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.