DISORDERS OF THE UPPER LIMB

DISORDERS OF THE UPPER LIMB NOTE : THIS PRESENTATION DOES NOT REPLACE ATTENDANCE OR INFORMATION GIVEN IN THE LECTURE. IT IS INTENDED AS A HIGHLIGHT FOR THE TOPIC. DR DEVDAS SHRIYAN MS ORTH., D.ORTH., MSc TRAUMA(UK), Fellow Inst Accident Surgery(UK) Consultant, Dept of Orthopedics King Fahd Hospital of the University, Al-Khober, KSA. Professor/ FMR Chairman, Dept of Orthopedics 8/11/2008 Adi. Institute of Medical Science,PROF DSS Karnataka, India. 1 SHOULDER EXAMINATION Inspection: Surface from the front Surface anatomy from behind surf-anat PROF DSS 2 SHOULDER EXAMINATION ANATOMY 8/11/2008 PROF DSS 3 SHOULDER EXAMINATION ANATOMY 8/11/2008 PROF DSS 4 SHOULDER EXAMINATION INSPECTION Look for  Wasting or asymmetry of shoulder height,  Scapular position  Muscle bulk Observation from behind 8/11/2008 PROF DSS 5 SHOULDER EXAMINATION PALPATION. . 8/11/2008 PROF DSS 6 SHOULDER EXAMINATION MOVEMENTS Abduction Adduction Flexion Extension Internal, External rotation Active external rotation with elbows at side 8/11/2008 PROF DSS 7 SHOULDER EXAMINATION MOVEMENTS External rotation –active at 90 degrees PROF DSS 8/11/2008 8 SHOULDER EXAMINATION MOVEMENTS Internal rotation –active Measure the level of the spine of tip of middle finger on each side 8/11/2008 PROF DSS 9 SHOULDER EXAMINATION MOVEMENTS Resisted movements - external rotation. 8/11/2008 PROF DSS 10 SHOULDER EXAMINATION MOVEMENTS Resisted movements - Subscapularis lift off test - (Gerber's test). - Push away from the spine 8/11/2008 against resistance. PROF DSS 11 SHOULDER EXAMINATION MOVEMENTS Resisted movements deltoid. Resisted abduction at 90 degrees with the arm in neutral rotation frozen PROF DSS 12 DISORDERS OF THE UPPER LIMB FROZEN SHOULDER / PERIARTHRITIS (ADHESIVE CAPSULITIS)      Pain Reduced range of motion Commonly occurs in diabetics Stiffness Restriction of passive movement in all range pict PROF DSS 13 DISORDERS OF THE UPPER LIMB FROZEN SHOULDER / PERIARTHRITIS (ADHESIVE CAPSULITIS) stage PROF DSS 14 DISORDERS OF THE UPPER LIMB FROZEN SHOULDER / PERIARTHRITIS (ADHESIVE CAPSULITIS) STAGING OF DISEAE:  CLINICAL STAGE    Painful Stiff Thawing Gradual onset of diffuse pain Decreased ROM, affects ADL Gradual return of motion path pict PROF DSS 15 DISORDERS OF THE UPPER LIMB Impingement syndrome treat PROF DSS 16 DISORDERS OF THE UPPER LIMB FROZEN SHOULDER / PERIARTHRITIS (ADHESIVE CAPSULITIS) TREATMENT:  NSAID  Physiotherapy  Local steroid  Manipulation under anesthesia  Role of arthroscopy controversial disorders PROF DSS 17 DISORDERS OF THE UPPER LIMB            OLECRANON BURSITIS TENNIS ELBOW GOLFERS ELBOW CUBITAL TUNNEL SYNDROME ANTERIOR INTEROSSEOUS SYNDROME CARPAL TUNNEL SYNDROME TRIGGER FINGER DE QUERVAIN TENOSYNOVITIS OCCUPATIONAL HAND CRAMP GANGLION GAME KEEPERS THUMB PROF DSS 18 cause DISORDERS OF THE UPPER LIMB OLECRANON BURSITIS Causes:     Acute trauma (eg, falling onto a hard floor or a playing field with artificial turf and landing on the olecranon process) Minor cumulative trauma, such as repetitive rubbing of the olecranon region against a desktop during writing Infection due to abrasion or laceration at the site or due to seeding from hematogenous spread by bacteremia Inflammation as part of a systemic inflammatory process (eg, rheumatoid arthritis) or crystal deposition disease (eg, gout, pseudogout) PROF DSS 19 8/11/2008 DISORDERS OF THE UPPER LIMB treat PROF DSS 20 DISORDERS OF THE UPPER LIMB Treatment:       Ice packs 20 to 30 minutes every 3 to 4 hours for 2 to 3 days or until the pain and swelling go away Wrapping an elastic bandage around your elbow to keep the bursa from swelling more Aspiration bursa fluid by with a needle and syringe Taking anti-inflammatory medication Protecting elbow with a pad. Surgical removal of the bursa -In some longstanding (chronic) olecranon bursitis. PROF DSS 21 aspi DISORDERS OF THE UPPER LIMB surg PROF DSS 22 DISORDERS OF THE UPPER LIMB tenis PROF DSS 23 DISORDERS OF THE UPPER LIMB TENNIS ELBOW     Also called lateral epicondylitis. Degeneration of extensor muscle origin from lateral epicondyle of humerus. Extensor carpi radialis brevis origin commonly involved. Result of overuse injuries & poor technique in racket sports. PROF DSS 24 path DISORDERS OF THE UPPER LIMB clin PROF DSS 25 DISORDERS OF THE UPPER LIMB TENNIS ELBOW CLINICALLY:    Tenderness over lateral epicondyle. Common in younger age group. Increased tenderness by resisted wrist extension. clin pict PROF DSS 26 DISORDERS OF THE UPPER LIMB treat PROF DSS 27 DISORDERS OF THE UPPER LIMB TENNIS ELBOW TREATMENT:  Rest, NSAID.  Orthotic support designed to decentralize area of stress (Tennis elbow strap).  Ultrasonography, electrical stimulation.  Stretching, strengthening, equipment modification.  Local injection.  Surgical release. surg PROF DSS 28 DISORDERS OF THE UPPER LIMB golfer PROF DSS 29 DISORDERS OF THE UPPER LIMB GOLFER’S ELBOW (MEDIAL EPICONDILITIS OF HUMERUS) Medial epicondylitis is commonly known as golfer's elbow. CAUSES:  Golf swing is a common cause of medial epicondylitis.  Repetitive activities can also lead to golfer's elbow  Throwing, chopping wood with an ax, running a chain saw  Using many types of hand tools.  Any activities that stress the same forearm muscles can cause symptoms of golfer's elbow. surg PROF DSS 30 DISORDERS OF THE UPPER LIMB GOLFER’S ELBOW (MEDIAL EPICONDILITIS OF HUMERUS) Medial epicondylitis is commonly known as golfer's elbow. cubital PROF DSS 31 DISORDERS OF THE UPPER LIMB CUBITAL TUNNEL SYNDROME    Compression of ulnar nerve under the cubital tunnel. Course through arch of flexor carpi ulnaris origin. Causes: UN trapped, irritated, subluxed. Osteophte, cubitus valgus, work related excessive repetitive flexion. pict PROF DSS 32 DISORDERS OF THE UPPER LIMB CUBITAL TUNNEL SYNDROME clinic PROF DSS 33 DISORDERS OF THE UPPER LIMB CUBITAL TUNNEL SYNDROME surg PROF DSS 34 DISORDERS OF THE UPPER LIMB CUBITAL TUNNEL SYNDROME pict PROF DSS 35 DISORDERS OF THE UPPER LIMB CUBITAL TUNNEL SYNDROME AIS PROF DSS 36 DISORDERS OF THE UPPER LIMB ANTERIOR INTEROSSEOUS SYNDROME Compression of anterior inter-osseous nerve in the forearm. Muscles supplied are radial half of FDF, FPL, Pronator quadratus. Decreased pinch between thumb & index finger. Decreased strength of pronation Treatment: conservative / operative. cts PROF DSS 37 DISORDERS OF THE UPPER LIMB CARPAL TUNNEL SYNDROME    Compression of the median nerve at the wrist under flexor retinaculum. Females are more affected. Causes: Idiopathic Pregnancy Trauma Rheu. arthritis PROF DSS 38 pict DISORDERS OF THE UPPER LIMB CARPAL TUNNEL SYNDROME clinic PROF DSS 39 DISORDERS OF THE UPPER LIMB CARPAL TUNNEL SYNDROME CLINICALLY:    Wasting of thenar eminence. Weakness of thenar muscles. Loss of sensation over radial 3 ½ fingers on volar aspect. pict PROF DSS 40 DISORDERS OF THE UPPER LIMB CARPAL TUNNEL SYNDROME treat PROF DSS 41 DISORDERS OF THE UPPER LIMB CARPAL TUNNEL SYNDROME Treatment:      Medication Physical Therapy Wrist Brace Conservative Treatment Surgical Treatment: Release of flexor retinaculum open surgery / endoscopic local PROF DSS 42 DISORDERS OF THE UPPER LIMB CARPAL TUNNEL SYNDROME surg PROF DSS 43 DISORDERS OF THE UPPER LIMB CARPAL TUNNEL SYNDROME gangl PROF DSS 44 DISORDERS OF THE UPPER LIMB GANGLION     Accumulation of synovial fluid adjacent to a joint capsule or tendon sheath. Most common tumor of the hand. The fluid in the pseudocyst contains mainly hyaluronic acid. Common location is dorsum of the hand. treat PROF DSS 45 DISORDERS OF THE UPPER LIMB GANGLION TREATMENT:   Aspiration & steroid injection. Excision. trigg PROF DSS 46 DISORDERS OF THE UPPER LIMB TRIGGER FINGER     Stenosing tenosynovitis of the digital flexor tendons. Snapping occurs on extension of the flexed fingers. Painful finger movement which catch in mid position. Trauma/diabetes mellitus. pict PROF DSS 47 DISORDERS OF THE UPPER LIMB TRIGGER FINGER treat PROF DSS 48 DISORDERS OF THE UPPER LIMB TRIGGER FINGER TREATMENT:    NSAID Local injection. Surgical release. treat PROF DSS 49 DISORDERS OF THE UPPER LIMB TRIGGER FINGER dqt PROF DSS 50 DISORDERS OF THE UPPER LIMB DE QUERVAIN’S TENOSYNOVITIS      Inflammation of tendon sheath of first compartment. New job, repetitive grasping. Pain over radial styloid, swelling + Finkelstein test positive. D/D: #Scaphoid, first carpo-metacarpal OA pict PROF DSS 51 DISORDERS OF THE UPPER LIMB DE QUERVAIN’S TENOSYNOVITIS treat PROF DSS 52 DISORDERS OF THE UPPER LIMB DE QUERVAIN’S TENOSYNOVITIS Treatment:  Limit grasping activities.  (Gardeners, painters etc)  Local steroid/ Surgery occu hand PROF DSS 53 DISORDERS OF THE UPPER LIMB OCCUPATIONAL HAND CRAMP     Due to repetitive injury Pain, fatigue Involuntary contraction of the flexors, extensors when they grasp a pen or place hand on target instrument Treatment: Stop doing activities, reduce tension game-keep PROF DSS 54 DISORDERS OF THE UPPER LIMB GAME KEEPER’S THUMB treat PROF DSS 55 DISORDERS OF THE UPPER LIMB GAME KEEPER’S THUMB Treatment:  If the ligaments are only partially torn, they usually heal without surgery.  Your thumb will be immobilized for four to six weeks in a special cast, called a thumb spica cast.  Surgery for stener leision, complete tears. game-keep PROF DSS 56 DISORDERS OF THE UPPER LIMB GAME KEEPER’S THUMB 8/11/2008 PROF DSS 57