The Upper Limb - in context

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The Upper Limb - in context

• Anne
• Cx Spondylosis
• RA Hands
• Andy
• PMR
• DeQuervans
• David
• Rotator Cuff problems
• Cubital Tunnel
• Joyce
• Tennis Elbow
• OA hands
• Malcolm
• Carpal Tunnel Syndrome
• Frozen Shoulder

http//www.arthritisresearchuk.org - you could
start here!
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The Upper Limb - in context

• Bring laptops / other IT equipment to prepare a
  2-3 slide thumbnail about the condition
• Features in Diagnosis
• Possible helpful tests and 
• Management options

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Objectives

• Upper limb disorders are common in general
  practice 3rd most common M/Sk presentation and
  shoulder pain alone accounts of 5 of all GP
  encounters....
• By the end of this session we hope you will be
  able
• To approach upper limb disorder diagnosis with
  more confidence
• To examine the upper limb with greater competence
  and efficiency
• To be able to recommend evidence-based sensible
  options for up to date management
• To work together as a team to produce
  well-focused presentations

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Afternoon programme

• 220 work in groups prepare 2 x short power
  points on the 2 conditions per cluster
  respectively
• 250 work in groups of 4 on cases until tea.
  Hand in diagnosis as soon as group certain.
• Diagnosis correct no extra prompts 10 points
• Diagnosis correct 1 extra prompt
  8 points
• Diagnosis correct 2 extra prompts 5 points
• Diagnosis correct - 3 extra promts
  3 points
• 320 tea
• 340 Presentations broken up by use of DVD and
  final cases
• 450 Big Prize for highest-scoring group and
  round up
• 500 - End

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Case 1

• Mr Desai is 56 is a non-smoker and a type 2
  diabetic. He has been a rare visitor at the
  surgery over the years until 10 months ago when
  he had an MI. He had successful stenting and is
  on the usual medications and has done cardiac
  rehab well, now doing regular exercise himself. A
  month ago he began to complain of pain in his
  right shoulder which you have examined and now
  his left is causing him the same pain. He cant
  recollect any trauma. The pain is in the deltoid
  area, prevents him reaching up, reaching forward
  and is keeping him awake.

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Additional info, case 1

• The onset was insidious
• He has pain and significant, solid limitation on
  external rotation of the gleno-humeral joint,
  both actively and passively.
• X rays of the shoulder are normal

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Shoulder pain
Shoulder pain is the third most common reason
for musculoskeletal consultation in general
practice, after back and neck pain. Adults
present to primary care with shoulder pain with a
prevalence of 2.36 and incidence of 1.47
Shoulder pain accounts for 5 of all GP
encounters. In a study of adults consulting for
shoulder pain in a UK primary care setting a,
peaking at 50 years and showing a linear increase
with age. Self-reported prevalence of shoulder
pain is between 16 and 26 with a lifetime
prevalence of over 30 in adults.
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Adhesive capsulitis

• Prevalence of about 3 in the adult population.
  10- 35 diabetics
• Usually sixth decade of life, and onset before
  the age of 40 is very uncommon. The peak age is
  56, and the condition occurs slightly more often
  in women than men
• 39 full recovery, 54 clinical limitation
  without functional disability, and 7 functional
  limitation
• Three phases of clinical presentation
• Painful freezing phase
• Duration 10-36 weeks. Pain and stiffness around
  the shoulder with no history of injury. A nagging
  constant pain is worse at night, with little
  response to non-steroidal anti-inflammatory drugs
  
• Adhesive phase
• Occurs at 4-12 months. The pain gradually
  subsides but stiffness remains. Pain is apparent
  only at the extremes of movement. Gross reduction
  of glenohumeral movements, with near total
  obliteration of external rotation
• Resolution phase
• Takes 12-42 months. Follows the adhesive phase
  with spontaneous improvement in the range of
  movement. Mean duration from onset of frozen
  shoulder to the greatest resolution is over 30
  months

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Adhesive capsulitis

• Summary points
• True frozen shoulder is a clinical diagnosis
• The three hallmarks of frozen shoulder are
  insidious shoulder stiffness severe pain, even
  at night and near complete loss of passive and
  active external rotation of the shoulder
• Lab tests are normal
• Frozen shoulder is rare under the age of 40 the
  peak age is 56
• Frozen shoulder progresses through three clinical
  phases
• It lasts about 30 months, but recovery can be
  accelerated by simple measures
• Physiotherapy alone is of little benefit,
  although steroid injection is effective and best
  combined with physiotherapy
• Refractory cases can be referred for manipulation
  under anaesthesia and, rarely, arthroscopic
  release
• Nearly all patients recover, but normal range of
  movement may never return

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Rotator cuff problems

• Mechanical impingement is the most common
  recognisable source of recurring rotator cuff
  pain and disability in the active population
• Tearing of the rotator cuff as a function of
  age is a common occurrence, and may be clinically
  silent
• Often, the diagnosis can be made by history and
  clinical examination alone

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Rotator cuff problems
USS/ MRI scans for those anticipating shoulder
surgery can be helpful in evaluating tears and
muscle atrophy and in establishing the presence
of co-morbidities

• Most patients with symptomatic rotator cuff
  disease respond to non-operative treatment
• Early surgical management should be considered
  for acute rotator cuff tears in physiologically
  young and active individuals

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• Subacromial impingement is defined as shoulder
  pain resulting from the catching of the rotator
  cuff under the coracoacromial arch of the
  shoulder. Repeated impingement can lead to a tear
  in the tendon of rotator cuff muscles which can
  be either partial (partial-thickness tear) or
  complete (full-thickness tear).
• Sensitivity and specificity of various diagnostic
  modalities in establishing a diagnosis of
• rotator cuff disorders.
• Sensitivity () Specificity
  ()
• Clinical examination 90 50
• Ultrasound 85 92
• Magnetic resonance 86 90
• imaging
• Magnetic resonance 92 97
• arthrography

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Case 2

• Ellen Bridges, aged 74, comes in to see you with
  her son, who is concerned about her. She has been
  getting a lot of aching all over recently,
  especially in her shoulders. She has been feeling
  low in energy, and her appetite has not been as
  good as usual. She has not lost any weight. She
  has started to ask her son to walk her little
  dog, as she is finding it too much now. She lives
  alone, but is struggling to do her own washing
  and shopping over the last few weeks.

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• PMH OA knees 2002
• Hypothyroidism 2000
• Widowed 2008
• DH Co-codamol 2 qds
• Levothyroxine 100mcg daily
• SH lives alone
• son lives 10 minutes away by car

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Extra information, case 2

• Full range of movement, but pain on shoulder
  abduction
• On exam tender over upper arms on squeezing,
  but no weakness or atrophy of muscles
• ESR98, CRP86

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PMR

• Polymyalgia (poly many myalgia aching
  muscles) rheumatica (PMR) is an inflammatory
  rheumatic condition.
• It affects around 4 per 1000 people over the age
  of 50. The usual onset is after age 60. Symptoms
  can start abruptly, or they can come on over a
  week or two.
• Both men and women are equally affected but women
  slightly more than men. It's common in Caucasians
  and rare in Asians and Afro-Caribbeans.

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PMR

• predominantly occurs in patients over 60 years
  old. Incidence of PMR is approximately 20/100,000
  (more than 50/100,000 in patients over 50 years
  old) in the UK. The age-adjusted incidence of
  diagnosed PMR has increased by 35 between 1990
  and 2001 more common in females to males
  (31)more common in Caucasians, especially those
  of Scandinavian extraction association with
  HLA-DR4 association between malignancy and PMR

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Case 3

• Graham is 46 and has come to see you. You know
  him as a mountain bike enthusiast who has needed
  various trips to AE because of various fractures
  wrists and on one occasion his right elbow. He
  has begun to have problems with painful tingling
  in his right hand and arm when playing the guitar
  which can actually be quite painful on occasions.
  What has really pressured him was that he found
  he could not use the hand properly because it was
  a bit weak at the end of the last session. Now
  the pain disturbs him at night and goes all the
  way past the elbow.

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Additional Information, case 3

• Froments sign is positive
• There is no tenderness or reproduction of pain on
  pressure over the ulnar portion of the wrist or
  hypothenar eminence
• There is tenderness similar to golfers elbow but
  moreso between this and the olecranon

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Cubital Tunnel Syndrome

• Ulnar nerve palsy causes wasting and weakness of
  the small muscles of the hand and partial clawing
  of the ring and little finger.
• The extent of the deformity and disability
  depends on the site of the lesion.
• numbness and tingling along the little finger and
  ulnar half of the ring finger
• weakness of grip, and particularly when the
  patient rests on or flexes the elbow.
• pain and tenderness at the level of the cubital
  tunnel.
• The severity of pain is very variable and the
  distribution of pain may spread proximally and/or
  distally.
• Symptoms may be intermittent at first and then
  become more constant.
• Patients with chronic ulnar neuropathy may
  complain of loss of grip and pinch strength and
  loss of fine dexterity.
• Severe prolonged compression may present with
  intrinsic muscle wasting and clawing or abduction
  of the little finger.

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• Palpate the cubital tunnel region to exclude mass
  lesions.
• Tinel sign
• Tapping over the cubital tunnel causes pain,
  tingling or shock-like sensation down the arm
  into the fingers.
• A positive Tinel sign finding is typically
  present in cubital tunnel syndrome. However the
  Tinel sign may be positive in asymptomatic
  people.
• The elbow flexion test
• Is the most diagnostic test for cubital tunnel
  syndrome.
• The patient flexes the elbow past 90 degrees,
  supinating the forearm, and extending the wrist.
• Result is if discomfort is reproduced or
  paraesthesia occurs within 60 seconds.
• The addition of shoulder abduction may enhance
  the sensitivity of the test.
• Froment's sign
• The patient holds a piece of paper between the
  thumb and the side of the adjacent index finger
  as the paper is pulled away.
• A patient with an ulnar nerve palsy will flex the
  thumb at the interphalangeal joint to try to keep
  hold of the paper.

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• Guyon canal at the wrist. Causes of ulnar nerve
  lesions at the wrist include compression by
  tumour or ganglion, blunt trauma, fractures.
• Other causes of neurological dysfunction along
  the C8-T1 distribution.
• Syringomyelia, Pancoast tumour (apical lung
  cancer).
• Carpal tunnel syndrome.
• Polyneuropathy, e.g. diabetes, renal disease,
  multiple myeloma, amyloidosis, chronic
  alcoholism, malnutrition, leprosy.

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• Investigations
• e.g. fasting glucose for diabetes.
• Elbow x-rays evidence of arthritis, traumachest
  x-ray for Pancoast tumour, neck x-ray for
  evidence cervical spondylosis.
• Nerve conduction studies will confirm the site of
  the lesion.3
• Ultrasound of cubital tunnel there is a
  correlation between the stage of ulnar nerve
  palsy and the diameter of the major axis.4
• MRI scan is sensitive and specific for diagnosis
  of ulnar nerve lesions at the elbow.
• Management
• Physiotherapy, splinting, non-steroidal
  anti-inflammatory drugs, surgical transposition
  of the nerve, and surgical decompression for
  cubital tunnel syndrome. The treatment depends on
  the site and severity of the lesion
• Avoidance of aggravating factors such as full
  elbow flexion and pressure on the elbow may be
  sufficient in mild cases.
• Decompression of the nerve may be necessary in
  more severe cases.
• It may be necessary to transfer the nerve to the
  front of the medial epicondyle.
• Recovery may be slow and incomplete often the
  symptoms are temporarily exacerbated.

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Case 4

• Stella Jones is 75, and comes in to see you with
  pain in her hands. Several joints are affected
  and she has had to take her rings off. She is
  struggling to hold heavy things e.g. a kettle,
  and is struggling to use her computer keyboard.
• She has been suffering for 3 weeks, and has tried
  ibuprofen and paracetamol, which have helped a
  bit, but she is worried about it.

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Extra information, case 4

• On exam - Some swelling in hand joints and tender
  on squeezing
• Early morning stiffness, about 1 hour
• Rheumatoid factor positive ESR73, CRP52

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RA

• RA exists all over the world, although the more
  severe cases are found more often in Northern
  Europe. More than 350,000 people in Britain have
  rheumatoid arthritis. It can happen in people of
  any age, from children to those in their 90s, but
  the most common age for the disease to start is
  between 40 and 50. About three times as many
  women as men are affected. There is some evidence
  that lifestyle factors are associated with
  rheumatoid arthritis e.g. smoking, red meat etc

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Case 5

• Muhammed Saqib is 55 and comes in with a 4 weeks
  history of pain in his right elbow, which is
  relieved partially by rest, but aggravated by
  work. He works as a plasterer for a building
  firm. He has had to have the last 2 days off work
  as the job is making the pain unbearable. He has
  tried paracetamol, but it didnt seem to help
  much. He used to row for a rowing club, but gave
  up 10 years ago.

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Extra information, case 5

• Pain worse when wrist extended against resistance
• Tender over right lateral epicondyle
• ESR and CRP normal

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Tennis elbow

• Tennis elbow is caused by inflammation of the
  common extensor origin, at the lateral epicondyle
  of the humerus. There may also be concommittant
  rupture of aponeuritic fibres. It is a frequent
  cause of elbow pain.
• Tennis elbow is a common problem in primary care
  with an incidence of between four and seven per
  1,000 people per year.

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Case 6

• Whilst examining a 9 month old baby Liam with
  bronchiolitis his grandmother (Rose44 years) who
  has brought him asks you to take a quick look at
  her wrist. You know Rose as she has had some
  previous hip pain.
• Its become a problem over the last week or two
  with throbbing pain at the base of the thumb/
  that portion of the wrist. Picking up Liam is now
  agony as is gripping anything with that thumb
  she is dropping some things - with sometimes
  tingling around the base of the thumb too. It is
  painful to text on her mobile She has tried pain
  killers and even nurofen which only help a bit
  it is keeping her awake. She thinks there is
  now some wrist swelling as well which you too can
  immediately see on that aspect of the wrist.

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Additional Information case 6

• Finklesteins test is positive
• 1st metacarpal grind test is negative
• The radial styloid is swollen and tender.

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• The tendons of the abductor pollicis longus and
  the extensor pollicis brevis are tightly secured
  against the radial styloid by the overlying
  extensor retinaculum. Any thickening of the
  tendons from acute or repetitive trauma restrains
  gliding of the tendons through the sheath.
  Efforts at thumb motion, especially when combined
  with radial or ulnar deviation of the wrist,
  cause pain and perpetuate the inflammation and
  swelling.
• inflammation causes thickening stenosis of
  synovial sheath of first compartment pain w/
  tendon movement    - most common in women
  between 30 and 50 years    - pts develop pain
  over radial styloid process
• ( sometimes forearm thumb)

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• - swelling palpable thickening of fibrous
  sheath    - sharp tenderness over styloid
  process of radius    - Finkelstein's test   
         - pt makes fist over thumb, and ulnarly
  deviating wrist           - ulnar deviation
  stress is applied to index metacarpal         
   - positive test is indicated by exquisite pain
  in region of radial styloid this test may also be
  positive in pts w/ CMC DJD           - sharp
  pain at this site is also produced by active
  extension abduction of the thumb against
  resistance
• Diff Dx of Radial Wrist Pain    - DJD of CMC
  joint         - grind test will be negative in
  DeQuervain's but positive in DJD              
   - performed by forcefully pushing thumb against
  CMC joint, while also rotating it slightly, to
  cause a grinding motion         - typically,
  the pain will be located on volar side of the
  wrist    - Intersection Syndrome         -
  tendons of first compartment may cross over the
  tendons of the second compartment (ECRL/B), just
  proximal to the extensor retinaculum         -
  caused by irritation at the intersection of the
  outrigger muscles, ie. between (APL, EPB) and the
  (ECRL/ECRB), about 4 cm proximal to wrist
  joint           - resultant tenosynovitis
  occurs mainly in the second compartment, and
  steroid injections into this compartment relieve
  most symptoms    - Wartenberg's Syndrome     
     - isolated neuritis of the superficial radial
  nerve         - may have positive Tinel sign 
         - may be caused by tight jewelry