NOTES NOTES UPPER LIMB INJURY GENERALLY, WHAT IS IT? PATHOLOGY & CAUSES ▪ Upper limb joint damage, dislocation ▪ Weakening/damaging of ligaments, tendons → distortion of normal anatomical joint structure, function loss/impairment MRI ▪ Damaged ligaments and soft tissue Ultrasound ▪ Soft tissue damage ▪ Tendon dislocations OTHER DIAGNOSTICS CAUSES ▪ Trauma, overuse SIGNS & SYMPTOMS ▪ Pain, swelling, numbness ▪ Reduced range of motion ▪ Visible/palpable malformations DIAGNOSIS DIAGNOSTIC IMAGING X-ray ▪ Dislocation ▪ Distorted articular spaces ▪ Fractures ▪ Physical examination ▫ Reduced range of motion ▫ Visible dislocation ▫ Swelling TREATMENT MEDICATIONS ▪ Pain management ▫ Sedation, analgesia SURGERY ▪ Joint reduction OTHER INTERVENTIONS ▪ Rest, ice ▪ Physical rehabilitation OSMOSIS.ORG 715
DISLOCATED SHOULDER osms.it/dislocated-shoulder PATHOLOGY & CAUSES ▪ Humeral head detaches from glenoid fossa in glenohumeral joint ▪ Loose ligaments provide high mobility, but are prone to injury in abduction/external rotation TYPES Anterior dislocation ▪ Most common ▪ Blow to extended, raised, outwardly turned arm → damaged inferior glenohumeral ligament SIGNS & SYMPTOMS Shoulder feels unstable/like it’s “rolling out” Shoulder pain (can radiate down arm) Limited range of motion Visible displacement Injured/compressed axillary artery: hematoma/weak distal pulse ▪ Stretched axillary nerve: shoulder area numbness ▪ ▪ ▪ ▪ ▪ Posterior dislocation ▪ Strong muscle cramp/electric shock ▪ Associated with tuberosity, surgical neck fractures of humerus Inferior dislocation ▪ Uncommon ▪ Force applied to completely raised arm (e.g. individual falls, tries to grab onto something above) ▪ Highest incidence of axillary nerve, artery injuries CAUSES ▪ Force from fall/blow → ligaments tear/ stretch → humeral head slips out of position RISK FACTORS ▪ Previous dislocations ▪ Sports COMPLICATIONS ▪ Axillary artery, nerve damage from injury/ while performing reduction 716 OSMOSIS.ORG Figure 121.1 An X-ray image of the shoulder demonstrating an anterior dislocation. DIAGNOSIS DIAGNOSTIC IMAGING X-ray ▪ Two views necessary ▫ Anteroposterior view (AP) ▫ Lateral view ▪ Anterior dislocation: humeral head is in front of glenoid
Chapter 121 Upper Limb Injury ▪ Posterior dislocation: humeral head is in place in AP view ▪ Fractured bones MRI ▪ Damaged ligaments (contrast enhancement for better visualisation) CT angiogram ▪ Arterial damage TREATMENT ▪ Reduction ▫ Perform as soon as possible for easier reduction, less chance of complications ▫ e.g. Hill–Sachs lesion/compression fractures on humeral head ▪ Immobilisation, rest ▫ Age < 30 → three weeks ▫ Age > 30 → 7–10 days Figure 121.2 An X-ray image of the left shoulder demonstrating a Hill–Sachs lesion. A Hill–Sachs lesion is a posterolateral compression fracture that occurs as a result of recurrent anterior dislocations of the shoulder. NURSEMAID'S ELBOW osms.it/nursemaids-elbow PATHOLOGY & CAUSES ▪ Dislocation of radial head in elbow joint ▫ Pulled elbow/radial head subluxation CAUSES ▪ Pulling extended arm makes annular ligament slip above radial head ▪ Lifting/swinging child ▪ Common in children < six years old SIGNS & SYMPTOMS DIAGNOSIS DIAGNOSTIC IMAGING X-ray ▪ When fracture suspected TREATMENT OTHER INTERVENTIONS ▪ Reduction ▫ Supination, elbow ﬂexion ▫ Hyperpronation (less painful) ▪ Child refuses to bend/use affected arm ▫ Fear of pain ▪ Holds affected arm in prone position, close to body ▪ Inability to supinate OSMOSIS.ORG 717
ROTATOR CUFF TEAR osms.it/rotator-cuff-tear PATHOLOGY & CAUSES ▪ One/more tendons of rotator cuff tear(s) ▫ Supraspinatus, infraspinatus, teres minor, subscapularis comprise the rotator cuff ▪ Most common shoulder problem ▫ Occurs in all age groups TYPES By course ▪ Acute tears ▫ Strong force damages tendons (e.g. rowing, powerlifting) ▪ Chronic tears ▫ Prolonged repetitive motions (especially overhead moves) ▫ Tendon degeneration: aging, blood supplies worsen ▫ Tendons become irritated, inﬂamed while passing through narrowed gaps ▪ Weakness, instability, restricted range of motion ▪ Compressed nerves → numbness DIAGNOSIS DIAGNOSTIC IMAGING X-ray ▪ Anteroposterior view ▫ Sclerosis, cyst formation, smaller gap between acromion, humerus ▪ Lateral view ▫ State of acromion ▪ Axillary view ▫ Humeral head position MRI ▪ Connective tissue visualization ▪ Size, location of damage ▪ Swelling By amount of damage ▪ Partial thickness tears ▫ Damaged supraspinatus tendon ▪ Full thickness tears ▫ Damaged supraspinatus, infraspinatus, subscapularis, biceps tendon By exterior/interior factors ▪ Exterior factors ▫ Tendon impingement due to curved/ hooked acromion ▪ Interior factors ▫ Small repetitive injuries over prolonged period → tendon degeneration SIGNS & SYMPTOMS ▪ “Arc of pain” (pain while lowering arm) ▪ Night pain 718 OSMOSIS.ORG Figure 121.3 An MRI scan of the shoulder in a non-orthogonal plane demonstrating a complete tear of the supraspinatus and infraspinatus tendons.
Chapter 121 Upper Limb Injury Ultrasound ▪ Evaluate tear extent ▪ Tendon dislocations OTHER DIAGNOSTICS Supraspinatus injuries ▪ Active painful arc & drop arm test ▫ Fully raise arm, then steadily lower it back ▫ If pain occurs → positive test ▪ Jobe’s test (aka “empty can”) ▫ Individual raises straight arm 90°, ﬂexes forward 30° with thumb pointing down → resists attempt to depress arm ▫ Pain without weakness → tendinopathy ▫ Pain with weakness → tendon tear Infraspinatus, teres minor injuries ▪ Test external rotation ▫ Individual attempts external rotation of arm, examiner provides resistance Subscapularis injuries ▪ Gerber’s lift-off test ▫ Place hand behind back → push backwards against resistance ▪ Supine Napoleon test ▫ Individual lays down, places hand on abdomen with elbow ﬂexed 90° → attempts to raise elbow while examiner secures hand, shoulder Impingement test ▪ Neer test ▫ Individual ﬂexes pronated arm (with thumb pointing downwards) above head ▪ Hawkins test ▫ Individual raises arm 90° with halfﬂexed elbow → examiner attempts to internally rotate shoulder TREATMENT MEDICATIONS ▪ Pain management ▫ NSAIDs SURGERY ▪ Small tears → arthroscopically ▪ Large tears → open surgical repair OTHER INTERVENTIONS ▪ Rest, ice ▫ Pain, inﬂammation management ▪ Physical therapy ▫ Restore range of motion ▪ Strengthen muscles that support joint ▪ Exercises for preserving neurologic control OSMOSIS.ORG 719