DIAGNOSIS AND MANAGEMENT IN UPPER EXTREMITY PROBLEM

Made Bramantya Karna

Orthopaedi& Traumatology Udayana University, Sanglah General Hospital, Denpasar-Bali

General principle of fracrure management are recognition, reduction, retaingin, and

rehabilitation. The goal of treatment in upper limb is function.
Chief complain of problem in shouder are pain, dislocation, subluxation,
apprehension and weakness. We should ask about patients identity and past history such as
age, dominance arm, occupation, sport, activities, mechanism of injury, current and previous
treatment, and also reccurency. From physical examination we should check from look such
as attitude, muscle features - tone/atrophy/hypertrophy of dominant side, bony deformity AC joint, SC joint, erythema, skin manifestations/ecchymosis. From feel we should check
about local tenderness, edema, temperature change, deformities, and muscle characteristic.
From move we should examine for actiive and passive range of motion. Pain because of
impingement can be examine from Neers impingent sign, flexion/internal rotation causes
pain in last 10-15 of motion arc. Thought to be due to supraspinatus tendon being impinged
against anterior inferior acromion and positive if maximum passive forward. Hawkins
impingement sign we can check with humerus forward flexed to 90 (with elbow flexed to
90) then actively internally rotate shoulder. Positive test is pain. Impingement injection test
is response to subacromial injection of lidocaine 2%. Regarded as positive if >50% reduction
or abolition of impingement signs. Yergasons test is active resisted supination with the elbow
flexed to 90 and forearm fully pronated, positive if elicits pain at bicipital groove. Speeds
test is humerus forward flexed to ~ 60, resisted elevation of arm with the elbow fully
extended and forearm fully supinated. Positive if elicits pain at bicipital groove. Considered
more accurate test for biceps tendinitis. Common instability test are apprehension test,
relocation test, and sulcus sign.
Rotator cuff tendinitis/impingement have a history of pain with overhead activity, lack
of trauma, age over 35, more insidious onset, sometimes weakness (secondary to pain), not
true neuromyopathic weakness.From physical examination we can find pain to palpation in a
variety of areas, pain with manual muscle testing of RC, biceps, impingement signs (Neer's,
Hawkin's signs), impingement injection test.Radiological examination are AP view, West
Point views, the supraspinatus outlet view (Alexander view). Treatment of rotator cuff
tendinitis/impingement are rehabilitation RC strengthening, Cryotherapy, NSAID's, Steroid
injection if no concern for RC tear or labral tear. Indication for surgery are chronic pain, large
subacromial spur/type 3 acromion.
Rotator cuff tear is Full thickness disruption of the tendon. Most common is the
supraspinatus tendon at insertion into the greater tuberosity. Mostly in patients greater than 40
years. Mechanism of injury usually Indirect force on an abducted arm. The symptom is acute
pain and weakness after a traumatic event. Physical examination we can find are painful arc
from 70-120 abduction. There may be a positive drop arm test with large tears. If initially
undiagnosed, there may be atrophy of supraspinatus and infraspinatus. The diagnosis mainly

come from history and physical examination. Differential diagnose with nerve entrapment,
adhesivecapsulitis, RC impingement. Traetment of rotator cuff tear are RC strengthening ,
cryotherapy, NSAID's, consider surgical options more quickly in young athletes.
Acute traumatic anterior dislocation/subluxation have 4 types; Subcoracoid(most
common), Subglenoid, Subclavicular, Intrathoracic. Mechanism of injury can be direct or
indirect. Physical examination that we can find are arm held in slight abduction and external
rotation, limited adduction and internal rotation, humeral head may be palpable anteriorly,
posterior aspect of GH joint may appear hollow below acromion, document neurovascular
status, especially axillary nerve (motor = deltoid, sensory = lateral shoulder). Imaging studies
can be Plain Radiographs and MRI. Treatment of anterior shoulder dislocation/subluxation
are closed reduction and open reduction. Technique of closed reduction Stimson technique,
Milchs tecchnique, scapular rotation technique. The goal of the treatment is prevent
recurrence.
Clavicle fracture usually due to fall on outstretched hand or directly on lateral aspect
of shoulder. Classifiaction of clavicle fracture are Proximal third, Middle third (most
common), Distal third. Physical examinationwe can find Pain to palpation of clavicle,
deformity, crepitus. We can do plain xray for diagnosis. Treament of clavicle fracture are
figure-of-eight bracing for 4-8 weeks, clavicular strapping for 4-8 weeks. Surgery indicated
for severely displaced or comminuted fracture.
Lateral epicondylitis manifest with pain on the lateral aspect of the elbow and may
radiate to extensor tendon muscle bellies proximally. Mechanism of injury is repetitive
microtrauma like in tennis player, carpentry or painter. On physical examination we can find
pain to palpation of lateral epicondyleand pain with resisted supination and extension.
Treatment for this condition are PRICES, NSAID's, stretch/strengthening exercises for the
elbow and wrist, and counterforce brace.
Medial epicondylitis manifest with pain on medial aspect of the elbow. The signs are
tender to palpation of medial epicondyle andpain with resisted flexion and pronation.
Differential diagnose are ulnar neuropathy, MCL sprain of the elbow, traction apophysitis of
medial epicondyle (little-league elbow). The treatment are PRICES, NSAID's,
stretch/strengthening exercises for the elbow and wrist.
Mechanism of injury in radial head fracture mostly fall in outstreched hand. On
physical examination we can find Significant edema, pain antecubital fossa, pain with
supination/pronation. Elbow X-ray AP/Lateral view is use to visualize of an anterior fat pad
on lateral xray may be normal, pathologic anterior fat pad is thickened with characteristic
"sail sign". Posterior fat pat pad on lateral xray is always considered pathologic. Treatment
for this fracture are Type I, and some types II and III (no mechanical block, less
displacement/angulation) sling or posterior splint for comfort 1-2 wks. The 3-3-3 rule:
surgery for fracture depressed 3mm, angulated 30, or involves 30% of articular surface.
Mechanism of injury in olecranon fracture could be direct or indirect. The symptoms
pain well localized to posterior elbow, palpable defect and inability to extend elbow.true
lateral essential for determination of fracture pattern. CT scan may be useful for preoperative
planning in comminuted fractures. Treatment can be non operative or operative.

Elbow dislocation can be cause by usually a combination of axial loading,

supination/external rotation of the forearm. Posterior dislocations may involve more than one
injury mechanism. On physical examination pain may be the primary symptom. It is
important assesthe status of the skin, presence of compartment syndrome, andneurovascular
status. The treatment are closed reduction or open reduction.
DeQuervain's tenosynovitis is an inflammation of tendons and tendon sheaths of the
abductor pollicislongus and extensor pollicisbrevis as they course over the radial styloid.
Usually dominant hand. Mechanism of injury repetitive thumb abduction, extension and
overuse. In physical examination we can find tender to palpation tendons over radial styloid.
Finkelsteins test is by ask patient to grasp his/her own thumb; examiner passively deviates
the wrist in ulnar direction. Positive test is pain at radial styloid. The treatment with RICE,
NSAIDs, universal thumb splint, steroid injection.
Carpal tunnel syndrome is entrapment of the median nerve that can causes pain,
paresthesias in the volar hand, wrist and forearm (even to the shoulder). Common with
repetitive motion, worse with wrist flexion. Worse at night with altered sleep patterns. We can
do physical examination with Tinels test (tap on volar wrist) positive for paresthesias/pain in
median nerve distribution. Phalens test (60 seconds of bilateral wrist flexion to 90 o) positive
for paresthesias/pain in median nerve distribution. Thenar atrophy is late sign. The treatment
consist of activity modification (avoid vibratory machines, etc.), NSAID, volar cock-up wrist
splints at night can be helpful, oral steroids- variable results, steroid injection and Surgery.
Schapoid fracture usually cause byfall on outstretched hand with wrist in
hyperextension. In physical exxamination we can find pain in anatomicsnuffbox and/or
palmarly andDecreased ROM. AP, lateran and oblique xray can help to diagnose. If negative,
repeat 2-4 weeks. Treatment for undisplaced fracture is thumb spica cast. If there is avascular
necrosis we can put screw placement.
Mallet finger deformity occurs with a disruption of the extensor tendon that normally
inserts into the proximal portion of distal phalanx. Usually because of sudden forceful
flexion of the finger. In physical examination we can find lack of full extension at DIP and
pain on palpation of dorsum of the DIP.X ray usually normal, but may demonstrate avulsion
fracture. The treatment can be Splint for 6-8 weeks in full extension or surgery.
Boxer fracture is Fracture of 5th neck metacarpal. We can find Pain, edema and
ecchymosis at MCP, Loss of knuckle prominence may be seen. Deformity is accept up to 40o
volar angulation of the 4th and 5th digits.Up to 10o of volar angulation of the 2nd and 3rd digits.