology.
 diagnosis: clinically
x-rays: often normal
ultrasound or MRI :
(thickening of the tendon or fluid around the tendon)
Prevention
 Treatment
- rest and nonsteroidal anti-inflammatory drugs (NSAIDs)
- rehabilitation consisting of scapular stabilization techniques and
rotator cuff strengthening.
- Ultrasound-guided steroid injection around the tendon
 in refractory cases: surgery
consisting of debridement, biceps tenodesis, or tenotomy
Labral Tears
• Labrum deepen and stabilize the joint
• torn with either an acute injury or from repetitive overhead activity
(throwing athlete)
•
Tears over the superior part of the labrum are known as SLAP
lesions, or superior labral anterior to posterior lesions, (throwing
athletes such as pitchers)
• Traumatic dislocation of the shoulder: Bankart lesion
(tearing of the labrum and a portion of the inferior glenohumeral ligament
from the anterior and inferior portion of the joint.
Clinical Findings
• deficit of internal
rotation compared to the other side
•
O’Brien test :pain in the presence of a SLAP tear.
forward flex his or her adducted arm in full pronation against resistance
by the examiner
The pain is improved when the test is
repeated with the arm in supination.
• Bankart lesions:
• history of a shoulder dislocation and injury and signs of anterior
apprehension on examination.
Differential Diagnosis
• MRI
impingement, tendonitis, and rotator cuff pathology
Imaging & Diagnostic Studies
• x-rays(not useful)
• simple MRI (cannot detect all labral tears).
• An MRI with arthrogram is more sensitive in assessing the labrum
• Prevention
Careful adherence to proper mechanics with throwing
• Treatment
strengthening the dynamic stabilizers of the shoulder in chronic
instability.
However, large labral lesions that are symptomatic
often require arthroscopic repair.
Shoulder Osteoarthrosis




glenohumeral and/or acromioclavicular (AC)
decreased range of motion of the shoulder
pain with shoulder motion.
tenderness and swelling over the AC joint.
 Differential Diagnosis
adhesive capsulitis, distinguishable by x-ray.
 Imaging
-x-rays (internal and external rotation as well as an axillary and an outlet:
narrowing of the glenohumeral or AC joint with subchondral cysts and
osteophyte formation.
Prevention
•
treatment of the tear in patients with Massive rotator cuff tears
•
•
•
•
Treatment:
Conservative treatment includes rest, NSAIDs, and therapy.
Steroid injection in glenohumeral or AC joint
Surgery(arthroscopic or open distal clavicle resection, arthroplasty)
Frozen-Shoulder (Adhesive Capsulitis)
 diffuse capsular inflammation :
marked restriction of glenohumeral joint motion
 diabetes or other endocrine or autoimmune conditions.
 Symptoms:
attempt to move the glenohumeral joint beyond that allowed by the
inflammation and adhesions
 All ranges of motion are limited
Differential Diagnosis
osteoarthritis of the glenohumeral joint (radiographs)
•




Imaging
Standard radiographs are normal(rule out underlying arthritis)
Treatment
short period of sling immobilization
Shoulder motion will recover gradually with therapy over 6–18 months.
Recovery of motion can be facilitated initially by distension of the glenohumeral
joint with saline with lidocaine, and triamcinolone.
 This is followed by gentle manipulation of the arm into external rotation.
Shoulder Dislocations
•
•
•
•
Stability
shoulder capsule and specific ligament
forces applied to the arm held in a position of abduction and external
rotation:
humeral head is driven forward, tearing the anterior and middle
glenohumeral ligaments and capsule from the margin of the glenoid
Rarely, dislocate posteriorly with automobile accidents, grand mal
seizures, or electroshock therapy.
Clinical Findings
•
•
Acute anterior shoulder dislocation severe anterior shoulder pain.
Patients guard against shoulder motion by holding the elbow flexed with the
ipsilateral forearm in the opposite hand.
•
Any attempt at motion is associated with severe pain.
•
Differential Diagnosis
fractures or acute rotator cuff or labral tears
•
Imaging
AP and axillary radiographs
Anterior dislocations: humeral head displaced inferiorly to the glenoid
posterior dislocations: the humeral head is at the same level as the glenoid on the
AP radiograph.
The diagnosis can be confirmed axillary view.
Prevention
- General fall prevention
- good seizure control
- Strengthening of the dynamic stabilizers of the shoulder may be helpful in
chronic dislocators.
Treatment
Anterior and posterior dislocations are reduced by closed techniques
immediately.
• Following reduction, patients are immobilized with the elbow at the side
and the arm in a position of 10 degrees of external rotation for 3 weeks.
Patients are allowed to return to their usual activities at 6–8 weeks
If patients become recurrent dislocators,
repair of the torn capsular arthroscopically or with open surgery.
• Clavicular Fractures
-direct blow to the shoulder
-rarely from falling on an outstretched hand
Middle-third fractures are most common
•
Clinical Findings
The proximal fragment of the clavicle is elevated by the action of the
sternocleidomastoid, distal fragment downward.
• Local swelling (bleeding)
• The patient supports the involved extremity with the opposite hand.
• Rarely, Fx can perforate the skin, producing an open fracture.
Imaging & Diagnostic Studies
Plain radiographs of the clavicle.
Prevention
• avoidance of falls and workplace safety.
Treatment
-Immobilization of the fracture is provided by the application of a
figure-of-eight bandage or a sling.
Surgery (open reduction with internal fixation ):
• distal third fracture,
• highly displaced fractures,
• fractures with tenting of the skin, or for early return to work or
sporting activity.
• Open fractures
• Proximal Humeral Fractures
direct fall onto the arm or elbow.
•
Clinical Findings
• pain over the proximal shoulder region or radiating the length of the
arm.
• Local swelling( bleeding).
Differential Diagnosis
Dislocation of the glenohumeral joint
• Imaging & Diagnostic Studies
plain radiographs of the scapula and shoulder.
• An axillary view is necessary to rule out a dislocation of the head
fragment.
• Prevention
Fall prevention
treatment of osteoporosis.
.
o Treatment
Nondisplaced or minimally displaced fractures of neck or greater or
lesser tuberosities: temporary immobilization
o Displaced fractures of one or both tuberosities: indicative of a
rotator cuff tear.
o Displaced fractures: surgical treatment by open reduction and
internal fixation.
o The goal of physical therapy: restore normal range of motion and
strength around the shoulder.
Brachial Plexus Neuropathy (Thoracic Outlet Syndrome(
• Compression of the vessels and nerves of the brachial plexus and/or
subclavian vessels occurs in the interscalene triangle, behind or below
the clavicle or subcoracoid space, or more distally at the pectoralis
minor.
•
thoracic outlet compression:
• 1- Cervical ribs
• 2-congenital fibrous bands
• 3- rarely a nonunion or malunion of the clavicle
• The disorder is uncommon and the diagnosis is missed frequently.
Women are affected more frequently than men,
• usually between the ages of 20 and 50.
Clinical Findings
 neurogenic disorder is more common than the vascular
 pain and/or paresthesia radiating from the neck or shoulder and down to
the forearm and fingers
 difficulty with overhead activities
 The hand may feel swollen or heavy
The lower trunk of the brachial plexus is involved more commonly
numbness, tingling, and weakness in the ulnar innervated intrinsic
muscles and symptoms on ulnar side of the forearm and hand.
•
Differential Diagnosis
-cervical disk disease at the C7–T1 level (C8 radiculopathy)
- Entrapment of the ulnar nerve in the cubital tunnel or Guyon canal
(physical examination, EMG)
Diagnosis test:
Adson maneuver, Wright test, Roos Test or shoulder hyperabduction to
180 degrees (observe the palm for pallor indicating an accompanying
vascular compromise)
Imaging & Diagnostic Studies
• Plain radiographs of the cervical spine
(congenital differences such as cervical ribs and long transverse
processes or even hypoplastic first ribs)
• Apical lordotic chest views (Pancoast-type tumors)
•
MRI and angiographic , EMG(muscle weakness).
Prevention
• Identification and correction of postural triggers are an important part
of management.
• Computer users:
 lowering the keyboard and mouse to elbow height
 moving the monitor closer and to an appropriate height (eg, top of
monitor at eye level)
 standing workstation.
•
•
•
•
•
Treatment
reduce the mechanism of thoracic outlet compression :
Conservative treatment, appropriate postural strength training
reduction of obesity and general physical fitness
Overhead activities or carrying heavy loads should be minimized.
• Progress is measured in weeks or months.
surgery :
• release the anterior scalene muscles
• resect of the first rib or fibrous band.
• clavicular malunion (clavicular osteotomy )
Lateral Epicondylitis (Tennis Elbow)
• workers who perform repeated forceful pinching or power grasps,
wrist dorsiflexion or supination (eg, turning a door knob).
• work with the wrist in sustained extension
• pain radiating into the dorsal aspect of the forearm (maybe at night
and at rest)
• tendon tears and necrosis at the attachment of the extensor carpi
radialis brevis (ECRB) to the lateral humeral epicondyle and the
extensor carpi radialis longus origin along the supracondylar line
.
• Symptoms can be reproduced by:
• 1- asking the patient to straighten the elbow then extend the wrist
against resistance (Cozen test)
• 2- extend the middle finger against resistance with the wrist straight;
• 3- grasp the back of a chair with the elbows straight and attempt to
lift it (Chair test).
Differential Diagnosis
 radial head osteoarthritis (radiography)
 fractured radial head or neck
(history of trauma and radiographic views)
 Radial tunnel syndrome(symptoms are usually more distal)
entrapment of the posterior branch of the radial nerve(in refractory
cases)
 C6 radiculopathy or a shoulder tendinopathy
• Imaging & Diagnostic Studies
• clinical examination.
• in major trauma or refractory symptoms:
• Imaging( rule out fracture or arthritis), MRI (rule out intra-articular
pathology)
• Prevention
• General strengthening of elbow and forearm musculature
• proper instruction in the use of hand tools and/or modification of the
hand tool to reduce high-force pinching or gripping or repeated forceful
wrist or finger flexion.
Treatment
• Nonsteroidal anti-inflammatory drugs and ice (night pain)
Steroid injections:
• reduce the pain for short durations (eg, weeks)
• Removing or modifying the offending activities
• avoid forceful pinching or gripping especially with wrist extension.
• Forearm muscle strengthening:
• initiated with low loads with slow progression. (start with wrist curls
using 250 g weight and increasing the load each week or two).
Surgery:
• debridement of the common extensor origin or extensor carpi radialis
brevis, with or without repair, is rarely necessary.
Medial Epicondylitis (Golfer’s Elbow)
repeated forceful finger or wrist flexion or wrist pronation, especially
when the elbow is flexed.
Clinical Findings
• local tenderness over the medial epicondyle or common proximal
flexor origin.
• The symptoms can be reproduced by resisted wrist flexion.
• The tissue swelling : compress the ulnar nerve
.
Imaging & Diagnostic Studies
 clinical examination.
 in major trauma or refractory symptoms:
 imaging(to rule out fracture or arthritis,MRI ( rule out intra-articular
pathology)
 A nerve conduction study( rule out ulnar neuropathy)
Prevention
 General strengthening of elbow and forearm musculature and proper
instruction in the use of hand tools and/or modification of the hand tool
 reduce high force pinching or gripping or repeated forceful wrist or
finger flexion.
Treatment
 rest of the involved tissues and modified activity.
 Steroid injection is generally not recommended(ulnar nerve damage).
 . The need for surgical relief is rare.
Ulnar Neuropathy at the Elbow
(Cubital Tunnel Syndrome)
• the second most common nerve entrapment
(First: carpal tunnel syndrome)
• Risk factors:
• old elbow injuries with enlarging osteophytes,
• cubitus valgus deformity at the elbow, or subluxation of the nerve out of the
groove.
•
Work-related medial epicondylitis, contact stress or sustained elbow flexion
(eg, telephone use)  localized edema  nerve compression, ischemia,
fibrosis, and neuropathy.
• Clinical Findings
•
neuropathic symptoms (eg, numbness, tingling, aching, burning,
shooting, or stabbing pain, allodynia, weakness) in the ulnar
innervated fingers (eg, small and ring fingers) and less frequently in
the medial aspect of the forearm and elbow.
• Symptoms aggravated by elbow flexion or resting the elbow on a
work surface.
physical examination
• Tinel sign or tenderness over the ulnar nerve.
Full elbow flexion for 60 seconds (with wrists straight) trigger the symptoms
.
Sensory examination in the ulnar distribution on the fingers may be
abnormal (eg, 2-point discrimination , pin prick).
severe condition :Weakness and atrophy of the interossei/thumb adductor
muscles.
Differential Diagnosis
 compression of the ulnar nerve in Guyon canal at the wrist
(uncommon),
 cervicothoracic C8–T1 radiculopathy,
 brachial plexus neuropathy (eg, thoracic outlet syndrome).
physical examination or nerve conduction: identify the location of the
entrapment.
• Imaging & Diagnostic Studies
• Diagnosis:
• combination of clinical data and nerve conduction studies of
the ulnar nerve across the elbow.
•
•
ultrasound and MRI :
identifying morphological changes of the nerve within the
cubital tunnel.
• Prevention
• eliminate sustained elbow flexion
(use of telephone head set instead of handheld telephone)
• sustained contact stress, such as resting the arm
on arm-rest that presses on the unlar groove, should be
avoided
• Treatment
• conservative
• pain relief
• activity modification, such as avoiding elbow flexion of 90 degrees or more
or pressure over the medial epicondyle region.
• Night-time elbow splints :
maintain the elbow in approximately 45 degrees of flexion.
surgical decompression :
-interosseous muscle atrophy
-who do not respond to conservative management.
Olecranon Bursitis
irritation and swelling in bursa between the olecranon prominence and the
overlying skin.
Acute type;
usually not work-related ,
but a sudden trauma at work might precipitate an inflammation.
chronic type :
- more common in men
- caused by repeated contact stress on the elbow
• Clinical Findings
• gradual swelling and pain,
• Signs of increased warmth suggest a septic process
• Pressure exacerbates the pain.
• Differential Diagnosis
• Sepsis and inflammatory diseases, like rheumatoid disease,
crystalline deposits, or CRESTsyndrome (calcinosis, Raynaud
phenomenon, esophageal dysmotility, sclerodactyly, and
telangiectasia)
• Imaging & Diagnostic Studies
• Aspiration of the bursa and specific blood tests
MRI in complex cases may be indicated
(hypointensity on T1-weighted images).
• Prevention
- protection of repetitive trauma on the posterior face of the elbow.
-Use of a protective pad in specific jobs highly exposed to elbow trauma
• Treatment
• simple immobilization
• For acute and painful cases: an elastic bandage and steroid injection
(after infection is ruled out with an aspiration of the bursal fluid)
• For recurrent bursitis, arthroscopic bursal resection may be required.
• Ganglion Cyst
•
•
•
•
most common soft tissue tumor of the hand.
mucin-filled cystic lesions
second to fourth decades.
asymptomatic or produce pain with direct pressure or during wrist
motions.
• Refer when they change size or become symptomatic.
• Clinical Findings:
•
over the dorsum of the wrist (can on the volar side) well
circumscribed and feel fluid filled.
• transilluminated with a small penlight (large cases)
• in the hand( on the volar ):
• small,round, firm mass near the base of the digits.
• Imaging & Diagnostic Studies
• diagnosis: clinically.
• Radiographs ( if the mass feels bony or calcified in nature)
• Confirm diagnosis (if the physical examination is inconclusive):
• MRI, CT scan, or ultrasound
• Prevention
• The evidence is limited:
• Modifing: work involving repeated wrist motions.
Treatment
• Asymptomatic lesions, ( small and present for less than a year):
• observed, resolve on their own.
•
Avoiding weight-bearing with wrist extension can decrease pain.
• Aspiration :
• recurrence rates 50–70%.
• Injection with steroid:
increased incidence of skin depigmentation, subcutaneous fat atrophy.
• Surgical excision:
symptomatic ganglia that do not respond to conservative treatment.
De Quervain Tenosynovitis
(First Dorsal Wrist Extensor Compartmen Tenosynovitis)
• first dorsal compartment of the wrist.
• abductor pollicis longus and the extensor pollicis brevis.
• overuse of the thumb and wrist particularly with radial deviation, as in
repetitive hammering, repetitive lifting .
• Clinical Findings
• localized tenderness and swelling over the radial side of the distal
radius..
• When the patient grasps the fully flexed thumb into the palm and then
ulnar deviates the hand at the wrist, exquisite pain develops and
reproduces the patient’s complaint (Finkelstein test)
Differential Diagnosis
•
Chronic nonunion of the scaphoid bone, osteoarthritis of the first
carpometacarpal joint, (in 25% of white women older than 55 years of age)
Imaging & Diagnostic studies
• clinical diagnosis
• no specific radiographic findings.
( rule out carpometacarpal osteoarthritis and nonunion of the scaphoid bone)
Prevention

lift with the palm facing upwards (full supination) rather than with the
palm down,
 avoid using the thumb.
 Tools can be modified to reduce repeated forceful thumb flexion
 (The thumb that strikes the spacebar on a keyboard, usually the right, may
be at risk)
Treatment
•
activity modification( lifting with the palm in supination)
• avoiding repetitive lifting and thumb abduction, and use of a thumb spica
splint to immobilize the thumb.
• NSAIDs, Steroid injection (local anesthetic and steroid given into the
tendon sheath over the area of the radial styloid)
• surgical decompression of the common extensor sheath:
in patient who do not respond to local injection .
Other xtensor Tendinopathies of the Wrist
• five specific sites on the extensor side:
• intersection syndrome (ECR,third compartment), extensor digitorum
communis (EDC, fourth compartment),
• and extensor carpi ulnaris (ECU,sixth compartment)
repeated or sustained wrist extension or other overuse, such as with
excessive typing or mousing:
• Intersection syndrome (ECR travels beneath muscle of APL and EPB)
and fourth extensor compartment tenosynovitis (EDC) can occur.
• ECU tendonitis occurs after a twisting injury and presents as vague or
deep pain over the ulnar side of the wrist. EDC synovitis with swelling
and fluid is unusual
• outside the setting of inflammatory or crystalline arthropathy, and
patients with these findings should be evaluated for these conditions.
• Clinical Findings
•
•
•
•
•
•
•
•
very localized tenderness or pain with resisted loading of the
tendon/muscle.
Patients with tendonitis over the ECU tendon have ulnar-sided wrist
pain that can often extend from the insertion point over the base of the
fifth metacarpal bone, over the distal ulnar, and into the distal forearm.
The pain is often worse with resisted wrist extension and ulnar
deviation
Similarly, tendonitis of the ECR tendons creates pain at
the second and third metacarpal that also can extend into the forearm.
Pain with this condition tends to be worse with resisted wrist extension
and radial deviation.
Intersection syndrome :
At distal forearm where the muscle bellies of the tendons the first dorsal
compartment cross over the radial wrist extensors, causing
compression in this area.
• Differential Diagnosis
tear of the triangular fibrocartilage complex.
De Quervain
scaphoid fractures
Nonunion or radiocarpal arthritis.
• Imaging & Diagnostic studies
• clinical diagnosis. However,
• MRI: sometimes show fluid or inflammatory changes around the
affected tendon
• Prevention
• Reduction of duration of forceful gripping and repeated wrist
motion may prevent these conditions for hand intensive work.
• For computer users:
• ergonomic modifications can reduce wrist extension with
• keyboard and mouse use.
• Treatment
• activity modifications, wrist splints, NSAIDs.
• ergonomic evaluation of work tasks and tools.
• Corticosteriod injections (limited in number to prevent the risk of
tendon rupture)
• Surgery:
• refractory pain.
Trigger Digit (Stenosing Tenosynovitis)
• Stenosing tenosynovitis of the flexor tendon to a finger or of the flexor
pollicis longus to the thumb may produce pain when the digit or thumb
is forcibly flexed or extended(actively rather than passively flexed)
• Motion of (PIP) joint of the finger or (IP) joint of the thumb produces
symptoms, painful snap  joint to collapse suddenly much like a
trigger.
• Rf: repetitive finger flexion.
• Systemic diseases :
• diabetes, thyroid dysfunction, and rheumatoid arthritis.
•
most cases are idiopathic.
Clinical Findings
• In the early stage: pain and no triggering.
• Sometimes, nodule can be palpated near the MCP joint, with passive
flexion of the PIP joint.
•
In the later stages: the digit may become “locked” in extension (or more
rarely in flexion)
Imaging & Diagnostic Studies
• Imaging studies are not needed and are usually normal.
Prevention
• Avoidance of repetitive digit flexion against a load
• good diabetic control
Treatment
• At the early stages: splinting in extension at night
• injection of steroid and local anesthetic into the area of the synovial
sheath.
• Surgery:
• Patients not responding to injection or developing recurrent
Carpal Tunnel Syndrome
 entrapment or pressure neuropathy of the median nerve
 (as it passes through the carpal tunnel volar to the nine flexor tendons)
 Occure any age
 more common in women.
 Rf:
• Pregnancy, increasing age, obesity, hypothyroid, space occupying
Lesion (Rheumatoid arthritis)
• Direct blow to the dorsiflexed wrist or an injury associated with a Colles
fracture.
• Work risk factor:
• repeated or sustained forceful gripping or repetitive wrist and finger
movements.
:
• association between carpal tunnel and the use of a keyboard or
computer mouse is controversy
• Patients with CTS:
• keyboarding, especially with the wrist in extension , exacerbates
their symptoms.
Clinical Findings:
• paresthesias in the median nerve (volar surface of the thumb, index,
and long fingers, radial half of the ring finger).
• progression of the syndrome:
• awakening at night with pain, tingling, burning, or numbness
• Characteristically, patients tend to stand up and massage the area
or shake the wrist and fingers.
• Triggening of Symptoms:
• driving or sustained gripping.
• Further progression  hand weakness result in permanent
damage, skin sensory deficit and thenar motor atrophy and
weakness.
• In early stage:
• there is no evidence of thenar atrophy
• Phalen sign:
• hold the wrists maximally flexed for 60 seconds, may develop
symptoms
• carpal compression test :
• direct pressure with the thumb over the carpal tunnel area .
• Tinel sign :
• Tapping with a reflex hammer at the volar wrist may recreate
shooting pains into the tips of the digits .
•
•
The diagnosis: EMG-NCV
• Differential Diagnosis
• nerve compression occurring proximally.
• cervical radiculopathy (C5, C6,C7)
• Imaging & Diagnostic Studies
• Imaging are not needed.
• Nerve electro diagnostic( confirming and estimating severity of
nerve dysfunction)
• Prevention
• Avoidance of repeated or sustained forceful gripping or repetitive wrist
and finger movements, prolonged wrist flexion or extension, or direct
pressure on the carpal tunnel.
• Use tools or jigs with less forceful pinch or grip.
•
• Tools reduce sustained posture extremes : split keyboards or
asymmetrical computer mice.
Treatment
 Treat Underlying conditions (rheumatoid arthritis,
hypothyroidism)
 In the absence of signs of neuropathy:
 reducing provocative or repetitive activities.
 Wrist splints holding the wrist in neutral,
(Splinting consistently at night for a period of 4–6 weeks can
be curative in the early stages)
 injections of cortisone into the carpal tunnel
(For patients not responding to rest and splinting)
 Surgery:
 Patients who fail to respond to the preceding measures
 whose symptoms recur.
 diagnosis should be confirmed by electrodiagnostic
studies before surgery is undertaken
Hand Arm Vibration Syndrome
• Rf: use of electric and pneumatic vibrating hand tools over months or
years.
• ( chain saws, grinders, sanders, and rock drills)
• clinical pathology is usually confined to the distal upper extremity.
• most commonly with outside work performed in colder climates.
underlying pathology is caused by the tool signature not cold temperature.
• Clinical Findings
• The classic presentation:
• neurologic and vascular signs and symptoms
• cold-provoked blanching of the fingers:
• vibration white fingers (VWF) or occupational Raynaud phenomenon.
•
•
At lower exposures: neurologic symptoms predominate:
problems of hand coordination and fine manipulation.
• Progression: intermittent numbness, tingling, and pain
• (see Stockholm Workshop Scales for severity assessment).
•
•
•
At earlier stages:
reversed if vibration exposure is minimized or stopped.
the prognosis is more variable.
• Rarely in severe cases(collagen vascular disease or obstructive arterial
disease ):
• skin trophic changes and gangrene.
•
•
examination :
skin perfusion evaluation, digit sensory testing where available(with
monofilaments or 2-point discrimination, and
• provocative maneuvers (as in the carpal tunnel syndrome)
• Differential Diagnosis
• Raynaud disease and entrapment neuropathies
• ( CTS and thoracic outlet syndrome).
•
In addition, because VWF is a vasospastic disorder, routine
noninvasive vascular imaging will usually be normal.
• Thoracic outlet syndrome (TOS):
• effects on large arteries and the brachial plexus.
( vascular expressions of TOS are unusual and can be visualized by
Doppler, angiography, MRA, or multidetector CT)
• Imaging & Diagnostic Studies
• Sensory function :
• vibration and thermal perception threshold tests (VPT and
TPT),limited availability.
• Nerve conduction studies:
• digital nerve function and rule out CTS.
•
Routine noninvasive vascular tests are not useful, unless an
obstructive pathology is under consideration.
• Prevention
• tools with lower levels of handle acceleration (m/s2) .
• reducing the minutes of tool use per day
• Monitoring of exposure duration and symptoms
•
The use of antivibration gloves or tape wrapped around tool
handles( reduce vibration exposure levels at higher frequencies)
• Smoking cessation (reduces arterial vasospasm)
• Treatment
• minimizing exposure to vibrating hand tools.
• If CTS is also present, carpal tunnel surgery may be useful
•
•
•
•
•
Kienböck Disease
avascular necrosis (AVN) of the lunate.
often idiopathic but can be associated with chronic steroid use.
It may be bilateral.
present in young men.
• Preiser disease :
• A similar condition can occur in the scaphoid .
• very high levels of exposure to vibrating or percussing hand tools: AVN
of both carpal bones.
• Clinical Findings
• wrist pain centered over the lunate but it may be vague in nature.
• swelling and synovitis of the wrist.
• Stiffness with wrist flexion and extension may be present.
• Differential Diagnosis
• Wrist sprains, scaphoid nonunions, and osteoarthritis of the wrist.
• Imaging & Diagnostic Studies
• PA, lateral, and oblique views of the wrist
• sclerosis of the lunate, lunate collapse or loss of lunate height, lunate
fragmentation, and eventually degenerative changes in the radiocarpal
and midcarpal joints.
• Stage 1 Kienböck is diagnosed on MRI:
• decreased vascularity of the lunate.
• The disease occasionally occurs bilaterally and radiographs of the
opposite side should also be performed.
• Prevention
• generally idiopathic, sometimes high levels of
• exposure to vibrating or percussing hand tools.
• Treatment
• Treatment depends on stage of the disease.
• earlier stages and those with open physes:
• casting or splinting and can show revascularization of the lunate
over 1–2 years.
•
•
•
significant lunate collapse: surgery.
radial positive (radius longer than the ulnar):
radial shortening or other “joint leveling procedures.”
Revascularization procedures can also be done.
•
• Once degenerative changes have begun in the wrist, salvage
procedures including proximal row carpectomy or partial or total
wrist arthrodesis may be needed
• Dupuytren Contracture
•
thickening of the palmar fascia, which is the layer of tissue between
the skin and the underlying tendon sheath.
•
begins as a small nodule or nodules
•
grow over time to form cords contracture of the digit at the
proximal interphalangeal and metacarpophalangeal joints.
•
more common over the ulnar digits.
•
often seen in individuals of Northern European descent,
•
more common in males
• hereditary predisposition.
• Clinical Findings
• At the early stages:subcutaneous, nonmobile nodules at the palm.
• At later stages, palpable subcutaneous cords ,extend into the digits
and cause puckering of the overlying skin.
• relatively fixed contractures of the MP and PIP joints and an inability
to lay the hand flat on a table.
• Differential Diagnosis
•
joint sprains, missed fractures, and tendon injuries, masses of the
hand such as ganglion cysts or nerve sheath tumors.
•
•
•
•
•
Imaging & Diagnostic Studies
No imaging is needed.
Radiographs of the involved digits:
( assessing underlying arthritis)
MRI: differentiating from other types of masses.
• Prevention
• primarily genetic in nature
• some studies :
• association with alcohol abuse, smoking, and very high levels of
physical exposure (vibration and force) during the working life.
• Treatment
• asymptomatic Patients: observation
• when the contractures reach around 30 degrees:
functional deficits.
Splinting and therapy: not particularly effective.
• Collagenase injections : have acceptable midterm results.
• gold standard :
• Surgery: needle fasciotomy or open partial fasciectomy, with the open
procedure remaining the.
• Scaphoid Fractures
• fall on the outstretched hand.
• In elderly patients (osteoporosis) the same mechanism:
Colles (distal radius) fracture
• acute fall and snuffbox tenderness:
should be treated as if they have a scaphoid fracture since early
diagnosis and immobilization play a key role in healing.
nonunion almost: degenerative changes at the wrist.
• Clinical Findings
• tenderness over the anatomic snuffbox or volarly over the distal pole
of the scaphoid.
• swelling, ecchymosis, and limited range of motion.
Differential Diagnosis
• Fx radial styloid, De Quervain’s tenosynovitis, CMC arthritis.
Imaging & Diagnostic Studies
• PA, lateral, oblique views of the wrist, scaphoid view.
• Often the fracture is only visible on one of these three views.
• Nondisplaced scaphoid fx are often not apparent on initial plain
radiographs, so repeat radiographs 1–2 weeks later or MRI or CT
scan.
• Treatment
• immediately immobilized with a thumb spica splint or
cast until radiographs can be repeated in 1–2 weeks
or CT,MRI.
• nondisplaced Fx : short arm thumb spica cast.
• Immobilization is continued until fracture union is
seen radiographically, usually at least 12 weeks.
• displaced Fx: open reduction and internal fixation.
• Symptoms in scaphoid nonunion occur long after the
original injury.
• In scaphoid nonunion :Surgical treatment with bone
grafting.
• Mallet Finger
• injuries to the extensor tendon of the finger near the DIP joint.
• Rf: high velocity load to the end of the digit, such as when a ball hits
the end of the finger leading to a stretch or rupture of the extensor
tendon.
•
•
•
•
Clinical Findings
Pain at the DIP joint
inability to actively extend the DIP joint is the usual presentation .
Fractures may or may not be present.
• Imaging & Diagnostic Studies
• A lateral view of the phalanges :
• fractures and subluxation of joint.
•
•
•
•
Treatment
Most injuries: conservative treatment
(even if they are several months old)
The DIP joint is splinted in extension full-time with a Mallet splint for
6–8 weeks.
• The splint allows time for the tendon to recover.
• surgical pinning:
• fracture with joint subluxation.
• Radius or Ulnar Fractures
• result from a fall or trauma.
• In young patients, the trauma is usually fairly high energy.
• In osteoporotic patients it is often a fall from standing.
• Clinical Findings
• pain, swelling, ecchymosis, and deformity of the forearm or wrist.
• check skin: for any breaks that may indicate an open fracture.
• neurovascular examination.
• Differential Diagnosis
• Sprains and soft tissue injuries.
Imaging & Diagnostic Studies
• PA and lateral views of the forearm or PA, lateral, and oblique
views of the wrist (depending on the site of injury)
• Prevention
• Osteoporotic patients should be carefully treated and monitored
• Forearm guards may be used in high-risk sporting activities such
as martial arts.
• Treatment
• radial shaft are treated surgically in adults.
• Isolated ulnar fractures treated with casting or splinting
depending on location, displacement, and age of the patient.
Distal radius fractures: treated with either casting or surgery again
depending on the age of the patient,
activity level, displacement of the fracture, and intra-articular
involvement.
Elbow Osteoarthritis
 rare condition
 almost in males
 repetitive strenuous use of the arm in activities ranging from weight
lifting to operating vibrating heavy machinery.
 Elbow OA is marked by osteophytes formation
Clinical Findings:
 Progressive diffuse pain .
 During the early course: osteophytes in the olecranon fossa cause
pain in maximal extension.
 osteophyte in the trochlea or in the coronoid process: impingement
pain may be noted in extreme flexion.
• Differential Diagnosis
secondary OA or rheumatoid arthritis.
• Imaging & Diagnostic Studies
• Imaging is necessary .
• Plain radiograph or CT of the elbow (osteophyte).
• Treatment
• Conservative management:
• decreased biomechanical exposure, pain relief, intra-articular,
steroid injections, physical therapy, and splinting.
• surgery :
• conservative treatment fails
• OA is advanced
•
Nonspecific Forearm, Wrist, or Hand Pain
• nonlocalizing aches or pains in distal upper extremities or symptoms that
change in quality and location with time.
• normal physical examination (50%)
• One approach is to treat these as somatizations and try to identify
underlying psychological or psychosocial factors that may be triggering
symptoms.
• This approach should be considered if the symptom location and quality
change with time and there is no apparent aggravation by specific tasks
or biomechanical activities.
• Psychosocial factors at work:
• relationships with coworkers and supervisors; concerns of job loss; the
patient’ pattern of wellbeing and energy level through the workweek; …
• psychosocial factors :A poor sleep pattern
-daily exercises as simple as nondirected walks. -Low dose pm tricyclic
antidepressants,…
-referral to a therapist.
• Another approach is:
• identify the specific tasks and biomechanical activities at work or
home that aggravate the symptoms
• (if the symptom location does not change over time and the patient
can identify specific aggravating activities)
• risk factors that might affect tissues in the location of the symptoms.:
• pain in the elbow region may be due to the repeated forceful pinching
or gripping; sustained wrist extension; or contact stress at the elbow.
• For pain at the wrist: sustained wrist extension or ulnar deviation;
sustained forearm pronation; repeated wrist motion; or contact stress on
the volar surface of the wrist.
•
workplace intervention (new tools or changes in work practices ) in
aggravating activities:
• computer users are symptomatic using a conventional keyboard or
mouse because their symptoms are aggravated by forearm
pronation(split keyboard and an asymmetrical mouse)
• The symptoms may take several weeks to resolve after the intervention.