Clinical Pearls: Upper Limb Back-to-Top Back-to-Top Bursitis of the Elbow Repeated pressure or friction on a bursa may cause it to become inflamed and tender Subcutaneous olecranon bursitis ("student's elbow") most common, often occurring in students (from resting elbows on desk), darts players and from falls and abrasions to the elbow Subtendinous olecranon bursitis less common, as is bicipitoradial bursitis Back-to-Top Calcific Supraspinatus Tendonitis Inflammation and calcification of the subacromial bursa resulting in pain, tenderness and limitation of movement of the shoulder joint Calcium deposits frequently also seen in the supraspinatus tendon Pain is especially severe with the arm abducted between 50 to 130 degrees (the painful arc) as the supraspinatus tendon is in contact with the inferior surface of the acromion here Back-to-Top Carpal Tunnel Syndrome (Plate 461) A result of compression of the median nerve as it passes under flexor retinaculum Compression caused by any process that significantly reduces the size of the carpal tunnel: inflammation of the synovial sheaths, fluid retention, and infection Pain or paraesthesia felt in the lateral 3½ digits, may radiate toward the elbow and often is at night Also loss of sensation and diminished control of the median nerve-innervated muscles Surgical division of the flexor retinaculum may be necessary to relieve symptoms Back-to-Top Colles' Fracture Complete transverse fracture within the distal 2 cm of the radius Distal fragment displaced dorsally, giving the classic "dinner fork deformity" Ulnar styloid may also be avulsed Results from forced dorsiflexion of the hand, such as in breaking a fall with an outstretched, pronated hand Most common fracture in adults older than 50 years old Seen most frequently in elderly women Healing usually good as the bone has a rich blood supply Back-to-Top Dupuytren's Contracture Progressive fibronodular thickening of the palmar fascia Leads to fixed flexion deformity of the fingers (most commonly the fourth and fifth digits) Condition often bilateral and usually affects middle-aged males of Northern European decent, suggesting hereditary predisposition Risk factors include alcohol, liver disease, and antiepileptic medication Treatment is surgical Back-to-Top Epicondylitis Activities involving repetitive movements of wrist may lead to localized elbow pain Repeated extension of wrist causes lateral epicondylitis ("tennis elbow")-microtrauma of common extensor muscle origin, with pain felt over the lateral aspect of the elbow Medial epicondylitis ("golfer's elbow") from repeated wrist flexion, with pain felt over the medial epicondyle, especially on resisted wrist flexion Bursitis or synovitis may coexist with epicondylitis Back-to-Top Fracture of the Clavicle Common, especially in children Usually results from a fall on outstretched hand or direct trauma to the shoulder Fractures of middle third are most frequently seen Sternocleidomastoid muscle pulls the proximal fragment superiorly and the shoulder pulls the distal fragment inferiorly Small lump may remain after the clavicle has healed Back-to-Top Fracture of the Humerus Fractures of the humerus most common at the surgical neck Especially common in elderly individuals with osteoporotic bone, falling on an outstretched arm The axillary nerve vulnerable to damage here Direct blow to the arm may Fracture humerus through its midshaft, with risk of injury to the radial nerve Fracture humerus at distal end, risking damage to the median nerve Back-to-Top Radial Nerve Injury Palsy of the radial nerve common after prolonged pressure on the back of the arm by resting it against a hard surface (such as back of movie theater seat-the "Saturday night palsy") Nerve may also be injured in fractures of humerus as it winds along spiral groove Extensors of the wrist are paralyzed, resulting in a wrist drop Triceps not affected unless the nerve is injured proximally in the axilla Back-to-Top Rotator Cuff Injury Musculotendinous rotator cuff may be damaged by trauma or degenerative disease One or more of tendons may be torn when the arm is forcefully abducted, leading to pain in the anterosuperior aspect of the shoulder Supraspinatus tendon is most commonly involved in degenerative tendonitis Leads patient's arm to drop suddenly at approximately 90-degree abduction, when instructed to lower it slowly from a fully abducted position Back-to-Top Rupture of the Biceps Brachii This produces "Popeye deformity" with muscle forming a ball in distal part of the anterior arm Tendon of long head has the highest rate of spontaneous rupture of any tendon in the body Rupture of the tendon on background of chronic tendonitis usually affects those older than 40 Traumatic rupture may occur in younger individuals, but is rare Back-to-Top Scaphoid Fracture Scaphoid is the most commonly fractured bone of the carpus Proximal pole of the bone has a poor blood supply and as a result, fracture may take several months to heal This increases risk of avascular necrosis and subsequent degenerative joint disease at the wrist Fracture often difficult to spot on initial radiographs, which should be repeated at 2 to 3 weeks in any patient presenting with a severely sprained wrist Back-to-Top Shoulder Dislocation High mobility and instability of the glenohumeral joint leads to frequent dislocation 95% of dislocations are in interoinferior direction, caused by excessive extension and lateral rotation of humerus (e.g., in the throwing motion) Humeral head places stress on joint capsule, which may be torn anteriorly, with elements of the rotator cuff Axillary and musculocutaneous nerves may also be injured Posterior dislocation is uncommon, but may occur during epileptic seizure or electrocution Back-to-Top Subluxation of the Radial Head (Nursemaid Elbow) Caused by sudden pulling on the upper limb with the forearm pronated Distal attachment of the annular ligament is torn and radial head slips out, trapping the ligament between it and the capitulum Preschool children, especially girls, most vulnerable Head of radius is repositioned by supinating forearm fully and then flexing elbow Back-to-Top Ulnar Nerve Injury Ulnar nerve may be compressed as it passes behind medial epicondyle of the humerus or through the Guyon canal at the wrist Pain and/or paraesthesia felt at medial aspect of the elbow radiating to the medial forearm and medial 1½ digits Also may be weakness of the intrinsic muscles of the hand Back-to-Top Winged Scapula Normally the scapula is held closely against the posterior thoracic wall. Damage to the long thoracic nerve to serratus anterior (which courses superficially over the muscle) causes "winging" of the scapula as its medial border lifts away from the thorax when the arm is raised. This is accentuated when the individual leans on the hand or pushes the upper limb against a wall. Most importantly, the arm cannot be abducted above the horizontal plane because glenoid cavity cannot be rotated upward without the action of the serratus anterior.