Chapter 13

Upper Limb
Conditions
Aetiological classification
Anatomical classification
Shoulder
Elbow
Wrist and hand

Upper Limb Conditions 487

 Classification
Aetiological classification
Congenital abnormalities
Amelia and phocomelia
Macrodactyly
Syndactyly
Synostoses
Osteochondroma and other neoplasms
Neoplasia
Benign -- bony
cartilaginous
soft tissue
Malignant -- primary -- bony
cartilaginous
soft tissue
secondary
Trauma
Soft tissue injuries -- tendons and
ligaments
nerves
vessels
Subluxation and dislocation
Fractures
Infection
Soft tissue
Bone
Joint
Arthritis
Degenerative (primary or secondary)
Autoimmune
Metabolic
Haemophilic arthropathy
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Paralysis
Cerebral -- cerebral palsy
neoplasia
vascular conditions
trauma
Spinal -- fractures
disc protrusion
syringomyelia
poliomyelitis
spina bifida
Peripheral nerves -- c a r p a l tunnel
syndrome
peripheral neuritis and toxins
diabetic neuropathy
Anatomical classification
Shoulder conditions
Supraspinatus and rotator cuff
Acromioclavicular and sternoclavicular
joints
Biceps tendon
Elbow conditions
Tennis elbow
Golfer’s elbow
Ulnar neuritis
Olecranon bursitis
Wrist and hand conditions
Ganglion
Dupuytren’s contracture
Carpal tunnel syndrome
Trigger finger
de Quervain’s syndrome

Upper Limb Conditions 489

Aetiological
Classification
Most of the conditions affecting the upper
limb are discussed in other chapters. This
chapter will therefore describe only those
conditions that do not ‘fit’ into any spe-
cific category.
The following is a summary of conditions
which are described elsewhere:
Congenital abnormalities
These include deficient growth, overgrowth
or fusion of limbs and various other con-
genital abnormalities due to genetic defects
such as achondroplasia. Developmental
abnormalities may also be secondary to ante-
natal insults such as infections, drugs and
radiation.
Neoplasia
Some bony neoplasms are inherited in an au-
tosomal dominant pattern such as multiple
osteochondromata, (diaphyseal aclasis). Most
neoplasms, however, are of unknown aetiology.
Examples are benign neoplasms such as bone
cysts and fibrous dysplasia, or malignant
neoplasms such as osteogenic sarcoma, chon-
drosarcoma and Ewing's sarcoma.
Trauma
The differential diagnosis in many orthopaedic
conditions must include old or recent injuries
to bone, ligaments, tendons or other

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Congenital webbing X-ray appearance of an

of the elbow osteogenic sarcoma

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X-ray appearance of an Traumatic tendon

osteochondroma of the injury
upper humerus
Upper Limb Conditions 491
structures, which otherwise may cause
difficulty in diagnosis.
Infection
Bone and joint infections may be acute or
chronic and may cause osteomyelitis of bones
or pyogenic arthritis of joints. Acute in-
fections may result from organisms such as
pyogenic staphylococci, whereas chronic low
grade infection may be due to an organism
such as Mycobacter-ium tuberculosis. The be-
haviour of an acute pyogenic organism may be
modified by antibiotics so as to mimic that
of a chronic organism.
Arthritis
Degenerative osteoarthritis and rheumatoid
arthritis are the most common types. Gout
and haemophilic arthritis are two other non-
infective causes of arthritis in the upper
limb.

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X-ray appearance Severe gouty

of osteomyelitis tophi

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Rheumatoid arthritis Ulnar nerve palsy

Upper Limb Conditions 493

Paralysis
Paralytic conditions can be divided into those
of cere-bral, spinal cord, or peripheral nerve
origin.
These are described in detail in both Chapter
3 and Chapter 11.

Anatomical Classification
Shoulder conditions
Supraspinatus and rotator cuff
The rotator cuff inserts into the upper end
of the humerus, and particularly the tuber-
osity and posterior and upper part of the
head of the humerus. This allows the deltoid,
which inserts into the deltoid tuberosity
one-third of the way down the shaft, to act
as an abductor. The posterior insertion also
acts as an external rotator of the shoulder.
Complete rupture of the rotator cuff is
not uncommon in older patients with
degenerative arthritis, and may be caused by
minimal trauma.
Partial rupture also occurs, but may appear
to be complete as pain limits any movement.
It may be differentiated from complete rup-
ture by injecting the supra-spinatus with
local anaesthetic to eliminate the pain and
thus allow the remaining fibres to act.
In partially degenerated tendons, calci-
fication in the supraspinatus tendon may occur
and lead to a painful arc of movement between
about 60½ and 120½ of abduction, as the

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Chronic tendinitis — the Acromioclavicular

painful arc syndrome joint subluxation

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Ruptured biceps X-ray appearance of

tendon cervical spondylosis
Upper Limb Conditions 495
inflamed area impinges on the undersurface
of the acromion. X-ray often shows the area
of calcification in the supraspinatus tendon.
There may also be degenerative changes in
the shoulder. Associated cervical spondy-
losis is common with C5 and C6 root pressure
due to narrowing in the C4/5 and C5/6 fo-
ramina on the affected side from osteophytic
formation.
Inflammation of the subacromial bursa may
also cause pain and is often associated with
degenerative changes in the tendon.
In addition to X-rays, and injection of a
suspected partial rupture, investigations
include an arthrogram, a computerised tomogram
(CT) or magnetic resonance imaging (MRI) to
show a ruptured tendon. Arthroscopy may also
be carried out both for diagnosis and treat-
ment.
Attempted repair of the tendon may be in-
dicated in younger patients, but in older
patients physiotherapy with active assisted
exercises will give almost as good long term
results.
Supraspinatus calcification is often dis-
persed by an injection of hydrocortisone and
local anaesthetic into the area, but sometimes
operative decompression may be necessary for
the acute pain associated with this condi-
tion. Treatment of the associated shoulder
arthritis and cervical spondylosis may also
be necessary.
Acromioclavicular joint
Acromioclavicular joint osteoarthritis,
subluxation or dislocation may also cause
shoulder pain and limitation of abduction.
It is easily diagnosed by palpation of the
tender area, and is treated by physiotherapy
and occasionally excision of the outer end
of the clavicle.
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Sternoclavicular joint
Sternoclavicular osteoarthritis or subluxa-
tion usually also requires physiotherapy and
rarely operative treatment.
Biceps tendon
Biceps tendonitis may occur over the anterior
aspect of the long head of biceps in the
anterior upper aspect of the humerus.
Occasionally a degenerated tendon may rup-
ture and produce a painless swelling in the
arm on contraction of the muscle.
Tendonitis is often relieved by an injection
of hydro-cortisone and perhaps physiotherapy.
A rupture of the tendon is usually associated
with osteoarthritis of the shoulder which is
often accompanied by cervical spondy-losis.
The actual rupture does not cause any appre-
ciable disability and does not require treat-
ment.
Cervical spondylosis
This may cause referred pain into the
shoulder. It is often associated with pain
and numbness radiating down the arm and
occasional weakness, with stiffness of the
shoulder. Cervical spondylosis may also cause
tenderness in the extensor muscles of the
forearm. The diagnosis and treatment of cer-
vical spondylosis is discussed elsewhere in
this book (Chapter 11).
Trauma
Shoulder trauma includes fractures of the
neck and tuberosity of the humerus and both
anterior and posterior dislocation of the
joint. This should always be considered in
the differential diagnosis.
Arthritis
Arthritis of various types, including
osteoarthritis, rheumatoid arthritis and gout
are all discussed under the relevant sec-
tions of this book (Chapter 10).

Upper Limb Conditions 497

Elbow conditions
Tennis elbow
This condition is due to a tear of a number
of the fibres of the common origin of the
forearm extensor muscles over the lateral
epicondyle. It is usually caused by wringing
of clothes and similar repetitive actions
rather than tennis. There is a localised
tender area, mainly over the lateral epi-
condyle (not the extensor muscles in the
upper forearm). Gripping will usually exac-
erbate the pain, as will extension of the
second and third fingers against resistance.
Pain caused by dorsiflexion of the wrist
against resistance is of limited diagnostic
value.
Injection of hydrocortisone and local
anæsthetic into the tender area will relieve
the pain in over 80% of cases but may have to
be repeated.
A support around the forearm just below
the elbow is often successful. In very severe
cases operation and freeing of the extensor
origin is necessary.
Golfer’s elbow
This occurs with tenderness over the common
origin of the forearm flexor muscles and is
much less common. Treatment is similar to
the above.
Ulnar neuritis
This is commonly due to trauma to the nerve
behind the medial epicondyle. A valgus de-
formity of the elbow due to a previous supra-
condylar fracture may also stretch the nerve.
Ulnar neuritis may necessitate transposi-
tion of the nerve anterior to the epicondyle.

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Tennis elbow Golfer’s elbow

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Ulnar neuritis

Upper Limb Conditions 499

Olecranon bursitis (student’s elbow)
This is due to pressure over the bursa which
may become inflamed and infected. This
occasionally requires antibiotics or incision
and decompression.
Cutaneous nodules
Rheumatoid or gouty nodules sometimes occur
over the olecranon process. These may also
involve the elbow joint itself and cause
pain and stiffness.
Trauma
Fractures around the elbow, including the
supracondylar region, olecranon and head of
radius must always be considered in a
differential diagnosis. Neoplasms, bone and
joint infections and arthritis due to vari-
ous causes are discussed elsewhere in this
book.
Pyogenic infection of the elbow joint
itself may be secondary to an overlying wound
or infected bursa, or due to systemic
infection.
Osteoarthitis secondary to a previous
fracture or injury often causes both
deformity and stiffness of the elbow.
Associated with this is often limitation of
rotation of the elbow joint.

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 Elbow Conditions

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Olecranon
bursitis

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Rheumatoid nodule or
gouty tophus

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X-ray appearance
X-ray appearance of a of osteoarthritis
supracondylar fracture of the elbow
Upper Limb Conditions 501
Wrist and hand conditions
Ganglia
This is a firm cystic swelling, usually over
the dorsum but sometimes palmar surface of
the wrist. It probably arises from
degeneration of the capsule of the wrist
joint rather than a true outpouching. It is
filled with glairy fluid and is firm and
spherical. It may transilluminate, is only
slightly tender and may disappear into the
joint on extension or flexion of the wrist.
Although it may burst with trauma (the
traditional cure is hitting it with the family
bible!) it is best excised properly under
tourniquet control if symptomatic.
Dupuytren’s contracture
A Dupuytren’s contracture is a fascial thick-
ening of the palm, usually most marked over
the fourth metacarpal and proximal phalanx.
It may be associated with a similar condi-
tion in the sole of the foot and in the
corpus cavernosum of the penis. Some drugs,
especially those given for epilepsy, are
sometimes responsible, as is trauma. Mild
cases in the elderly may not require
treatment.
In young patients, and in severe cases
excision of the fibrous bands in the palm is
indicated.
Carpal tunnel syndrome
Carpal tunnel syndrome results from narrow-
ing of the carpal tunnel. This narrowing may
be secondary to a previous fracture, os-
teoarthritis or synovial thickening in
pregnancy or conditions such as rheumatoid
arthritis.
The patient complains of an aching wrist,
often worse at night when the arm is warm,
together with variable numbness in the radial
three and a half fingers and weakness and
wasting of the thenar muscles.

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Ganglion Dupuytren's
contracture

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Carpal tunnel syndrome-

Swollen hand-
thenar muscle wasting,
tendon sheath
weakness and
infection
paraesthesia

Upper Limb Conditions 503

 Rest with a simple detachable splint and
anti-inflammatory drugs may give some relief
but division of the flexor retinaculum of
the wrist is often necessary.
Infections of the hand
Infections of the soft tissues of the hand
are common. They vary from infection of the
nail fold (paronychia) to infection of the
palmar spaces and tendon sheaths.
In the palm, considerable swelling may
occur and early drainage is essential if
infection does not rapidly resolve with
antibiotics.
Trigger finger
A trigger finger or thumb results from con-
striction of a flexor tendon sheath which
produces swelling of the corresponding tendon.
Repeated friction leads to localised tendon
hypertrophy and nodule formation. A nodule
may occasionally be congenital but is usually
secondary to repetitive trauma. There is a
tender nodule at the base of the affected
finger over the metacarpophalangeal joint.
The finger can usually be flexed but exten-
sion is difficult, producing a ‘trigger’ or
flicking motion as the nodule passes through
the constriction. Treatment options include
the injection of hydrocortisone and local
anaesthetic and if this is unsuccessful, sim-
ple division of the sheath.

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Paronychia Trigger finger

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X-ray appearance
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of avascular
necrosis
de Quervain’s syndrome of the lunate

Upper Limb Conditions 505

de Quervain’s syndrome
This is a tenovaginitis or constriction of
the tendon sheaths of extensor pollicis brevis
and abductor pollicis longus over the lower
radius. The cause is usually excessive use
of the tendons through repetitive movements,
such as wringing of clothes.
The patient complains of tenderness over
the radial styloid which is exacerbated by
abducting the thumb against resistance or
forcibly flexing the thumb across the palm
of the hand (Finglestein’s test).
The differential diagnosis includes a
fracture of the radial styloid process, a
fractured scaphoid or fracture or osteoar-
thritis of the first carpometacarpal joint.
Treatment options include injection of the
area with hydrocortisone and local anæsthetic
(less than 50% success) or division of the
tendon sheaths.
Avascular necrosis of the lunate
(Kienbock’s disease)
This is a rare condition and is probably
caused by injury to the blood supply to the
bone. Tenderness over the lunate will occur
but the diagnosis is made on the X-ray ap-
pearance of an avascular bone which may show
collapse.
Arthritis
Rheumatoid arthritis, osteoarthritis and gout
are discussed in Chapter 10.

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