Dr. A. - PowerPoint Presentation

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Dr. A. Mortazavi MD Occupational Medicine Specialist

DISORDERS OF

UPPER EXTIMITY

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Musculoskeletal problems :

10–20% of outpatient visits

traumatic (injury-related) or

atraumatic

( degenerative or overuse syndromes)

acute or chronic

most helpful part of the history in determining the diagnosis

mechanism of injury

With acute traumatic injuries, patients typically seek medical attention within 1–6 weeks of onset.

Slide3

Symptoms and Signs

Nonspecific

pain (most common)

instability, or dysfunction around the joints

“locking” or “catching,” internal derangement in joints

“instability” or “giving way” suggest

ligamentous

injury

these symptoms may also be due to pain causing muscular inhibition

fever or weight loss, swelling with no injury, or systemic illness suggest medical conditions (such as infection, cancer, or rheumatologic disease)

.

Slide4

Physical examination :

inspection, palpation, and assessment of range of motion and neurovascular status

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Shoulder examination

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Imaging

Radiography:

Bony pathology, soft tissue findings

CT scans:

most effective for bony pathology

Nuclear bone scans:

less commonly used (stress injuries, infection, malignancy, or multisite pathology)

Slide11

Positron emission tomography (PET) scans:

metastatic malignant lesions.

MRI:

ligaments, cartilage, and soft tissues

Gadolinium contrast:

internal derangements in joints such as

labral

Injuries

Musculoskeletal ultrasound:

superficial tissue problems, including

tendinopathies

and synovial problems

Slide12

Special Tests:

Arthrocentesis

:

acute knee pain with effusion and inflammation

(rule out an infection)

Joint fluid should be sent for cell count, crystal analysis, and culture.

EMG-NCV:

neurologic concerns; prognostication in chronic conditions.

Markers of inflammation:

CBC,ESR and C-reactive protein, and rheumatologic

tests

Slide13

Treatment:

most musculoskeletal problems:

treated conservatively,

the first consideration:

whether there is an immediate surgical need.

Slide14

conservative treatment:

“MICE”:

modification of activities, ice, compression, and elevation.

Controlling pain:

analgesics (

nonsteroidal

anti-inflammatory drugs [NSAIDs], acetaminophen, or

opioids

).

muscle relaxants for neuropathic pain [

eg

, gabapentin or tricyclic antidepressants).

Topical medications:

capsaicin cream or patch(

lidocaine

, NSAID)

Slide15

Immobilization by casting, slings, and braces for an injured limb.

Crutches :reduce weight bearing.

Rehabilitation and physical therapy, chiropractic manipulation, massage therapy, and osteopathy.

Slide16

When to Refer

1- emergency referral (immediate)

Neurovascular injury

Fractures (open, unstable)

Unreduced joint dislocation

Septic arthritis

2- urgent referral (within 7 days)

Fractures (closed, stable)

Reduced joint dislocation

“Locked” joint (inability to fully extend a joint due to mechanical derangement, usually a loose body or torn cartilage)

Slide17

3- Indications for early orthopedic assessment (2–4 weeks)

Motor weakness (neurologic)

Constitutional symptoms (

eg

, fever not due to septic arthritis, weight loss)

Multiple joint involvement

4- Indications for routine orthopedic assessment (for further management)

Failure of conservative treatment (persistent symptoms > 3 months)

Persistent numbness and tingling in an extremity

Slide18

DEFINITIONS OF COMMON ORTHOPEDIC CONDITIONS

Strain:

A strained muscle or tendon has been pushed or pulled to its extreme by exposing it to an extreme load.

results from an unexpected external force, such as a fall.

The symptoms of strain should resolve within a few days to several weeks.

Slide19

Sprain

ligament has been stretched beyond its limit, causing tears or disruption in fibers.

edema and local venous congestion develops over hours to days.

A complete tear of a ligament is sometimes called a third-degree sprain.

Slide20

Peripheral Neuropathies

The peripheral nerves crosses a joint or is in a tunnel external compression,vibrating hand tools, repeated forceful hand exertions, or sustained posture extremes (eg, overhead work)

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INJURIES OF THE SHOULDER

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Impingement Syndrome, Rotator Cuff

Tendinosis

or Tears,

Supraspinatus

Tendinitis,

Saubacromial

Bursitis

repetitive-motion work activities, especially overhead position in forward flexion or abduction

subacromial

bursitis→ irritation of the

supraspinatus

tendon

or tendonitis → beginning of ulceration (partial-thickness tear) of the tendon → full-thickness discontinuity or rupture of the rotator cuff

long head of the biceps

may be damaged

Acromion

develops

osteophytic

.

Slide24

Posttraumatic impingement

syndrome

minor injury to the arm or shoulder:

painful inhibition of normal motion :

self-imposed immobilization of the shoulder → imbalanced rotator cuff muscle function → impingement syndrome

Slide25

Clinical Findings

Pain:

anterior shoulder pain may be gradual or acute

pain is limited to the lateral arm about the deltoid insertion on the

humerus

.

Occasionally, pain is referred to the distal arm, elbow, and rarely, to the hand.

severe pain at rest caused by a tense

subacromial

bursa

Night pain is a common complaint

shoulder pain:

when the arm is abducted to 30–40 degrees or flexed forward to 90 degrees or more.

internal rotation.

Slide26

significant

disruption of the rotator cuff↠ no active elevation past 90 degrees of flexion or weakness to external rotation

.

full-thickness tears of the rotator cuff :lost motion.

Point tenderness anterior to the acromion over the

subacromial

bursa is common.

Two common tests for impingement are the supraspinatus isolation test (empty can test), and the Hawkins-Kennedy test.

Slide27

supraspinatus

isolation test:

downward resistance is applied to the arm after the shoulder is abducted to 90 degrees and forward flexed 30 degrees and the straight arm is rotated so that the thumb is pointing to the ground. Weakness, when compared to the opposite side

, indicates disruption of the

supraspinatus

tendon.

Slide28

Hawkins-Kennedy test:

the arm is passively flexed forward to 90 degrees and the elbow is flexed to 90 degrees. When the examiner internally rotates the shoulder, pain indicates impingement of the

supraspinatus

tendon

Slide29

Differential Diagnosis

Angina

Cervical

radiculopathy

Acute shoulder sepsis

(quite rare, systemic signs: elevated ESR and WBC)

Osteoarthritis of the

glenohumeral

joint (plain radiographs)

degenerative arthritis of the

acromioclavicular

joint

With progressive age:

increasing incidence of asymptomatic partial or full-thickness cuff tears

( after 70 years of age, most people will have cuff tears).

Slide30

Imaging & Diagnostic Studies

x-rays

(AP) in internal and external rotation and an

axillary

and an outlet view

sclerotic change at the greater

tuberosity

or evidence of (AC) joint degenerative arthritis

in massive disruptions of the cuff, humeral head elevate in relationship to the

glenoid

cavity.

MRI

Slide31

Prevention

Avoidance of prolonged or repeated overhead work

rotator cuff strengthening exercises

Treatment

resolve the patient’s pain and restore normal function and muscle balance

anti-inflammatory medications, pendulum exercises

(reduces

the pressure, increase the

circulation)

Resistance exercises such as with an elastic band (

Thera

-Band), with the arm at the side, elbow flexed 90 degrees, applying force in internal and external rotation.

Slide32

fastest way in treatment:

inject the

subacromial

space( corticosteroid and local anesthetic (

eg

,

triamcinolone

40 mg and 1%

lidocaine

4 cc).

then started on progressive resistance exercises

The diagnosis is made when the patient’s symptoms are relieved immediately after injection

surgery or arthroscopic surgery:

1- respond temporarily to the injection

2- recurrence after two or three injections and who have participated in proper exercises

(removal of

acromion

and AC joint,

bursectomy

, and cuff debridement,….)

Slide33

Bicipital Tendinosis

anterior shoulder pain that is often worse with overhead activity

point tenderness in the area of the

intertubercular

groove

anteriorly

over the

humerus

.

Differential Diagnosis

:

impingement or rotator cuff pathology.

diagnosis

: clinically

x-rays: often normal

ultrasound or MRI :

(thickening of the tendon or fluid around the tendon)

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Prevention

Treatment

- rest and

nonsteroidal

anti-inflammatory drugs (NSAIDs)

- rehabilitation consisting of scapular stabilization techniques and rotator cuff strengthening.

- Ultrasound-guided steroid injection around the tendon

in refractory cases: surgery

consisting of debridement, biceps

tenodesis

, or

tenotomy

Slide36

Labral Tears

Labrum deepen and stabilize the joint

torn with either an acute injury or from repetitive overhead activity (throwing athlete)

Tears over the superior part of the labrum are known as SLAP lesions, or superior

labral

anterior to posterior lesions, (throwing athletes such as pitchers)

Traumatic dislocation of the shoulder:

Bankart

lesion

(tearing of the labrum and a portion of the inferior

glenohumeral

ligament from the anterior and inferior portion of the joint.

Slide37

Clinical Findings

deficit of internal

rotation compared to the other side

O’Brien test

:pain in the presence of a SLAP tear.

forward flex his or her adducted arm in full

pronation

against resistance by the examiner

The pain is improved when the test is

repeated with the arm in

supination

.

Bankart

lesions:

history of a shoulder dislocation and injury and signs of anterior apprehension on examination.

Slide38

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Differential Diagnosis

MRI

impingement, tendonitis, and rotator cuff pathology

Imaging & Diagnostic Studies

x-rays(not useful)

simple MRI (cannot detect all

labral

tears).

An MRI with

arthrogram

is more sensitive in assessing the labrum

Prevention

Careful adherence to proper mechanics with throwing

Treatment

strengthening the dynamic stabilizers of the shoulder in chronic instability.

However, large

labral

lesions that are symptomatic

often require arthroscopic repair.

Slide40

Shoulder Osteoarthrosis

glenohumeral

and/or

acromioclavicular

(AC)

decreased range of motion of the shoulder

pain with shoulder motion.

tenderness and swelling over the AC joint.

Differential Diagnosis

adhesive

capsulitis

, distinguishable by x-ray.

Imaging

-x-rays (internal and external rotation as well as an

axillary

and an outlet:

narrowing of the

glenohumeral

or AC joint with

subchondral

cysts and

osteophyte

formation

.

Slide41

Prevention

treatment of the tear in patients with Massive rotator cuff tears

Treatment:

Conservative treatment includes rest, NSAIDs, and therapy.

Steroid injection in

glenohumeral

or AC joint

Surgery(arthroscopic or open distal clavicle resection,

arthroplasty

)

Slide42

Frozen-Shoulder (Adhesive Capsulitis)

diffuse capsular inflammation :

marked restriction of

glenohumeral

joint motion

diabetes or other endocrine or autoimmune conditions.

Symptoms:

attempt to move the

glenohumeral

joint beyond that allowed by the inflammation and adhesions

All ranges of motion are limited

Slide43

Differential Diagnosis

osteoarthritis of the

glenohumeral

joint (radiographs)

Imaging

Standard radiographs are normal(rule out underlying arthritis)

Treatment

short period of sling immobilization

Shoulder motion will recover gradually with therapy over 6–18 months.

Recovery of motion can be facilitated initially by distension of the

glenohumeral

joint with saline with

lidocaine

, and

triamcinolone

.

This is followed by gentle manipulation of the arm into external rotation.

Slide44

Shoulder Dislocations

Stability

shoulder capsule and specific ligament

forces applied to the arm held in a position of abduction and external rotation:

humeral head is driven forward, tearing the anterior and middle

glenohumeral

ligaments and capsule from the margin of the

glenoid

Rarely, dislocate

posteriorly

with automobile accidents, grand mal seizures, or electroshock therapy.

Slide45

Clinical Findings

Acute anterior shoulder dislocation severe anterior shoulder pain.

Patients guard against shoulder motion by holding the elbow flexed with the

ipsilateral

forearm in the opposite hand.

Any attempt at motion is associated with severe pain.

Differential Diagnosis

fractures or acute rotator cuff or

labral

tears

Slide46

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Imaging

AP and

axillary

radiographs

Anterior dislocations: humeral head displaced inferiorly to the

glenoid

posterior dislocations: the humeral head is at the same level as the

glenoid

on the AP radiograph.

The diagnosis can be confirmed axillary view.

Prevention

- General fall prevention

- good seizure control

- Strengthening of the dynamic stabilizers of the shoulder may be helpful in chronic

dislocators

.

Treatment

Anterior and posterior dislocations are reduced by closed techniques immediately.

Slide48

Following reduction, patients are immobilized with the elbow at the side and the arm in a position of 10 degrees of external rotation for 3 weeks.

Patients are allowed to return to their usual activities at 6–8 weeks

If patients become recurrent

dislocators

,

repair of the torn capsular arthroscopically or with open surgery.

Slide49

Clavicular

Fractures

-direct blow to the shoulder

-rarely from falling on an outstretched hand

Middle-third fractures are most common

Clinical Findings

The proximal fragment of the clavicle is elevated by the action of the

sternocleidomastoid

, distal fragment downward.

Local swelling (bleeding)

The patient supports the involved extremity with the opposite hand.

Rarely,

Fx

can perforate the skin, producing an open fracture.

Slide50

Imaging & Diagnostic Studies

Plain radiographs of the clavicle.

Prevention

avoidance of falls and workplace safety.

Treatment

-Immobilization of the fracture is provided by the application of a figure-of-eight bandage or a sling.

Surgery (open reduction with internal fixation ):

distal third fracture,

highly displaced fractures,

fractures with tenting of the skin, or for early return to work or sporting activity.

Open fractures

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Proximal Humeral Fractures

direct fall onto the arm or elbow.

Clinical Findings

pain over the proximal shoulder region or radiating the length of the arm.

Local swelling( bleeding).

Differential Diagnosis

Dislocation of the

glenohumeral

joint

Slide52

Imaging & Diagnostic Studies

plain radiographs of the scapula and shoulder.

An axillary view is necessary to rule out a dislocation of the head fragment.

Prevention

Fall prevention

treatment of osteoporosis.

.

Slide53

Treatment

Nondisplaced

or minimally displaced fractures of neck or greater or lesser

tuberosities

: temporary immobilization

Displaced fractures of one or both

tuberosities

: indicative of a rotator cuff tear.

Displaced fractures: surgical treatment by open reduction and internal fixation.

The goal of physical therapy: restore normal range of motion and strength around the shoulder.

Slide54

(Brachial Plexus Neuropathy (Thoracic Outlet Syndrome

Compression of the vessels and nerves of the brachial plexus and/or

subclavian

vessels occurs in the

interscalene

triangle, behind or below the clavicle or

subcoracoid

space, or more distally at the

pectoralis

minor.

thoracic outlet compression:

1- Cervical ribs

2-congenital fibrous bands

3- rarely a nonunion or

malunion

of the clavicle

The disorder is uncommon and the diagnosis is missed frequently.

Women

are affected more frequently than men,

usually between the ages of

20 and 50

.

Slide55

Slide56

Clinical Findings

neurogenic

disorder is

more common

than the vascular

pain and/or

paresthesia

radiating from the neck or shoulder and down to the forearm and fingers

difficulty with overhead activities

The hand may feel swollen or heavy

The

lower trunk of the brachial plexus

is involved

more commonly

numbness, tingling, and weakness in the

ulnar

innervated intrinsic muscles and symptoms on

ulnar

side of the forearm and hand.

Slide57

Differential Diagnosis

-cervical disk disease at the C7–T1 level (C8 radiculopathy)- Entrapment of the ulnar nerve in the cubital tunnel or Guyon canal (physical examination, EMG)Diagnosis test: Adson maneuver, Wright test, Roos Test or shoulder hyperabduction to 180 degrees (observe the palm for pallor indicating an accompanying vascular compromise)

Slide58

Imaging & Diagnostic Studies

Plain radiographs of the cervical spine

(congenital differences such as cervical ribs and long transverse processes or even

hypoplastic

first ribs)

Apical

lordotic

chest views (

Pancoast

-type tumors)

MRI and angiographic , EMG(muscle weakness).

Slide59

Prevention

Identification and correction of postural triggers are an important part of management.

Computer users:

lowering the keyboard and mouse to elbow height

moving the monitor closer and to an appropriate height (

eg

, top of monitor at eye level)

standing workstation.

Slide60

Treatment

reduce the mechanism of thoracic outlet compression :

Conservative treatment, appropriate postural strength training

reduction of obesity and general physical fitness

Overhead activities or carrying heavy loads should be minimized.

Progress is measured in weeks or months.

surgery :

release the anterior scalene muscles

resect

of the first rib or fibrous band.

clavicular

malunion

(

clavicular

osteotomy

)

Slide61

workers who perform repeated forceful pinching or power grasps, wrist dorsiflexion or supination (eg, turning a door knob).work with the wrist in sustained extension pain radiating into the dorsal aspect of the forearm (maybe at night and at rest) tendon tears and necrosis at the attachment of the extensor carpi radialis brevis (ECRB) to the lateral humeral epicondyle and the extensor carpi radialis longus origin along the supracondylar line.

Lateral Epicondylitis (Tennis Elbow)

Slide62

Symptoms can be reproduced by:1- asking the patient to straighten the elbow then extend the wrist against resistance (Cozen test) 2- extend the middle finger against resistance with the wrist straight;3- grasp the back of a chair with the elbows straight and attempt to lift it (Chair test).

Slide63

Differential Diagnosis

radial head osteoarthritis (radiography)

fractured radial head or neck

(history of trauma and radiographic views)

Radial tunnel syndrome(symptoms are usually more distal) entrapment of the posterior branch of the radial nerve(in refractory cases)

C6

radiculopathy

or a shoulder

tendinopathy

Slide64

Imaging & Diagnostic Studies

clinical examination.

in major trauma or refractory symptoms:

Imaging( rule out fracture or arthritis), MRI (rule out intra-

articular

pathology)

Prevention

General strengthening of elbow and forearm musculature

proper instruction in the use of hand tools and/or modification of the hand tool

to reduce high-force pinching or gripping or repeated forceful wrist or finger flexion.

Slide65

Nonsteroidal anti-inflammatory drugs and ice (night pain)Steroid injections:reduce the pain for short durations (eg, weeks)Removing or modifying the offending activitiesavoid forceful pinching or gripping especially with wrist extension. Forearm muscle strengthening: initiated with low loads with slow progression. (start with wrist curls using 250 g weight and increasing the load each week or two). Surgery: debridement of the common extensor origin or extensor carpi radialis brevis, with or without repair, is rarely necessary.

Treatment

Slide66

Medial Epicondylitis (Golfer’s Elbow)

repeated forceful finger or wrist flexion or wrist

pronation

, especially when the elbow is flexed.

Clinical Findings

local tenderness over the medial

epicondyle

or common proximal flexor origin.

The symptoms can be reproduced by resisted wrist flexion.

The tissue swelling : compress the

ulnar

nerve

.

Slide67

Imaging & Diagnostic Studies

clinical examination.

in major trauma or refractory symptoms:

imaging(to rule out fracture or

arthritis,MRI

( rule out intra-

articular

pathology)

A nerve conduction study( rule out

ulnar

neuropathy)

Prevention

General strengthening of elbow and forearm musculature and proper instruction in the use of hand tools and/or modification of the hand tool

reduce high force pinching or gripping or repeated forceful wrist or finger flexion.

Treatment

rest of the involved tissues and modified activity.

Steroid injection is generally not recommended(

ulnar

nerve damage).

. The need for surgical relief is rare.

Slide68

Ulnar Neuropathy at the Elbow (Cubital Tunnel Syndrome)

the second most common nerve entrapment

(First: carpal tunnel syndrome)

Risk factors:

old elbow injuries with enlarging

osteophytes

,

cubitus

valgus

deformity at the elbow, or

subluxation

of the nerve out of the groove.

Work-related medial

epicondylitis

, contact stress or sustained elbow flexion (

eg

, telephone use)



localized edema



nerve compression, ischemia, fibrosis, and neuropathy.

Slide69

Clinical Findings

neuropathic symptoms (

eg

, numbness, tingling, aching, burning, shooting, or stabbing pain,

allodynia

, weakness) in the

ulnar

innervated fingers (

eg

, small and ring fingers) and less frequently in the medial aspect of the forearm and elbow.

Symptoms aggravated by elbow flexion or resting the elbow on a work surface

.

Slide70

physical examination

Tinel

sign or tenderness over the

ulnar

nerve.

Full elbow flexion for 60 seconds (with wrists straight) trigger the symptoms .

Sensory examination in the

ulnar

distribution on the fingers may be

abnormal (

eg

, 2-point discrimination , pin prick).

severe condition :Weakness and atrophy of the

interossei

/thumb adductor muscles.

Slide71

Slide72

Differential Diagnosis

compression of the

ulnar

nerve in

Guyon

canal at the wrist (uncommon),

cervicothoracic

C8–T1

radiculopathy

,

brachial plexus neuropathy (

eg

, thoracic outlet syndrome).

physical examination

or

nerve conduction

:

identify the location of the entrapment

.

Slide73

Imaging & Diagnostic Studies

Diagnosis:

combination of clinical data and nerve conduction studies of the

ulnar

nerve across the elbow.

ultrasound and MRI :

identifying morphological changes of the nerve within the

cubital

tunnel.

Prevention

eliminate sustained elbow flexion

(use of telephone head set instead of handheld telephone)

sustained contact stress, such as resting the arm

on arm-rest that presses on the

unlar

groove, should be avoided

Slide74

Treatment

conservative

pain relief

activity modification, such as avoiding elbow flexion of 90 degrees or more or pressure over the medial

epicondyle

region.

Night-time elbow splints :

maintain the elbow in approximately 45 degrees of flexion.

surgical decompression :

-

interosseous

muscle atrophy

-who do not respond to conservative management.

Slide75

Olecranon Bursitis

irritation and swelling in bursa between the

olecranon

prominence and the overlying skin.

Acute type;

usually not work-related ,

but a sudden trauma at work might precipitate an inflammation.

chronic type :

- more common in men

- caused by repeated contact stress on the elbow

Slide76

Clinical Findings

gradual swelling and pain,

Signs

of increased warmth

suggest a

septic process

Pressure exacerbates the pain.

Differential Diagnosis

Sepsis and inflammatory diseases, like rheumatoid disease, crystalline deposits, or

CRESTsyndrome

(

calcinosis

,

Raynaud

phenomenon, esophageal

dysmotility

,

sclerodactyly

, and

telangiectasia

)

Slide77

Imaging & Diagnostic Studies

Aspiration of the bursa and specific blood tests

MRI in complex cases may be indicated

(

hypointensity

on T1-weighted images).

Prevention

-

protection of repetitive trauma on the posterior face of the elbow.

-Use of a protective pad in specific jobs highly exposed to elbow trauma

Treatment

simple immobilization

For acute and painful cases: an elastic bandage and steroid injection (after infection is ruled out with an aspiration of the

bursal

fluid)

For recurrent bursitis, arthroscopic

bursal

resection may be required.

Slide78

Ganglion Cyst

most common soft tissue tumor of the hand.

mucin

-filled cystic lesions

second to fourth decades.

asymptomatic or produce pain with direct pressure or during wrist motions.

Refer when they change size or become symptomatic.

Clinical Findings:

over the dorsum of the wrist (can on the

volar

side) well circumscribed and feel fluid filled.

transilluminated

with a small penlight (large cases)

in the hand( on the

volar

):

small,round

, firm mass near the base of the digits.

Slide79

Imaging & Diagnostic Studies

diagnosis: clinically.

Radiographs ( if the mass feels bony or calcified in nature)

Confirm diagnosis (if the physical examination is inconclusive):

MRI, CT scan, or ultrasound

Prevention

The evidence is limited:

Modifing

: work involving repeated wrist motions.

Slide80

Treatment

Asymptomatic lesions, ( small and present for less than a year):

observed, resolve on their own.

Avoiding weight-bearing with wrist extension can decrease pain.

Aspiration :

recurrence rates 50–70%.

Injection with steroid:

increased incidence of skin

depigmentation

, subcutaneous fat atrophy.

Surgical excision:

symptomatic ganglia that do not respond to conservative treatment.

Slide81

De Quervain Tenosynovitis (First Dorsal Wrist Extensor Compartmen Tenosynovitis)

first dorsal compartment of the wrist.

abductor

pollicis

longus

and the extensor

pollicis

brevis

.

overuse of the thumb and wrist particularly with radial deviation, as in repetitive hammering, repetitive lifting .

Slide82

Clinical Findingslocalized tenderness and swelling over the radial side of the distal radius.. When the patient grasps the fully flexed thumb into the palm and then ulnar deviates the hand at the wrist, exquisite pain develops and reproduces the patient’s complaint (Finkelstein test)

Slide83

Differential Diagnosis

Chronic nonunion of the

scaphoid

bone, osteoarthritis of the first

carpometacarpal

joint, (in 25% of white women older than 55 years of age)

Imaging & Diagnostic studies

clinical diagnosis

no specific radiographic findings.

( rule out

carpometacarpal

osteoarthritis and nonunion of the

scaphoid

bone)

Prevention

lift with the palm facing upwards (full

supination

) rather than with the palm down,

avoid using the thumb.

Tools can be modified to reduce repeated forceful thumb flexion

(The thumb that strikes the spacebar on a keyboard, usually the right, may be at risk)

Slide84

Treatment

activity modification( lifting with the palm in

supination

)

avoiding repetitive lifting and thumb abduction, and use of a thumb

spica

splint to immobilize the thumb.

NSAIDs, Steroid injection (local anesthetic and steroid given into the tendon sheath over the area of the radial

styloid

)

surgical decompression of the common extensor sheath:

in

patient who do not respond to local injection

.

Slide85

Other xtensor Tendinopathies of the Wrist

five specific sites on the extensor side:

intersection syndrome (

ECR,third

compartment), extensor

digitorum

communis

(EDC, fourth compartment),

and extensor

carpi

ulnaris

(

ECU,sixth

compartment)

repeated or sustained wrist extension or other overuse, such as with excessive typing or

mousing

:

Intersection syndrome (ECR travels beneath muscle of APL and EPB) and fourth extensor compartment

tenosynovitis

(EDC) can occur.

Slide86

ECU tendonitis occurs after a twisting injury and presents as vague or deep pain over the ulnar side of the wrist. EDC synovitis with swelling and fluid is unusualoutside the setting of inflammatory or crystalline arthropathy, and patients with these findings should be evaluated for these conditions.

Slide87

Clinical Findings

very localized tenderness or pain with resisted loading of the tendon/muscle.

Patients with tendonitis over the ECU tendon have

ulnar

-sided wrist pain that can often extend from the insertion point over the base of the fifth metacarpal bone, over the distal

ulnar

, and into the distal forearm.

The pain is often worse with resisted wrist extension and

ulnar

deviation

Similarly, tendonitis of the ECR tendons creates pain at

the second and third metacarpal that also can extend into the forearm.

Pain with this condition tends to be worse with resisted wrist extension and radial deviation.

Intersection syndrome :

At distal forearm where the muscle bellies of the tendons the first dorsal compartment cross over the radial wrist extensors, causing compression in this area.

Slide88

Differential Diagnosis

tear of the triangular

fibrocartilage

complex.

De

Quervain

scaphoid

fractures

Nonunion or

radiocarpal

arthritis.

Imaging & Diagnostic studies

clinical diagnosis. However,

MRI: sometimes show fluid or inflammatory changes around the affected tendon

Prevention

Reduction of duration of forceful gripping and repeated wrist motion may prevent these conditions for hand intensive work.

For computer users:

ergonomic modifications can reduce wrist extension with

keyboard and mouse use.

Slide89

Treatment

activity modifications, wrist splints, NSAIDs.

ergonomic evaluation of work tasks and tools.

Corticosteriod

injections (limited in number to prevent the risk of tendon rupture)

Surgery:

refractory pain.

Slide90

Trigger Digit (Stenosing Tenosynovitis)

Stenosing

tenosynovitis

of the flexor tendon to a finger or of the flexor

pollicis

longus

to the thumb may produce pain when the digit or thumb is forcibly flexed

or extended(actively rather than passively

flexed)

Motion of (PIP) joint of the finger or (IP) joint of the thumb produces symptoms, painful snap



joint to collapse suddenly much like a trigger

.

Rf

: repetitive finger flexion.

Systemic diseases :

diabetes, thyroid dysfunction, and rheumatoid arthritis.

most cases are idiopathic

.

Slide91

Clinical Findings

In the early stage: pain and no triggering.

Sometimes, nodule can be palpated

near

the MCP

joint, with

passive flexion of the PIP joint.

In the later stages: the digit may become “locked” in extension (or more rarely in flexion)

Slide92

Imaging & Diagnostic Studies

Imaging studies are not needed and are usually normal.

Prevention

Avoidance of repetitive digit flexion against a load

good diabetic control

Treatment

At the early stages: splinting in extension at night

injection of steroid and local anesthetic into the area of the synovial

sheath.

Surgery:

Patients not responding to injection or developing recurrent

Slide93

Slide94

Carpal Tunnel Syndrome

entrapment or pressure neuropathy of the

median nerve

(as it passes through the carpal tunnel

volar

to the nine flexor tendons)

Occure

any age

more common in women.

Rf

:

Pregnancy, increasing age, obesity, hypothyroid, space occupying Lesion (Rheumatoid arthritis)

Direct blow to the

dorsiflexed

wrist or an injury associated with a

Colles

fracture.

Slide95

Work risk factor:

repeated or sustained forceful gripping or repetitive wrist and finger movements.

:

association between carpal tunnel and the use of a keyboard or computer mouse is controversy

Patients with CTS:

keyboarding, especially with the wrist in extension

,

exacerbates their symptoms.

Slide96

Clinical Findings:

paresthesias

in the median nerve (

volar

surface of the thumb, index, and long fingers, radial half of the ring finger).

progression of the syndrome:

awakening at night with pain, tingling, burning, or numbness

Characteristically, patients tend to stand up and massage the area or shake the wrist and fingers.

Triggening

of Symptoms:

driving or sustained gripping.

Further progression



hand weakness



result in permanent damage, skin sensory deficit and

thenar

motor atrophy and weakness.

Slide97

In early stage:

there is no evidence of

thenar

atrophy

Phalen

sign:

hold the wrists maximally flexed for 60 seconds, may develop symptoms

carpal compression test

:

direct pressure with the thumb over the carpal tunnel area .

Tinel

sign

:

Tapping with a reflex hammer at the

volar

wrist may recreate shooting pains into the tips of the digits .

The diagnosis

: EMG-NCV

Slide98

Differential Diagnosis

nerve compression occurring proximally.

cervical

radiculopathy

(C5, C6,C7)

Imaging & Diagnostic Studies

Imaging are not needed.

Nerve electro diagnostic( confirming and estimating severity of nerve dysfunction)

Slide99

PreventionAvoidance of repeated or sustained forceful gripping or repetitive wrist and finger movements, prolonged wrist flexion or extension, or direct pressure on the carpal tunnel.Use tools or jigs with less forceful pinch or grip. Tools reduce sustained posture extremes : split keyboards or asymmetrical computer mice.

Slide100

Treatment

Treat Underlying conditions (rheumatoid arthritis, hypothyroidism)

In the absence of signs of neuropathy:

reducing provocative or repetitive activities.

Wrist splints holding the wrist in neutral,

(Splinting consistently at

night

for a period of

4–6 weeks

can be curative in the early stages)

injections of cortisone into the carpal tunnel

(For patients not responding to rest and splinting)

Surgery:

Patients who fail to respond to the preceding measures

whose symptoms recur.

diagnosis

should be confirmed by

electrodiagnostic

studies before surgery is undertaken

Slide101

Hand Arm Vibration Syndrome

Rf

: use of electric and pneumatic vibrating hand tools over months or years.

( chain

saws,

grinders, sanders, and rock drills

)

clinical pathology is usually confined to the distal upper extremity.

most commonly with outside work performed in colder climates.

underlying pathology is caused by the tool signature not cold temperature

.

Slide102

Clinical Findings

The classic presentation

:

neurologic and vascular signs and

symptoms

cold-provoked blanching of the fingers:

vibration white fingers (VWF) or occupational

Raynaud

phenomenon.

At lower exposures

: neurologic symptoms predominate:

problems of hand coordination and fine manipulation.

Progression

: intermittent numbness, tingling, and pain

(see Stockholm Workshop Scales for severity assessment).

Slide103

At earlier stages

:

reversed if vibration exposure is minimized or stopped.

the prognosis is more variable.

Rarely in severe cases(collagen vascular disease or obstructive arterial disease ):

skin

trophic

changes and gangrene.

examination :

skin perfusion evaluation, digit sensory testing where available(with monofilaments or 2-point discrimination, and

provocative

maneuvers (

as in the carpal tunnel syndrome)

Slide104

Differential Diagnosis

Raynaud

disease and entrapment neuropathies

( CTS and thoracic outlet syndrome).

In addition, because VWF is a

vasospastic

disorder, routine noninvasive vascular imaging will usually be normal.

Thoracic outlet syndrome (TOS):

effects on large arteries and the brachial plexus.

( vascular expressions of TOS are unusual and can be visualized by Doppler, angiography, MRA, or

multidetector

CT)

Slide105

Imaging & Diagnostic Studies

Sensory function :

vibration and thermal perception threshold tests (VPT and TPT),limited availability.

Nerve conduction studies:

digital nerve function and rule out

CTS.

Routine noninvasive vascular tests are not useful, unless an obstructive pathology is under consideration.

Slide106

Prevention

tools with lower levels of handle acceleration (m/s2)

.

reducing

the minutes of tool use per day

Monitoring of exposure duration and symptoms

The use of

antivibration

gloves or tape wrapped around tool handles( reduce vibration exposure levels at higher frequencies)

Smoking cessation (reduces arterial vasospasm

)

Treatment

minimizing exposure to vibrating hand tools.

If CTS is also present, carpal tunnel surgery may be useful

Slide107

Slide108

Slide109

Kienböck

Disease

avascular

necrosis (AVN) of the

lunate

.

often idiopathic but can be associated with chronic steroid use.

It may be bilateral.

present in young men.

Preiser

disease

:

A similar condition can occur in the

scaphoid

.

very high levels of exposure to vibrating or

percussing

hand tools: AVN of both carpal bones.

Clinical Findings

wrist pain centered over the

lunate

but it may be vague in nature.

swelling and

synovitis

of the wrist.

Stiffness with wrist flexion and extension may be present.

Slide110

Differential Diagnosis

Wrist sprains,

scaphoid

nonunions

, and osteoarthritis of the wrist.

Imaging & Diagnostic Studies

PA, lateral, and oblique views of the wrist

sclerosis of the

lunate

,

lunate

collapse or loss of

lunate

height,

lunate

fragmentation, and eventually degenerative changes in the

radiocarpal

and

midcarpal

joints.

Stage 1

Kienböck

is diagnosed on MRI:

decreased

vascularity

of the

lunate

.

The disease occasionally occurs bilaterally and radiographs of the opposite side should also be performed.

Slide111

Prevention

generally idiopathic, sometimes high levels of

exposure to vibrating or

percussing

hand tools.

Treatment

Treatment depends on stage of the disease.

earlier stages and those with open

physes

:

casting or splinting and can show revascularization of the

lunate

over 1–2 years.

significant

lunate

collapse: surgery.

radial positive (radius longer than the

ulnar

):

radial shortening or other “joint leveling procedures.” Revascularization procedures can also be done.

Once degenerative changes have begun in the wrist, salvage procedures including proximal row

carpectomy

or partial or total wrist

arthrodesis

may be needed

Slide112

Dupuytren

Contracture

thickening of the

palmar

fascia, which is the layer of tissue between the skin and the underlying tendon sheath.

begins as a small nodule or nodules

grow over time to form cords



contracture of the digit at the proximal

interphalangeal

and

metacarpophalangeal

joints.

more common over the

ulnar

digits.

often seen in individuals of Northern European descent,

more common in males

hereditary predisposition.

Slide113

Clinical Findings

At the early

stages:subcutaneous

,

nonmobile

nodules at the palm.

At later stages, palpable subcutaneous cords ,extend into the digits and cause puckering of the overlying skin.

relatively fixed contractures of the MP and PIP joints and an inability to lay the hand flat on a table.

Differential Diagnosis

joint sprains, missed fractures, and tendon injuries, masses of the hand such as ganglion cysts or nerve sheath tumors.

Imaging & Diagnostic Studies

No imaging is needed.

Radiographs of the involved digits:

( assessing underlying arthritis)

MRI: differentiating from other types of masses.

Slide114

Prevention

primarily genetic in nature

some studies :

association with alcohol abuse, smoking, and very high levels of physical exposure (vibration and force) during the working life.

Treatment

asymptomatic Patients: observation

when the contractures reach around 30 degrees:

functional deficits.

Splinting and therapy: not particularly effective.

Collagenase

injections : have acceptable midterm results.

gold standard

:

Surgery: needle

fasciotomy

or open partial

fasciectomy

, with the open procedure remaining the.

Slide115

Scaphoid

Fractures

fall on the outstretched hand.

In elderly patients (osteoporosis) the same mechanism:

Colles

(distal radius) fracture

acute fall and snuffbox tenderness:

should be treated as if they have a

scaphoid

fracture since

early diagnosis

and

immobilization

play a key role in healing.

nonunion almost: degenerative changes at the wrist.

Clinical Findings

tenderness over the anatomic snuffbox or

volarly

over the distal pole of the

scaphoid

.

swelling,

ecchymosis

, and limited range of motion.

Slide116

Differential Diagnosis

Fx

radial

styloid

, De

Quervain’s

tenosynovitis

, CMC arthritis.

Imaging & Diagnostic Studies

PA, lateral, oblique views of the wrist,

scaphoid

view.

Often the fracture is only visible on one of these three views.

Nondisplaced

scaphoid

fx

are often not apparent on initial plain radiographs, so repeat radiographs 1–2 weeks later or MRI or CT scan.

Slide117

Treatment

immediately immobilized with a thumb

spica

splint or cast until radiographs can be repeated in 1–2 weeks or CT,MRI.

nondisplaced

Fx

: short arm thumb

spica

cast.

Immobilization is continued until fracture union is seen

radiographically

, usually at least 12 weeks.

displaced

Fx

: open reduction and internal fixation.

Symptoms in

scaphoid

nonunion occur long after the original injury.

In

scaphoid

nonunion :Surgical treatment with bone grafting.

Slide118

Mallet Finger injuries to the extensor tendon of the finger near the DIP joint. Rf: high velocity load to the end of the digit, such as when a ball hits the end of the finger leading to a stretch or rupture of the extensor tendon.Clinical FindingsPain at the DIP joint inability to actively extend the DIP joint is the usual presentation . Fractures may or may not be present.

Slide119

Imaging & Diagnostic Studies

A lateral view of the phalanges :

fractures and

subluxation

of joint.

Treatment

Most injuries: conservative treatment

(even if they are several months old)

The DIP joint is splinted in extension full-time with a Mallet splint for 6–8 weeks.

The splint allows time for the tendon to recover.

surgical pinning:

fracture with joint

subluxation

.

Slide120

Radius or

Ulnar

Fractures

result from a fall or trauma.

In young patients, the trauma is usually fairly high energy.

In osteoporotic patients it is often a fall from standing.

Clinical Findings

pain, swelling,

ecchymosis

, and deformity of the forearm or wrist.

check skin: for any breaks that may indicate an open fracture.

neurovascular examination.

Differential Diagnosis

Sprains and soft tissue injuries.

Slide121

Imaging & Diagnostic Studies

PA and lateral views of the forearm or PA, lateral, and oblique views of the wrist (depending on the site of injury)

Prevention

Osteoporotic patients should be carefully treated and monitored

Forearm guards may be used in high-risk sporting activities such as martial arts.

Treatment

radial shaft are treated surgically in adults.

Isolated

ulnar

fractures treated with casting or splinting depending on location, displacement, and age of the patient. Distal radius fractures: treated with either casting or surgery again depending on the age of the patient,

activity level, displacement of the fracture, and intra-

articular

involvement.

Slide122

Elbow Osteoarthritis

rare condition

almost in males

repetitive strenuous use of the arm in activities ranging from weight lifting to operating vibrating heavy machinery.

Elbow OA is marked by

osteophytes

formation

Clinical Findings:

Progressive diffuse pain .

During the early course:

osteophytes

in the

olecranon

fossa

cause pain in maximal extension.

osteophyte

in the

trochlea

or in the

coronoid

process: impingement pain may be noted in extreme flexion.

Slide123

Differential Diagnosis

secondary OA or rheumatoid arthritis.

Imaging & Diagnostic Studies

Imaging is necessary .

Plain radiograph or CT of the elbow (

osteophyte

).

Treatment

Conservative management:

decreased biomechanical exposure, pain relief, intra-

articular

, steroid injections, physical therapy, and splinting.

surgery :

conservative treatment fails

OA is advanced

Slide124

Nonspecific Forearm, Wrist, or Hand Pain

nonlocalizing

aches or pains in

distal upper extremities

or symptoms that change in quality and location with time.

normal physical examination

(50%)

One approach is to

treat

these as

somatizations

and try to identify underlying psychological or psychosocial factors that may be triggering symptoms.

This approach should be considered if the symptom location and quality change with time and there is

no apparent aggravation by specific tasks or biomechanical activities.

Psychosocial factors at work:

relationships with coworkers and supervisors; concerns of job loss; the patient’ pattern of wellbeing and energy level through the workweek; …

Slide125

psychosocial factors :A poor sleep pattern

-daily exercises as simple as

nondirected

walks. -Low dose pm

tricyclic

antidepressants,…

-referral to a therapist.

Another approach is:

identify the specific tasks and biomechanical activities at work or home that aggravate the symptoms

(if the symptom location does not change over time and the patient can identify specific aggravating activities)

risk factors that might affect tissues in the location of the symptoms.:

pain in the elbow region may be due to the repeated forceful pinching or gripping; sustained wrist extension; or contact stress at the elbow.

Slide126

For pain at the wrist: sustained wrist extension or

ulnar

deviation; sustained forearm

pronation

; repeated wrist motion; or contact stress on the

volar

surface of the wrist.

workplace intervention (new tools or changes in work practices ) in aggravating activities:

computer users are symptomatic using a conventional keyboard or mouse because their symptoms are aggravated by forearm

pronation

(split keyboard and an asymmetrical mouse)

The symptoms may take several weeks to resolve after the intervention.