O&T: Upper Limb Flashcards
History
1. Pain E.g. - Mechanical - Inflammatory - Nocturnal
- Swelling
- Deformity
- Stiffness
- Loss of function (Motor + Sensation)
- Big muscle (shoulder): over-head activity
- Small muscle (hands): writing, chopstick, signature, buttoning, sensation
Common diseases encountered in orthopaedic
- Injury / Mechanical derangement
- Acute injuries
- Chronic repetitive stress injuries: Shoulder impingement, Tennis elbow, DeQuervain’s disease, Trigger digits - Infections
- Joint infection - Muscle weakness + Sensory disturbance (Carpal tunnel syndrome)
- Peripheral nerve lesion: Cervical spondylosis - Degenerative / Overuse disorders (Rotator cuff, Tennis elbow, Trigger finger, DeQuervain)
- CMCJ arthritis
- DIPJ arthritis - Tumours / Lesions that mimic them
- Ganglion - Metabolic dysfunction
- Gouty arthritis - Rheumatic disorder
- RA
- Inflammed joints: shoulder, elbow, wrist, fingers - Congenital / Developmental abnormalities
Anatomy of Upper limb
Areas:
- Shoulder, Arm, Elbow, Forearm, Hand
- Proximal vs Distal
Levels:
- Skin
- SC tissue
- Muscle / Tendon
- Neurovascular
- Bone / Joint
***P/E of Upper limb
- Look
- Feel
- Warmth (compare both sides, proximal + distal)
- Tenderness
- Fluid (e.g. joint effusion) - Move A/P
- Passive (more likely to be mechanical)
- Active (usually due to pain, weakness) (can be neurological problems e.g. brain, spinal cord, peripheral nerves)
—> muscle, tendon, bone problem - Neurovascular
- Tinel’ sign
- Aneurysm / Pseudoaneurysm - Special test
- Proximal + Distal
- Systemic assessment (e.g. regional LN, 5 common site of bone secondary: Thyroid, Lung, Breast, Kidney, Prostate)
***Special test
Hand:
- Finkelstein (for De Quervain syndrome) —> thumb in wrist —> ulnar deviation —> pain: +ve sign
- Phalen (for Carpal tunnel syndrome) —> fully flex wrist for 60s —> numbness: +ve sign
Elbow:
- Extensor stress (for Lateral epicondylitis (Tennis elbow)): pronate arm + extend digits —> pain: +ve sign
- Flexor stress (for Medial epicondylitis (Golfer’s elbow)): supinate arm + extend elbow + wrist —> pain: +ve
Shoulder:
- Rotator cuff examination
- Supraspinatus: abduction of arm
- Infraspinatus: lateral rotation of arm
- Teres minor: lateral rotation of arm
- Subscapularis: medial rotation of arm - Impingement
- Hawkin’s test
- Neer’s test
Extension lag vs Flexion deformity
Flexion deformity (contracture): cannot passively extend joints (mechanical blockage at skin / tendon / joint level) Extension lag: passively can fully extend joints but cannot actively extend (nerve / muscle / tendon problem)
Lumps
- Size
- larger —> higher chance of malignancy - Mobility
- in relation to other levels of structure
- in all direction / one plane? - Tethering
- attachment to skin / underlying tissue
- attach to tendon —> ask to tense up fist + extend finger, when relax —> more mobile on horizontal direction instead of longitudinal direction
- attach to bone —> not move regardless of movement of fist - Consistency
- soft: like lips
- firm: like nose
- hard: like forehead
DDx:
- Infection
- Inflammation: Bursitis
- Cyst (Simple vs Complex): Ganglion cyst
- Neoplastic: Sarcoma, SCC, Schwannoma
- Metabolic: Gouty tophi
Movement of a limb
Require 4 components:
- Powering muscle
- Moment arm (i.e. Bone)
- Intact fulcrum point (i.e. Joint)
- Painless limb
Sensation grading
S0: Absence of all modalities of sensation in the area exclusively supplied by affected nerve
S1: Recovery of deep pain sensation
S2: Recovery of protective sensation (skin touch, pain, thermal)
S3: Recovery of protective sensation with accurate localisation. Sensitivity / Hypersensitivity to cold is usual
S3+: Recovery of ability to recognise objects and texture, any residual cold sensitivity / hypersensitivity should now be minimal, in the case of hand, recovery of 2 point discrimination to <8mm
S4: Normal sensation
Brachial Plexus lesion
- Erb’s palsy (Waiter’s tip deformity)
- Upper trunk of brachial plexus (C5, 6)
- Wrist flexed + pronated
- Elbow extended
- Shoulder internally rotated - Klumpke’s paralysis
- Lower trunk of brachial plexus (C8, T1)
- Thenar + Hypothenar wasted
- Claw hand deformity
- Sensory loss of medial side of arm
- Horner’s syndrome
Ulnar nerve lesion
- Abduction of little finger
- Hypothenar wasting
- Flexion of IP + Hyperextension of MCP of 4th, 5th finger (Ulnar claw hand)
- distal IP flexed: flexor digitorum profundus intact —> lesion is distally placed (paradoxical: deformity less marked in lesions proximal ∵ more motor involvement) - Interosseous wasting
- Trophic changes: ulceration of skin, brittleness of nails
Radial nerve lesion
Wrist drop (rather than Finger drop: Posterior interosseous nerve)
Osteoarthritis: Examination in upper limb
Joints affected:
- DIP joint —> Heberden’s nodes (DIP) + Bouchard’s nodes (PIP)
- CMC joint of thumb
- Elbow joint
- Shoulder joint with cuff arthropathy
Examination:
- Active / Passive mobilisation
- Hand opening, hand closing, thumb movement
- Intrinsic plus + Intrinsic minus
Arthritis of thumb CMC joint
- Idiopathic
- Common in women 30-60
- Men usually due to old trauma
- People with lax ligament arc more prone to degeneration
Symptoms:
- Pain at base of thumb, occurs with grip / pinch activity
- Clicking with certain movement
- Swan neck deformity
Signs:
- Tenderness over volar + radial aspect of base of thumb
- Grinding sign positive
Shoulder impingement syndrome
Arm abducted >90o
—> Greater tuberosity of humerus compress rotator cuff against acromion
—> Pain + decreased motion in shoulder
Test:
- Hawkin’s test
- Neer’s test
