Conditions of the Shoulder, Elbow, Wrist and Hand

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Conditions of the Shoulder, Elbow, Wrist and Hand

• HHP 495

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• Movement of scapula relative to the humerus
• Initial 30 degrees of glenohumeral abduction does
  not incorporate scapular motion (setting phase)
  
• 30 to 90 degrees the scapula abducts and upwardly
  rotates 1 degree for every 2 degrees of humeral
  elevation
  
• Above 90 degrees the scapula and humerus move in
  11 ratio
  

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• Etiology
• Rupture of extensor tendon dorsal to the middle
  phalanxForces DIP joint into extension and PIP
  into flexion
  
• Signs and Symptoms
• Severe pain, obvious deformity and inability to
  extend DIP joint
  
• Swelling, point tenderness

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• Etiology
• Fall on outstretched arm, fall on tip of shoulder
  or direct impact
  
• Occur primarily in middle third (greenstick
  fracture often occurs in young athletes)
  
• Signs and Symptoms
• Generally presents w/ supporting of arm, head
  tilted towards injured side w/ chin turned away
  
• Palpation reveals pain, swelling, deformity and
  point tenderness
  

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• Etiology
• Superficial location makes it extremely
  susceptible to injury (acute or chronic) --direct
  blow
  
• Signs and Symptoms
• Pain, swelling, and point tenderness
• Swelling will appear almost spontaneously and
  w/out usual pain and heat

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• Etiology
• These fractures can occur as a result of a direct
  blow, or fall on outstretched arm
  
• Proximal fractures occur due to direct blow,
  dislocation, fall on outstretched arm
  
• May pose danger to nerve and blood supply
• Epiphyseal fractures are more common in young
  athletes - occur due to direct blow or indirect
  blow travelling along long axis of this bone
  
• Signs and Symptoms
• Pain, swelling, point tenderness, decreased ROM

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• Etiology
• Impairment of blood supply to anterior surface
  resulting in degeneration of articular cartilage,
  creating loose bodies
  
• Repetitive microtrauma in movements of elbow
  rotation, extension, valgus stress causing
  compression of the radial head ad shearing of the
  radiocapitular joint
• Seen in young athletes involved in throwing
  motion
  
• Panners disease in incidents of children age
  
  
• Signs and Symptoms
• Sudden pain, locking range usually returns in a
  few days
  
• Swelling, pain at radiohumeral joint, creptitus,
  decreased ROM (full extension) grating w/
  pronation and supination
  
• X-ray may show flattening and crater of capitulum
  w/ loose bodies
  

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• Etiology
• Rupture of flexor digitorum profundus tendon from
  insertion on distal phalanx
  
• Often occurs w/ ring finger when athlete tries to
  grab a jersey
  
• Signs and Symptoms
• DIP can not be flexed, finger remains extended
• Pain and point tenderness over distal phalanx

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• Etiology
• Indirect force, blunt trauma (may cause
  displacement)
  
• Signs and Symptoms
• Grade 1 - pain and slight disability
• Grade 2 - pain, subluxation w/ deformity,
  swelling and point tenderness and decreased ROM
  
• Grade 3 - gross deformity (dislocation), pain,
  swelling, decreased ROM
  
• Possibly life-threatening if dislocates
  posteriorly

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• Etiology
• MOI is excessive resistive motion (falling on
  outstretched arm), repeated microtears that cause
  chronic injury
  
• Rupture of distal biceps is most common muscle
  rupture of the upper extremity
  
• Signs and Symptoms
• Active or resistive motion produces pain point
  tenderness in muscle, tendon, or lower part of
  muscle belly
  

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• Etiology
• Result of direct blow (from any direction),
  upward force from humerus,
  
• Can be graded from 1-6 depending on severity
• Signs and Symptoms
• Grade 1 - point tenderness and pain w/ movement
  no disruption of joint
  
• Grade 2 - tear or rupture of one ligament,
  partial displacement of lateral end of clavicle
  pain, point tenderness and decreased ROM
  (abduction/adduction)
• Grade 3 - Rupture of two ligaments
• Grade 4 - posterior dislocation of clavicle
• Grade 5 - loss of both ligaments tearing of
  deltoid and trapezius attachments gross
  deformity, severe pain, decreased ROM
  
• Grade 6 - displacement of clavicle behind the
  coracobrachialis

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• Etiology
• Compression of median nerve due to inflammation
  of tendons and sheaths of this area
  
• Result of repeated wrist flexion or direct trauma
  to anterior aspect of wrist
  
• Signs and Symptoms
• Sensory and motor deficits (tingling, numbness
  and paresthesia) weakness in thumb

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• Etiology
• Forced abduction and/or external rotation or a
  direct blow
  
• Signs and Symptoms
• Pain during movement especially when re-creating
  MOI
  
• Decreased ROM and pain w/ palpation

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• Etiology
• Stenosing tenosynovitis in thumb (extensor
  pollicis brevis and abductor pollicis longus
  
• Constant wrist movement can be a source of
  irritation
  
• Signs and Symptoms
• Aching pain, which may radiate into hand or
  forearm
  
• Positive Finklesteins test
• Point tenderness and weakness during thumb
  extension and abduction painful catching and
  snapping

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• Etiology
• Repeated forceful flexion of wrist and extreme
  valgus torque of elbow
  
• Signs and Symptoms
• Pain produced w/ forceful flexion or extension
• Point tenderness and mild swelling
• Passive movement of wrist seldom elicits pain,
  but active movement does

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• Etiology
• Sprain of UCL of MCP joint of the thumb
• Mechanism is forceful abduction of proximal
  phalanx occasionally combined w/ hyperextension
  
• Signs and Symptoms
• Pain over UCL in addition to weak and painful
  pinch

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• Etiology
• Subluxation involves excessive translation of
  humeral head w/out complete separation from
  joint
  
• Anterior dislocation is the result of an anterior
  force on the shoulder, forced abduction and
  external rotation
  
• Posterior dislocation occurs due to forced
  adduction and internal rotation or falling on an
  extended and internally rotated shoulder
  
• Signs and Symptoms
• Anterior dislocation - flattened deltoid,
  prominent humeral head in axilla arm carried in
  slight abduction and external rotation moderate
  pain and disability
• Posterior dislocation - severe pain and
  disability arm carried in adduction and internal
  rotation prominent acromion and coracoid
  process limited external rotation and elevation

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• Complications often associated with GH
  instability
  
• 1
• Inferior GH ligament is avulsed from the labrum,
  with or without a piece of the labrum
  
• 2
• Finding associated with an anterior GH
  dislocaton
  
• A small defect in the humeral heads articular
  cartilage caused by the impact of the head into
  the glenoid fossa
  
• May lead to degenerative problems

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• Etiology
• Pronounced cubital valgus may cause deep friction
  problem
  
• Ulnar nerve dislocation
• Traction injury from valgus force, irregularities
  w/ tunnel, subluxation of ulnar nerve due to lax
  impingement, or progressive compression of
  ligament on the nerve
• Signs and Symptoms
• Pain medially which may be referred proximally or
  distally
  
• Tenderness in cubital tunnel on palpation and
  hyperflexion
  
• Intermittent paresthesia in 4th and 5th fingers

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• Etiology
• Nodules develop in palmer aponeurosis, limiting
  finger extension - ultimately causing flexion
  deformity
  
• Signs and Symptoms
• Often develops in 4th or 5th finger (flexion
  deformity

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• Etiology
• Chronic inflammatory condition due to trauma or
  overuse
  
• Fibrosis, fluid build-up resulting in constant
  inflammation
  
• Signs and Symptoms
• Pain w/ motion and tenderness during palpation in
  subacromial space positive impingement tests

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• Etiology
• Forceful hyperextension or fall on outstretched
  hand
  
• Signs and Symptoms
• Pain, swelling, and difficulty executing wrist
  and finger flexion
  
• Numbness/paralysis of flexor muscles due to
  pressure on median nerve

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• Etiology
• Injured as the result of a valgus force from
  repetitive trauma
  
• Can also result in ulnar nerve inflammation, or
  wrist flexor tendinitis overuse flexor/pronator
  strain, ligamentous sprains elbow flexion
  contractures or increased instability
• Signs and Symptoms
• Pain along medial aspect of elbow tenderness
  over Medial Ligament
  
• Associated paresthesia, positive Tinels sign
• Pain w/ valgus stress test at 20 degrees
  possible end-point laxity
  
• X-ray may show hypertrophy of humeral condyle,
  posteromedial aspect of olecranon, marginal
  osteophytes calcification w/in MCL loose bodies
  in posterior compartment

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• Etiology
• Fall on flexed elbow or from a direct blow
• Can occur in any one or more of the bones
• Fall on outstretched hand often injures the
  humerus above condyles or between condyles
  
• Condylar fracture may result in gunstock
  deformity
  
• Direct blow to ulna or radius may cause radial
  head fracture as well
  
• Signs and Symptoms
• May not result in visual deformity
• Hemorrhaging, swelling, muscle spasm

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• Etiology
• Distal tear of volar plate may cause injury 1
  proximal tear may cause injury 2
  
• Signs and Symptoms
• Pain, swelling w/ varying degrees of
  hyperextension
  
• Tenderness over volar plate of PIP
• Indication of volar plate tear passive
  hyperextension
  

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• Etiology
• Occurs in lower end of radius or ulna
• MOI is fall on outstretched hand, forcing radius
  and ulna into hyperextension
  
• Signs and Symptoms
• Forward displacement of radius causing visible
  deformity (silver fork deformity)
  
• When no deformity is present, injury can be
  passed off as bad sprain
  
• Extensive bleeding and swelling
• Tendons may be torn/avulsed and there may be
  median nerve damage
  

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• Etiology
• Repetitive overhead athlete - ballistic activity
  that involves repeated stretching of biceps
  tendon causing irritation to the tendon and
  sheath
• Signs and Symptoms
• Tenderness over bicipital groove, swelling,
  crepitus due to inflammation
  
• Pain when performing overhead activities

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• Etiology
• Caused by twisting or shearing force
• Signs and Symptoms
• Pain, swelling and stiffness at MCP joint
• Proximal phalanx is angulated at 60-90 degrees

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• Etiology
• Caused by force on outstretched hand, compressing
  this area between radius and second row of carpal
  bones
  
• Often fails to heal due to poor blood supply
• Signs and Symptoms
• Swelling, severe pain in anatomical snuff box
• Presents like wrist sprain
• Pain w/ radial flexion

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• Etiology
• Repetitive microtrauma to insertion of extensor
  muscles of lateral epicondyle
  
• Signs and Symptoms
• Aching pain in region of lateral epicondyle after
  activity
  
• Pain worsens and weakness in wrist and hand
  develop
  
• Elbow has decreased ROM pain w/ resistive wrist
  extension
  

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• Etiology
• Direct axial force or compressive force
• Fractures of the 5th metacarpal are associated w/
  boxing or martial arts (boxers fracture)
  
• Signs and Symptoms
• Pain and swelling possible angular or rotational
  deformity

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• Slow onset of symptoms
• C/O deep pain within shoulder after activity,
  then progress to always
  
• Factors poor muscle balance between IR/ER,
  capsular laxity, scapular dyskinesis, impingement
  in subacromial space
  
• Supraspinatus is most common site, especially
  near its insertion

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• Etiology
• Blunt trauma or stretch type injury
• Signs and Symptoms
• Constant pain, muscle weakness and paralysis or
  atrophy

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• Etiology
• High incidence in sports caused by fall on
  outstretched hand w/ elbow extended or severe
  twist while flexed
  
• Bones can be displaced backward, forward, or
  laterally
  
• Distinguishable from fracture because lateral and
  medial epicondyles are normally aligned w/ shaft
  of humerus
  
• Signs and Symptoms
• Swelling, severe pain, disability
• Complications w/ median and radial nerves and
  blood vessels
  
• Often a radial head fracture is involved

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• Most common congenitial deformity of the shoulder
  characterized by an underdeveloped scapula
  
• Scapular muscles will be poorly developed
• Can be found both unilateral and bilaterally
• ROM is often effected, with decreased strength

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• This condition can occur due to a serious injury
  to the elbow where the may be compression to a
  blood vessel
  
• Signs and Symptoms
• Pain, Palor, Loss of Pulse, Paresthesia,
  Paralysis
  
• Flexure contracture of the wrist and fingers

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• Pathological Hand and Finger Postures
• 1
• Inhibition of the medial nerve results in atrophy
  of the muscles within the thenar eminence. The
  extensor muscles draw the thumb parallel with the
  fingers and the patients ability to flex or
  oppose the thumb is lost.

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• 2
• Inhibition of the ulnar nerve results in atrophy
  of the hypothenar, interossei, and the medial two
  lumbrical muscles. The finger assumes a posture
  of flexion in the PIP and DIP joints that is more
  pronounced in the 4th and 5th fingers.

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• 3
• Extension of the MCP and flexion of the PIP and
  DIP joints as the result of pathology of the
  ulnar and median nerves

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• Etiology
• Occurs at carpometacarpal joint of the thumb as a
  result of an axial and abduction force to the
  thumb
  
• Signs and Symptoms
• CMC may appeared to be deformed - X-ray will
  indicate fracture
  
• Athlete will complain of pain and swelling over
  the base of the thumb

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• Etiology
• Caused by a blow that contacts tip of finger
  avulsing extensor tendon from insertion
  
• Signs and Symptoms
• Pain at DIP X-ray shows avulsed bone on dorsal
  proximal distal phalanx
  
• Unable to extend distal end of finger (carrying
  at 30 degree angle)
  
• Point tenderness at sight of injury

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Informational

• Fingernail Deformities
• Changes in normal appearance of the fingernail
  can be indicative of a number of different
  diseases
  
• Scaling or ridging psoriasis
• Ridging and poor development hyperthyroidism
• Clubbing and cyanosis congenital heart
  disorders or chronic respiratory disease
  
• Spooning or depression chronic alcoholism or
  vitamin deficiency