Embed Size (px)
Citation preview
EAST CUMBRIA VOCATIONAL TRAINING SCHEME
Musculoskeletal
Upper Limb
Differential Diagnosis
• Local Problem
• Referred pain
• With paraesthesia/anaesthesia always check spine
• Local and referred can exist together
Assessment
• Subjective
• Objective:• Range of movement – how far and quality• Soft tissue structures• Nerve• Palpation
• Cyriax Orthopaedic Medicine
Soft Tissue Healing
– Bleeding (injury to max 24 hours)– Inflammation (essential for tissue repair starts
within 2 hours and can last up to 2 weeks)– Proliferation (starts 24-48 hours, reaches a
peak at 2-3 weeks when the bulk of the scar tissue is formed, and lasts several months)
– Remodelling (results in an organised and functional scar starts about 2 weeks and goes on for months)
Soft Tissue Injury
• R
• I
• C
• E
• AND • M
Physiotherapy Treatment
• Frictions
• Soft tissue mobilisation
• Exercises
• Acupuncture
• Trigger point release
• Electrotherapy
• Re-education of movement
Shoulder Joint Complex
• Scapulothoracic Joint
• AC and SC Joints• Glenohumeral joint – ball and socket, head of
humerus articulates in the glenoid cavity of the scapula deepened by the glenoid labrum
• Large ROM • Unstable • Supported by ligaments and rotator cuff muscles
Fracture Clavicle
• Fall onto an outstretched arm or shoulder. • Collision with opponent in a contact sport • Usually fractured in middle third and is very
painful. • Treatment: immobilise for pain relief, analgesia,
mobilise and strengthen shoulder
Acromioclavicular Joint
• Fall onto tip of shoulder, elbow or outstretched hand• Pain felt over the tip of the shoulder-epaulette• Tender over the AC Joint • Depending on the severity of the injury a step may be
visible if ligament rupture • Positive Scarf test• Degenerative osteoarthritis especially active sporty
people• Overuse can provoke traumatic arthritis • Treatment: rest, ice use of sling, strapping, analgesia,
exercises, surgery if chronic ?steroid injection
Glenohumeral Joint
Shoulder Dislocation
• Common traumatic injury – usually anterior.• Arm usually in abduction and lateral rotation• Posterior 3%(fall onto outstretched hand,
epileptic seizures)• Causes damage to joint capsule, tendon,
ligament and glenoid labrum. Also nerve, vascular damage.
• Can be recurrent problem• Treatment: reduction, immobilise, rehabilitation• Surgery may be necessary
Rotator Cuff Injury
• Supraspinatus and infraspinatus most commonly affected.
• Sports involving shoulder rotation/over arm mvt.• Acute Tear:• – sudden powerful action or fall onto outstretched hand
at speed • – sharp pain.• - limited mobility• - inability to abduct shoulder
Rotator Cuff Injury
• Chronic: develops over period of time overuse & usually associated with impingement syndrome
• Usually found on the dominant side • More often an affliction of the 40+ age group • Pain is worse at night, and can affect sleeping • Gradual worsening of pain, eventually some weakness • Eventually unable to abduct arm (lift out to the side)
without assistance or do any activities with the arm above the head
• Some limitations of other movements depending on the tendon affected
Impingement Syndromegeneric term rotator cuff lesions
• caused by the rotator cuff and long head of biceps tendons becoming irritated and inflamed as they pass under the acromion - Subacromial Space. Tendons become thickened and are impinged further. Eventually partial or complete tears can occur
• Can be due to: - bony changes of the acromion• - poor scapular control, athletes swimming/throwing• - overuse , cumulative microtrauma• - muscle imbalance• Treatment: rest, ice, frictions, nsaids, correct posture,
correct movement pattern in sport, sub acromial steroid injection, surgery last resort
Adhesive Capsulitis(Frozen Shoulder)
• 40-70 age range.
• 3% of the population affected
• slightly higher incidence in women
• five times higher prevalence in diabetics.
• Often no significant reason for problem although it can follow trauma, illness or surgery
Adhesive Capsulitis(Frozen Shoulder)
• Painful Stage: short duration suggests shorter recovery refered pain distally more severe
• ache, pain at night unable to lie on affected side. 2-9 months
• Freezing Stage: Increasing symptoms• ache, restriction of mobility, problems with daily
activities. 4-12 months
• Thawing Stage:• Decrease pain and stiffness. 5-12 months.
• Treatment: analgesia, Steroid injections, mobilising and strengthening exercises, MUA.
Elbow Joint
Arthritis , older patient history of recurrent joint pain over months or years
• Loose body , typically ‘twinges’ of pain and locking although tennis elbow can cause twinge on gripping
• Treatment:refer young person for loose body surgical removal/manipulate older analgesia, ?steroid injection,rehabilitation
Tennis Elbow
• Tennis Elbow: overuse or repetitive strain caused by repeated extension of the wrist against resistance.
• Symptoms:• Pain and weakness on gripping and lifting activities. • Pain on extending the wrist and or fingers against
resistance. • Tenderness on palpation around the lateral epicondyle at
common extensor origin
• Treatment: frictions, ultrasound, exercises
• acupuncture, injection, support, surgery.
Golfers Elbow
• Golfers elbow: overuse injury affecting common flexor origin. Common in throwers and golfers.
• Symptoms: • pain and weakness on resisted wrist and finger flexion,
forearm pronation. • tenderness on palpation over the common flexor origin• Treatment: as for tennis elbow
Wrist Fracture
• Colles fracture: 25% of all fractures• fall onto outstretched hand, • dinner fork deformity• Smiths fracture:• fall onto flexed wrist or backward fall onto
outstretched hand.• Rehabilitation: reassurance, mobilisation and
strengthening programme• Complex Regional Pain Syndrome
Wrist
• Repetitive Strain injuries: occupational – typing, using computer mouse, manual/production line workers,
cleaners, musicians or sport related - racket sports. • exacerbated by poor posture, inadequate wrist support
or desk set-up, poor sporting technique or inadequate
equipment. • Symptoms: Pain, dull ache, throbbing, tingling,
numbness, tightness.• Treatment: ice, rest, work place assessment, regular
breaks, local treatment of symptoms, steroid inj
Carpal Tunnel Syndrome
• Compression of the median nerve as it passes through the carpal tunnel. Three times more common in women and affects dominant hand more commonly
• Causes: pregnancy, hypothyroid, traumatic injury, overuse, arthritis, use of vibrating equipment.
• Symptoms: ache/pain in wrist, forearm and radiation into thumb and 2-4 fingers, worse at night, burning and tingling into same area, weakness of fingers.
Carpal Tunnel Syndrome
• Tests: • Tinels sign - Tap with two fingers over the palm side of
the wrist - positive if any symptoms are reproduced. • - Phalens test - Place hands in front at chest height with
the fingers of the two hands touching. Flex the wrists and put the backs hands together. Hold for a minute. Symptom reproduction is a positive.
• Treatment: Conservative initially, rest, splint, ice, medication, stretching and strengthening, injection and surgery if conservative measures fail .
De Quervian’s Tenosynovitis
• inflammation of the abductor pollicis longus and extensor pollicis longus tendon sheaths
• Causes: repetitive wrist and hand movements – production line work, tennis, squash or badminton canoeing.
• Symptoms: crepitus, local tenderness and swelling over radial wrist , positive Finkelstein’s test (thumb flexion, wrist adduction)
• Treatment: rest, splint, physio, injection.
Scaphoid Fracture
• Most frequently injured carpal bone• Fall onto outstretched hand (younger age group)• 10-15% not identified on initial Xray• Complications of non union, avascular necrosis• Symptoms: local pain and tenderness in the
anatomical snuff box• Treatment: as a fracture with immobilisation and
then rehab.
Thumb and Finger Hyperextension
• Hyperextension injury strain of ligaments of the metacarpo-phalangeal joint or phalangeal joints.
• common in skiing (thumb), contact sports and ball sports e.g. rugby, goal keeper, basketball and netball
• Symptoms: Pain with thumb extension, in the web of the thumb when it is moved, swelling over the MCP joint, laxity and instability in the joint.
• Treatment: RICE, exercises to regain mobility and strength, may need strapping to return to sport initially
Hand
• Trigger finger/Thumb
• Dupuytrons contracture
• Arthritis in small joints 1st MCP most commonly
• Treatment : analgesia, steroid injection if appropriate to trigger finger/joints if meets criteria refer for surgery
Neck Pain-upper limb symptoms could be refered
• Red flags :Under 20 or 1st episode over 55• Vertebrobasilar /carotid artery symptoms• Trauma• Malignancy /Osteoporosis history• Constant/unremitting pain /rest pain• Systemically unwell, fever weight loss• Drug use/immunosuppression• Nerve signs in more than one root
History
• Occupation, hobbies,sports • Age, onset duration, • Refered arm pain from a disc lesion
usually >35yrs • Site and spread of pain • Exacerbating/relieving factors • Dizziness/drop attacks• PHx medications
Management
• If no trauma/instability gentle mobilisation, physio, analgesia , if worsening neurological symptoms or nerve root pain unresolving after 6 weeks refer neurosurgeon.
• Cervical traction/manipulation should not be done unless properly trained and contraindications excluded
• Yellow flags-social problems , mental illness, gain from medical problems benefits etc passivity and inactivity, symptoms and signs don’t fit .
Bibliography
• Turner, Howard., Diagnosis of the Sporting Shoulder; Sportex Medicine 9, Jan 2001.
• Henry, Gray., Anatomy of The Human Body.
• Cyriax, J., Textbook of Orthopaedic Medicine,
• www.electrotherapy.org
