Upper Extremities Exam Ppt

Front 1

Differential for Extrinsic Shoulder Pain

Back 1

Myocardial Infarction
Angina pectoris
Irritation of the diaphragm
Cervical radiculopathy
Lung tumor (Pancoast/superior sulcus)

Front 2

Differential for Intrinsic Shoulder Pain

Back 2

Impingement syndrome/rotator cuff tendinitis (Most common diagnosis in shoulder -- osteoarthritis isn’t as common in the shoulder because it is not a weight bearing joint like the hip or the knee and gout can be in the shoulder but not as common), Acromioclavicular syndromes, Frozen shoulder/capsulitis, Calcific tendinitis, Rotator cuff tear, Biceps tendinitis, Glenohumeral instability, Septic joint, Osteoarthritis, Osteonecrosis, Rheumatoid arthritis, Dislocation, Fracture

Front 3

Impingement Syndrome (Rotator Cuff Tendinitis)

Back 3

*Tendons of rotator cuff get inflamed, impingement of tendon (LH of Bic) or bursa NOT Nerve
*Classic Presentation: Insidious, gradual onset (rules out an acute fracture, dislocation, septic arthritis), lateral aspect of the upper arm (classic for syndrome),
can’t sleep on that side, Manual labor (maybe from repetitive injury), no constitutional symptoms (which would make worry about tumors, gout, etc.), no asymmetry, no muscle atrophy, decreased flexion and internal rotation
*Tests: positive Hawkins, positive Neer, Negative lift off test, neg empty can test negative -- positive hawkins and need --> impingement of the subacromial bursa and tendon
*TTP lateral to the acromion, AROM is abnormal, PROM is normal

Front 4

Rotator Cuff ROM Tests

Back 4

*Hawkins -- positive if pain w/ raising and internal rotation at elbow
*Neer -- positive if pain with pronation plus flexion
*Lift off test -- neg if pt can lift hand off back --> meaning subscapularis muscle OK (if positive, people complain can't tuck shirt in)
*Empty can test -- neg if no pain or weakness in empty can position vs full can on symptomatic side -- meaning supraspinatus tendon OK

Front 5

Indications for X-Rays of Upper Extremity

Back 5

Trauma- to r/o fracture or dislocation
After 3 months of symptoms
Suspect OA
A-C joint pain
*Get 3 Views: AP, external rotation, axillary

Front 6

Treatment of Impingement Syndrome

Back 6

Non-steroidal anti-inflammatory 10-14 days
Ice
Rest from the offending activity
OT/PT
Rockwood shoulder rehab with therabands
*subacromial shoulder Steroid injection if no improvement (If steroids help, it's inflammation causing the pain NOT a tear)

Front 7

Rotator Cuff Repair

Back 7

Rotator Cuff Repair (RCR)
Procedure involves re-attaching cuff muscles at humeral footprint
Sutures serve as anchors to hold until physiologic attachment takes place.
Bleeding from bone anchors is source of bone healing
*the only one that is an emergency is a young patient with acute traumatic rotator cuff tear- treat relatively expediently. the other 99% can be treated whenever.

Front 8

Lateral Epicondylitis

Back 8

*Inspection: no deformity, no erythema, no swelling
*Palpation: TTP over the lateral epicondyle, Decreased grip strength, exaggerated in elbow extension -- hard for them to open jars
*AROM of the elbow is nl (if not normal, might be joint)
*Resisted extension at the wrist aggravates the pain!!
*Most common source of elbow pain
*Pathophysiology : Eccentric overloading at common extensor tendon (ECRB/ECRL), Repetitive microtears leading to angiofibrotic changes

Front 9

Treatment for Lateral Epicondylitis

Back 9

Rest, Ice, NSAIDS (don't work all that well because tendon tear)
Straps: Goal is to create new muscle “origin” putting less tension at tendon.
Injections may often temporize symptoms during rest
Patience, patience, patience.
*No steroid injections because short-term symptom relief only
*May give steroids only to make pt comfortable with surgery (if 9-12 months symptoms --> Open and arthroscopic debridement/ECRB release) -- communication is key!

Front 10

Carpal Tunnel Syndrome

Back 10

*Compressed Median Nerve
*PE and History: numbness and burning in 2nd and 3rd fingers - wakes her up at night - she has to shake it out -- says that she has trouble doing her work -- no erythema, no swelling, no atrophy -- No TTP -- AROM nl
**Since palmer cutaneous branch of medial is given off in forearm, it is intact in pts with CTS so they likely only have numbness and burning in fingers not palm area

Front 11

Carpal Tunnel Tests and Maneuvers

Back 11

--Tinel’s test where you tap tap tap
-- Phalen’s test where you bend their hands down – see if it reproduces the tingling sensation
-- problems with opposition of thumb and little finger
*Risk factors: pregnancy (increase in volume can really cause problems with carpal tunnel) AND obesity (it’s a very small compartment and fats gets in there and can compress/aggravate it)

Front 12

Carpal Tunnel Treatment

Back 12

Cockup wrist splint
Avoid exacerbating activities
NSAIDs
OT
*can give steroid injection after three months if no relief
*Atrophy/weakness from long untreated CTS often does not reverse

Front 13

Carpal Tunnel Diagnostic Tests

Back 13

Clinical and electrophysiologic diagnosis -- Most physicians will rely in a combination of: Exam, Response to injections – diminishing returns, EMG/NCS

*Electromyography – Measures skeletal muscle electric potential
*Nerve Conduction Study – Measures conduction velocities across sections of nerve

---CTS will have slowed velocities and decreased potentials at innervated muscles

Front 14

Open Carpal Tunnel Release (CTR)

Back 14

*Incision through skin to aponeurosis -- Aponeurosis is continuous with transverse carpal ligament proximally

---Structures at Risk:
*Superficial palmar arch – near proximal crease
*Ulnar artery/nerve – enters Guillon’s canal ulnar to hook of hamate
*Median nerve – directly deep to aponeurosis and ligament
*Recurrent branch of median nerve- most commonly injured

Front 15

Fractures

Back 15

Usually requires some type of trauma, Bone quality has an impact on fracture areas and types, Often occur at characteristic locations in characteristic patterns, Radiography is often key to diagnosis (X rays, sometimes CT scans)
*If no to minimal comminution (small fragments) --> splint (worry if you don’t restore the joint, can get arthritis)
*BUT if severe Comminution --> restore articular surface with surgery

Front 16

Goal of Fracture care

Back 16

to restore:
Anatomic length
Anatomic alignment
Anatomic rotation

Front 17

Common fracture sequelae

Back 17

Surrounding tissue injury
Post Traumatic Arthritis
Malunion/Nonunion
Hypercoagubulity/embolism
Compartment Syndrome

Front 18

Fractures of Proximal Humerus

Back 18

--3rd most common fracture of elderly (Hips, Spine)
--Often minimal to no displacement
--Shoulder motion allows for good function with different degrees of malunion
-- Usually occur at points of rotator cuff muscle insertion.
**Can use Non-operative treatment if: Minimally displaced, Preservation of articular surfaces, Elderly or less active patients BUT Younger patients with more complex fractures often require operative fixation
**Non-operative pts require follow up with SERIAL RADIOGRAPHS

Front 19

Cervical Radiculopathy vs. Carpal Tunnel Syndrome

Back 19

--Different from CTS bc:
*Location of signs and symptoms include >1 peripheral nerve --> Median and ulnar nerve
*Spare some distributions of an affected nerve --> Spares volar Thumb – M. nerve
*Palmar cutaneous branch not included in carpal tunnel
*Signs/Symptoms decrease with shoulder/arm elevation --> This does not affect the carpal tunnel
*Weakness proximal to carpal tunnel

Front 20

Cervical Radiculopathy

Back 20

*Get x-rays (AP/Lateral and Oblique C-Spine) after physical exam
*Cervical spine exam -- Myotomes
C4 – Shoulder elevation
C5 – Shoulder Abduction
C6 – Elbow Flexion, Wrist Extension
C7 – Elbow Extension, Wrist Flexion
C8 – Finger Flexors (OK sign), Thumb extension
T1 – Finger Abduction

Front 21

Cervical Radiculopathy Treatment

Back 21

Rest, NSAIDS, Physical Therapy
Select level injections – (PM&R, Anesthesiology)

Operative:
Anterior Cervical Discectomy and Fusion (ACDF)
Posterior Foramenotomy – Isolated foramenal narrowing