Download Upper Limb - Bradfordvts

Upper Limb
Orthopaedic Medicine
Scope
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Neck
Shoulder
Elbow
Wrist
Hand
Neck
• Chronic pain syndromes.
• Mechanical neck pain.
• Red flags:
– Weight loss, anorexia, fever, dysphagia,
hoarseness.
– Neurological signs in arm.
Neck
• X rays.
– Very poor correlation with symptoms.
– 80% of people over 50 years will have abnormalities.
– CT / MRI: 30% of people under 40 have abnormalities.
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Collars probably useless.
Traction ditto.
Encourage home exercises.
Simple analgesia.
Keep on with work and normal activities.
Shoulder Examination
• Wasting of supraspinatus or infraspinatus suggests
a rotator cuff problem.
• Painful abduction arcs:
– Starting at about 60° and easing or stopping after 120 °
suggests supraspinatus / cuff inflammation.
– Starting at 90-120 ° and continuing suggests OA of one
or more joints.
– Passively abduct to 90 ° and internally rotate, suggests
impingement of supraspinatus.
Shoulder Examination
• Can’t abduct due to weakness: passively abduct to
90 °, forward flex to about 30 ° and rotate
internally (so the thumb points down). This
isolates supraspinatus. Then ask ‘em to lower arm
slowly – if it drops they have either a cuff tear or
severe muscle atrophy.
• Internal rotation: glenohumeral problems and
frozen shoulder.
Shoulder Examination
• External rotation: tendonitis of cuff muscles
and frozen shoulder.
• Passive, as opposed to active shoulder
movements improve with tendonitis but not
arthritis or frozen shoulder.
Shoulder Problems
• Impingement syndromes(supraspinatus or rotator
cuff tendonitis).
– Common, =“rotator cuff syndrome”.
– Pain often worse at night.
– Pain during abduction (combing hair, reaching above
head).
– Chronically may lead to rotator cuff atrophy or tear.
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Avoid precipitating factors.
NSAID’s.
Improving range of movement.
Steroids into subacromial bursa.
Surgical decompression (no use in rheumatoid).
Shoulder Problems
• Calcific tendonitis.
– Hydroxyapatite deposits in supraspinatus
tendon and subacromial bursa.
– Presents acutely.
– Check electrolytes and phosphate.
• NSAID’s.
• Steroid injection.
Shoulder Problems
• Biceps tendonitis.
– Pain on carrying things with the elbow flexed.
– If you inject the subacromial space some will
get into the biceps sheath. Easier than getting
the sheath !
– NSAID’s.
Shoulder Problems
• Frozen shoulder.
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Women:Men, 3:1.
Insidious onset.
Commoner after 50years.
Global restriction of movement, external rotation most
reduced.
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Physio – to gradually improve passive range of movement.
NSAID’s.
Glenohumeral steroid injection.
AC & sternoclavicular arthritis.
Shoulder Problems
• Glenohumeral arthritis.
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Rarer than other joints.
OA.
Rheumatoid.
Crystal arthropathies.
• Physio to encourage use.
• NSAID’s.
• Steroid less helpful.
Shoulder Problems
• Acromoclavicular arthritis.
– Tenderness over the joints.
– AC joint problems often secondary OA from
earlier sporting injuries.
– AC joint pain after 90 ° of abduction and
continues.
– Easy to feel crepitus.
– Common in IV drug users.
Shoulder Problems
• Sternoclavicular arthritis.
– Tender over joint.
– Most shoulder movements cause pain.
– Common in IV drug users.
Elbow
• Medial epicondylitis.
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Commonest cause of elbow pain.
Pain on gripping.
Wrist extensors.
Forearm pain.
Chronic pain syndromes also get pain here.
• Resisted wrist extension is painful in epicondylitis
but not in chronic pain syndromes.
Elbow
• Lateral epicondylitis.
– Wrist flexors.
– Check ulnar nerve as entrapment may mimic
lateral epicondylitis.
– Pain on gripping.
– Chronic pain syndromes also get pain here.
• Resisted wrist flexion is painful in epicondylitis but
not in chronic pain syndromes.
• Bilateral epicondylitis – think of the neck.
Elbow
• Olecranon bursitis.
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Common in rheumatoid.
Trauma.
Gout, pseudogout.
Infection.
Elbow
• “Pulled elbow”.
• OA.
– Often secondary to rheumatoid or trauma.
– Restricted movement.
• First to appear is restriction in extension then
pronation / supination.
– Pain closer to joint.
Wrist & Hand
• Objective synovitis is easy to feel.
• If multiple joints think of systemic
arthropathies.
• Heberden’s and Bouchard’s nodes.
Wrist & Hand
• De Quervain’s tendonitis.
– Finkslstein’s test.
– Extensor pollucis longus and abductor pollucis brevis.
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Avoidance of precipitants.
Wrist splint.
NSAID’s.
Possibly steroid injection into sheaths.
• Thumb OA.
– Common of the carpometacarpal joint.
– Sore in anatomical snuff box.
Wrist & Hand
• Trigger finger.
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Modify gripping if possible.
NSAID’s.
Steroid injection.
Surgical decompression.
• Carpal tunnel syndrome.
– Should start with nocturnal pain – usually wakes them
from sleep.
– Should be proper dermatomal symptoms.