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MUSCULOSKELETAL PROBLEMS OF THE UPPER LIMB. SPECIAL TEST. SPECIAL TEST. SPECIAL TESTS. SPECIAL TEST. MUSCULOSKELETAL PROBLEMS OF THE UPPER LIMB. SHOULDER. Shoulder. Sternoclavicular sprain Anterior dislocation – 2/3 of sternoclavicular joint dislocation
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MUSCULOSKELETAL PROBLEMS OF THE UPPER LIMB • SHOULDER
Shoulder • Sternoclavicular sprain • Anterior dislocation – 2/3 of sternoclavicular joint dislocation • Medial end of clavicla becomes prominent • Trauma • Posterior dislocation – 1/3 of sternoclavicula dislocation • More pain, less prominent medial clavicular end. • Asso. w/ vascular compromise to the ipsilateral limb, neck,upper limb venous congestion difficulty of breathing/swallowing.
Shoulder • Sternoclavicular sprain • Treatment • Grade 1 and 2 > ice (24-48 hours) > sling immobilization > NSAIDs and analgesics > return to activity 1-2 weeks (gr.1), 4-6 weeks (gr.2) • Grade 3 > anterior/posterior dislocation – reduction; surgical intervention
shoulder • Radiologic – serendipity view
Shoulder • Clavicular fracture • Common in children and adult under 25 years old. • 80% middle/3rd; 15% lateral/3rd; 5% medial/3rd • Radiologic: • Proximal third – serendipity view, AP • Lateral third – Zanca view, axillary lateral view, AP • Treatment > partial immobilization w/ sling, figure of eight bandage
Shoulder • Acromioclavicular joint sprain • Treatment: • Type 1,2 and 3 > non-operative > immobilizaton with sling, ice, analgesics > if pain subsides – ROME, strengthening ex > indication for surgery in type 3 – persistent pain, unsatisfactory cosmetic results • Type 4,5 and 6 • > surgical treatment
Shoulder • Osteolytic of the distal clavicle • Repetitive overload of the distal clavicle • Young weight lifters – bench press/ military press lifter • Gradual onset of acromioclavicular joint pain that is increased with bench press • Bilateral
Shoulder • Osteolytic of the distal clavicle • Radiographic findings: - Pathologic changes: distal clavicular subchondral bone loss and cystic changes - Widening of acromioclavicular joint – late stage • Treatment : • Avoidance of aggravating activities • Ice, NSAIDs, corticosteroid injection • Distal clavicular resection
Shoulder • Scapulothoracic crepitus • “snapping scapula” or scapular crepitus. • 3 primary types of sounds: • Gentle friction sound - physiologic • Loud grating sound – soft tissue disease (bursitis,fibrotic muscle etc) • Loud snapping sound – bony pathology (osteophyte, rib or scapular oateochondroma) • Treatment > correction of biomechanical deficits > mobilization > NSAIDscorticosteroid injection
Shoulder • Pectoralis major strain • Sudden pain in the pectoral region during a forcrful activity employing shoulder adduction or internal rotation. • Edema and ecchymosis on chest wall/proximal anterior arm region • Axillary fold –visible defect when shoulder is abducted • Weakness and pain with shoulder adduction and internal rotation
Shoulder • Pectoralis major strain • Treatment: • Grade 1 and 2 > ice, NSIDs, mild analgesics, sling > gentle passive range of motion = active ROME = strengthening ex. • Radiologic findings • x-ray – normal • MRI
Shoulder • Adhesive Capsulitis • Codman -“frozen shoulder” • Painful restriction in shoulder ROM with normal radiographs. • Neviaser – “adhesive capsulitis” • Occur in 2-5% of general population • Women • 40-60 years of age
Shoulder • Adhesive Capsulitis • Causes: • Idiophatic • Diabetes mellitus • Inflammatory arthritis • Pathologic evaluation • Perivascular inflammation • Fibroblastic proliferation with increased collagen and nodular band formation
Shoulder • Adhesive Capsulitis
Shoulder • Adhesive Capsulitis • Treatment: • Hannafin et al – recommend early use of intra-articular corticosteroid injection for stages 1 & 2 > decrease the initial inflammatory stage > reduce the development of fibrosis • NSAIDs • ROME, shoulder girdle strengthening ex. • Restoration of normal function – 14 months
Shoulder • Adhesive Capsulitis • Treatment: • Manipulation of shoulder under anesthesia • Hydrodilatation of the glenohumeral joint • Surgical management: arthroscopic capsular release
Shoulder • Superior labral anterior to posterior lesions • SLAP lesion – injuries to superior labrum and biceps tendon • MOI: • Fall on outstretched arm – causes superior translation of the humeral head and compression of the superior glenoid labrum. • Deceleration phase of overhead throw – traction force of the by the biceps on the superior labrum • Traction injuries
Shoulder • Superior labral anterior to posterior lesions
Shoulder • Superior labrum anterior to posterior lesions • Classification of SLAP
Elbow joint • Lateral Epicondylitis • “tennis elbow” • Repetitive stress on the lateral forearm musculature. • >35 years old (peak 40-50 years old) • Male • Degenerative changes • vascular granulation in the damaged tissue >angiofibroblastic hyperplasia
Elbow joint • Medial epicondylitis • “golfer’s elbow” • Risks factors: Training errors, faulty equipment, repetitive activities requiring wrist flexion and forearm supination, poor strength, flexibility imbalance and joint instability • Degenerative changes are most frequently found in the pronator teres and flexor carpi radialis origin. • Weaknes in grip strength
Elbow joint • Medial epicondylitis • Radiographic findings: • Punctuate calcifications in the region of the flexor tendon origins • Non-operative management: • Anti-inflammatory medications • Cryotherapy • Galvanic ES / iontophoresis • Corticosteroid • ROME, strengthening ex, endurance and flexibility ex.
Elbow joint • Distal biceps tendinitis • (+) pain in the antecubital fossa • Physical findings: tenderness, pain w/ resisted elbow flexion • Radiologic findings: Normal
Elbow joint • Rupture of the distal biceps tendon • 30 – 50 years old • Men • MOI: heavy lifting activities w/ elbow at 90* flexion • Acute pain, popping or tearing sensation in the ante-cubital fossa • PE – ecchymosis, edema, eruthema absence of distal biceps brachii tendon
Elbow joint • Distal triceps tendonitis • Symptoms: aching and burning pain in the distal triceps. • PE: tenderness over the distal triceps tendon and pain w/ resisted elbow extension • Radiologic evaluation: Normal
Elbow joint • Triceps tendon rupture • MOI: fall on outstretched hand, direct blow to the triceps tendon • Most common site of disruption: insertion site on the olecranon
Elbow joint • Snapping triceps tendon • Pathologic band over the medial side of the distal triceps can cause a snapping sensation over the medial epicondyle during elbow flexion and extension • Treatment : deep tissue massage, stretching of the triceps muscle, corticosteroids
Elbow joint • Olecranon bursitis • Aseptic bursitis • Seen football/hockey player 1.Acute hemorrhagic bursitis > due to macrotraumatic insult to the bursa 2.Chronic bursitis > due to repetitive microtrauma • Septic bursitis • Due to localized or systemic infection • PE: edema, erythema, hyperthermia in the area of infected bursa w/ systemic symptoms
Elbow joint • Ulnar collateral ligament sprain • Due to valgus stress to the elbow – associated with throwing activities • PE: -5* elbow flexion contracture - tenderness over the ulnar collateral ligament - (+) pain w/ valgus stress to a slightly flexed elbow.
Elbow joint • Valgus extension overload of the elbow • Common in overhead throwing athletes • Pain noted at the medial lip of the olecranon • Radiograph: olecranon osteophytes or intraarticular loose bodies.
Elbow joints • Medial epicondylar traction apophysitis and stress fracture. • “ liitle leaguer’s elbow” • Dominant hand of a throwing athletes between the ages of 9 – 12 years old. • Medial epicondylar apophysis closes at 14 years old in females and at 17 years old in male. • Radiologic findings” - Medial epicondylar enlargement, fragmantation, beaking and avulsion of the medial epicondyle
Elbow joint • Osteochondrosis of the capitellum • “Panner disease” • 7 – 10 years old • Degeneration or necrosis of the capitellum and regenration and calcification of this area. • Etiology: unknown • Due to endochondral ossification in association with trauma or vascular impairment. • Dull, aching lateral elbow pain aggravated by throwing activities • (+) effusion, ROM are usually restricted
Elbow joint • Elbow dislocation • Involves the ulna and distal humerus, frequently occur in posterolateral direction • MOI: fall on outstretched arm w/ elbow in hyper extension. • May injure brachial artery, or the median, ulna, radial nerve • Treatment: - reduction • Sling or posterior long arm splint (2 – 3 days) • ROME
Forearm and wrist • Flexor carpi ulnaris tendonitis • Due to repetitive microtrauma from activities requiring wrist flexion and ulnar deviation • Associated with pisotriquetral compression syndrome, may lead to osteoarthritis. • Pain on the volar ulnar aspects • Treatment: - wrist-hand orthosis with wrist in 25* of volar flexion
Forearm and wrist • Flexor carpi radialis tendinotis • MOI: repetitive gripping w/ wrist flexion and radial deviation • (+) radial wrist pain when gripping and forceful wrist flexion with radial deviation. • Treatment: • Ice • Anti-inflammatory medication • Splinting – wrist-hand orthosis with 25* wrist flexion • ES and iontophoresis
Forearm and wrist • Flexor carpi radialis tendinotis • Treatment: • Correct strength, endurance and flexibility deficits
Forearm and wrist • De Quervain’s syndrome • Most common tendonitis of the wrist • Abductor pollicis longus and extensor pollicic brevis • MOI: forceful gripping w/ radial deviation of the wrist/ repetitive use of the thumb. • (+) finkelstein’s test – pathognomonic • Thumb spica