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MUSCULOSKELETAL PROBLEMS OF THE UPPER LIMB

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

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  1. MUSCULOSKELETAL PROBLEMS OF THE UPPER LIMB

  2. SPECIAL TEST

  3. SPECIAL TEST

  4. SPECIAL TESTS

  5. SPECIAL TEST

  6. MUSCULOSKELETAL PROBLEMS OF THE UPPER LIMB • SHOULDER

  7. 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.

  8. 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

  9. shoulder • Radiologic – serendipity view

  10. Shoulder

  11. 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

  12. Shoulder

  13. 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

  14. 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

  15. 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

  16. 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

  17. Shoulder

  18. 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

  19. 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

  20. Shoulder

  21. 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

  22. Shoulder • Adhesive Capsulitis • Causes: • Idiophatic • Diabetes mellitus • Inflammatory arthritis • Pathologic evaluation • Perivascular inflammation • Fibroblastic proliferation with increased collagen and nodular band formation

  23. Shoulder • Adhesive Capsulitis

  24. 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

  25. Shoulder • Adhesive Capsulitis • Treatment: • Manipulation of shoulder under anesthesia • Hydrodilatation of the glenohumeral joint • Surgical management: arthroscopic capsular release

  26. 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

  27. Shoulder • Superior labral anterior to posterior lesions

  28. Shoulder • Superior labrum anterior to posterior lesions • Classification of SLAP

  29. ELBOW JOINT

  30. 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

  31. 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

  32. 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.

  33. Elbow joint • Distal biceps tendinitis • (+) pain in the antecubital fossa • Physical findings: tenderness, pain w/ resisted elbow flexion • Radiologic findings: Normal

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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.

  40. 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.

  41. 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

  42. 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

  43. Elbow joint

  44. 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

  45. FOREARM and WRIST

  46. 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

  47. 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

  48. Forearm and wrist • Flexor carpi radialis tendinotis • Treatment: • Correct strength, endurance and flexibility deficits

  49. 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

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