Upper Extremity Injuries Corinne Gratson, M.S., P.A.-C.

1. Upper Extremity InjuriesCorinne Gratson, M.S., P.A.-C.

2. Shoulder Girdle • Comprised of: -Glenohumeral Joint: Humeral head articulates with glenoid fossa of the scapula -Acromioclavicular Joint: Acromion process of the scapula articulates with distal clavicle -Sternoclavicular Joint: Sternum articulates with proximal end of clavicle -Scapulothoracic Joint: Body of the scapula & muscles covering the posterior chest wall

3. Shoulder • Muscles: -Trapezius, levator, rhomboids, serratus ant. (stabilize scapula, aid motion @ GH joint) -Deltoid (flex/ext, Abduct) -Rotator Cuff -Pec Major (ADDuct) -Coracobrachialis/Biceps (flexors)

4. Shoulder • Nerves: -Brachial Plexus (passes through axilla, origin of branches C5-T1) -Axillary N. (innervates deltoid; commonly injured in shoulder dislocations) -Musculocutaneous N. (innervates biceps & coracobrachialis)

5. Shoulder • Rotator Cuff -Muscles: Supraspinatus (ABduct, Ext. Rot.) Infraspinatus (Ext. Rot.) Teres Minor (Ext. Rot.) Subscapularis (Int. Rot., ADDuct) -Injuries: Tear/Rupture, Tendonitis, Impingement

6. Shoulder • Rotator Cuff (cont.) -Tear: May be partial or full (partial thickness occurs 2x more often; full thickness occurs in pt’s with long standing h/o shoulder injury, rarely under 40 y/o); one or more of the muscle bellies/ tendons; almost always near their insertion on the greater tuberosity; almost always the supraspinatus tendon -Tendonitis: Inflammation of rotator cuff tendon(s); overuse -Impingement: Mechanical compression of soft tissue structures (suprasp.tendon) under the coracoacromial arch during humeral elevation

7. Shoulder Rotator Cuff Tear (cont.) -S/Sx: Diffuse, dull, aching pain localized over deltoid & upper arm/back; pain with overhead activities; tender to palp. -Dx: Subjective pt. symptoms, PE (+ empty can, + droparm test, MRI -Tx: Depends on severity. Conservative = PT, NSAIDs, Modalities (RICE, e-stim/US); If no improvement = surgery (subacromial decompression)

8. Empty Can Test Abduct arm 90°, then horizontally ADDuct 30° at shoulder joint Internally rotate shoulder, like emptying a can onto the floor Apply resistance, looking for pain and/or weakness

9. Shoulder • Adhesive Capsultitis - “Frozen Shoulder” -exact etiology unclear -contracted & thickened joint capsule which is tight around humeral head, little synovial fluid -chronic inflammation, some fibrosis; rotator cuff muscles also contracted & inelastic -constant inflamm. causes pain w/PROM & AROM; pt. progressively resists moving the shoulder joint

10. Shoulder • Adhesive Capsulitis (cont.) -S/Sx: pain in all directions w/movement, restricted movement in all directions -Dx: PE -Tx: Relieve discomfort, restore motion through aggressive joint mobs, stretching tight muscles; e-stim to decrease pain, US brings heat to area; surgical release

11. Shoulder • Thoracic Outlet Compression Syndrome -Compression of brachial plexus, subclavian a., subclavian v. in neck & shoulder; usually congenital; 30% result after trauma/accident due to whiplash -Narrowed space b/t 1st rib & clavicle -Ant. & middle scalene muscles -Pectoralis minor (as neurovasc. bundle passes beneath coracoid process, or b/t clavicle & first rib) -Presence of a cervical rib (an abnormal rib, originates from a cervical vertebra & thoracic rib)

13. Shoulder

14. Shoulder • Thoracic Outlet Syndrome (cont.) -S/Sx: Paresthesias, pain, sensation of cold, decreased circulation in fingers, muscle weakness, muscle atrophy, radial n. palsy (all due to pressure on subclavian a./v., brachial plexus); worsened by lifting or carrying weights;; -Dx: Subjective s/sx, special testing (Adson’s –ant. scalene,); Roo’s-costoclavicular; Allen – hyperabduction) -Tx: Conservative (early, mild) = correct anatomical condition responsible; stretching (pec minor, scalenes, strengthening (traps, rhomboids, serratus ant., spine erector muscles); if no improvement may consider surgical decompression

15. Adson’s Test for Thoracic Outlet Anterior Scalenes tested pt breathes deeply, neck extended, chin toward affected side (+) ↓ radial pulse, extremity pain reproduced

16. Roo’s Test for Thoracic Outlet Costoclavicular Arms Abducted 90°, elbows flexed 90°, open/close hands x3min. (+) unable to maintain position or pain, weakness, numb/tingling on affected side

17. Allen Test for Thoracic Outlet Elbow flexed to 90°, shoulder externally rotated & horizontally ext. Rotate head away from tested side (+) if radial pulse becomes non-palpable when head is turned away

18. Shoulder • Biceps -Biceps Brachii Rupture: occurs when powerful concentric or eccentric contraction of muscle is performed; commonly occurs near origin of the muscle in bicipital groove, dominant arm, males >40 y/o – 60 y/o -Causes: tendonitis, impingement, degeneration, aging, nontraumatic -S/Sx: pt. hears/feels “snap”, feels intense pain @ point of injury; may have bulge in midline of upper arm; weakness with elbow flexion & supination; ecchymosis -Dx: Hx (MOI, anabolic steroid use), subjective s/sx., PE, MRI (if full tear is questionable) -Tx: Immediate cold pack (control muscle hemorrhage), sling; eventually surgery. If only partial, can try PT first

19. Shoulder

20. Shoulder

21. Shoulder

22. Shoulder • Biceps (cont.) -Bicipital Tendonitis: typically long head of biceps; common in pt’s w/repetitive overhead motion; caused by repeated ballistic activities that cause irritation of tendon and/or synovial sheath as it passes under transverse humeral ligament in bicipital groove -S/Sx: tenderness to palp. ant. upper arm over the groove; possible swelling, warmth, crepitus -Dx: Yergason’s test, Speed’s test, Ludington’s test (tendonitis vs. rupture) -Tx: Rest-several days, cold therapy or US to decrease inflamm., NSAIDs; gradual PT w/stretching, strengthening

23. Yergason’s Test for Biceps Tedonopathy Elbow flexed @ 90°, examiner resists supination while pt. also ext. Rotates arm against resistance (+) pain/tender in bicipital groove

24. Speed’s Test Arm is supinated, examiner resists shoulder forward flexion; test repeated in pronation (+) pain/tender in bicipital groove; if profound weakness, suspect 2nd/3rd degree strain/rupture

25. Ludington’s Test Clasp hands on top or behind head, interlock fingers (allows biceps to relax) Alternately contract/relax the biceps muscles; palpate tendon (+) non-palpable biceps tendon = rupture

26. Shoulder Dislocation • Most common MOI Abduction, Ext. Rotation • Anterior, Inferior dislocations most common • Check ROM, strength& always compare BILATERALLY! • Always check neurovasc. status BEFORE & AFTER relocation (Don’t forget your AXILLARY nerve!)

27. Normal Shoulder Xray (Axillary View)

28. Shoulder Dislocation

29. Shoulder Dislocation

30. Shoulder Dislocation - anatomy

31. Shoulder Dislocation - anterior

32. Shoulder Dislocation - posterior

33. Shoulder Dislocation - inferior

34. Shoulder Dislocation

35. Shoulder Dislocations • MOI: usually a direct impact to posterior or post/lateral shoulder (if ant. disloc.); humeral head forced out of glenoid (FOOSH, grand mal seizure, tear of rotator cuff, etc.) • S/Sx: feeling of the shoulder give way, “pop”, sudden & severe pain, flattened deltoid contour, palpation of axilla reveals prominence of humeral head; pt. unable to touch the opposite shoulder with hand of affected arm, disability; apprehension

36. Shoulder Dislocations • Tx: Immediate immobilization in a position of comfort using a sling w/small towel placed under the arm • Tx (cont.): Xrays to eval for glenoid fx, then reduction by a doctor or PA, ASAP! Always get post-reduction Xrays as well to make sure you fully reduced; cont. immobliziation (2-4 weeks) • Complications: Nerve damage, tissue damage, recurrent dislocations (~90% after 1st dislocation)

37. Shoulder Girdle Fractures • Clavicle Fx -Frequent fx in sports, occurs during birth to infant -MOI: FOOSH, fall on tip of shoulder, direct impact -Majority occur middle 3rd (70%), followed by distal 3rd (25%), proximal 3rd (5%)

39. Shoulder Girdle Fractures • Clavicle Fx S/Sx: pt. presents typically w/protective splinting (holds injured arm, tilts head toward injury); deformity (depends on severity); pain swelling, point tenderness Dx: Hx, PE, XR Tx: Sling/swathe, analgesics, immobilization w/figure 8 brace x 1wk (then begin gentle ROM); limit overhead activity until tenderness resolves; rarely requires surgical repair

40. Figure ‘8’ Brace

41. Shoulder Girdle Fractures • Humerus Fx (proximal, shaft, distal) -Proximal: articular surface of shoulder jt. & attachments of rotator cuff to greater/lesser tuberosities ->90% result from low-energy fall directly onto shoulder; other = high energy trauma -Increased risk w/osteoporosis -Classification: articular surface, greater tuberosity, lesser tuberosity, surgical neck; number of fragments

42. Shoulder Girdle Fractures • Proximal:

43. Shoulder Girdle Fractures • Mid-Shaft Humerus Fx: -Proximal, Mid, Distal (divided into 3rds) -Fx Pattern (tranverse, oblique, comminuted) -Open vs Closed -Pathologic (2ndary to underlying bone dz) -40% of all humerus fxs -Results from direct force to upper extremity

44. Shoulder Girdle Fractures • Mid-Shaft Humerus Fx:

45. Pathologic Humerus Fracture

46. Shoulder Girdle Fractures • Distal Humerus Fx: -Etiology: FOOSH, auto vs. peds, MVA, direct blow to elbow

47. Shoulder Girdle Fractures • Tx: stability & early motion (10-14 days immob.), RICE, early surgical repair (if indicated); if limb has diminished/absent pulse, reduction with immobilization or traction should be performed

50. Orthosis – Sarmiento Brace