Orthopedic Problems cspineupperext4/18/2009 8 Acute cervical strain 1:10 Neck pain at any time...
Transcript of Orthopedic Problems cspineupperext4/18/2009 8 Acute cervical strain 1:10 Neck pain at any time...
4/18/2009
1
Strengthening your musculoskeletal Strengthening your musculoskeletal assessment ofassessment of common common
complications of the cervical spine complications of the cervical spine and upper extremityand upper extremity
Louise McDevitt MS, FNPLouise McDevitt MS, FNP--BC, ANPBC, ANP--BC, BC, ACNPACNP--BCBC
Copyright © 2008 L. McDevitt All rights reserved
At the end of this program the At the end of this program the participant will: participant will:
Identify common musculoskeletal problems in Identify common musculoskeletal problems in the acute and primary care settingthe acute and primary care settingUnderstand differential diagnosis of specific Understand differential diagnosis of specific boney or m sc loskeletal complaintsboney or m sc loskeletal complaintsboney or musculoskeletal complaintsboney or musculoskeletal complaintsUtilize specialty tests to unearth differentialUtilize specialty tests to unearth differentialProvide appropriate treatmentProvide appropriate treatmentRefer as necessaryRefer as necessary
Musculoskeletal examinationMusculoskeletal examination
Moving from overt pessimismMoving from overt pessimismEducational prepEducational prepKnow your anatomyKnow your anatomyDevelop relationship with OrthoDevelop relationship with OrthoPractice, Practice, PracticePractice, Practice, Practice, ,, ,
Review basic physical examinationReview basic physical examinationEssentials of Musculoskeletal Care, SniderEssentials of Musculoskeletal Care, SniderPhysical Examination of the Spine and Extremities, Physical Examination of the Spine and Extremities, HoppenfeldHoppenfeldDiagnostic Exam, Degowin and DegowinDiagnostic Exam, Degowin and Degowin
Physical rehab exercisesPhysical rehab exercisesThe Sport Medicine Advisor, Rouzier The Sport Medicine Advisor, Rouzier
4/18/2009
2
HistoryHistoryMOI/location of painMOI/location of painChronicity of problemChronicity of problem
OnsetOnsetRecentRecentRemoteRemote
Quality of pain or swelling:Quality of pain or swelling:DurationDurationPrecipitatingPrecipitatingRelievingRelievingOveruseOveruse
TraumaTrauma--detailsdetailsInitial or altered Initial or altered biomechanical partsbiomechanical partsBlunt/penetratingBlunt/penetratingCumulative/acuteCumulative/acuteR/O FxR/O Fx
Decreased ROMDecreased ROMDegree of dysfunctionDegree of dysfunctionLockingLocking
Referred painReferred painPreeruptive Preeruptive DiabeticDiabetic
HistoryHistory
Neurological symptomsNeurological symptomsRadiation, numbness, tingling Radiation, numbness, tingling Weakness, paresthesiaWeakness, paresthesia
Symptoms in other jointsSymptoms in other jointsSystemicSystemic
Associated constitutional symptomsAssociated constitutional symptomsFever, fatigueFever, fatigue
Previous injuries to affected or contralateral joint Previous injuries to affected or contralateral joint Tetanus statusTetanus statusEffective treatmentEffective treatment
HistoryHistory
General healthGeneral healthPreviousPrevious
InjuriesInjuriesDisabilityDisabilityDisabilityDisabilitySurgeriesSurgeriesProblem listProblem list
MedicationsMedicationsRisk factors: occupation, weight, anorexia, Risk factors: occupation, weight, anorexia, hobbieshobbies
4/18/2009
3
With differential DX consider: With differential DX consider:
D D egenerativeegenerativeI I njurynjuryM M etabolicetabolicSS no ialno ialS S ynovialynovialT T umorumorI I nfectionnfectionC C irculationirculationC C ongenitalongenital
Remember these PearlsRemember these Pearls
Check: NV status distal to injury before manipulation Check: NV status distal to injury before manipulation of jointsof joints
Compare affected to unaffected sideCompare affected to unaffected side
Children: epiphysis injury, investigate back painChildren: epiphysis injury, investigate back painp p y j y g pp p y j y g pRadiculopathy: vascular, CNS, neuropathyRadiculopathy: vascular, CNS, neuropathyRICE is very niceRICE is very niceEvaluate for underlying injuriesEvaluate for underlying injuriesSystemic disease: multiple jointsSystemic disease: multiple jointsTenderness: infection, neoplasm, occult traumaTenderness: infection, neoplasm, occult trauma
Physical examinationPhysical examination
General appearanceGeneral appearanceVSVSGait/PostureGait/PostureInspectionInspectionppPalpationPalpationRange of MotionRange of Motion
Joint above and below Joint above and below Motor, sensory, reflex testingMotor, sensory, reflex testingSpecialty testsSpecialty tests
4/18/2009
4
In GeneralIn General
Treatment of overuse syndromesTreatment of overuse syndromesPRICEMMPRICEMMPProtectionrotectionRRestest
American Acadamy of Family Physicians, Evaluation of Overuse
Elbow Injuries. 2000
IIceceCCompressionompressionEElevation levation MMedicationedicationMModalityodality
Cervical spineCervical spine
7 vertebrae7 vertebrae8 cranial nerves8 cranial nerves
CN 6 from C5CN 6 from C5--66
C1C1--2 strong ligaments2 strong ligamentsC1C1 2 strong ligaments 2 strong ligaments =rotation=rotationC5C5--6 =90% disc lesions6 =90% disc lesionsC7 prominent spinous C7 prominent spinous process=landmarkprocess=landmark
4/18/2009
5
Cervical spine Cervical spine
Cervical ROMCervical ROM
C spineC spine DegreesDegrees CommentsComments
FlexionFlexion 6060--9090 Chin to chestChin to chest
ExtensionExtension 5050--7070 Ceiling gazeCeiling gaze
RotationRotation 8080--9090 Chin to shoulderChin to shoulder
Lateral flexionLateral flexion 4545--5555
Diminished ROMDiminished ROM
4/18/2009
6
Altered biomechanicsAltered biomechanics
Cervical impingementCervical impingementNerve rootNerve root RadiationRadiation MotorMotor SensorySensory ReflexReflex
C5C5 Lower neck, Lower neck, shouldershoulder
Weak Weak deltoid deltoid bicepsbiceps
DeltoidDeltoid BicepsBiceps
C6C6 N kN k BiBi D l tD l t BiBiC6C6 Neck, scap, Neck, scap, shoulder, lat shoulder, lat arm, dorsum arm, dorsum forearmforearm
Biceps, Biceps, EPLEPLWrist extWrist ext
Dorsolat Dorsolat thumb, index thumb, index fingerfinger
Biceps Biceps BrachiradBrachirad
C7C7 As above, but As above, but med scapmed scap
TricepsTricepsWrist Wrist flex, fing flex, fing extext
Dorsal index, Dorsal index, mid fingermid finger
TricepsTriceps
4/18/2009
7
Volar aspect right arm
Dorsal aspect
Clinical pictureClinical picture
DermatomesDermatomes
Know your anatomyKnow your anatomy
C5C5--6 90% disc problems6 90% disc problems
Neck to thumbNeck to thumb
The cervical vertebrae are normally aligned with some straightening through the mid and lower cervical spine. There is disc space narrowing at C5-6 andseverely at C6-7 yconsistent with underlying degenerative disc disease. Thereare anterior osteophytes at C5, C6, and C7. There is a small post.osteophytic ridge at C5-6
4/18/2009
8
Acute cervical strainAcute cervical strain
1:10 Neck pain at any time1:10 Neck pain at any timeMajority recover with conservative tx within 3 weeksMajority recover with conservative tx within 3 weeksWhiplash, neck sprain, myofascial neck painWhiplash, neck sprain, myofascial neck pain
Not neurological: SelfNot neurological: Self--limiting nonlimiting non--radicular neck radicular neck gg ggand shoulder painand shoulder pain
Pt HX: Pt HX: Hyperextension forceHyperextension forceGradual onset of pain: hrs later Gradual onset of pain: hrs later Generalized to neck and shoulderGeneralized to neck and shoulderOccipital nerve: nausea, tinnitus, blurred vision Occipital nerve: nausea, tinnitus, blurred vision
Cervical strain Cervical strain
Physical Findings: Physical Findings: Tenderness of sub occipital area to upper thoracic vertebraeTenderness of sub occipital area to upper thoracic vertebraeTrapezius/ SCM spasm/torticolisTrapezius/ SCM spasm/torticolisDecreased ROM in any of the areas esp. extensionDecreased ROM in any of the areas esp. extensionNormal neuro examNormal neuro examSpurling’s test negativeSpurling’s test negativeXX--ray: loss of lordosis on lateral viewray: loss of lordosis on lateral view
Differential cervical fracture, disc herniation, Differential cervical fracture, disc herniation, radiculopathyradiculopathy
Cervical strainCervical strain
TreatmentTreatmentGoalsGoals
Reduce pain, muscle sensitivity and spasm and return to normal Reduce pain, muscle sensitivity and spasm and return to normal functionfunction
Symptoms> 6 weeks, radiological studies, ? others Symptoms> 6 weeks, radiological studies, ? others y p , g ,y p , g ,PosturePosture
Straight sitting, shoulders backStraight sitting, shoulders backDriving: arms on rests, slightly shruggedDriving: arms on rests, slightly shruggedAvoid shoulder loads, backpacksAvoid shoulder loads, backpacksSleep: small neck pillow, pillow under kneesSleep: small neck pillow, pillow under kneesSedentary: head set, limit computer time Sedentary: head set, limit computer time
4/18/2009
9
Cervical strainCervical strain
MedicationMedicationMildMild--moderate pain: Acetaminophen, NSAID’smoderate pain: Acetaminophen, NSAID’sSevere pain in acute phase: moderate opioids or Severe pain in acute phase: moderate opioids or tramadoltramadoltramadoltramadolSpasm: Cyclobenzaprine 5mg daytime useSpasm: Cyclobenzaprine 5mg daytime use
10 mg at HS if sleep problematic10 mg at HS if sleep problematicAdding to high dose Ibuprofen in 1Adding to high dose Ibuprofen in 1stst 48 hrs does not 48 hrs does not increase reliefincrease relief
Cervical strainCervical strain
Home exercises: B.I.D. with heat first Home exercises: B.I.D. with heat first 10 repetitions, held 5 seconds10 repetitions, held 5 secondsNeck rotation: Chin towards shoulder, “finger press” Neck rotation: Chin towards shoulder, “finger press” for mild stretchingfor mild stretchingNeck tilt: Ear to shoulder apply tension on templeNeck tilt: Ear to shoulder apply tension on templeNeck tilt: Ear to shoulder, apply tension on templeNeck tilt: Ear to shoulder, apply tension on templeNeck bend: Neck bending, deep breathing between Neck bend: Neck bending, deep breathing between flexingflexingShoulder rolls: Sitting or standing, rowing movement Shoulder rolls: Sitting or standing, rowing movement Cervical collar: Randomized trials: delays healing Cervical collar: Randomized trials: delays healing Generally not recommended. If used under 3 hours per Generally not recommended. If used under 3 hours per day for 1day for 1--2 weeks. 2 weeks.
Cervical radiculopathyCervical radiculopathy
Sharp/referred nerve pain along the nerve Sharp/referred nerve pain along the nerve pathwayspathways
With or without changes in sensation or paresthesiasWith or without changes in sensation or paresthesiasExtremity painExtremity painy py p
EtiologyEtiologyDisc herniationDisc herniationSpinal stenosisSpinal stenosisLateral foramen narrowingLateral foramen narrowingSpondylolisthesisSpondylolisthesis
4/18/2009
10
Cervical radiculopathyCervical radiculopathy
Specialty testsSpecialty tests
Spurling’s test: evaluates nerve root compressionSpurling’s test: evaluates nerve root compressionSpondylosis, disc herniation, foramen narrowingSpondylosis, disc herniation, foramen narrowingExtension of headExtension of headR t ti n t ff t d h ld rR t ti n t ff t d h ld rRotation to affected shoulder Rotation to affected shoulder
Axial loadAxial loadPt is standing, compression of headPt is standing, compression of head
If LIf L--S pain, think nonorganic causeS pain, think nonorganic cause
Positive test: evaluate for bony/soft tissuePositive test: evaluate for bony/soft tissue
Cervical radiculopathyCervical radiculopathy
Treatment:Treatment:Many imperfect studies about multiple modes of Many imperfect studies about multiple modes of therapy, biofeedback, Tens, trigger point injectiontherapy, biofeedback, Tens, trigger point injectionPain and sleep: TCA’s amitriptyline 10Pain and sleep: TCA’s amitriptyline 10--30 mg HS30 mg HSPain and sleep: TCA s amitriptyline 10Pain and sleep: TCA s amitriptyline 10 30 mg HS30 mg HSCoexisting depression: Duloxetine or venlaxafineCoexisting depression: Duloxetine or venlaxafineGabapentin: stronger for neuropathic pain, utilized Gabapentin: stronger for neuropathic pain, utilized in pain clinicsin pain clinicsNeurosx evaluationNeurosx evaluationPain reliefPain relief
4/18/2009
11
ShoulderShoulder
Rotational joint with decreased stabilityRotational joint with decreased stabilityMMuscles: RTCuscles: RTCRReferred: GB, Cardiaceferred: GB, CardiacCCapsule: Ligamentsapsule: LigamentsOOsseous: Trauma, stenosissseous: Trauma, stenosisAArticular: Systemic conditionsrticular: Systemic conditionsTTendons: Bicepsendons: Biceps
Anterior View of Shoulder
Posterior View of Shoulder
4/18/2009
12
Subacromial Arch
Shoulder ROMShoulder ROM
ShoulderShoulder DegreesDegrees RestrictedRestricted
FlexionFlexion 180180 <160<160
ExtensionExtension 5050 <40<40
AbductionAbduction 180180 <160<160
AdductionAdduction 5050 <30<30
External rotationExternal rotation 9090 <60<60
Internal rotationInternal rotation 9090 <60<60
AC separationAC separation
Disruption of AC joint, coracoid ligaments, and or Disruption of AC joint, coracoid ligaments, and or clavicleclavicleMOIMOI
Direct forceDirect forceDi f ll i f dd d h ldDi f ll i f dd d h ldDirect fall to superior aspect of adducted shoulderDirect fall to superior aspect of adducted shoulderFall onto outstretched handFall onto outstretched hand
Pt c/oPt c/oPain with AC joint palpationPain with AC joint palpationArm elevation painful, occ. impossibleArm elevation painful, occ. impossibleDeformity, instability, cosmetically unacceptableDeformity, instability, cosmetically unacceptable
4/18/2009
13
AC separationAC separation
Physical examinationPhysical examinationCheck clavicle for fractureCheck clavicle for fractureDeformity: comparisonDeformity: comparisonTender to palpationTender to palpationp pp pPain to passive abduction 90Pain to passive abduction 90--180 degrees180 degrees+ Crossover test: pain passive adduction in + Crossover test: pain passive adduction in horizontal plane horizontal plane
AC arthritisAC arthritisCreptitus with dorsal/ventral glideCreptitus with dorsal/ventral glide
AC separationAC separation
Diagnosis: Weighted comparison AP view of Diagnosis: Weighted comparison AP view of shouldersshouldersTreatment: Treatment:
Mi R I A iMi R I A i i fli flMinor: Rest, Ice, AntiMinor: Rest, Ice, Anti--inflammatoryinflammatory? Sling: 2 days if it relieves pain? Sling: 2 days if it relieves painRTW/RTP: @ 2 weeks, ROM is painless RTW/RTP: @ 2 weeks, ROM is painless
Coracoclavicular Coracoacromial Ligament injury
4/18/2009
14
AC separationAC separation
Biceps tearBiceps tear
> common than tendonitis> common than tendonitisIntraIntra--articular tendon exposed to shearing forcesarticular tendon exposed to shearing forcesTear of the proximal aspect long headTear of the proximal aspect long headMOAMOA
Male > 40 y.o.Male > 40 y.o.Trivial event superimposed upon chronic Trivial event superimposed upon chronic impingement syndromeimpingement syndromeYounger: weight liftingYounger: weight lifting
Biceps tearBiceps tear
Pt c/oPt c/oSharp snapping painSharp snapping painSudden biceps retraction, bulging near antecubital spaceSudden biceps retraction, bulging near antecubital space
“Popeye” sign“Popeye” sign
Physical examinationPhysical examinationApparent deformity, possible ecchymosisApparent deformity, possible ecchymosis
1010°° internal rotation of humerus/palapation bicipital internal rotation of humerus/palapation bicipital groove=paingroove=pain10% loss of supination10% loss of supination
4/18/2009
15
Biceps tearBiceps tear
Specialty testsSpecialty testsLudington’s sign: ext. rotation/ abduction, flexion of bicepsLudington’s sign: ext. rotation/ abduction, flexion of bicepsSpeed’s test: extended forearm, resisted flexionSpeed’s test: extended forearm, resisted flexion
Diagnostic testDiagnostic testggRadiograph r/o fxRadiograph r/o fxMRA: look for RCTMRA: look for RCT
TreatmentTreatmentConservativeConservativeHeavy laborer: Orthopedic referralHeavy laborer: Orthopedic referral
Biceps tendonitis Specialty testBiceps tendonitis Specialty test
InstabilityInstability YergasonYergason Elbow 90Elbow 90°°pronationpronation
Speed’s maneuverSpeed’s maneuver Elbow 20Elbow 20--3030°°fl i ffl i fflexion, forearm flexion, forearm supinationsupination
Impingement syndromeImpingement syndrome
Persistent symptomatic compression of the RTC Persistent symptomatic compression of the RTC and subacromial bursa between the acromion and subacromial bursa between the acromion and the humerusand the humerus
3 primary complications3 primary complications3 primary complications3 primary complicationsRTC tendonitisRTC tendonitisRTC tearRTC tearSubacromial bursitisSubacromial bursitis
4/18/2009
16
Rotator Cuff Rotator Cuff
Trading stability for rotationTrading stability for rotation4 SITS muscles4 SITS muscles
S S upraspinatusupraspinatusMost commonly inuredMost commonly inuredAbduction Abduction
Concept: Pain vs weaknessConcept: Pain vs weaknessPain: inflammation, edemaPain: inflammation, edemaWeakness: tearWeakness: tear
I I nfraspinatusnfraspinatusExt rotationExt rotation
T T eres Minoreres MinorExt rotationExt rotation
S S ubscapularisubscapularisInternal rotationInternal rotation
Rotator cuff problemsRotator cuff problems
Causes of impingement of RTCCauses of impingement of RTCHooked acromion Hooked acromion Glenohumeral instabilityGlenohumeral instabilityWeak scapula muscles, narrow subacromial spaceWeak scapula muscles, narrow subacromial space
P HP HPt HxPt HxOccupation/advocationOccupation/advocationGradual onset of painGradual onset of painPain overhead reachPain overhead reachAnteriorlateral shoulder painAnteriorlateral shoulder painProgressive weaknessProgressive weakness
Age is a determinantAge is a determinant
Younger < 30 yoYounger < 30 yo InstabilityInstabilityAC separationAC separationRarely RTCRarely RTC
Middle aged 30Middle aged 30--50 yo50 yo As aboveAs aboveRTC , impingementRTC , impingementFrozen shoulderFrozen shoulder
Older 50 yoOlder 50 yo Complete RTC tearComplete RTC tearDegenerative arthritisDegenerative arthritis
4/18/2009
17
Rotator cuff tendonitisRotator cuff tendonitis
Pain 45Pain 45°° abductionabduction--severe impingementsevere impingement90 90 °° abductionabduction--mild impingementmild impingement
Pain flexion and internal rotationPain flexion and internal rotationSubacromial tendernessSubacromial tendernessNormal strengthNormal strengthWith time muscle atrophy With time muscle atrophy
Subacromial bursitisSubacromial bursitis
Pt hx: Pt hx: Repetitive overhead activitiesRepetitive overhead activitiesPain increased with activityPain increased with activityUnable to sleep on affected sideUnable to sleep on affected sidepp
Physical examinationPhysical examinationMarked pain with abductionMarked pain with abductionErythemaErythemaEdemaEdemaExtension of shoulder palpate bursa + painExtension of shoulder palpate bursa + pain
Subacromial bursitisSubacromial bursitis
DiagnosticDiagnosticJoint aspiration for evaluation of synovial fluidJoint aspiration for evaluation of synovial fluid
Crystal analysis: GoutCrystal analysis: GoutR.A.R.A.R.A.R.A.LymeLymeInfectiousInfectious
TreatmentTreatmentSteroid injectionSteroid injection
4/18/2009
18
Treatment of Impingement Treatment of Impingement syndromesyndrome
Limited research, common practiceLimited research, common practicePRICEMMPRICEMMAvoid overhead activityAvoid overhead activityGentle weighted pendulum exercisesGentle weighted pendulum exercisesGentle weighted pendulum exercisesGentle weighted pendulum exercises
For all shoulder problems except AC problemsFor all shoulder problems except AC problems
P.T. for strengthening, flexibility, joint mobilization P.T. for strengthening, flexibility, joint mobilization Recheck 3Recheck 3--4 weeks for adherence to program4 weeks for adherence to program
M.R.I. for continued weaknessM.R.I. for continued weaknessOrthopedic referralOrthopedic referral
Adhesive capsulitisAdhesive capsulitis
Frozen shoulder: Contracted soft tissues, joint Frozen shoulder: Contracted soft tissues, joint capsulecapsulePt c/oPt c/o
Progressive loss of ROMProgressive loss of ROMProgressive loss of ROMProgressive loss of ROMNo injuryNo injuryNondominant handNondominant hand
Pt hxPt hxPost M.I., hypothyroidism, diabetes, parkinsons, Post M.I., hypothyroidism, diabetes, parkinsons, post neuro or breast sx post neuro or breast sx
Adhesive capsulitisAdhesive capsulitis
Physical examinationPhysical examination3 phases: painful, loss of ROM, resolution p 2 yrs3 phases: painful, loss of ROM, resolution p 2 yrsApley’s scratch test: Unable to comb hairApley’s scratch test: Unable to comb hairUn bl t p t h nd in pr in p iti nUn bl t p t h nd in pr in p iti nUnable to put hands in praying positionUnable to put hands in praying positionFirm end point with ROM testingFirm end point with ROM testing
Pt will abduct with shoulder shrug Pt will abduct with shoulder shrug
4/18/2009
19
JuliaJuliaH.P.I. One month ago in 65 y.o. female received H.P.I. One month ago in 65 y.o. female received 80mg depo80mg depo--medrol for bursitis in left shoulder medrol for bursitis in left shoulder due to incomplete pain relief from Tramadol. due to incomplete pain relief from Tramadol. Notes limited ROM. Arthrogram no full Notes limited ROM. Arthrogram no full thickness RTC tear.thickness RTC tear.P.E. Limited active flexion and abduction to 90 P.E. Limited active flexion and abduction to 90 degrees. Passively examiner can only extend degrees. Passively examiner can only extend these movements another 10 degrees with firm these movements another 10 degrees with firm end point.end point.Dx Subacromial bursitis resulting in decreased Dx Subacromial bursitis resulting in decreased ROM, then adhesive capsulitis. ROM, then adhesive capsulitis.
Osteoarthritis Osteoarthritis
OsteoarthritisOsteoarthritis
Pt HxPt HxPain localized to shoulder and upper armPain localized to shoulder and upper armPain increases with activityPain increases with activityPoor sleep qualityPoor sleep qualityp q yp q yProgressive loss of ROM and ADLProgressive loss of ROM and ADL
Physical examinationPhysical examinationNo swellingNo swellingCrepitus with flexion and rotation Crepitus with flexion and rotation Radiograph: flattening of humeral head, osteophytesRadiograph: flattening of humeral head, osteophytes
4/18/2009
20
Separating the physical findings Separating the physical findings
RTC tendonitisRTC tendonitis Subacromial tendernessSubacromial tenderness
RT TearRT Tear Loss of strengthLoss of strength
BursitisBursitis Tender bursa with extension ofTender bursa with extension ofBursitisBursitis Tender, bursa with extension of Tender, bursa with extension of shouldershoulder
Biceps tendonitisBiceps tendonitis Pain against supination or bicepital Pain against supination or bicepital groove groove
Adhesive Adhesive CapsulitisCapsulitis
Decreased active or passive ROMDecreased active or passive ROM
OsteoarthritisOsteoarthritis Grinding flexion, extensionGrinding flexion, extension
Specialty tests Specialty tests
RTC tendonitisRTC tendonitisteartear
Apley scratch Apley scratch testtest
Superior/inferior Superior/inferior reach of opposite reach of opposite scapulascapula
ImpingementImpingement Neer’sNeer’s Arm 180Arm 180°° forced forced p gp gflexionflexion
Supraspinatus Supraspinatus tendon/impingement tendon/impingement
Hawkin’sHawkin’s 9090°° elevation, elevation, internal rotationinternal rotation
RTC tearRTC tear Drop armDrop arm 180180°° abduction abduction passive loweringpassive loweringFalse + above 90False + above 90°°
Elbow AnatomyElbow Anatomy
Purpose: position hand to mouthPurpose: position hand to mouthHumerus/ulna=hinge joint Humerus/ulna=hinge joint Humerus/radius=hinge and rotationHumerus/radius=hinge and rotationProximal radius/ulna=rotates with sup/pronProximal radius/ulna=rotates with sup/pronCollateral ligaments stabilizes medial and lateral aspectsCollateral ligaments stabilizes medial and lateral aspectsCollateral ligaments stabilizes medial and lateral aspects Collateral ligaments stabilizes medial and lateral aspects Annular ligament: encircles radius, placement in the radial notchAnnular ligament: encircles radius, placement in the radial notchFlexors: biceps, brachioradialis, brachialis musclesFlexors: biceps, brachioradialis, brachialis musclesExtensors: tricepsExtensors: tricepsSupinators: supin/biceps brachiiSupinators: supin/biceps brachiiPronators: FCR, pronator quadratus and teres Pronators: FCR, pronator quadratus and teres Nerves: Median/radial, ulnaNerves: Median/radial, ulna
4/18/2009
21
Elbow radiographElbow radiograph
Med. epicondyleLat.flexors
Lat. epicondyleextensors
olecrannon
History: Overuse syndrome History: Overuse syndrome
Activity Activity ProblemProblemBowlingBowling Biceps tendonitis, redial nerveBiceps tendonitis, redial nerveFriction sports: wrestlingFriction sports: wrestling Olecrannon bursitisOlecrannon bursitisGolfGolf Medial epicondylitis, radial nerveMedial epicondylitis, radial nerveGymnastics Gymnastics Biceps/triceps tendonitisBiceps/triceps tendonitisRacketballRacketball As above + ulna nerveAs above + ulna nerveThrowingThrowing As above, epiphysis injury, fxAs above, epiphysis injury, fxWeight liftingWeight lifting Biceps, triceps tendonitis, nerve Biceps, triceps tendonitis, nerve
entrapment entrapment
4/18/2009
22
ElbowElbow
ElbowElbow DegreesDegrees RestrictedRestricted
FlexionFlexion 140140--150150°° 130130°°
ExtensionExtension 11--1010°° >10>10°°
SupinationSupination 9090°° 6060°°
PronationPronation 8080--9090°° 7070°°
Nursemaid’s elbowNursemaid’s elbow
Subluxed radial head, annular ligament displacementSubluxed radial head, annular ligament displacementRadius slips under the annular ligamentRadius slips under the annular ligamentPt Hx:Pt Hx:
Children carried by wrist with elbow extended and axialChildren carried by wrist with elbow extended and axial
http://www.emedicine.com/emerg/topic392.htm
Children carried by wrist with elbow extended and axial Children carried by wrist with elbow extended and axial tractiontraction
I.E.: pulled over an obstacleI.E.: pulled over an obstacle
Physical examinationPhysical examinationChild refuses to use arm and fussyChild refuses to use arm and fussyAvoids supination and elbow flexionAvoids supination and elbow flexion
Nursemaid’s elbowNursemaid’s elbow
Treatment Treatment First do no harmFirst do no harmGoal return annular ligament and radial head to anatomic Goal return annular ligament and radial head to anatomic positionposition
Radiographs: useful if suspecting fxRadiographs: useful if suspecting fx
http://www.emedicine.com/emerg/topic392.htm January 4, 2007
g p p gg p p gReview hx if uncertain obtainReview hx if uncertain obtain
Maneuver: Work with ortho firstManeuver: Work with ortho firstImmobilize elbowImmobilize elbowPalpate radial head, pressure on radial headPalpate radial head, pressure on radial headAxial compression at the wrist with full supination of forearm Axial compression at the wrist with full supination of forearm while flexing the elbow. while flexing the elbow. Clicking or snapping of radial head + indicator of reductionClicking or snapping of radial head + indicator of reduction
4/18/2009
23
Olecrannon bursitisOlecrannon bursitis
Synovial lined sac over the olecrannon processSynovial lined sac over the olecrannon processMarked inflammation between the olecrannon & ulnaMarked inflammation between the olecrannon & ulna
OnsetOnsetGradual: Secondary to overuse or pressureGradual: Secondary to overuse or pressurey py pAcute inflammationAcute inflammation
TraumaTraumaRarely infection: staph aureusRarely infection: staph aureus
Pt HxPt HxMale, laborer 50’s, etoh Male, laborer 50’s, etoh Pain varies, mass prevents flexionPain varies, mass prevents flexion
Olecrannon bursitisOlecrannon bursitis
Physical examinationPhysical examinationSkin dry, abradedSkin dry, abradedErythematous or painful if infection or acute traumaErythematous or painful if infection or acute traumaLarge mass often > 6 cmLarge mass often > 6 cm
Di iDi iDiagnosticDiagnosticAspirationAspiration
Blood: traumaBlood: traumaCrystals: goutCrystals: goutCulture cloudy fluid Culture cloudy fluid
TreatmentTreatmentThey recur. Aspiration, compression, elbow protection They recur. Aspiration, compression, elbow protection
4/18/2009
24
Lateral epicondylitisLateral epicondylitis
Tennis elbow, most commonTennis elbow, most commonInflammation or tissue degeneration of wrist extensors Inflammation or tissue degeneration of wrist extensors at lateral epicondyleat lateral epicondyle
tendonosistendonosisPt hxPt hx
3030--60 yo, peak age 40 yo60 yo, peak age 40 yoRepetitive wrist extension, pronation or supination of Repetitive wrist extension, pronation or supination of forearmforearm
OccupationalOccupationalRecreational: tennis backhandRecreational: tennis backhand
Lifting with palm in pronation, holding a cup painfulLifting with palm in pronation, holding a cup painful
Lateral epicondylitisLateral epicondylitis
Physical examinationPhysical examinationPain to pressure one cm Pain to pressure one cm under lateral epicondyleunder lateral epicondyleLosee positionLosee position
Elb 90Elb 90
Tx: eliminate offending Tx: eliminate offending activities, NSAID’s 10activities, NSAID’s 10--14 days14 days
Elbow 90 , across Elbow 90 , across abdomenabdomenPalm upPalm upIsolates the extensor Isolates the extensor carpi radialis breviscarpi radialis brevis
DiagnosticDiagnosticRadiograph: r/o radial Radiograph: r/o radial head arthritishead arthritis
Medial epicondylitisMedial epicondylitis
Golfer’s elbow, 2Golfer’s elbow, 2ndnd most commonmost commonInjury to pronator teres and flexor carpi radialis Injury to pronator teres and flexor carpi radialis muscles secondary to wrist snapping and muscles secondary to wrist snapping and pronationpronationpronationpronation
Forceful, rapid flexionForceful, rapid flexionTennis serve, end phase acceleration of pitchers, Tennis serve, end phase acceleration of pitchers, hammeringhammering
If nerve symptoms=ulna nerve entrapmentIf nerve symptoms=ulna nerve entrapment
4/18/2009
25
Golfer’s elbowGolfer’s elbow
Physical examinationPhysical examinationInability to straighten elbowInability to straighten elbowLocal tenderness 1 inch below medial epicondyle, Local tenderness 1 inch below medial epicondyle, along the pronator teres flexor carpi radialisalong the pronator teres flexor carpi radialisalong the pronator teres, flexor carpi radialisalong the pronator teres, flexor carpi radialisPain with elbow extended, forearm supinated, with Pain with elbow extended, forearm supinated, with resisted wrist flexionresisted wrist flexionPain with resisted pronationPain with resisted pronation
Separating the physical findingsSeparating the physical findings
Olecrannon bursitisOlecrannon bursitis Posterior ballotable cystic Posterior ballotable cystic type swelling type swelling
Lateral epicondylitisLateral epicondylitis + Cozen’s test+ Cozen’s testP i i h i d ifl iP i i h i d ifl iPain with wrist dorsiflexionPain with wrist dorsiflexion
Medial epicondylitisMedial epicondylitis Pain with wrist flexionPain with wrist flexion
OsteoarthritisOsteoarthritis Decreased ROMDecreased ROMCrepitus Crepitus
Elbow complicationsElbow complications
TreatmentTreatmentNontraumatic injury radiographs rarely necessary Nontraumatic injury radiographs rarely necessary Rest, IceRest, IceE r i Impr tr n thE r i Impr tr n thExercises: Improve strengthExercises: Improve strength
Outstretched arm, palm down, flex wrist hold 20 seconds, Outstretched arm, palm down, flex wrist hold 20 seconds, extend wrist 20 seconds x 5extend wrist 20 seconds x 5Squeezing a tennis ballSqueezing a tennis ball
Bracing: counterforce to affected musclesBracing: counterforce to affected musclesGradual return to activitiesGradual return to activities
4/18/2009
26
Hand and WristHand and Wrist
Get a grip with 8 carpal, 5 metacarpal, 14 Get a grip with 8 carpal, 5 metacarpal, 14 phalangesphalanges2 rows of carpal bones close to 2 rows of carpal bones close to radius/metacarpals radius/metacarpals / p/ pScaphoid ( carpal navicular bone) links 2 rowsScaphoid ( carpal navicular bone) links 2 rows
Most common fracture, one artery, nonunionMost common fracture, one artery, nonunionPt HxPt Hx
Fall onto the outstretched handFall onto the outstretched handPain base of the thumbPain base of the thumb
Scaphoid fractureScaphoid fracture
Physical examinationPhysical examinationPt abducts and extends the thumb with hand Pt abducts and extends the thumb with hand pronatedpronated+ pain in the depression r/o fx of navicular and or+ pain in the depression r/o fx of navicular and or+ pain in the depression r/o fx of navicular and or + pain in the depression r/o fx of navicular and or radiusradius
Radiograph, even if negative thumb spica splintRadiograph, even if negative thumb spica splintRepeat xRepeat x--ray in 2 weeksray in 2 weeksReferral Referral
Fracture navicular, radiusFracture navicular, radius
4/18/2009
27
Carpal tunnel syndromeCarpal tunnel syndrome
Most common neuropathy from repetitive wrist Most common neuropathy from repetitive wrist flexion and extension flexion and extension
50% bilateral50% bilateralMedian nerve compressionMedian nerve compressioned e ve co p ess oed e ve co p ess oOsteofibrous tunnel with 9 flexor tendonsOsteofibrous tunnel with 9 flexor tendonsThink hypothyroid, pregnancy, R.A., arthritisThink hypothyroid, pregnancy, R.A., arthritisPt c/oPt c/o
Nocturnal paresthesias of radial 3.5 fingers leading Nocturnal paresthesias of radial 3.5 fingers leading to weaknessto weakness
Physical examinationPhysical examinationTinel’s: + if tapping the volar wrist skin Tinel’s: + if tapping the volar wrist skin crease= paresthesiascrease= paresthesiasPhalen’s: + if complete flexion in 30Phalen’s: + if complete flexion in 30--60 60 seconds=parethesiasseconds=parethesiasseconds=parethesiasseconds=parethesiasSensory > 5 mm discrimination from 2,3rd Sensory > 5 mm discrimination from 2,3rd fingers to 5th and compare to opposite handfingers to 5th and compare to opposite handMotor: weak abd pollicus brevisMotor: weak abd pollicus brevis
Oppose abducting thumbOppose abducting thumbAtrophied thenar eminenceAtrophied thenar eminence
CTSCTS
TreatmentTreatmentEliminate the causeEliminate the causeSplinting neutral position, OT or forearm wrist Splinting neutral position, OT or forearm wrist splintsplintsplintsplintNSAID’sNSAID’sTreat the diseaseTreat the diseaseEMGEMGReferralReferral
4/18/2009
28
GanglionGanglion
Cystic area from synovial Cystic area from synovial sheath or jointsheath or jointVolar: wrist creaseVolar: wrist creaseDorsal: over the lunateDorsal: over the lunate
Lunate location: ulna side Lunate location: ulna side mid radius/3mid radius/3rdrd metacarpalmetacarpal
Pt c/o Pt c/o Waxing and waning bump Waxing and waning bump Pain increases with Pain increases with extreme flexion or extreme flexion or extension of the wristextension of the wristMay increase with May increase with increased activity increased activity
GanglionGanglion
Physical examinationPhysical examinationSmooth round noduleSmooth round noduleMore prominent with flexion or extensionMore prominent with flexion or extensionTender to touchTender to touchRarely compression of radial nerve Rarely compression of radial nerve
TreatmentTreatmentRadiograph: r/o occult bone pathologyRadiograph: r/o occult bone pathologyAspiration, immobilize, reassurance, refer if Aspiration, immobilize, reassurance, refer if significant symptoms significant symptoms
Wrist tendonitis Wrist tendonitis
EPB and APL tendons cross distal radiusEPB and APL tendons cross distal radiusPt HX: Repetitive gripping/ulna and radial Pt HX: Repetitive gripping/ulna and radial deviationdeviationP EP EP.E. P.E.
Pain with thumb movementPain with thumb movementPain with resisted extensionPain with resisted extensionLocalized tenderness distal radius/swellingLocalized tenderness distal radius/swelling
4/18/2009
29
deQuevain’sdeQuevain’s
Wrist tendonitisWrist tendonitis
Pain reliefPain reliefIce 15 min q 4 hoursIce 15 min q 4 hoursPhonophoresisPhonophoresisThumb spica splintThumb spica splintBuddy tape to index finger Buddy tape to index finger
Extensor tendon injury DIP jointExtensor tendon injury DIP joint
Most common finger injuryMost common finger injuryMallet fingerMallet finger
Forceful flexion thus extensor tendon stretched or rupturedForceful flexion thus extensor tendon stretched or rupturedBaseball hitting finger tip, jamming finger in basket ball Baseball hitting finger tip, jamming finger in basket ball
Physical examinationPhysical examinationSwellingSwellingInability to actively extend DIP jointInability to actively extend DIP joint
TreatmentTreatmentRadiograph Radiograph Splint in neutral or slight hyperextension x 6 weeksSplint in neutral or slight hyperextension x 6 weeks
4/18/2009
30
Mallet fingerMallet finger
Thank youThank you
Spend some time with your local N.P. or P.A. Spend some time with your local N.P. or P.A. orthopedic specialistorthopedic specialistJump start to optimismJump start to optimism
BibliographyBibliography
Anderson, BC. Anderson, BC. Office Orthopedics for Primary Care: Diagnosis Office Orthopedics for Primary Care: Diagnosis and Treatment ,3and Treatment ,3rdrd Ed Ed Philadelphia, W.B. Saunders. 2005.Philadelphia, W.B. Saunders. 2005.Benson, Leon S. Benson, Leon S. Orthopedic PearlsOrthopedic Pearls, Philadelphia: F.A. Davis , Philadelphia: F.A. Davis Company. 1999Company. 1999Burbank,K M.D. Chronic Shoulder Pain: Evaluation and Burbank,K M.D. Chronic Shoulder Pain: Evaluation and Diagnosis Part1Diagnosis Part1 American Academy of Family PhysicianAmerican Academy of Family Physician FebruaryFebruaryDiagnosis. Part1. Diagnosis. Part1. American Academy of Family PhysicianAmerican Academy of Family Physician. February . February 15,200815,2008. Vol.77.No 4.. Vol.77.No 4.Burbank,K M.D. Chronic Shoulder Pain: Treatment. Part2. Burbank,K M.D. Chronic Shoulder Pain: Treatment. Part2. American Academy of Family Physician.American Academy of Family Physician. February 15,2008February 15,2008. Vol.77.No . Vol.77.No 4.4.Chumley, E., O’Connor, F, Nirshel, R, Chumley, E., O’Connor, F, Nirshel, R, Evaluation of Overuse Evaluation of Overuse Elbow Injuries,Elbow Injuries, American Family Physician, Vol61.No3. American Family Physician, Vol61.No3. Feb.2000. . Feb.2000. .
4/18/2009
31
BibliographyBibliography
Karnath, Bernard M.D., Karnath, Bernard M.D., Common Musculoskeletal Problems of the Upper Common Musculoskeletal Problems of the Upper Extremity,Extremity, Hospital Physician, January 2003.Hospital Physician, January 2003.McDevitt, L McDevitt, L Expert Exam: Cervical, Thoracic and Lumbar Spine, Expert Exam: Cervical, Thoracic and Lumbar Spine, No. No. Andover, MA: Fitzgerald Health Education Associates, Inc. 2006.Andover, MA: Fitzgerald Health Education Associates, Inc. 2006.McDevitt, L McDevitt, L Expert Exam: Practical OrthopedicsExpert Exam: Practical Orthopedics--Shoulder,Shoulder, No. Andover, No. Andover, MA. Fitzgerald Health Education Associates, Inc. 2002.MA. Fitzgerald Health Education Associates, Inc. 2002.Mercier LonnieMercier Lonnie Practical Orthopedics 5Practical Orthopedics 5thth EdEd St Louis Mosby Year BookSt Louis Mosby Year BookMercier, Lonnie Mercier, Lonnie Practical Orthopedics,5Practical Orthopedics,5 Ed.Ed. St Louis, Mosby Year Book. St Louis, Mosby Year Book. 20002000Rouzier, Pierre Rouzier, Pierre The Sports Medicine Patient AdvisorThe Sports Medicine Patient Advisor. Amherst, MA. Sports . Amherst, MA. Sports Med Press.1999.Med Press.1999.Woodward, T, & Best, T. Woodward, T, & Best, T. The Painful Shoulder Part 1 Clinical Evaluation,The Painful Shoulder Part 1 Clinical Evaluation,American Family PhysicianVOl61/No10, May 15, 2000.American Family PhysicianVOl61/No10, May 15, 2000.