Upper Limb
Orthopaedic Medicine
Scope
• 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.
• 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.
• 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.– Women:Men, 3:1.
– Insidious onset.
– Commoner after 50years.
– Global restriction of movement, external rotation most reduced.
• Physio – to gradually improve passive range of movement.
• NSAID’s.
• Glenohumeral steroid injection.
• AC & sternoclavicular arthritis.
Shoulder Problems
• Glenohumeral arthritis.– 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.– 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.– 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.
• 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.– 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.