Disorders of upper limb

Disorders of upper limb

SHOULDER DISORDERS

Clavicle

Scapula

Humerus

Articulations:

Sternoclavicular joint

Acromioclavicular joint

Glenohumeral joint

Shoulder Anatomy

Ligaments

AcromioClavicular

Glenohumeral lig/joint capsule

Labrum

Shoulder Anatomy

MusculatureRotator cuff

Subscapularis

Supraspinatus

Infraspinatus

Teres Minor

Pectoralis major

Deltoid

Trapezius

Shoulder Anatomy

Subacromial Bursa

Shoulder Anatomy

It is a chronic painful condition of the shoulder joint, characterized by pain and uniform limitation of all movements , with a tendency to slow spontaneous recovery.

Frozen shoulder (adhesive capsulitis; chronic Subacromial bursitis)Frozen shoulder

Symptoms of primary frozen shoulder have been divided into 3 phases:Painful phase (there is a gradual onset of diffuse shoulder pain lasting from weeks to months. )

Stiffening phase (progressive loss of motion that may last up to 1 year. Most patients lose glenohumeral external rotation, internal rotation, and abduction during this phase. )

Thawing phase (gradual motion improvement). This phase may take up to 9 months for the motion improvement for the patient to regain a functional ROM.

It is clinical conditions, including:Subacromial bursitis

Calcifying tendinitis

Partial rotator cuff tears.

Adhesive capsulitis (frozen shoulder syndrome ;FSS)Progressive painful restriction of shoulder movement

Joint capsule adheres to humeral head

Diabetics & cardiac patients

It is a clinical syndrome characterized by pain in the shoulder and upper arm during abduction.

Supraspinatus tendinitis:

SUBACROMIAL BURSITIS

ELBOW DISORDERS

Anatomy Elbow
Humerus:
Trochlea
Capitulum
Coronoid Fossa
Medial & Lateral Epicondyle

Radius:
Radial head
Radial neck
Radial tuberosity
Radial Fossa

Ulna:
Coronoid Process
Olecranon Process
Ulna Tuberosity

ELBOW DISORDERS Carrying angle: The normal elbow, when fully extended, is in apposition of 10-15 degrees of valgus.

The Carrying Angle

- 15 degrees in the newborn- 17.8 degrees in adults

Cubitus varus: The carrying angle is decreased or reversed;

Cause: malunited SCFH.

ELBOW DISORDERS Cubitus valgus: Angle is increased, so that the forearm is abducted excessively in relation to the upper arm;

Cause:M.U fracture lateral condyle of the humerus.

Cubitus valgusCarrying angle:The normal elbow, when fully extended, is in apposition of 10-15 degrees of valgus

Cubitus valgus: Carrying angle is increased, so that the forearm is abducted excessively in relation to the upper arm;

Cause:M.U fracture lateral condyle of the humerus.

A deformity of the elbow in which the forearm deviates toward the midline of the body when extended.

Varus means a deformity of a limb in which part of it is deviated towards the midline of the body) is a common deformity in which the extended forearm is deviated towards midline of the body

Causes : Malunited SCFH (with medial displacement, internal rotation, and extension of the distal fragment; this then permits distal fragment to tilt into varus;)

It can be corrected via a corrective osteotomy of the humerus and either internal or external fixation of the bone until union.

A cubitus varus deformity is more cosmetic than limiting of any function .

Cubitus varus Gunstock deformity

Cubitus valgus deformity of the elbow in which it deviates away from the midline of the body when extended

cubitus varus deformity of the elbow in which it deviates toward the midline of the body when extended

It is an overuse injury involving the extensor/supinator muscles that originate on the lateral epicondylar region of the distal humerus.

It is an extra-articular affection characterized by pain and acute tenderness at the region of the extensor muscles of the forearm.

Tennis Elbow(Lateral Epicondylitis)

Conservative:

Rest, use of a counterforce brace &NSAIDs.

Local corticosteroid injections.

Physiotherapy.

Extracorporeal shock wave therapy

Surgical :debridement of the diseased tissue of the ECRB muscle with decortication of the lateral epicondyle.

Treatment

Surgical Treatment

Very obvious bubble

Caused by landing right on olecranon process

Care: ice, pad & wrap

Be cautious that there isnt a chip fracture

Olecranon bursitis

Forearm, Wrist & Hand Disorders

Wrist & Hand

Bones of the Wrist Joint (Carpals)
Eight bones of the carpus, which occur in two rows (proximal and distal).

The proximal row, consists of scaphoid, lunate, triquetrum and pisiform, and the first three of these articulate with the distal ends of the radius or ulna.

The distal row, made up of the trapezium, trapezoid, capitate and hamate, articulates with the bases of the metacarpal bones.

Bones of the Hands
Metacarpals and Phalanges

An avascular necrosis of the lunate bone due to impairment of its blood supply.

Softening, fragmentation& deformation of the lunate .

It may give rise to osteoarthritis of the wrist joint.

Kienbcks Disease

Tenovaginitis of the abductor pollicis longus & extensor pollicis brevis.

Local tenderness at the styloid process of the radius.

Conservative TTT.

Release of the sheaths of the 2 tendons.

De Quervains Disease

Finkelstein

Women >Men

Age : 55-60 years .

The most commonly affected digit is the thumb, followed by the ring, long, little, and index fingers.

More frequent in patients with rheumatoid arthritis or diabetes mellitus

Trigger FingerStenosing tendovaginitis of flexor tendons

snapping or jerking movements

Locking or catching during active flexion-extension activity; may need passive manipulation to extend the digit in later stages

Stiff digit, especially in long-standing or neglected cases

Pain over the distal palm

Pain radiating along the digit

Clinical PictureTriggering on active or passive extension by the patient

Palpable snapping sensation or crepitus over the A1 pulley

Tenderness over the A1 pulley

Palpable nodule in the line of the FDS, just distal to the MCP joint in the palm

Fixed-flexion deformity in late presentations, especially the PIP joint

Evidence of associated conditions (eg, RA, gout)

Early signs of triggering in other digits (may be bilateral)

SignsSymptoms

Local steroid injection into the tendon sheath

Treatment

Incision marked out in the distal palmar crease for surgical division of the A1 pulley. A1 pulley is sectioned using blunt-tipped fine scissors, keeping strictly in the midline. Note the digit being held hyperextended by an assistant to displace the neurovascular bundles away from the midline. Surgical treatment of trigger finger

Surgical treatment of trigger thumb

It is the commonest cystic swelling at the back of the wrist.

The swelling is soft and cystic, but it may be tense.

Asymptomatic or minimally symptomatic.

Symptoms such as limitation of motion, pain, paresthesias, and weakness.

Ganglion

Transillumination

Mucoid degeneration of collagen and connective tissues.

Trauma or tissue irritation. Modified synovial cells lining the synovial-capsular interface are stimulated to produce mucin. Mucin dissects along the attached joint ligament and capsule to form capsular ducts, which function as valvelike structures producing lakes. The ducts and lakes of mucin eventually coalesce to form a solitary ganglion cyst (Angelides ,1999).

Etiology

Ganglion cysts may be single or multilobulated.

They are smooth-walled, translucent, and white.

Their contents are characterized as clear and highly viscous mucin that consists of hyaluronic acid, albumin, globulin, and glucosamine.

The cyst wall is made up of collagen fibers.

Multilobulated cysts may communicate through a network of ducts.

No necrosis or epithelial or synovial cellularity of the wall occurs.

Pathophysiology

Aspiration & local steroid injection

Excision.

Treatment

It gives firm cord-like bands that extend into the ring and little finger, or both .

Skin is closely adherent to the fascical bands and is often puckered.

Excision of taut contracted bands.

Dupuytrens contracture

Contracture of palmar aponeurosis (palmar fascia) .

Syndactyly:Polydactyly

Syndactyly: webbing of two or more digitsPolydactyly: More than 5 digits.

Macrodactyly

Compression Neuropathy

CT is a fibro-osseous tunnel at the wrist formed by a semi-circle of carpal bones on three sides. The 4th side that forms the carpal tunnel is the TCL.

TCL cannot stretch. Thus the CT is a defined space that cannot enlarge.

Contents of CT: Median N.+ 9 flexor tendons (FPL; 4 FDP; 4 FDS ).

Median N. lying superficially and anteroradially in the tunnel.

Anatomy of CTCarpal tunnel syndrome

The floor is formed by the carpal bones which are concave in its flexor surface. This bony gutter is converted into a tunnel by the flexor retinacular on the volar aspect. The median nerve and the long flexor tendons namely flexor pollicis longus, flexor digitorum profundus, and flexor digitorum superficialis together with their synovial sheaths pass through this tunnel to the digits. Carpal Tunnel Syndrome

Flexor tenosynovitis.

Fractures and dislocations of the floor of the canal and distal radius.

Space-occupying lesions (tumors and ganglia ) volume of the contents of the noncompliant carpal tunnel pressure on its contents, which include the median N.

Idiopathic: nonspecific synovitis, .

ETIOLOGY

Compression of the median nerve within the carpal tunnel

Both hands or the dominant hand

Pain & Numbness in the Distribution of the median nerves may occur intermittently during the daytime and/or at night and awaken one from sleep.

Patient thinks the hands have "poor circulation" and shake the hands in an attempt to "restore circulation".

Treatment:

NSAIDs; wrist splint, local injectionm.

Decompression of the median nerve.

Carpal tunnel syndrome

Tinels Phalens

A: A flattened thenar eminence indicates atrophy of the abductor pollicis brevis.B: Abductor pollicis brevis AB

Carpal tunnel syndrome

Nerve conduction studies show reduce nerve conduction velocities across wrist

CTSManagement

Avoidance of precipitating activity

Night time splints

Local steroid injection

Surgery division of flexor retinaculum and decompression of carpal tunnel (80% success)

Approach to the carpal tunnel. The more proximal porton (dashed and dotted lines) is used when a more extensive exposure is required. Open Carpal Tunnel Release (OCTR)

Endoscopic Carpal Tunnel Release (ECTR)

Compression of the ulnar nerve in a groove behind the medial epicondyle of the humerus.

Cl.P: numbness or tingling in distribution of the ulnar N.

Clumsiness to do fine finger movements

Cubital tunnel syndrome

Cubital Tunnel Syndrome syndrome is the most common pathological entrapment of the ulnar nerve. Causes: It may be caused by: Constricting fascial bands,

Hypertrophied synovium

A tumor, a ganglion etc.

Bony abnormalities like cubitus valgus as a result of previous fracture around the elbow or bony spur may also cause ulnar neuropathy.

Subluxation of the ulnar nerve over the medial epicondyle with elbow flexion will also result in frictional injury to the nerve.

Cubital Tunnel Syndrome

Guyon's Canal Syndrome is numbness and tingling in the ring and small fingers caused by irritation of the ulnar nerve in the Guyon's canal.

Symptoms begin with a feeling of pins and needles in ring and little finger.

This is followed by decreased sensation and eventually weakness and clumsiness in the hand as the small muscles of the hand are involved.

Guyons Canal Compression

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Health & Medicine

Disorders of upper limb