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Upper Limb Injuries

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Upper Limb Injuries 12/14/20 Upper limb Injuries www.belmatt.co.uk 1 Jeshni Amblum Images Pearsons Education Pearsons Amblum Images Jeshni By the end of the session student will: - Be able to identify anatomical structures of the upper limb - Develop skills in examination of elbow, wrist and hand Learning - Recognise functional importance - Recognise common pathology related to above Outcomes structures. - Be able to assess and manage minor injury presentations of the upper limb 2 Jeshni Amblum Images Pearsons Education Pearsons Amblum Images Jeshni History • Past history : Medical/ Surgical • OPQRSTU/ SOCRATES • Drug History • Social History • Other 3 1 12/14/20 Jeshni Amblum Images Pearsons Education Pearsons Amblum Images Jeshni History • Pain • Swelling • Stiffness • Deformity • Weakness • Instability • Neurovascular Changes • Loss of Function 4 Jeshni Amblum Images Pearsons Education Pearsons Amblum Images Jeshni Physical Examination • Compare limbs • Look • Feel • Move - Active - Passive - Resisted 5 6 2 12/14/20 7 Views of Elbow Jeshni Amblum Images Pearsons Education 8 Fat pad signs 9 3 12/14/20 Common fracture in FOOSH usually Radial adults head/neck Assure proper alignment of fractures Detection may head on require oblique capitellum view (radiocapitellar line) 10 Radial head fracture 11 State location and function of Trochlea structures below: Elbow Capitulum Olecranon fossa Joint Medial Lateral epicondyle epicondyle Jeshni Amblum Images Pearsons Education 12 4 12/14/20 Supination & Pronation Supination Pronation Jeshni Amblum Images Pearsons Education 13 Muscles - Elbow • Pronation • Pronator Teres • Pronator Quadratus • Brachioradialis 14 Anterior Aspect of Elbow 15 5 12/14/20 16 17 18 6 12/14/20 19 EXTENSORS FLEXORS 20 Case Study A 32 year old woman who was learning to play tennis practised daily for about 2weeks. She reported to her coach that she felt pain over the lateral region of her elbow that radiated down her forearm Familiar with this complaint in beginners he asked her to hold the tennis racket and extend her hand at the wrist. She felt no pain until he resisted extension of her hand. She pinpointed the area of most pain over her lateral epicondyle. Pressure on this area made pain worse. Intense pain was also felt when the coach compressed the common extensor tendon. 21 7 12/14/20 Lateral Epicondylitis • Tennis elbow 22 Lateral Epicondylitis Golfers or tennis elbow Repetitive use of superficial extensor muscles of forearm. Pain over lateral epicondyle and radiates down posterior surface of forearm. Advise stop repetitive movement, rest and anti inflammatories. Later physio. Jeshni Amblum Images Pearsons Education 23 Nerve supply - Sensory q Sensory q Digital nerves: Each finger has two which run on the volar aspect of each digit laterally. Each supplies half of the finger. 24 8 12/14/20 • Median nerve: passes through the carpal tunnel. It supplies the thenar muscles of the Nerve thumb. Supply - • Ulna nerve: Passes through ulna side of wrist. It supplies all the interossei , 2-3 Motor lumbricals and hypothenar muscles . • Radial : No motor function in hand 25 Case Study • A 12 year old boy fell off his skateboard hitting his right elbow on the sidewalk. Because he was suffering considerable elbow pain and numbness on the right side of his hand his mother brought him to hospital. He tells you he fell on his funny bone and right away his little finger began to tingle. • Exam : The boy shows no response to pinpricks of his little finger and the medial border of his palm. He is unable to grip a piece of paper placed between his fingers. • X-ray shows considerable displacement of the epiphyses of the medial condyle of the humerus and possible nerve stretching and compression are evident. 26 Jeshni Amblum Images Pearsons Education Pearsons Amblum Images Jeshni Questions • What nerve was probably injured? • • Explain the numbness of the boy’s fifth digit and his inability to hold a piece of paper between his fingers? • Drawing on knowledge of degeneration and regeneration of nerves make an attempt to forecast the probable degree of recovery of the boy’s motor and sensory functions that may occur. 27 9 12/14/20 Case Study • A 52 year old carpenter visits his general practitioner(GP) with severe ‘pins and needles’ sensations in his right hand which also involved the palmar surface of his thumb and lateral two and a half fingers. He told the GP that the pain was becoming progressively worse and often awakened him during the night. He also experienced difficulty using his hand tools and buttoning his shirt. • Exam - No objective impairment of sensation in the hand noted. However, slight weakness of the thenar muscles present. The GP told the patient he has a nerve entrapment syndrome. 28 Case Study • A depressed 15year old girl who had slashed her wrists with a razor blade attends the emergency department. The moderate bleeding from her left wrist was soon stopped with slight pressure. The small spurts of blood coming from lateral side of her right wrist were more difficult to stop. O/e - Left hand - movements normal and no loss of sensation. Right Hand - Two superficial tendons and a nerve were cut, she could adduct her thumb but could not oppose it and she had lost some fine control of movements of her 2nd and 3rd digits and she also experienced anaesthesia over the lateral half of her palm and digits. 29 Jeshni Amblum Images Pearsons Education Pearsons Amblum Images Jeshni Superficial Flexors Flexor Tendons Deep Flexors of Forearm Located in anterior compartment and supplied by median and ulna nerve 30 10 12/14/20 Olecranon Bursitis 31 Another view? 32 Jeshni Amblum Images Pearsons Education Pearsons Amblum Images Jeshni Fall on elbow with concentrated triceps contraction pulling elbow apart. Often avulsion fracture Fracture of the Look for posterior fat pad as Olecranon positive. Broad arm sling if undisplaced. Surgery if avulsion fracture because of traction of triceps muscle. 33 11 12/14/20 Dislocation of Elbow 34 Mechanism of injury • Fall on outstretched arm • Hyperextension • Severe twist with elbow in flexed position • Blow to posterior humerus with fixed radius/ulna 35 Signs & Symptoms • Ulna and/or radius displaced posteriorly, w/ olecranon process sitting posteriorly • Severe swelling/bleeding • Disability • LOM • Extreme pain 36 12 12/14/20 Wrist Anatomy • Bones • Quiz - What bones comprise the wrist? • Joints • Quiz - What joints comprise the wrist? 37 Jeshni Amblum Images Pearsons Education Pearsons Amblum Images Jeshni Anatomy of the wrist • Bones - Interosseus membrane - Distal radius - Distal ulna - Carpal bones • Arteries and Veins • Nerves • Muscles 38 Carpals Scaphoid (boat shaped) Lunate (moon shaped) Triquetrum (3 cornered) Pisiform (pea shaped) Trapezium Trapezoid Capitate (head shaped) Hamate (hooked) 39 13 12/14/20 Anatomical Snuffbox Extensor pollicis longus (medial side) Medial Abductor Extensor Lateral pollicis longus pollicis brevis (lateral side) (lateral side) 40 The Normal Wrist • AP and Lateral are the standard views • AP Radial Styloid should be more distal than Ulnar styloid • Lateral Radial articular surface should have 50 of palmar angulation • Distal radius, Lunate and Capitate should be in alignment 41 42 14 12/14/20 Wrist and Hand Anatomy • Nerves/Vessels –Radial & ulnar artery and veins – Radial, ulnar, & median nerves • Carpal Tunnel - – Flexor Tendons - 9 – Median Nerve 43 Wrist Injuries • Strains • Onset usually acute – FOOSH or Overexertion • S/S: Active ROM limited • Wrist Ganglion • Herniation of the joint capsule or synovial sheath of a tendon. 44 Wrist Injuries • deQuervain’s Disease - thumb/wrist • stenosing tenosynovitis of the extensor pollicis brevis and abductor pollicis longus. • S/S: crepitation, tenderness, strength loss. • Special Test: = Finkelstein’s test • Tx: RICE, NSAIDs 45 15 12/14/20 Carpal Tunnel Syndrome • Carpal Tunnel Syndrome • Compression of median nerve • Fibrosis of the synovium of flexor tendons secondary to tenosynovitis • MOI: Insidious onset with repetitive wrist movement (and finger movement); Acute onset with trauma; Progressive degeneration • S/S: numbness palmar thumb, index, middle fingers, dull ache, weak finger flexion (grip). May worsen with sleep. • Poor posture may predispose. • Special Tests: Tinel’s sign and Phalen’s • Tx: Conservative (PRICE, NSAIDs) and Surgical 46 Nerve Injuries • Biker’s Palsy • Ulnar nerve compression • Ulnar nerve passes through tunnel of Guyon between pisiform and hamate. • MOI: repetitive jarring or pressure, repetitive flx/ext/ulnar deviation • Tx: Padding (Gloves), Ice, NSAIDs • Drop Wrist Syndrome • Radial nerve compression at elbow • Inability to extend wrist and fingers 47 Wrist Injuries • Wrist Fractures • Distal Radius/Ulna and Forearm Fractures • Onset is acute • MOI: Hyperextension or hyperflexion combined with rotatory motion – FOOSH • S/S: Deformity felt and observed; Crepitus • Evaluated Neurovascular status • Tx: Splint, Ice, Referral 48 16 12/14/20 Wrist Injuries • Wrist Fractures • Distal Radius/Ulna • Colles’ Fracture • MOI: hyperextension-fall on outstretched • S/S: “silver forK deformity” - radius & ulna posteriorly • Smith’s Fracture (Reverse Colles) • MOI: hyperflexed • S/S: “garden spade deformity” - radius & ulna anteriorly 49 Wrist Injuries • Wrist Fractures • Scaphoid - most common carpal • MOI: fall on outstretched hand • S/S: wrist aches, pain in anatomical snuff box, • painful handshake or with overpressure • Tx: Splint, Referral, Ice • Plain X-rays may not be enough • Immobilization
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