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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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. .

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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.