Upper limb and chest Flashcards
What is the dermatomal distribution to the upper limb?
C4 - shoulder and clavicle
C5 - lateral arm
C6 - posterolateral to thumb
C7- posterior elbow to digits 2-3 and middle palm
C8 - armpit to digits 4-5
What is the nerve supply to the upper limb
- Axillary nerve -
- intercostobrachial - lateral trunk medial arm
- Radial nerve - posterolateral arm, posterior forearm, dorsum of hand 2 -3 digint and thumb
- medial antebrachial cutaneous nerve
- lateral antebrachial cutaneus nerve
- Median nerve - palm between thumb and 3 digit
- Ulnar nerve -
Brachial plexus
- Dorsal scapular - C5 - Root
- Long thoracic - C4,5,6,7 - Roots
- Suprascapular - C5-6 - Superior division
- Subclavius - C5-6 - Superior division
- Axillary - C5-6 - Posterior cord
- Lateral Pectoral - C5,6,7 - Lateral cord
- Musculocutaneus - C4-5,6,7 - Lateral cord
- Radial - C5,6,7,8,T1 - Posterior Cord
- Median - C5,6,7,8,T1 - Lat - medial cord
- Ulnar - C7,8, T1 - Medial Cord
- Subscapular - C5,6 - Posterior cord
- Thoracodorsal - C5,6,7 - Posterior cord
- Medial Pectoral - C8, T1 - Medial cord
- Medial AnteBrachial - C8, T1 - medial cord
- Medial brachial - C8 - medial cord
What is the light touch pathway?
3 Neuron pathway
- 1st order neuron stimulates the copurscle mechanorecepter travel through the nerve
- Enters via the dorsal root ganglion
- Enters the cuneate nucleus - synopsis with second order neuron
- Thalamus via DCML to synopsis with 3th order neuron
What are the cutaneous supply to the thorax?
Poterior thorax dorsal rami spinal nerve
Anterior thorax, anterior rami spinal nerve - give anterior medial cutaneus branch
What is the sensory supply to the viscera
visceral afferent fibres give sensory supply.
What are the red flags for chest pain?
- •Dizziness/syncope
- Pain in arms L>R, jaw
- Thoracic pain
- Sweating
- Palpitations
- Dyspnoea
- Pain on inspiration
- Pallor
- Past history: ischaemia, diabetes, hypertension
Always assume a person is having a heart attack
True
False
What are the most likely causes of chest pain?
- Musculoskeletal
- intercostals, pecs, mm. strain (coughing - overuse)
- Costochondritis (inflammation)
- rib fracture
- rib sprain
- Facet sprain referral
- TOS
- Psychogenic - (localized pain over heart)
- Stress
- anxiety
- Angina - (referred locations)
- Stable
- unstable
What are the chest pain serious disorders?
- Cardiovascular
- unstable angina
- aortic dysection
- pulmonary embolism
- Neoplasia - tumour
- Infection
- pneumonia
- pleurisy
- pericardis
- Pneumothorax
- traumatic
- closed
What are other chest conditions often missed
- TOS
- Gastrointestinal
- gord
- gastritis
- ulcera
- reflux
- Herpes zoster
- esophageal pain
What are the most common conditions for shoulder pain?
- Cervical spine dysfunction
- Somatic referred
- Radiculopathy
- subacromial impingement syndrome
- Tendinopathy
- Rotator cuff
- Bicipital
- Adhesive capsulitis
- GH labral tear
Serious disorders affecting shoulder?
- Cardiovascular
- •Angina, myocardial infarction, pericarditis
- •Deep vein thrombosis (axillary, subclavian)
- Neoplasia
- •Primary or secondary bone tumours
- •Pancoast syndrome
- •Lymphoma
- Severe infections
- •Osteomyelitis
- •Pneumonia, pleurisy
- Pneumothorax
- Cervical Myelopathy
- Thoracic Outlet Syndrome
- Rheumatological
- •Osteoarthritis: glenohumeral joint, acromioclavicular joint
- •Rheumatoid arthritis
- •Gout
- •Polymyalgia rheumatica
- Visceral referral
- •Gastrointestinal
- •Other causes of diaphragmattic irritation?
What structures cause subacromial impingement?
Intrinsic factors
- Biceps tendonitis
- Supraspinatus tendonitis
- irritation of a subacromial bursa
- Rotator cuff pathology
Extrinsic factor
- scapular dyskinesis
- Abnormalities on AC joint
What are the Hx, S&S for subacromial impingement?
Hx
- Pain overhead
- repetitive movements (throwing)
- P sleeping on the shoulder
What test can be done for subacromial impingement
- Empty can
- Hackings - kenedy
- Neer’s
- Painful arch
What causes and Hx for adhesive capsulitis?
Idiopathic
spontaneus onset
women 3;1 40-60yr
metabolic condition
Loss of ROM GH
pain with movement
What is the hx and what test is done for a labral tear?
- Aprehension test
- o’brian
- catching grabbing
- trauma
What are the causes of arm pain?
- Referral from shoulder
- Referral from Cx
- Bone disease (osteomyelitis)
- lateral/ medial epicondylitis
- tenosynovitis (inflammation of fluid around tendon)
- carpal tunnel syndrome
- tendonitis
- ulnar nerve neuropathy
- OA
- Trauma #
What are the most common conditions of the arm?
- Cervical spine dysfunction
- •Radiculopathy
- •Somatic referral?
- Shoulder disorders
- Medial or lateral epicondylitis
- Wrist tendonitis
- •De Quervains
- Carpal tunnel syndrome
- OA of the thumb and DIP joints
What are the conditions most often missed?
- Cervical myelopathy
- Thoracic outlet syndrome
- Entrapment neuropathies
- •Ulnar nerve
- •Median nerve
- •Radial nerve
- Elbow inflammation
- •Osteoarthritis
- •Rheumatoid arthritis
- •Olecranon bursitis
- Ischaemic necrosis
- •Scaphoid #
Serious conditions of the arm
-
Cardiovascular
- •Angina, myocardial infarction
- •Deep vein thrombosis (axillary, subclavian)
-
Neoplasia
- •Primary or secondary bone tumours
- •Pancoast syndrome
- •Lymphoma
-
Severe infections
- •Osteomyelitis
- •Septic arthritis
What are the S&S of tennis elbow (lateral epicondylitis)?
wrist extension
P with stretching of the wrist
weakness
What are the tests for tennis elbow (lateral epicondylitis)?
Cozens test - resisted ext. wrist
Mills - arm pronated at 90’, flex the wrist and extend arm. pain reproduced at lateral epicondyle
What are the tests for carpal tunnel?
Phalens - reverse prayer
Tinels - tap on wrist
upper limb neuro
carpal compression test
What test are done to differentiate the upper limb entrapment neuropathies?
- Ulnar nerve
- Tinnels at gyon or olecranon
- Ulnar tension test
- Median nerve
- Median Nerve tension test
- tinnels at carpal tunnel
- Radial Nerve
- Radial tension test
What are the rotator cuff provocation tests, to test for a rotator cuff pathology
- Speeds - biceps brachii - resist shoulder flexion with extended supinated arm.
- Empty can - supraspinatus
- Lift off - Subscapularis
- Infraspinatus provocation test (resist ext. rot gh)
What are the tests for subacromial impingement?
- Neers - Passive flexion arm
- Hawkins Kenedy - PROM internal rotation at 90’ in a transverse plane
- painfull arch
- Rotator cuff pathology tests
What tests are done for labral tear
- Obrian test
- Crank test - apprehension dislocation
What test is done for tenosynovitis?
finkelstein
What test are done for GH instability
sulcus
load and shift
apprehension
What is the mechanism of action for Neural Tension test
•Assess sensitivity of nerve roots and peripheral nerves to movement and tension caused by movement (neurological mechanosensitivity)
What are the tests done for TOS?
Clinical Features
- Rarely purely arterial, venous or neurological
- Pain and heaviness in neck, shoulder, arm, hand.
- Adsons test for pure arterial
- Roos test – most sensitive
- • Combine with ULNTT
What is the clinical presentation for TOS?
- Compression of neurovascular structures from the neck into the axilla.
- 3 common compression points
Hx
- Common in overhead athletes, extended posture with protracted anterior GH.
- Congenital abnormalities
- Cervical rib, clavicle abnormalities,
- large C& TP’s
What is the recommended treatment for TOS?
- Patient education: improve posture
- Exercise: increase ROM, strengthen back mm.
- OMT: ST pecs, MET 1st rib, treat neck mm.
- Pharmacological: NSAIDS
- Venous TOS: avoid thrombus - blood thinners
- Arterial: surgery
What are the grades of an acromioclavicular injury
- Sprain on the capsule
- Localised tenderness and pain on
- movement especially horizontal flexion
- II:
- Tearing of AC ligs and sprain of CC ligs
- Localised pain, possible small step deformity
- III & IV:
- Complete Tearing of AC ligs and of
- CC lligs
- Marked step deformity
- V:
- High levels of displacement
- Radiograph and surgical intervention
What is the treatment for an acromioclavicular injury?
- I & II: RICE, NSAID, reduce swelling
- Reduce pain and inflammation.
- Normalise joint range of motion.
- Strengthen your shoulder.
- Improve your shoulder blade and shoulder alignment.
- Normalise your muscle lengths.
- Improve your upper limb proprioception.
- Improve your technique and function eg lifting, overhead activities.
- Minimise your chance of re-injury as you return to sport or work
- Grade 5: surgery
What is the clinical presentation of adhesive capsulitis?
- Occurring following trauma (fracture or surgery), injury to neural structures in the neck or spontaneously (idiopathic).
- Most common between ages 40-60, F>M.
- Increase risk with diabetes and thyroid disorders.
- Self limiting condition that lasts over 1.5 years on average.
- No one treatment modality has shown better outcomes.
- Focus on keeping ROM, addressing biomech compensations, advice, reassurance.
What is the treatment for adhesive capsulitis?
- Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.
- Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.
- Physical therapy. Specific exercises will help restore motion
What is the management for subacromial impingement?
Long term management
• NSAID
- US
- Cortisone
• Scapular retraining
When should I use the different imaging for the shoulder?
- xray : usually first in acute pain
- Ultrasound usually first line of evaluation in rotator cuff pathology
- MRI for adequate evaluation of extra-articular soft tissue trauma, Capsular and ligament tear
What are the vies for x-ray of the shoulder ?
- Views
- AP - humeral head on glenoid fossa
- AP internal rot - lesser tubercle
- AP external rot - greater tubercle
- Lateral - dislocation gh
- Axial -
- Scapular Y Should
What are the x-ray views of the elbow?
- AP
- Lateral flexion
- Medial Oblique - What are the x-ray views of the elbow?
WHat are the vies for x-ray of the wrist and hand?
- PA: Carpals, distal radio ulnar joint, radiocarpal and ulnar carpal
- Lateral: Carpal alignment (especially lunate) with radius
- Oblique: Scaphoid: Ulna deviation and flexion
For what conditions do you use ultrasound of the wrist?
- Tunnel Syndrome and
- Dequervains
- Tenosynovitis
