UEtitE lUpper Extremity ExamplesNAOEM, September 25, 2015 Upper Extremity SectionsUpper Extremity...

U E t it E lUpper Extremity Examples

Paul S. Darby, MD, PhD, MPH, FACOEM with thanks toPaul S. Darby, MD, PhD, MPH, FACOEM with thanks to

Douglas W. Martin, MD, FAADEP, FACOEM, FAAFPg , , , ,

NAOEM, September 25, 2015

Upper Extremity SectionsUpper Extremity Sections

16.2 Amputation16 3 Sensory Loss16.3 Sensory Loss16.4 Range of Motion16.5 Peripheral Nerve Disorders16.6 Vascular Disorders16.7 Other Disorders16.8 Strength16.8 Strength

Case ACase A

Musculocutaneous N I jNerve Injury

A seventeen year old right A seventeen year old right handed meat packing planthanded meat packing planthanded meat packing plant handed meat packing plant worker sustained an worker sustained an accidental stab wound of his accidental stab wound of his left upper arm damaging hisleft upper arm damaging hisleft upper arm, damaging his left upper arm, damaging his musculomusculo--cutaneous nerve.cutaneous nerve.

Six months later, he has fullSix months later, he has fullSix months later, he has full Six months later, he has full elbow flexion with a 10 lb. weight elbow flexion with a 10 lb. weight in his hand but cannot flex fullyin his hand but cannot flex fullyin his hand, but cannot flex fully in his hand, but cannot flex fully with 15 lb. He can detect with 15 lb. He can detect pinprick on the radial side of his pinprick on the radial side of his forearm most of the time but itforearm most of the time but itforearm most of the time, but it forearm most of the time, but it doesn't "feel right" in this area. doesn't "feel right" in this area. He has no pain.He has no pain.

Determination of impairment Determination of impairment d i jd i jdue to nerve injurydue to nerve injury

Degree of sensory Degree of sensory ll

Degree of motor Degree of motor lllossloss lossloss

Maximum Maximum impairment due to impairment due to

Maximum Maximum impairment due to impairment due to impairment due to impairment due to

sensory loss of this sensory loss of this nervenerve

impairment due to impairment due to motor loss of this motor loss of this nervenerve

Upper extremity Upper extremity impairment due to impairment due to sensory losssensory loss

Upper extremity Upper extremity impairment due to impairment due to motor lossmotor losssensory losssensory loss motor lossmotor loss

Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit

Table 16Table 16--10, p. 482 10, p. 482 Determination of percent of sensory deficitDetermination of percent of sensory deficitDetermination of percent of sensory deficitDetermination of percent of sensory deficit

Determination of impairment Determination of impairment due to nerve injurydue to nerve injury

Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor lossg yg y gg

Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of hh

Maximum impairment Maximum impairment due to motor loss of due to motor loss of hhthis nervethis nerve this nervethis nerve

Upper extremity Upper extremity Upper extremity Upper extremity Uppe e t e tyUppe e t e tyimpairment due to impairment due to sensory losssensory loss

Uppe e t e tyUppe e t e tyimpairment due to impairment due to motor lossmotor loss

Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit

Excerpt from Table 16Excerpt from Table 16--15, p. 49215, p. 492Maximum percent impairments Maximum percent impairments of the upper extremity due toof the upper extremity due topp ypp y

injury of specific nervesinjury of specific nerves

Sensory MotorSensory Motor


Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor loss

Maximum impairment Maximum impairment d t l f d t l f

Maximum impairment Maximum impairment d t t l f thi d t t l f thi due to sensory loss of due to sensory loss of

this nervethis nerve5 %5 % due to motor loss of this due to motor loss of this

nervenerve


Upper extremity Upper extremity impairment due to impairment due to motor lossmotor loss



Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor lossg yg y gg

Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of thi thi

5 %5 %Maximum impairment Maximum impairment due to motor loss of this due to motor loss of this

this nervethis nerve nervenerve

Upper extremity Upper extremity Upper extremity Upper extremity pp ypp yimpairment due to impairment due to sensory losssensory loss

1 %1 %pp ypp y

impairment due to impairment due to motor lossmotor loss

Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit

Table 16Table 16--11, p. 484. 11, p. 484. D i i f f d fi iD i i f f d fi iDetermination of percent of motor deficitDetermination of percent of motor deficit

Determination of impairment Determination of impairment due to nerve injurydue to nerve injurydue to nerve injurydue to nerve injury

Degree of sensory lossDegree of sensory loss 25%25% Degree of motor lossDegree of motor loss 20 %20 %

Maximum impairment Maximum impairment d t l f d t l f

Maximum impairment Maximum impairment d t t l f thi d t t l f thi due to sensory loss of due to sensory loss of

this nervethis nerve5%5% due to motor loss of this due to motor loss of this

nervenerve


1%1%Upper extremity Upper extremity impairment due to impairment due to motor lossmotor loss


Excerpt from Table 16Excerpt from Table 16--15, p. 49215, p. 492Maximum percent impairmentsMaximum percent impairmentsMaximum percent impairments Maximum percent impairments

of the upper extremity of the upper extremity due to injury of specific nervesdue to injury of specific nervesj y pj y p

Sensory MotorSensory Motor


Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor loss 20 %20 %

Maximum impairment Maximum impairment Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of this nervethis nerve

5 %5 % due to motor loss of this due to motor loss of this nervenerve

25 %25 %


1 %1 %Upper extremity Upper extremity impairment due to impairment due to motor lossmotor lossyy



D f lD f l 25 %25 % D f lD f l 20 %20 %Degree of sensory lossDegree of sensory loss 25 %25 % Degree of motor lossDegree of motor loss 20 %20 %

Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of 5 %5 %

Maximum impairment Maximum impairment due to motor loss of this due to motor loss of this 25 %25 %due to sensory loss of due to sensory loss of

this nervethis nerve5 %5 % due to motor loss of this due to motor loss of this

nervenerve25 %25 %


1 %1 %Upper extremity Upper extremity impairment due to impairment due to motor lossmotor loss

5 %5 %



Degree of sensory lossDegree of sensory loss 25%25% Degree of motor lossDegree of motor loss 20 %20 %Degree of sensory lossDegree of sensory loss 25%25% Degree of motor lossDegree of motor loss 20 %20 %

Maximum impairment Maximum impairment due to sensory loss of due to sensory loss of 5%5%

Maximum impairment Maximum impairment due to motor loss of this due to motor loss of this 25 %25 %due to sensory loss of due to sensory loss of

this nervethis nerve5%5% due to motor loss of this due to motor loss of this

nervenerve25 %25 %

Upper extremity Upper extremity Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to sensory losssensory loss

1%1%Upper extremity Upper extremity impairment due to impairment due to motor lossmotor loss

5 %5 %

U t it i i t d t d fi itU t it i i t d t d fi it 6 %6 %Upper extremity impairment due to nerve deficitUpper extremity impairment due to nerve deficit 6 %6 %

Case BCase B

Fractured HumerusFractured Humerus

A 48 year old file clerk fell down theA 48 year old file clerk fell down theA 48 year old file clerk fell down the A 48 year old file clerk fell down the stairs at work sustaining a fracture of stairs at work sustaining a fracture of her right distal humerus Openher right distal humerus Openher right distal humerus. Open her right distal humerus. Open reduction of the fracture was necessary. reduction of the fracture was necessary. Si h f i j h li f hSi h f i j h li f hSix months after injury, healing of the Six months after injury, healing of the fracture was complete and serial fracture was complete and serial measurements showed no further measurements showed no further improvement in range of motion.improvement in range of motion.p gp g

H lb fl d 120 d d l k dH lb fl d 120 d d l k dHer elbow flexed 120 degrees and lacked Her elbow flexed 120 degrees and lacked 40 degrees of full extension. She had 60 40 degrees of full extension. She had 60 degrees of pronation and 20 degrees of degrees of pronation and 20 degrees of supination. Her shoulder would flex 150 supination. Her shoulder would flex 150 ppdegrees and would extend 30 degrees. degrees and would extend 30 degrees. She had 40 degrees of adduction and 90She had 40 degrees of adduction and 90She had 40 degrees of adduction and 90 She had 40 degrees of adduction and 90 degrees of abduction. She had 30 degrees degrees of abduction. She had 30 degrees of internal rotation and 40 degrees ofof internal rotation and 40 degrees ofof internal rotation and 40 degrees of of internal rotation and 40 degrees of external rotation.external rotation.

Impairment due to loss of:Impairment due to loss of:

Elbow flexionElbow flexion Shoulder flexionShoulder flexion

extensionextension extensionextension

pronationpronation abductionabduction

supinationsupination adductionadductionsupinationsupination adductionadduction

internal rotation internal rotation

external rotationexternal rotation

Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion

impairment due to impairment due to limited shoulder motionlimited shoulder motion

Combined upper extremity impairmentCombined upper extremity impairment

Table 16Table 16--34, p. 47234, p. 472120120°° Elbow flexionElbow flexion120120 Elbow flexionElbow flexion


Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion

extensionextension extensionextension








Table 16Table 16--34, p. 472. 34, p. 472. 4040°° Elbow extensionElbow extension



extensionextension 44 extensionextension






impairment due to limited impairment due to limited shoulder motionshoulder motion


Table 16Table 16--37, p. 47437, p. 4746060°° forearm pronationforearm pronation6060 forearm pronationforearm pronation




pronationpronation 11 abductionabduction




Upper extremity Upper extremity Upper extremity Upper extremity impairment due to limited impairment due to limited elbow motionelbow motion

impairment due to limited impairment due to limited shoulder motionshoulder motion


Table 16Table 16--37, p. 47437, p. 4742020°° f i tif i ti2020°° forearm supinationforearm supination





supinationsupination 33 adductionadductionsupinationsupination 33 adductionadduction














1010 impairment due to limited impairment due to limited shoulder motionshoulder motion


Table 16Table 16--40, p 47640, p 476150150°° h ld fl ih ld fl i150150°° shoulder flexionshoulder flexion


Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22









Table 16Table 16--40, p 47640, p 4763030°° h ld t ih ld t i3030°° shoulder extensionshoulder extension


Elbow flexionElbow flexion 22 Shoulder flexionShoulder flexion 22extensionextension 44 extensionextension 11extensionextension 44 extensionextension 11pronationpronation 11 abductionabduction

supinationsupination 33 adductionadduction



Upper extremity Upper extremity Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to limited elbow motionlimited elbow motion

1010Upper extremity Upper extremity impairment due to impairment due to limited shoulder motionlimited shoulder motion


Table 16Table 16--43, p. 47743, p. 4779090°° shouldershoulder abductionabduction9090 shoulder shoulder abductionabduction



extensionextension 44 extensionextension 11

pronationpronation 11 abductionabduction 44





1010 impairment due to impairment due to limited shoulder motionlimited shoulder motion


Table 16Table 16--43, p. 47743, p. 4774040°° shouldershoulder adductionadduction4040 shoulder shoulder adductionadduction





supinationsupination 33 adductionadduction 00supinationsupination 33 adductionadduction 00






Table 16Table 16--46, p. 47946, p. 4793030°° Internal rotationInternal rotation3030 Internal rotation Internal rotation






internal rotation internal rotation 44





Table 16Table 16--46, p. 47946, p. 4794040°° External rotationExternal rotation4040 External rotation External rotation







external rotationexternal rotation 11











Upper extremity Upper extremity Upper extremity Upper extremity impairment due to impairment due to

limited elbow motionlimited elbow motion1010 impairment due to impairment due to

limited shoulder motionlimited shoulder motion1212











1212

Combined upper extremity impairmentCombined upper extremity impairment 2121

Case CCase C

Rotator Cuff TearRotator Cuff Tear

A 47 year old carpenter sustained a major rotator cuff tear of his rightmajor rotator cuff tear of his right shoulder while at work. He had surgical repair and appropriate rehabilitation.

Six months later, he was back at work as a carpenter, although he p gneeded help on some parts of his job that he used to do by himself. Hethat he used to do by himself. He had some aching pain after work, and occasionally had pain at nightand occasionally had pain at night.

At the time of his evaluation, six months after surgical repair he hadmonths after surgical repair, he had motions as follows:

Flexion 120° Extension 20°Adduction 20° Abduction 90°External rotation 40° Internal rotation 60°

M l l t ti h dManual muscle testing showed a strength loss index of between 10% and 20% in all shoulder motions.

Table 16Table 16--40, p 47640, p 476120120°° h ld fl ih ld fl i120120°° shoulder flexionshoulder flexion

Upper extremity impairment due to limitation of:Shoulder flexion 4%

extensionabduction

adduction

internal rotation

t l t tiexternal rotation

Upper extremity impairment due to limited shoulder motionUpper extremity impairment due to weakness

Impairment of upper extremity

Impairment of whole person

Table 16Table 16--40, p 47640, p 4762020°° h ld t ih ld t i2020°° shoulder extensionshoulder extension


extension 2%abduction

adduction

internal rotation





Table 16-43, p. 47790° shoulder abduction90 shoulder abduction


extension 2%abduction 4%

adduction

internal rotation





Table 16-43, p. 47740° shoulder adduction40 shoulder adduction

Upper extremity impairment due to limitation of:Shoulder flexion extension 4%

2%abduction 4%abduction 4%

adduction 1%


external rotation

Upper extremity impairment due to limited shoulder pp y pmotionUpper extremity impairment due to weakness

Impai ment of ppe e t emitImpairment of upper extremity


Table 16-46, p. 47960° Internal rotation60 Internal rotation



adduction 1%

internal rotation 2%





Table 16-46, p. 47940° External rotation40 External rotation



adduction 1%


t l t ti 1%external rotation 1%

Upper extremity impairment due to limited shoulder motion

14%

Upper extremity impairment due to weakness



Table 16-35, p. 510Impairment of Upper Extremity due to

Weakness of Shoulder or Elbow

3%

1%

2%

1%

1%

1%



adduction 1%




14%

Upper extremity impairment due to weakness 9%



NOT SO FAST MY FRIEND !!NOT SO FAST, MY FRIEND !!

16.8: Strength Evaluation16.8a: Principles, p. 50816.8a: Principles, p. 508

“If the examiner judges that loss of strength If the examiner judges that loss of strength should be rated separately in an extremity that presents with other impairments, the i i t d t l f t th ld b impairment due to loss of strength could be combined with the other impairments, only if based on unrelated etiologic or pathomechanical causes. Otherwise, the impairment ratings based on objective anatomic findings take precedence Decreased strength cannot be rated precedence. Decreased strength cannot be rated in the presence of decreased motion, painful conditions, deformities or absence of parts (eg,

t ti ) ” …amputation)…”



adduction 1%




14%

Upper extremity impairment due to weakness 9%





adduction 1%




14%

Upper extremity impairment due to weakness 9% NO!

Impairment of upper extremity 14%

Impairment of whole person BUT DON’T REPORT!!! 8%

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