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Upper Limb

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Encourage home exercises. Simple analgesia. Keep on with work and normal activities. ... Then ask em to lower arm slowly if it drops they have either a cuff tear or ... – PowerPoint PPT presentation

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Title: 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.
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