Upper Limb

1
Upper Limb

• Orthopaedic Medicine

2
Scope

• Neck
• Shoulder
• Elbow
• Wrist
• Hand

3
Neck

• Chronic pain syndromes.
• Mechanical neck pain.
• Red flags
• Weight loss, anorexia, fever, dysphagia,
  hoarseness.
• Neurological signs in arm.

4
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.
• Collars probably useless.
• Traction ditto.
• Encourage home exercises.
• Simple analgesia.
• Keep on with work and normal activities.

5
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.

6
Shoulder Examination

• Cant 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.

7
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.

8
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.
• Avoid precipitating factors.
• NSAIDs.
• Improving range of movement.
• Steroids into subacromial bursa.
• Surgical decompression (no use in rheumatoid).

9
Shoulder Problems

• Calcific tendonitis.
• Hydroxyapatite deposits in supraspinatus tendon
  and subacromial bursa.
• Presents acutely.
• Check electrolytes and phosphate.
• NSAIDs.
• Steroid injection.

10
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 !
• NSAIDs.

11
Shoulder Problems

• Frozen shoulder.
• WomenMen, 31.
• Insidious onset.
• Commoner after 50years.
• Global restriction of movement, external rotation
  most reduced.
• Physio to gradually improve passive range of
  movement.
• NSAIDs.
• Glenohumeral steroid injection.
• AC sternoclavicular arthritis.

12
Shoulder Problems

• Glenohumeral arthritis.
• Rarer than other joints.
• OA.
• Rheumatoid.
• Crystal arthropathies.
• Physio to encourage use.
• NSAIDs.
• Steroid less helpful.

13
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.

14
Shoulder Problems

• Sternoclavicular arthritis.
• Tender over joint.
• Most shoulder movements cause pain.
• Common in IV drug users.

15
Elbow

• Medial epicondylitis.
• 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.

16
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.

17
Elbow

• Olecranon bursitis.
• Common in rheumatoid.
• Trauma.
• Gout, pseudogout.
• Infection.

18
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.

19
Wrist Hand

• Objective synovitis is easy to feel.
• If multiple joints think of systemic
  arthropathies.
• Heberdens and Bouchards nodes.

20
Wrist Hand

• De Quervains tendonitis.
• Finkslsteins test.
• Extensor pollucis longus and abductor pollucis
  brevis.
• Avoidance of precipitants.
• Wrist splint.
• NSAIDs.
• Possibly steroid injection into sheaths.
• Thumb OA.
• Common of the carpometacarpal joint.
• Sore in anatomical snuff box.

21
Wrist Hand

• Trigger finger.
• Modify gripping if possible.
• NSAIDs.
• Steroid injection.
• Surgical decompression.
• Carpal tunnel syndrome.
• Should start with nocturnal pain usually wakes
  them from sleep.
• Should be proper dermatomal symptoms.