Upper Limb Pain & Trauma

 

• Shoulder pain

  Causes and their presentation

  Common non-traumatic causes

  Subacromial pain syndrome (SAPS, aka shoulder impingement syndrome):

  • Umbrella term for non-traumatic, usually unilateral shoulder pain due to pathology in the subacromial space.
  • Includes subacromial bursitis, supraspinatus tendinopathy (including calcific tendinopathy), rotator cuff degeneration or partial tear, and biceps tendinopathy. Note 'tendinopathy' is preferred to 'tendinitis' as we rarely have evidence of inflammation.
  • Presents with pain on lifting or overhead movements.
  • On examination: painful arc in 60-120° of abduction, Neer's sign.

  Frozen shoulder (aka adhesive capsulitis):

  • Stiffness and/or pain, and global reduction in active and passive movement, especially external rotation.
  • Risk factors: diabetes, prolonged immobilisation.

  Osteoarthritis:

  • Acromioclavicular joint OA: tenderness over ACJ.
  • Glenohumeral OA: results from overuse e.g. manual labour, walking with stick. Presents with pain (especially on external rotation) and reduced range of movement.

  Traumatic or complex causes

  • Traumatic full thickness rotator cuff tear: acute trauma (e.g. dislocation, traction) followed by reduced active movement, especially abduction, but normal range of passive movement. Remember, the rotator cuff muscle group SITS around the joint: Supraspinatus, Infraspinatus, Teres minor, and Subscapularis.
  • Fracture, dislocation, or infection.
  • Cancer, usually metastatic.
  • Referred pain from cervical spine, sensory nerve (shingles), myocardium (MI), lung apices (cancer), muscles (polymyalgia rheumatica), diaphragm.

  Imaging

  • X-ray (AP and lateral) if suspecting fracture, dislocation, or cancer, or initial management has failed and are considering steroid injection.
  • US or MRI if suspecting rotator cuff tear.

  Management

  SAPS, frozen shoulder, and OA:

  • 1st line: analgesia, normal activities as tolerated (though may require period of limited duties at work), and physiotherapy.
  • 2nd line: steroid injection (not for glenohumeral OA).
  • 3rd line: surgery, such as joint replacement (glenohumeral OA), manipulation under anasthesia or capsular release (frozen shoulder).
  • SAPS and frozen shoulder typically self-resolve, though may take several months, while OA may progress.

  Traumatic full thickness rotator cuff tears require prompt surgical repair (note that this isn't true for partial, non-traumatic tears, which are part of SAPS).

• Shoulder dislocation

  Dislocation definition

  • Dislocation is a loss of continuity between two joint surfaces.
  • Subluxation is a partial dislocation, with both parts still touching.
  • Can be combined with a fracture in a 'fracture dislocation' or 'fracture subluxation'.

  Clinical features

  • 95% are anterior dislocations, which most commonly follow a blow to an abducted, elbow-extended, externally rotated arm, such as a fall on an outstretched hand.
  • Associated injuries: Bankart lesion (avulsion of glenoid labrum anteriorly), Hill-Sachs lesion (damage to the humeral head), greater tuberosity fracture, axillary nerve palsy (check sensation in the Sargeant's patch before reduction), rotator cuff tear, arterial injury (very rare, but must always check radial pulse before reduction).
  • Posterior dislocation follows a blow to the anterior shoulder or extreme muscle contraction e.g. seizure. On XR, humeral head appears to be sitting in the glenoid, or is rounded (light bulb sign).
  • May go on to develop shoulder instability, in which shoulder is prone to recurrent subluxation/dislocation.

  Imaging

  X-ray (AP and lateral) before and after reduction.

  Management

  Reduction:

  • Under sedation and analgesia.
  • Use any one of various techniques e.g. scapular manipulation, external rotation, traction countertraction.

  Post-reduction:

  • Re-examine sensation, pulses, and movement.
  • Immobilization for 1 week (if age >30 as ↑risk of stiffness) or 3 weeks (if age <30 as ↑risk of redislocation).
  • Rehabilitation with home exercises.
  • MRI or US if ongoing symptoms at 2 weeks for possible rotator cuff injury. Some recommend routinely for all age 40-60 due to ↑risk.

• Elbow pain

  Causes and their presentation

  Epicondylitis

  • Pathology of the forearm muscles and tendons due to overuse, often work-related.
  • Presents with elbow and forearm pain, with limitation of forearm/wrist movement (e.g. with gripping) but not elbow movement.
  • Lateral epicondylitis (aka tennis elbow) is the commonest, and involves the extensors. Presents with lateral elbow pain and tenderness, and pain on wrist and middle finger extension (especially if resisted).
  • Medial epicondylitis (aka golfer's elbow) involves the flexors. Presents with medial elbow pain and tenderness, pain on wrist flexion and pronation, and may feature ulnar neuropathy (paresthesia of ring and little fingers).

  Others

  • Olecranon bursitis (aka student's elbow): boggy swelling of elbow ± pain, due to trauma or overuse, or less commonly, gout or RA. A minority of cases are due to infection (septic bursitis), typically Staph.aureus, following break in overlying skin.
  • Elbow osteoarthritis: pain, limited elbow flexion/extension.
  • Radial tunnel syndrome: posterior interosseous nerve compression causing dorsoradial forearm pain, but no motor or sensory deficits.
  • Inflammatory or septic arthritis, most commonly rheumatoid arthritis (RA) or gout.
  • Fracture (see Arm fractures).
  • Cancer (see Bone and soft tissue cancers)
  • Referred pain from cervical spine, shoulder (e.g. SAPS), or wrist (e.g. carpal tunnel syndrome).

  Imaging

  X-ray if fracture or other bony joint disease suspected.

  Management

  Epicondylitis:

  • Physiotherapy to guide strengthening exercises and cessation/modification of aggravating sport/work activities. No clear evidence for splints/orthotics, but still widely used.
  • Analgesia, preferably paracetamol.
  • Steroid injections provide up to 6 weeks of relief but do not alter long-term outcomes.
  • Most self-resolve within 1 year. Persistence beyond this may necessitate interventions such as botulinum toxin or surgery.

  Others:

  • Radial tunnel syndrome: as for epicondylitis, with radial tunnel release surgery for refractory cases.
  • Olecranon bursitis: rest, ice, analgesia, consider aspiration if very large or symptomatic, and reassure that it will likely self-resolve. If septic bursitis suspected (systemic or local signs of infection), aspirate and treat empirically with antibiotics (e.g. flucloxacillin).
  • Elbow OA: as for all OA, analgesia and physiotherapy, with arthroscopy or joint replacement in refractory cases.

• Arm fractures

  Humerus fractures

  Proximal humerus fractures

  • Fracture proximal to surgical neck i.e. in the shoulder.
  • Common among elderly following fall on outstretched hand (FOOSH).
  • Usually stable and can be managed with sling and early mobilization.
  • Complications: axillary nerve injury.

  Distal humerus (supracondylar) fractures

  Presentation:

  • Common in children following FOOSH.
  • Complications: anterior interosseous (median) nerve injury (can't make OK sign), brachial artery injury, compartment syndrome.

  X-ray:

  • Usually reveals fracture line, though it may be obscured by anterior/posterior fat pad sign reflecting joint effusion.
  • Gartland classification: undisplaced (type 1), posterior angulation with intact cortex (type 2), complete posterior displacement (type 3).

  Initial management is with posterior splint. Followed by:

  • Type 1: cast immobilization with elbow at 90° for 2-4 weeks; may be followed by removable posterior splint.
  • Type 3 and most type 2: reduce via MUA and immobilize with K-wires.

  Forearm fractures

  Elbow fractures

  • Mechanism: radial head fracture (adults) or radial neck fracture (kids) from FOOSH, or olecranon fracture from direct blow to flexed elbow.
  • Olecranon fractures are usually intra-articular. May have significant swelling.
  • Undisplaced fractures are managed with 7 days posterior splint, with elbow at 90°, then sling.

  Ulnar and radial shaft fractures

  Injuries and mechanisms:

  • Can be single or both-bone injuries. Usually result from a direct blow.
  • Ulnar shaft fractures classically result from direct blow to arm raised in defence, aka nightstick fracture.
  • Proximal ulnar fractures may be associated with radial head dislocation (Monteggia's fracture). Usually results from fall on outstretched, extended, pronated elbow.
  • Middle/distal radial fractures may be associated with dislocation of the distal radioulnar joint (Galeazzi fracture). Usually result from fall on extended, pronated wrist.

  Management:

  • Single bone fractures can usually be managed initially with splint with elbow at 90°. This may be followed by reduction (if needed) and immobilization, usually via ORIF in adults and closed reduction and casting in kids.
  • Both-bone fractures in adults often require urgent ORIF. In kids, they can often be managed with closed reduction and a splint or cast.

• Wrist fractures

  Background

  • Most commonly, this refers to fractures of the distal radius. However, the ulnar and carpal bones – especially the scaphoid and lunate – are also common fracture sites.
  • Often caused by fall on an outstretched hand (FOOSH). FOOSH may also cause supracondylar fractures in kids, radial head fractures in young adults, or transcondylar or proximal humerus fractures in older adults, as impact is transferred upwards.
  • Important to note if wrist fractures are intra-articular.

  Examination

  • Swollen, tender, deformed wrist.
  • Remember to examine elbow and check neurovascular status.

  X-ray

  Basics:

  • In any suspected fracture, get a PA and lateral view of the affected wrist (note the PA view is often mistakenly referred to as an AP view). Consider elbow too.
  • When describing positions, say radial/ulnar and dorsal/volar, as opposed to medial/lateral and anterior/posterior.

  To recognise an abnormal wrist X-ray, need to know features of a normal X-ray:

  • On AP view, the distal radius should have a 'radial inclination' (tilt down/proximal from radial to ulnar side), while the distal ulnar is flat.
  • On a lateral view, there should be a 15° volar tilt i.e. joint line running down/proximal from dorsum.

  See the fracture types below for pathological findings.

  Common fractures

  Colles fracture:

  • Extra-articular transverse fracture of distal radius, with radial shortening and dorsal tilt. Posterior displacement. Ulnar styloid fracture may be present.
  • Usually results from fall on an outstretched, extended (dorsiflexed) hand.
  • Non-union may result in 'dinner fork' deformity.
  • Cast immobilisation holds wrist in slight flexion and ulnar deviation.
  • Complications: median nerve injury, carpal tunnel syndrome, extensor pollicis longus tendon rupture, CRPS type 1, adhesive capsulitis ('frozen shoulder' from immobilisation).

  Smith fracture:

  • Like a reverse Colles. Much less common.
  • Distal radius fracture with volar translation/displacement. Transverse and extra-articular (type 1, commoner), or oblique and intra-articular (type 2).
  • Usually results from fall on a flexed hand.

  Colles and Smith fractures are often indicator fractures for osteoporosis, so make sure to screen.

  Scaphoid fracture:

  • Tenderness in the anatomical snuff box.
  • X-ray may be normal if undisplaced. Cast or futura splint anyway if symptoms are suggestive, then repeat XR in 10 days, or use MRI as initial investigation if available.
  • Risk of AVN, causing long-term pain and stiffness.

  Fractures of the radial metaphysis – often torus (buckle) type – are the commonest childhood fracture.

  Management

  Undisplaced

  • Cast immobilisation for 6 weeks.
  • Cast extends from the elbow to just proximal to the MCPs, allowing free finger movement.

  Displaced

  Reduction is needed before cast immobilisation.

  Non-surgical:

  • Closed reduction with manipulation under anaesthesia (MUA), either local (Bier's block, haematoma block) or general.

  Surgical reduction and fixation if non-surgical unsuccessful. Options:

  • MUA plus K-wires, a minimally invasive approach which work like skewers.
  • External fixation.
  • Open reduction and internal fixation with plates and screws.

• Upper limb mononeuropathies

  Axillary nerve lesions (C5-6)

  Causes:

  • Anterior shoulder dislocation.
  • Humeral neck fracture.

  Presentation:

  • Impaired shoulder abduction (deltoid weakness).
  • Sargeant's patch numbness.

  Radial nerve lesions (C5-T1)

  Causes:

  • Humeral fracture.
  • Sleeping with hand over back of chair (Saturday night palsy).
  • Crutches
  • Stabbing

  Presentation:

  • Wrist and finger drop.
  • Anatomical snuff box numbness.

  Posterior interosseous nerve lesions (C7-8)

  • PIN is the continuation of the deep branch of the radial nerve in the forearm.
  • Radial tunnel syndrome: pain without motor or sensory symptoms, possibly due to overuse.
  • PIN compression syndrome: weak extension of fingers and thumb, but no sensory loss. Due to trauma (e.g. Monteggia fracture), tumours, or inflammation (e.g. radiocapitellar synovitis).

  Median nerve lesions (C6-T1)

  Causes

  Most commonly due to carpal tunnel syndrome. Associated with:

  • Joint disease: RA, gout.
  • ↑Body size: pregnancy, obesity, acromegaly.
  • Metabolic: hypothyroidism, diabetes, amyloidosis.

  Can also be caused by elbow injury e.g. supracondylar fracture in kids after FOOSH.

  Presentation

  Mainly sensory symptoms:

  • Tingling and discomfort over lateral 3½ fingers.
  • May wake patient at night and is relieved by shaking hand: 'wake and shake'.

  Motor symptoms:

  • Affects LOAF muscles, the Lumbricals (lateral two) and the thenar muscles: Opponens pollicis, Abductor pollicis, and Flexor pollicis brevis.
  • Thenar wasting.
  • May produce hand of Benediction: when asked to make fist, can't flex index and middle finger due to paralysis of long flexors and lateral two lumbricals.
  • If injured at level of elbow, will also cause impaired pronation, weak wrist flexion, and ulnar deviation.

  Management

  • Try analgesia and nocturnal wrist splints initially. 25% self resolve in 1 year.
  • If symptoms continue, consider steroid injections or surgical nerve release via flexor retinaculum division. Pain should improve post-op, but numbness and wasting may remain.

  Anterior interosseous nerve lesions

  • Branch of median nerve supplying anterior forearm.
  • Caused by compression – usually at tendinous edge of pronator teres – or paediatric supracondylar fracture.
  • Unable to make OK sign (can't flex index DIP and thumb IP) due to flexor digitorum profundum (radial half) and flexor pollicis longus weakness.

  Ulnar nerve lesions (C7-T1)

  Causes

  Elbow injury:

  • Compression as it passes behind medial epicondyle (cubital tunnel syndrome).
  • Due to OA or RA, trauma, or resting a flexed elbow on a hard surface.

  Wrist injury (less common):

  • Compression in the Guyon canal, usually from handlebar injuries (crutches, bikes, pneumatic drills).
  • Usually motor symptoms.

  Presentation

  • Weak/wasted ulnar side of hand leading to poor grip i.e. mainly motor symptoms, versus the mainly sensory presentation of median nerve lesions.
  • Wrist lesions may produce claw-like hand, with flexed ring and little finger due to paralysis of the medial two lumbricals. Looks like hand of Benediction, but present the whole time (i.e. without having to make fist). Elbow lesions also paralyse the medial half of flexor digitorum profundus, countering the lumbrical paralysis and hence causing a less marked claw hand. In terms of injury, 'the closer to the paw, the bigger the claw'.
  • Froment's sign: ask patient to grip paper between thumb and index finger, then you try and pull the paper away. Weak adductor pollicis causes flexion of the thumb IPJ to compensate.
  • ↓Sensation over little finger and half of 4th finger.