Regional conditions of upper limb

1. Dr. AISHWARYA RAI, PT
BPT, FELLOW IN REGENERATIVE
REHABILITATION, CKTP.

2. ANATOMY
SHOULDER
ARM/ BRACHIUM
FOREARM/ ANTE-BRACHIUM
HAND/ MANUS

6. •The shoulder joint is a synovial joint of the ball and
socket variety.
•Structurally, it is a weak joint because the glenoid cavity
is too small and shallow to hold the head of the
humerus in place
•The shoulder joints get excessive mobility at the cost of
its own stability, since both are not feasible to the same
degree.
•BONES FORMING THE SHOULDER COMPLEX
1. Clavicle 2. Humerus 3. Scapula 4. Sternum
• Due to the compromised mobility of the joint a few
structures that provide stability to the joint are:
1. The rotator cuff 2. Ligaments 3. Glenoid Labrum
4. Long head of Biceps brachii muscle
SHOULDER
JOINT

7. Fig: SHOULDER JOINT COMPLEX

8. ELBOW JOINT
The elbow joint is a synovial joint between the lower
end of humerus and the upper ends of radius and ulna
bones.
Articular Surfaces:
Upper: The capitulum and trochlea of the humerus.
Lower: (i) Upper surface of the head of the radius
articulates with the capitulum, (ii) trochlear notch of
the ulna articulates with the trochlea of the humerus.
The elbow joint is continuous with the superior
radioulnar joint. The humeroradial, the humeroulnar
and the superior radioulnar joints are together known
as cubital articulations.

9. FIG: ELBOW JOINT FIG: RADIO-ULNAR JOINTS

10. WRIST JOINT
THE WRIST JOINT IS A SYNOVIAL JOINT OF
ELLIPSOID VARIETY BETWEEN LOWER END OF
RADIUS AND THREE LATERAL BONES OF
PROXIMAL ROW OF CARPUS.
Articular Surfaces
Upper:
1.Inferior surface of the lower end of the radius
2.Articular disc of the inferior radioulnar joint
Lower:
1.Scaphoid
2.Lunate
3.Triquetral bones.

11. Fig: wrist joint

12. SHOULDER
CONDITIONS
Rotator Cuff Lesions.
Adhesive Capsulitis
Deltoid Contracture
Bursitis

14. ROTATOR CUFF
LESIONSThis includes both rotator cuff tears and impingement
syndrome.
Impingement Syndrome: Commonly associated with
supraspinatus tendon, where the supraspinatus tendon
gets impinged below the coracoacromial arch. The
major site of compression is anterior to the angle
of the acromion. Hence, the proper term is anterior
impingement syndrome or painful arc syndrome.
The pathology of subacromial impingment generally
relates to a chronic repetitive mechanical process in
which the conjoint tendon of the rotator cuff muscles
undergoes repetitive compression and micro trauma as
it passes under the coraco-acromial arch.
As the arm is flexed, abducted or rotated the
subacromial space width changes and the cuff becomes
increasingly compressed.

15. In this syndrome, the arc of
shoulder abduction elevation
is painful from about 45–160
degrees, but this is painless up
to the initial 45 degrees as well
as in the terminal range from
about 160 degrees to full
elevation. The passive ROM is
pain free.
The cause is mechanical – the
tender structure get nipped in
between the tuberosity of the
humerus and the acromion
process or coracoacromial
ligament.

16. NEER’S STAGES OF
IMPINGEMENT
 Stage 1 is characterized by edema and tendinitis and is more typical in
patients under 25 years old.
 Stage 2 is characterized by chronic inflammation, thickening and fibrosis
of the impinged tendon due to repeated insults. This further decreases the
size of the suprahumeral space. Stage 2 is more typical in patients between
25 and 40 years old and patients who have had a history of episodes of
shoulder pain.
Stage 3 is characterized by tendon degeneration, rupture, and arthritis.
Patients with this stage of impingement are usually over 40 years old and
have a prolonged history of shoulder problems. Often, at this stage, there
will be radiographic evidence and a high likelihood of partial or full thickness
rotator cuff tears.

17. CLASSIFICATION:
PRIMARY:
Impingement occurs beneath the
coracoacromial arch and is due to the
subacromial overloading.
SECONDARY:
Occurs due to relative decrease in the
subacromial arch and is due to
microinstability of the GH joint or ST joint.
POSTERIOR(INTERNAL):
In this the supraspinatus and infrapinatus
tendons are pinched between the posterior
and superior aspects of the glenoid when the
arms are in an elevated and externally rotated
position. It is usually seen in athletes involved
in more of overhead activities like throwers,
swimmers, etc.

18. KEY SYMPTOMS OF
IMPINGEMENT
Toothache like Antero-lateral shoulder
region.
Pain sleeping on the affected side
Stiffness
Catching of the shoulder during use
Pain on active and passive range of
motion
Local tenderness
Nocturnal pain

21. TREATMENT:
If conservative method fails even after three months,
then surgical method is opted for
Arthroscopic repair in small and partial tears.
 Open methods in major tears.
Depending upon the etiological factors, the following
surgical techniques are described: Excision
of adhesions and manipulation of shoulder, excision of
calcium deposits, repair of incomplete tear,
acromioplasty, acromionectomy for more disabling
pain with normal range of movements, direct suture for
complete rupture of rotator cuff, rotation and
transposition of flap, free graft, etc. Results are good in
85-90 percent.

22. Deltoid contracture/fibrosis is a condition where
intramuscular fibrous bands within lead to contractures and
stiffness of the shoulder joint.
It is seen in people of all ages, but it has been reported
primarily in children. It is often associated with
congenital/developmental defects, a genetic disposition or
application of intramuscular injections.
The fibrosis could develop by any of the following
Direct injury to the muscle
 by the needle
 toxicity of the drug.
Volume of injection causing ischemia of selected portion
Local edema
Fibrotic compression
Damage to vessels
Fibrotic compartmentalization
Muscle ischemia
Entrapment neuropathy
DELTOID
CONTRACTURE

23. Fig: Deltoid fibrosis

24. Fig; Arms Resting in abduction
Fig: Winging of scapula

25. a. Abduction contracture of the left shoulder with winging of the scapula.
b. The winged scapula disappears with horizontal abduction of the shoulder.
c. anterior protrusion of the left humeral head and winging of the scapula.

26. Fig: Deltoid contracture along with scoliotic changes

27. Patient presents with a history of restriction of shoulder
movement affecting the activities of daily living. The patient
would typically complaint of inability to pull the arm fully
down to the side of the body or across. A complaint of pain
near the near the shoulder and neck may be present.
On examination, one may notice a dimple over the deltoid
skin. Palpation would reveal a fibrous palpable band.
Patient should be enquired for the history of injections,
similar contracture in other parts of the body and a family
history of similar contractures. Depending on the part of
the deltoid involved, the limb of the patient may be:
oAbducted – Middle portion
oFlexed and abducted – Anterior portion
oExtended and abducted – Posterior Portion
In severe cases involving anterior or posterior parts, the
subluxation/dislocation of the humeral head may occur.
Examination should look for high riding scapula(Sprengel
deformity) or other abnormalities like scoliosis or chest wall
abnormality. Motion of neck, glenohumeral joint
and scapula should be assessed. Winging of scapula and
freedom of scapular motion should be noted. Look for
evidence of contractures elsewhere in both the upper and
the lower extremities.

28. Diagnosis: X-ray, CT Scan, MRI.
May reveal flattening of the head of the humerus
and drooping of acromion due to constant
contracture. With increased contracture, inferior
border of the scapula rotates medially, causing the
winging of the scapula. In severe abduction
contracture, secondary scoliosis may occur.
Treatment:
The surgical treatment should be considered if
Contracture > 25 degrees; Age> 5 years;
Progressively increasing; Painful.
Fibrous bands are released or resected.
The arm is immobilized across the body in adducted
position for about two weeks after the surgery.
After this patient is put on physical therapy and
movements are started.

29. ADHESIVE
CAPSULITISIt is defined as a clinical syndrome characterized by painful
restriction (Figs 30.1A and B) of both active and passive shoulder
movements due to causes within the shoulder joint or remote
(other parts of the body).
Patient Presentation:
The hallmark of adhesive capsulitis is pain and decreased motion.
Needless to say, there are many conditions which cause either
pain or decreased motion or both; adhesive capsulitis can appear
as an isolated condition or accompanying another shoulder
condition.
Patients with adhesive capsulitis present with gradual unilateral
shoulder pain that is often diffuse and worse at night. They also
report an insidious onset of increasing stiffness. Some patients
may “remember” a trivial trauma inciting the process, though
this is likely a faulty attribution.

31. Fig: The capsule, outlined in blue, holds the
humeral head against the glenoid
Fig: Decreased ROM in an adhesive capsulitis affected patient

32. Clinically, isolated adhesive capsulitis has 3 distinct phases,
namely: the painful phase, the stiff phase, and the resolution
phases.
The Painful (or “freezing”) Phase begins gradually, with no
known precipitant. This phase, which lasts weeks to months, is
characterized by diffuse, disabling pain that is worse at night.
The Stiff Phase is noted by marked stiffness that limits range of
motion in multiple plains, interfering with activities of daily
living. Pain is less intense at this point. This phase can last a
year or longer.
Most patients enter a Resolution (“thawing”) Phase during
which motion improves, though often some limitations of range
of motion compared to the contralateral shoulder remain.
On physical exam, patients with adhesive capsulitis have
significantly reduced active and passive range of motion in two
or more planes (see Figure 3 for normal ranges of motion).
External rotation and abduction are the most commonly
affected movements. Patients also have difficulty internally
rotating, and report problems scratching their hand on their
back or hooking their bra from behind.

33. Fig: An arthrogram showing a reduced volume of contrast material within
the shoulder joint. The red line outlines the border of the normal border
of the capsule

34. BURSITIS
Bursae are membranous sacs lined by synovial
membrane and sited so that they prevent friction or
wear and tear of muscles and tendons as they pass
over the bone.
It is of two types:
True bursa: eg. Found subacromially, etc.
Adventitious bursa: Occur in response to friction
over tendon and can occur anywhere.

35. Bursitis is the inflammation of these bursa. The
inflammation arises because of excessive pressure, friction
or gouty deposit.
Irritative bursitis: This is the commoner of the two types. It
is caused by excessive pressure or friction, occasionally due
to a gouty deposit. Inflammation of the bursa results in the
effusion of a clear fluid within the bursal sac. With
prolonged inflammation, the sac gets thickened and may
cause pressure erosion on the adjacent bone.
Infective bursitis: Uncommonly, a bursa may get infected by
a pyogenic or tubercular infection.
TREATMENT:
Rest
Icing
NSAIDs
Corticosteroids
If infective- antibiotics and surgical drainage.
Surgical: Excision of the bursa (rarely done)

36. Fig: subacromial bursitis
Fig: Application of corticosteroid
injections

37. Fig: Prepatellar bursitis
Fig: Olecranon bursitis

38. ELBOW
CONDITION
S
Lateral Epicondylitis
Medial Epicondylitis

39. Lateral Epicondylitis is a common clinical entity characterized
by pain and tenderness at the common origin of the extensor
group muscles of the forearm, usually as a result of a specific
strain, overuse, or a direct bang. It is considered a cumulative
trauma injury that occurs over time from repeated use of the
muscles of the arm and forearm, leading to small tears of the
tendons (Tendonitis).
CAUSES
Epicondylitis: This is due to single or multiple tears in the
common extensor origin, periostitis, angiofibroblastic
proliferation of extensor carpi radialis brevis (ECRB), etc.
Inflammation of adventitious bursa: Between the common
extensor origin and radio humeral joint.
Calcified deposits: Within the common extensor tendon.
Painful annular ligament: It is due to hypertrophy of synovial
fringe between the radial head and the capitulum’s.
Pain of neurological origin: e.g. cervical spine affection,
radial nerve entrapment, etc
LATERAL
EPICONDYLITIS

40. STAGES
Stage I: There is acute inflammation but no angioblastic
invasion. The patient complains of pain during
activity.
Stage II: This is the stage of chronic inflammation. There
is some angioblastic invasion. The patient complains of
pain both during activity and at rest.
Stage III: Chronic inflammation with extensive
angioblastic invasion. The patient complains pain at rest,
night pains, and pain during daily activities.
PATIENT PRESENTATION
Patient complains of pain on the outer aspect of the
elbow and has difficulty in gripping objects and lifting
them. Sportspersons will have difficulty in extending the
elbow. Eventually the pain may become so constant and
severe so as to stop the patient from further
playing or interferes with activities of daily
living, such as carrying a briefcase, wringing wet
clothes or even holding a cup of tea. Grip
becomes weak. Morning stiffness may be felt.

42. TREATMENT
Conservative treatment:
The treatment consists of rest and trying to avoid the
movements that cause pain.
NSAIDs and a tennis elbow splint are used for pain relief.
Local injection of hydrocortisone with local anaesthetic
solution relieves pain in majority of cases.
Surgical treatment:
The extensor muscles are stripped from their origin, i.e.,
lateral epicondyle, and are allowed to fall back. An above-
elbow slab with elbow in 90 degrees flexion is given for a
period of 10 days postoperatively. The elbow is then
mobilized.

43. FIG: KINESIOTAPING FOR TENNIS ELBOW

44. This condition is not as common as the tennis elbow. The site
of tenderness being the medial epicondyle of the humerus
and the seat of inflammation is the common origin of the
flexor group of muscles. The muscles of the common flexor
group are strained or torn from the medial epicondyle of
humerus. Pain is produced by extension of the elbow,
supination and valgus strain. It is called Golfer elbow
because it is thought to be caused when a golfer hits the
ground instead of the ball, thus producing a valgus strain to
the elbow thereby straining the flexor group of muscles.
TREATMENT:
A steroid injection is given locally into the muscle belly at its
origin. The physiotherapeutic management programme
proceeds on the same lines as for lateral epicondylitis
MEDIAL
EPICONDYLITIS

45. FIG: KINESIOTAPING FOR GOLFER’S
ELBOW

47. HAND &
WRIST
CONDITIONS
De Quervain’s Disease
Carpal Tunnel Syndrome
Tenosynovitis
Tenovaginitis
Wrist Ganglion
Duputyren’s Contracture

48. TENOSYNOVITI
SFollowing an infection or an injury, the synovial lining of the
tendon sheath responds by secreting excessive synovial fluid.
This condition is called tenosynovitis.
When it is traumatic, it affects the tendons of the abductor
pollicis longus and extensor pollicis brevis, which form the
radial boundary of the anatomical snuff box.
It may present as irritative or infective tenosynovitis.
CLINICAL PRESENTATION
Severe Pain
Crepitus on palpation
No adhesions or limitations of ROM
*Usually irritative occurs at wrist and ankle
*Infective occurs due to low grade organisms or TB.

50. TREATMENT
Conservative:
Restriction of movement- use of splint, bandaging,
POP cast
Iceing
Antibiotics
Physical Therapy
Surgery:
Splitting of the fibrous sheath, which will require pre-op
and post-op PT.

51. TENOVAGINITI
S
The tendon sheath rather than fibrous sheath is affected.
In tenovaginitis, the difference in the pathology is that instead
of secreting abnormal amount of synovial fluid, the tendon
gets thickened and fibrosed. This limits the movement of the
tendon within its sheath.
TRIGGER FINGERS AND THUMB
It is a stenosing tenovaginitis, in which the sheath of a flexor
tendon thickens, apparently spontaneously, to entrap the
tendon.
CLINICAL FEATURES
Initially, the only symptom is pain at the base of the affected
finger, especially on trying to passively extend the finger. As
the sheath further thickens, the contained tendon gets
swollen proximal to it. The swollen segment of the tendon
does not enter the sheath when an attempt is made to
straighten the finger from the flexed position. This is called
‘locking of finger’. This locking can be overcome either by a
strong effort in which case the finger extends with a snap-like
trigger of a pistol or by extending the finger passively with
other hand.

53. TREATMENT
In early stages, local ultrasonic therapy
provides relief. In a long standing problem, a
local injection of hydrocortisone relieves the
pain. In some cases, splitting of the tight
tendon sheath may be required.

55. DE
QUERVAINS
DISEASEIt is also called as stenosing tenosynovitis of the first dorsal
compartment of the wrist involving the abductor pollicis
longus and extensor pollicis brevis tendons.
This is a condition characterised by pain and swelling over the
radial styloid process. It results from inflammation of the
common sheath of abductor pollicis longus and extensor
pollicis brevis tendons. On examination, the tenderness is
localised to the radial styloid process. Pain is aggravated by
adducting the thumb across the palm and forcing ulnar
deviation and on asking the patient to perform radial
deviation againstresistance (Finkelstein's test). There may be
a palpable thickening of the sheath.

58. TREATMENT
Conservative:
Drug therapy to combat inflammation.
Restriction of movements by applying a small hand splint
in functional position with immobilization of the thumb.
During early stage, ice massage, and at the later stage,
ultrasound or any deep heating modality helps in
reducing inflammation and pain.
Local corticosteroid infiltration may be effective in some.
Surgical intervention: in the form of splitting the lateral
wall of the tendon sheath may be necessary in non
responding cases.

59. CARPAL
TUNNEL
SYNDROME
This is a syndrome characterised by the compression of the
median nerve as it passes beneath the flexor retinaculum
through the carpal tunnel.
CARPAL TUNNEL
Carpal tunnel is the overcrowded fibro-osseous canal formed
between three carpal bones (scaphoid, trapezoid and
hamate) and the transverse carpal ligament. The median
nerve and the nine tendons of the digital flexors pass
through this 2–2.5 cm tunnel. Therefore, any bony or soft-
tissue pathology to it precipitates compressive forces over
the median nerve passing through it.

60. ETIOLOGY
Occupational overuse of wrist joint, e.g.,
computer keyboards
Malunited Colles’ fracture, rheumatoid or
osteoarthritis
Ganglia or haematoma at the wrist
Connective tissue disorders (amyloidosis)
Endocrine disorders like DM, hypothyroidism,
menopause
Metabolic causes like gout
Growth hormone abnormality (acromegaly)
Pregnancy
CLINICAL FEATURES
Pain and discomfort at the wrist during movements or even at rest.
Burning, aching, warmth, paraesthesia in the hand and wrist in the distribution of the
median nerve (tingling, numbness or burning sensation); relieved by shaking hands.
Vasomotor symptoms like swelling, cold, dry and shiny skin.
Motor weakness of opponens, flexor pollicis brevis results in difficulty in making circle
with thumb and index finger. Bottle sign – poor contact of thumb and index finger due to
the paralysis of abductor pollicis brevis, causing difficulties in gripping a cylindrical
object, e.g., bottle or cylinder.
Loss of true opposition.
 Late stage muscular atrophy – thenar muscles of the hand

62. TREATMENT
Conservative
Treatment of the relevant causative factor which has
precipitated the syndrome.
A simple splint that blocks movements at the wrist is
adequate to avoid compressive stretches to the carpal
tunnel.
Nonsteroidal anti-inflammatory drug (NSAID) agents
Local ultrasonic exposure
Pain-free relaxed passive or speedy active movements are
encouraged in the pain-free range by removing the splint.
Cryotherapy, TENS over the palmar aspect of the wrist may
be tried.
Local corticosteroid injection may be given only after
confirming the absence of sensory deficit.
Surgical:
Surgical release of the median nerve may have to be
undertaken by the division of the carpal flexor retinaculum
and/or transverse carpal ligament either by open surgery or
by endoscopic surgery.

64. It is the commonest cystic swelling on the dorsum
of the wrist. It results from mucoid degeneration of
the tendon sheath or the joint capsule. Ordinarily,
there are no symptoms other than the swelling
itself. Sometimes, a mild discomfort or pain is
experienced. The cyst may sometimes be so tense
as to resemble a solid tumour of the tendon sheath.
Often the cyst is multi-loculated. Aspiration of the
cyst is performed and an injection of hylase given.
If the cyst recurs, excision may be required.
WRIST
GANGLION= bible bumps

67. DUPUTYREN’S
CONTRACTURE
This is a condition characterised by a flexion deformity
of one or more fingers due to a thickening and shortening
of the palmar aponeurosis. The cause is unknown, but a
hereditary predisposition has been established. There is an
increased incidence of the disorder among cirrhotic
patients and in epileptics on sodium hydantoin.
CLINICAL FEATURES
In early stages, thickening of the palmar aponeurosis is felt
at the bases of ring and little fingers. Later, a flexion
deformity of the fingers develops. Dupuytren's contracture
can be differentiated from a similar deformity due to
contracture of the flexor tendons; in the former only the
MP and PIP joints are flexed, unlike the latter where the DIP
joints are also flexed.

70. Surgery. This is the most common treatment used for
advanced cases. It may be done when you have limited use
of your hand. During Dupuytren's contracture surgery, the
surgeon makes a cut (incision) in your hand and takes out
the thickened tissue. This can improve the mobility of your
fingers. Some people have contractures return. They may
need surgery again.
Steroid shot (injection). If a lump is painful, a steroid
injection may help ease the pain. In some cases, it may stop
your condition from getting worse. You may need repeated
injections.
Radiation therapy. This treatment is not as common in the
U.S. Low energy X-rays are directed at the nodules. This
works best in the early stage of the disease. It can soften the
nodules and help keep contractions from happening.
Enzyme injection. This is a newer, less invasive procedure
done by specially trained surgeons. Your doctor injects a
medicine into the area to numb the hand. Then the enzyme
is injected into the lump of tissue. Over several hours, the
enzyme breaks down and dissolves the tough bands. This
lets the fingers straighten when the cord is snapped by the
surgeon, usually the next day.
Needle aponeurotomy. This is another newer, less invasive
procedure. Medicine is injected into the area to numb the
hand.

71. REFERENCES
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Clinical; Volume 1; Upper Limb and Thorax
 Essential Orthopedics (Including Clinical Methods); Fifth Edition; J
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 Textbook of Orthopedics, Fourth Edition; John Ebnezar.
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shoulder injury. J Am Acad Orthop Surg. 2012 Jun. 20(6):364-72.
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by distal release of the deltoid. Clin Orthop Relat Res. 2000 Sep. (378):136-42.
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2007 Sep. 16(5):337-44.
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