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L 14 Musculoskeletal Conditions – Upper Extremities (Shoulder, Elbow, Wrist & Hand)

Learning Objectives

  • Review upper-extremity anatomy and recognize clinical presentations/mechanisms of injury.
  • Identify signs/symptoms and perform basic & specialized physical exams for shoulder, elbow, wrist, and hand disorders.
  • Formulate treatment plans (pain control, splinting/casting, surgical vs. non-surgical) and determine referral criteria.

Quick Shoulder Anatomy Review

  • Rotator cuff (SITS):
    • Supraspinatus (most common tear)
    • Infraspinatus
    • Teres minor
    • Subscapularis
  • Biceps long head runs in bicipital groove; subacromial/subdeltoid bursa under acromion.

Shoulder Pain – Differential Diagnosis

  • Impingement syndrome
  • Idiopathic adhesive capsulitis (frozen shoulder)
  • AC separation & AC arthritis
  • Glenohumeral arthritis
  • Calcific tendonitis
  • Biceps tendinosis
  • Rotator cuff tears
  • Fractures/dislocations (covered separately)

General Shoulder Physical Examination

  • Inspection: expose both shoulders simultaneously; note contour, asymmetry, ecchymosis, scars, muscle atrophy, deformity (AC, clavicle, GH).
  • Palpation: AC joints, biceps tendon, greater tuberosity, note warmth/swelling.
  • Range of Motion (ROM) – compare active vs. passive.
    • Normal values:
    • Abduction 150^\circ
    • Forward flexion 180^\circ
    • Extension 45\text{–}60^\circ
    • External rotation 90^\circ (elbow at 90^\circ)
    • Internal rotation 70\text{–}90^\circ
  • Strength testing: isolate each rotator cuff muscle.
  • Neurovascular: distal pulses, sensation (axillary, musculocutaneous nerves, etc.).

Specialized Shoulder Tests

  • Hawkins Sign: passive forward flexion to 90^\circ, elbow 90^\circ, internal rotation → pain = subacromial impingement.
  • Empty-Can (Jobe) Test: arms 90^\circ abduction, thumbs down; downward resistance → weakness = supraspinatus pathology.
  • Neer’s Sign: scapular stabilization + forced forward elevation in internal rotation; pain improves in external rotation if subacromial, persists if AC.
  • Drop-Arm: inability to slowly lower from 90^\circ abduction = supraspinatus tear.

Shoulder Imaging (“Shoulder Series”)

  • AP scapula, AP AC, Scapular-Y (lateral), Axillary view.

Pain-Management Principles (all joints)

  • Initial: RICE, NSAIDs, acetaminophen, immobilization.
  • Pre-operative or sedated procedures: hold oral meds/NSAIDs; use IV opioids/acetaminophen, consider nerve blocks, intra-articular injections, PT.

Idiopathic Adhesive Capsulitis (Frozen Shoulder)

  • Demographics: age 40\text{–}65, women, ↑ prevalence in DM & thyroid disease.
  • Pathophysiology: capsular inflammation → fibrosis & adhesions; self-limited 18\text{–}30 mo.
  • Presentation: global loss of active & passive ROM (esp. external rotation), severe pain initially.
  • Phases:
    1. Inflammatory 0\text{–}6 mo – painful.
    2. Freezing 6\text{–}12 mo – stiff > pain.
    3. Thawing 12\text{–}24 mo – gradual recovery.
  • Dx: clinical; imaging rarely needed.
  • Tx: PT (gentle ROM, resistance), NSAIDs, corticosteroid injection/oral burst. Manipulation under anesthesia for refractory (> 6 mo, worsening 3 mo).
  • Refer if no improvement ≥ 6 mo.

AC (Shoulder) Separation

  • Injury to AC & CC ligaments; mechanism: direct blow/fall on shoulder.
  • PE: swelling, focal tenderness, + Cross-arm adduction test.
  • Imaging: bilateral AC X-rays; normal joint width 1\text{–}3\,\text{mm} adults; classify Type I–VI.
  • Tx: Types I–II conservative (sling, ice, PT); Types III–VI surgical.

Subacromial/Posterior Shoulder Impingement Syndrome

  • Etiology: muscular weakness/dysfunction narrows subacromial space; throwing athletes may develop posterior variant.
  • Age spectrum:
  • Symptoms: anterolateral deltoid pain radiating to elbow, worse overhead/night; posterior pain in throwers.
  • Signs: rolled-forward posture, atrophy supraspinatus/infraspinatus, + Neer, + Hawkins.
  • Imaging: X-ray to rule out; MSK US dynamic; MRI for cuff evaluation.
  • Tx: education, activity mod, PT (scapular stabilizers, cuff strengthening); weak evidence for NSAIDs/ice. Refer if no relief > 3 mo or suspected full-thickness tear.

Rotator Cuff Disorders

Anatomy & Vulnerability

  • Poor vascularity of SITS → slow healing; supraspinatus tears most common and can extend to others/biceps.

Calcific Tendonitis

  • Hydroxyapatite deposits in cuff (40–60 yr, women, thyroid/DM).
  • X-ray & US show calcifications. Tx: rest, NSAIDs, steroid injection, extracorporeal shock wave, surgery if refractory.

Biceps Tendinosis

  • Long-head inflammation often accompanies cuff degeneration; provoked by lifting/overhead.
  • Special tests: Yergason’s, Speed’s (also screen SLAP lesions).
  • Tx: conservative ± steroid; MRI if persistent; risk of rupture long term.

Rotator Cuff Tears

  • MOI: acute FOOSH/pull or chronic overuse; tension overload due to weak cuff.
  • S/S: difficulty lifting arm, night pain, limited active ROM, weakness with resistance (full-thickness clue).
  • PE: + Neer, Hawkins, Drop-Arm; muscle-specific tests (Empty-can, ER lag, Lift-off, Hornblower).
  • Imaging: shoulder series; MRI best (MR arthrogram for small/partial tears).
  • Tx: partial—PT, steroid; ~40 % progress to full tear in 2 yrs. Full thickness—surgery (arthroscopic/open) esp. young/active; subscapularis tears always repaired.

Exam Clues Summary

  • Active loss w/ intact passive → RC tear/impingement spectrum.
  • Loss of passive ROM → adhesive capsulitis or GH OA.
  • Point AC tenderness → separation or AC OA.
  • Biceps groove tenderness → biceps tendinopathy.

Neurological/Structural Clues

  • Supraspinatus fossa asymmetry → chronic RC tear or impingement.
  • Shoulder sag/winged scapula → CN XI palsy.

Elbow Examination

  • Normal ROM: Extension 0^\circ, Flexion 150^\circ, Pronation 70^\circ, Supination 90^\circ.
  • Palpation landmarks: anterior biceps, posterior olecranon, medial epicondyle & ulnar nerve, lateral epicondyle & radial head.
  • Strength & distal neurovascular.

Olecranon Bursitis

  • Causes: trauma, infection (septic), RA, gout.
  • Presentation: superficial swelling; full painless ROM. Septic if erythema, warmth, tender, WBC >50{,}000/\mu L, S. aureus common.
  • Imaging usually normal.
  • Tx: NSAIDs, aspiration for analysis (+ compression bandage); steroid if non-infected; I&D + IV antibiotics if septic.

Medial & Lateral Epicondylitis (Golfer’s vs. Tennis Elbow)

  • MET: pain with resisted wrist flexion/pronation (pronator teres). LET: pain with resisted wrist/3rd-digit extension (ECRB).
  • Tx: RICE, PT (more effective than NSAIDs), brace, steroid injection short-term; refer > 6 mo; debridement/tenectomy if severe.

Wrist Examination

  • Normal ROM: Flex/Ext 70^\circ each, Ulnar dev 40^\circ, Radial dev 20^\circ.
  • Palpate pulses, pisiform, hook of hamate, scaphoid (anatomic snuff box), lunate.

Carpal Tunnel Syndrome (CTS)

  • Median nerve compression beneath transverse carpal ligament.
  • Causes: repetitive synovitis, fractures, tumors, pregnancy (fluid retention), RA, congenital.
  • S/S: pain, burning, tingling thumb–radial ring finger; worse with volar flexion/dorsiflexion, nocturnal; late thenar atrophy/weakness.
  • Tests: Tinel, Phalen (wrist flex 90^\circ for 60 s), Carpal Compression (direct pressure 30 s) – most sensitive.
  • Diagnostics: wrist X-ray (rule out), EMG/NCV (sensory delay precedes motor; required pre-op), US shows nerve flattening.
  • Tx: neutral splint + activity mod ≤ 3 mo; steroid injection preferred over oral; NSAIDs not proven. Refer if > 3 mo symptoms or thenar weakness; surgery often delayed ≤ 12 mo.

Rheumatoid Arthritis of Hand/Wrist

  • Symmetric peripheral inflammatory polyarthritis; early cartilage & bone erosion → misalignment.
  • Symptoms: constitutional fatigue, >1 h morning stiffness, hand/foot swelling.
  • Nodules (30–40 %): firm, non-tender, periosteal/tendinous; correlate with high disease activity & erosions.
  • Labs: ↑ ESR/CRP, +RF, +anti-CCP.
  • X-ray: marginal erosions, osteopenia, joint-space narrowing (MCP, PIP, MTP).
  • 2010 ACR/EULAR scoring (≥6) combines joint count, serology, ESR/CRP, duration ≥ 6 wks.
  • Tx: early rheumatology referral; DMARDs (methotrexate, sulfasalazine, hydroxychloroquine), exercise, monitor for vasculitis & ILD.

De Quervain’s Tenosynovitis

  • Stenosing tenosynovitis of 1st dorsal compartment (APL & EPB) at radial styloid.
  • S/S: aching wrist/thumb, tenderness over tendons.
  • Finkelstein Test: thumb in fist + ulnar deviation → pain.
  • Natural course 6–12 mo. Tx: NSAIDs, rest, warm soaks, thumb spica splint, steroid injection + splint (≈80 % success), surgical release if refractory.

Hand Examination Essentials

  • Inspect: skin color/temp, wounds, deformities, fixed positions, nodules.
  • Palpate: tenderness, pulses, cap refill.
  • Neuro: ulnar, median, radial motor/sensory, 2-point discrimination.
  • Strength: flex/ext, intrinsic AB/ADduction.
  • Inability to assume “position of function” = RED FLAG.

Extensor Tendon Injury – Boutonniere Deformity

  • Rupture of central slip insertion on middle phalanx → PIP flexion, DIP hyper-extension.
  • Common in sports trauma.
  • Tx: PIP extension splint (DIP free); surgery if associated fracture.

Flexor Tendon Avulsion – Jersey Finger

  • FDP avulsion from distal phalanx (ring finger 75 %). MOI: forced extension of flexed finger.
  • S/S: painful volar distal finger, cannot flex DIP; X-ray for bony avulsion.
  • Tx: surgical repair.

Mallet (Baseball) Finger

  • Terminal extensor tendon disruption at DIP; fingertip rests flexed \approx45^\circ, no active DIP extension.
  • Tx: continuous DIP extension splint 6–8 wks; surgery if volar subluxation.
  • Chronic untreated mallet may produce swan-neck deformity (PIP hyper-extension, DIP flexion).

Dupuytren Contracture

  • Nodular fibrosing of palmar fascia (unknown cause); men >50 yr; associated epilepsy, DM, pulmonary dz, alcoholism, vibration trauma.
  • Mainly affects 4th & 5th digits; painless progressive flexion contracture.
  • Tx: collagenase injection for growing nodules; surgery for severe contracture; splinting ineffective.

Trigger Finger (Stenosing Flexor Tenosynovitis)

  • Thickened A1 pulley; popping, catching or locking in flexion (self-assisted extension). Onset 50s–60s.
  • Tx: NSAIDs, night splint, corticosteroid injection, surgical release if persistent.