Common Problems of the Upper Extremity

Common Problems of the Upper Extremity

The structures in the upper extremity are frequently the sites of painful syndromes. The structures most frequently affected are the shoulder, wrist, and hand.

BURSITIS AND TENDINITIS

Bursitis and tendinitis are inflammatory conditions that com-monly occur in the shoulder. Bursae are fluid-filled sacs that pre-vent friction between joint structures during joint activity. When inflamed, they are painful. Similarly, muscle tendon sheaths be-come inflamed with repetitive stretching. The inflammation causes proliferation of synovial membrane and pannus formation, which restricts joint movement. Conservative treatment includes rest of the extremity, intermittent ice and heat to the joint, and nonsteroidal anti-inflammatory drugs (NSAIDs) to control the inflammation and pain. Arthroscopic synovectomy may be con-sidered if shoulder pain and weakness persist.

LOOSE BODIES

Loose bodies may occur in a joint as a result of articular cartilage wear and bone erosion. These fragments interfere with joint movement, locking the joint, and cause painful movement. Loose bodies are removed by arthroscopic surgery.

IMPINGEMENT SYNDROME

Overuse (microtrauma) may produce an impingement syndrome in the shoulder. The supraspinatus and biceps tendons become irritated and edematous and press against the acromion process, limiting shoulder motion. The patient experiences pain, shoulder tenderness, limited movement, muscle spasm, and atrophy. The process may progress to a rotator cuff tear. Conservative treat-ment includes rest, NSAIDs, joint injections, and physical ther-apy (Chart 68-4). Arthroscopic débridement is used for persistent pain. Gentle joint motion is begun after surgery.

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome is an entrapment neuropathy that occurs when the median nerve at the wrist is compressed by a thickened flexor tendon sheath, skeletal encroachment, edema, or a soft tis-sue mass. The syndrome is commonly caused by repetitive hand activities but may be associated with arthritis, hypothyroidism, or pregnancy. The patient experiences pain, numbness, paresthesia, and possibly weakness along the median nerve (thumb and first two fingers). Tinel’s sign may be used to help identify carpal tun-nel syndrome (Fig. 68-4). Night pain is common. Treatment is based on cause. Rest splints to prevent hyperextension and pro-longed flexion of the wrist, avoidance of repetitive flexion of the wrist (eg, use of ergonomic changes at work to reduce wrist strain), NSAIDs, and carpal canal cortisone injections may relieve the symptoms. Specific yoga postures, relaxation, and acupuncture may provide nontraditional alternatives to relieve carpal tunnel symptoms. Traditional or endoscopic laser surgical release of the transverse carpal ligament may be necessary. The patient wears a hand splint after surgery and limits hand use during healing. The patient may need assistance with personal care and ADLs. Full re-covery of motor and sensory function after nerve release surgery may take several weeks or months.

GANGLION

A ganglion, a collection of gelatinous material near the tendon sheaths and joints, appears as a round, firm, cystic swelling, usu-ally on the dorsum of the wrist. It most frequently occurs in women younger than 50 years of age. The ganglion is locally ten-der and may cause an aching pain. When a tendon sheath is in volved, weakness of the finger occurs. Treatment may include as-piration, corticosteroid injection, or surgical excision. After treat-ment, a compression dressing and immobilization splint are used.

DUPUYTREN’S CONTRACTURE

Dupuytren’s deformity is a slowly progressive contra1cture of the palmar fascia, which causes flexion of the fourth and fifth fingers, and frequently the middle finger. This renders the fingers more or less useless (Fig. 68-5). It is caused by an inherited autosomal dominant trait and occurs most frequently in men who are older than 50 years of age and who are of Scandinavian or Celtic ori-gin. It is also associated with arthritis, diabetes, gout, and alco-holism. It starts as a nodule of the palmar fascia. The nodule may not change, or it may progress so that the fibrous thickening ex-tends to involve the skin in the distal palm and produces a con-tracture of the fingers. The patient may experience dull aching discomfort, morning numbness, cramping, and stiffness in the affected fingers. This condition starts in one hand, but eventu-ally both hands are affected symmetrically. Initially, finger-stretching exercises may prevent contractures. With contracture development, palmar and digital fasciectomies are performed to improve function. Finger exercises are begun on postoperative day 1 or 2.