Upper Extremity Injuries

Overview

Upper extremity injuries are among the most prevalent among athletes. They can also be easily dismissed or minimized by the athlete when it comes time to return to athletics.

Any damage to the hand, elbow, arm, or shoulder is considered an upper extremity injury. Upper extremity injuries are classified into two kinds, acute injuries (those produced by a particular incident or accident), overuse injuries (those caused by repetition).

Athletes, like older individuals, are prone to overuse injuries due to the repeated nature of their sports. Baseball pitchers, for example, are particularly vulnerable to overuse injuries due to their frequent overhand throwing action. This is why rules limiting the amount of pitches each game, particularly for young athletes, are so vital.

Athletes who experience an injury should be withdrawn from the game and assessed by an athletic trainer or another medical specialist. Following the initial examination, a consultation with a primary care sports medicine physician or orthopaedic surgeon is advised. In order to determine the diagnosis, these professionals will take a thorough history, perform a thorough examination, and may propose an x-ray or other sophisticated imaging.

 

Upper Extremity Structures

The upper limb is necessary for our daily activities. It allows us to grip, write, lift, and throw, among other things. Evolution has molded the upper limb into a highly mobile component of the human body.

It is organized into four primary portions that are further separated into areas for more specific description:

• Shoulder
• Arm
• Forearm
• Hand

 

Glenohumeral joint

The glenohumeral joint is one of the joints linked with the shoulder girdle that permits complete upper limb mobility. It is merely the articulation between the scapula's laterally extending glenoid fossa (depression) with the head of the humerus.

 

Bones

The shoulder is the region where the upper limb is attached to the trunk. The bones of the shoulder are:

• the clavicle.
• the scapula.
• the humerus.

 

Muscles

The deltoid and trapezius muscles are the two most superficial muscles in the shoulder. These muscles give the shoulder its distinctive shape.

The rotator cuff muscles are another significant set of muscles in this area. This group includes four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis.

 

Nerves

The nerves in this area originate from the brachial plexus. The plexus is made by the merging of the anterior branches of the 5th, 6th, 7th and 8th cervical nerves (C5-C8) with participation of the anterior branch of the first thoracic spinal nerve (T1). 

In the shoulder and arm, the brachial plexus gives rise to two nerves:

• the suprascapular nerve.
• the axillary nerve.

When the brachial plexus is injured, these nerves are affected and some interesting clinical syndromes can be observed. 

 

Arteries and veins

The axillary artery is the primary artery in the shoulder. This artery originates as a continuation of the subclavian artery at the lateral border of the first rib and finishes at the inferior border of the teres major. It enters the arm posterior to the pectoralis minor and becomes the brachial artery when it reaches the inferior border of the teres major. All arterial branches that provide blood to the shoulder and arm originate in the axillary artery.

The venous drainage of the arm is a continuation of the forearm venous system. The deep brachial veins (deep veins that accompany the brachial artery), as well as the basilic and cephalic veins, are the primary veins of this region. All of these veins eventually drain to the subclavian veins.

 

Common Upper Extremity Injuries

Rotator cuff tendinitis

Swimmer's shoulder; Pitcher's shoulder; Shoulder impingement syndrome; Tennis shoulder 

• Definition:  

Rotator cuff tendinitis is an inflammation (irritation and swelling) of any of the 4 tendons of the rotator cuff muscles of the shoulder.  The most common ones injured are supraspinatus and infraspinatus.  Often the patient can develop what is known as “impingement syndrome”.

• What causes impingement syndrome?

Repeated movement of the arm overhead can cause the rotator cuff to make contact with the acromion, the outside extremity of the shoulder blade where the collarbone is attached. This causes the rotator cuff to become inflamed and swollen, a disease known as tendonitis. Swollen rotator cuffs might become trapped and pinched beneath the acromion. All of these disorders might cause inflammation of the bursa in the shoulder region. A bursa is a fluid-filled sac that acts as a cushion between a bone and surrounding tissues including skin, ligaments, tendons, and muscles. Bursitis is an inflammation of the bursa.

• Signs and tests:

Tenderness above the shoulder will be discovered during a physical examination. When the shoulder is elevated above, pain may ensue. When the shoulder is resisted in certain situations, it normally becomes weak. The Neer's impingement test is frequently positive. The Hawkins Kennedy test is another common impingement test. Both tests position the arm in such a way that the subacromial space is minimized, and if the tissues are larger, they will be squeezed in these postures, increasing discomfort.

X-rays may reveal a bone spur, whereas an MRI may reveal rotator cuff irritation. On MRI, a tear in the rotator cuff may generally be observed.

• Treatment:

Rest the injured shoulder from the activities that produced the issue as well as from activities that create discomfort. Ice packs and nonsteroidal anti-inflammatory drugs administered to the shoulder will help decrease inflammation and discomfort.

Physical treatment to strengthen the rotator cuff and scapula muscles should be initiated, and any underlying causes, such as poor posture, should be addressed. If the pain persists or therapy is impossible due to extreme discomfort, a steroid injection may decrease pain and inflammation sufficiently to allow successful therapy.

If the rotator cuff has been completely torn, or if the symptoms persist despite conservative treatment, surgery may be required. Bone spurs and inflammatory tissue surrounding the shoulder can be removed with arthroscopic surgery. The most frequent procedure is termed a subacromial decompression, and it involves removing the coracoacromial ligament, a third of the width of the acromion, and, in rare circumstances, the distal end of the acromion.

Arthroscopy can be used to treat minor tears. Even major tears may now be treated arthroscopically, while some large tears require open surgery to repair the torn tendon.

 

Shoulder Instability

• What Is Traumatic Shoulder Instability?

Traumatic shoulder instability begins with a dislocation that injures the shoulder's supporting ligaments. The glenoid (shoulder socket) is a generally flat surface that is slightly deepened by the labrum, a cartilage cup that covers portion of the humeral head. The labrum functions as a bumper, keeping the humeral head securely in place in the glenoid. More significantly, the labrum serves as an attachment site for the ligaments that stabilize the shoulder. These ligaments lose support when the labrum is ripped from the glenoid. The kind and extent of injury to the labrum and supporting ligaments determines the development of recurrent instability.
The most common dislocation that leads to traumatic instability is in the anterior (forward) and inferior (downward) direction. A fall on an outstretched arm that is forced overhead, a direct blow on the shoulder, or a forced external rotation of the arm are frequent causes of this type of dislocation. Much less common is a posterior (backward) dislocation, which is usually related to a seizure disorder or electrocution, events in which the muscular forces of the shoulder cause the dislocation.

• Signs  &Symptoms of Shoulder Dislocation.

If the shoulder is dislocated, it is usually very apparent:

• The shoulder is quite painful.
• Motion is severely restricted.
• The shoulder appears to hang down and forward, with a large dimple evident under the acromion (in the area of the collar bone).
• The humeral head may be visible as a bump on the front of the shoulder, or in the armpit.

• How Is Shoulder Instability Diagnosed?

A abrupt dislocation is usually obvious. Because any movement causes pain, the patient normally keeps his or her arm against the side. The direction of the dislocation is indicated by a significant wrinkle under the acromion and a protrusion in the armpit. When the shoulder spontaneously returns to its normal posture, the diagnosis might be more challenging. Patients may simply recall feeling their shoulder "slip" prior to the spontaneous decrease.

A qualified individual may generally relocate the humerus at the location of the damage. There is instant pain relief following the reduction. Without medication, some individuals may be unable to relax their shoulder muscles sufficiently to allow for the decrease. Often, these individuals must travel to the emergency room to have the reduction performed.

X-rays are usually taken to confirm the dislocation, its direction, and to check for a related fracture. After the reduction, follow up X-rays will confirm proper positioning and assess any other injuries. X-rays may reveal a "bony Bankart", which is a fracture of the anterior-inferior glenoid (front, lower portion of the glenoid). The presence of this fracture indicates that the labrum and ligaments in the front part of the shoulder are no longer attached to the glenoid.

If X-rays do not reveal such a fracture, an MRI or arthrogram may be ordered. In this diagnostic test, the status of the labrum and ligaments can be assessed. A Bankart lesion (detachment of the anterior-inferior portion of the labrum from the glenoid) is the most common cause of recurrent instability after an injury.

• Shoulder Instability treatment:

The initial reduction of a dislocation can be quite difficult. Contractions of the shoulder muscles can trap the humeral head against the glenoid. Gentle traction, and at times, medication may be needed to accomplish the reduction. Once the shoulder is reduced, a sling is used for a few days to protect it, and relieve discomfort. Physical therapy may help the patient regain motion in the joint.

 

Non-Operative Treatment

Initial treatment for recurrent instability of the shoulder centers on physical therapy. Strengthening the rotator cuff muscles and periscapular muscles (those around the scapula) gives stability to the joint. The goal of physical therapy is to help the muscles provide stability to the shoulder that the torn ligaments can no longer supply. The therapy for recurrent instability should be carefully designed for each patient since this condition often causes apprehension about certain arm positions or exercise maneuvers. Very often, physical therapy can help regain lost motion, reduce apprehension, and restore shoulder function.

 

Operative Treatment

Surgery is usually recommended if recurrent instability cannot be controlled with physical therapy and activity modification. The goal of surgery is to return stability to the shoulder with the least loss of motion. All shoulder procedures designed to stabilize the shoulder involve some loss of motion. The current procedures for anterior shoulder instability attempt to restore the normal anatomy without over tightening the ligaments. In certain instances, such as in young persons who have a higher risk of re-dislocation and in contact athletes who plan on continuing to participate in sports that put their shoulders at risk, surgery may be performed after the first dislocation.

• What Types of complications may occur?

Recurrent instability and/or loss of mobility are the most common consequences of anterior stabilization procedures. The rate of recurrent instability is primarily determined by the repair procedure utilized. The loss of mobility might be significant due to overtightening of the anterior capsule. In general, no more than 10 degrees of external rotation should be lost by the operative shoulder. Infection, post-operative stiffness, nerve damage, or blood vessel injury are all minor hazards (less than 1%).

 

Lateral Epicondylitis or Tennis Elbow

Injury to the lateral aspect of the elbow is the most common upper extremity tennis injury. Tennis elbow is generally caused by overuse of the extensor tendons of the forearm, particularly the extensor carpi radialis brevis. Commonly experienced by the amateur player, this injury is often a result of (1) a one-handed backhand with poor technique (the ball is hit with the front of the shoulder up and power generated from the forearm muscles), (2) a late forehand swing preparation with resulting wrist snap to bring the racquet head perpendicular to the ball, or (3) while serving, the ball is hit with full power and speed with wrist 

pronation (palm turned downward) and wrist snap which increases the stress on the already taught extensor tendons.

• Causes of Tennis Elbow.

Small tears in the tendon caused by overuse, according to one idea, are the cause of lateral epicondylitis. They begin to recover, but when wounded again by continuing use, the tendons appear to give up on attempting to mend and a disease known as angiofibroblastic degeneration takes hold. Consider this scar tissue that never matures and stays weak and uncomfortable. 

Others believe that the tendon alterations are mostly the result of reduced blood supply in the region. The creation of angiofibroblastic tendinosis tissue remains the ultimate consequence. Repeated stresses, such as pounding a nail, taking up a heavy bucket, or cutting shrubs, might cause the same events.

• Signs and Symptoms:

General:

• difficulty holding onto, pinching, or gripping objects. 
• pain, stiffness, or insufficient elbow and hand movement.
• forearm muscle tightness.
• insufficient forearm functional strength. 
• point tenderness at or near the insertion sites of the muscles of the lateral or medial elbow.

Specific:

• Lateral Epicondylitis.
• painful resisted wrist extension.
• painful resisted radial deviation.
• (bending wrist toward pinky).
• palpation tenderness of the lateral epicondyle.

 

• Treatment:

1. Initial treatment focus’ on R.I.C.E if acute.
2. If chronic, focus of treatment is on restoring blood supply to the area and promoting the formation of healthy collagen tissue in the tendon.
3. Treatment therefore will consist of TFM, many reps of submaximal exercises with a focus on eccentric work.
4. Regaining full ROM of the extensor musculature (Mills position).
5. Eventually re-strengthening the entire forearm and hand through specific exercises and ultimately functional re-training.
6. In some cases, counterforce brace assists recovery.
7. Physicians often inject with cortisone….be careful!
8. Very chronic cases may have surgery.

 

Humerus fractures

A humerus fracture is the medical name for breaking the bone in your upper arm (your humerus). Humerus fractures are usually caused by traumas like car accidents or falls.

• Types of fractures

Your healthcare provider will assign your fracture a type or classification depending on how your humerus is broken. Some fractures are classified by the shape or pattern of the break line:

• Transverse fracture.
• Oblique fracture.
• Spiral fracture.
• Segmental fracture.
• Comminuted fracture.
• Impacted fracture.
• Buckle fracture.
• Hairline fracture.

Some types of fractures are classified by how they happen:

• Stress fracture.
• Avulsion fracture.

 

• Supracondylar humerus fractures

If you break your humerus right above your elbow, you might have what’s called a supracondylar fracture. This is a type of elbow fracture that almost always affects kids. Supracondylar humerus fractures are usually caused by a child catching themselves from a fall with their arm stretched out in front of them. Your provider will diagnose and treat a supracondylar fracture like any other broken bone.

• Open vs. closed fractures

Your healthcare provider will classify your fracture as either open or closed. If you have an open fracture your bone breaks through your skin. Open fractures usually take longer to heal and have an increased risk of infections and other complications. Closed fractures are still serious, but your bone doesn’t push through your skin.

• Displaced humerus fractures

Your fracture will also be described as displaced or non-displaced by your physician. When your bone cracked, the fragments of your bone migrated so far apart that a gap formed around the fracture. Non-displaced fractures are still shattered bones, but the fragments were not shifted far enough to be out of alignment during the break. Displaced fractures are far more likely to have surgical correction.

• Humerus fracture locations and anatomy

Your provider might reference where on your humerus you experienced a fracture. There are lots of terms providers use to talk about specific bones, but the most common ones you’ll hear are:

1. Location (proximal and distal): Proximal and distal are words that describe where a fracture is located along your bone’s length. The proximal end of your humerus is the top. The distal end is the bottom. So, if you have a proximal humerus fracture, your upper arm bone is broken near its top — the end that connects to your shoulder. Similarly, if you have a distal humerus fracture that means your bone is broken at the bottom, closer to your elbow.
2. Anatomy (parts of your bones): Even though your bones are one piece, they have many parts that can be damaged during a fracture. Your humerus has a head (your proximal aspect, near your shoulder), shaft and distal aspect (the end at the bottom, near your elbow). Other common labels like the surgical neck and greater tuberosity are just specific areas on your bone. These terms are usually more for your healthcare provider to use as they describe where your bone is damaged.

 

• What are the symptoms of a humerus fracture?

Symptoms of humerus fractures include:

• Pain.
• Swelling.
• Tenderness.
• Inability to move your arm like you usually can.
• Bruising or discoloration.
• A deformity or bump that’s not usually on your body.

 

• What Tests Are Done to Diagnose Humerus Fractures?

You’ll need at least one of a few imaging tests to take pictures of your fracture:

• X-rays: An X-ray will confirm any fractures, and show how damaged your bones are.
• Magnetic Resonance Imaging (MRI): Your provider might use an MRI to get a complete picture of the damage to your bones and the area around them. This will show them the tissue around your bones too.
• CT scan: A CT scan will give your provider or surgeon a more detailed picture of your bones and the surrounding tissue than an X-ray.

 

• Humerus fractures treatment.

How your fracture is treated depends on which type it is, what caused it and how damaged your bones are.

 

Immobilization

If your fracture is mild and your bones did not move far out of place (if it’s non-displaced), you might only need a splint or cast. Splinting usually lasts for three to five weeks. If you need a cast, it will likely be for longer, typically six to eight weeks. In both cases, you’ll likely need follow-up X-rays to make sure your bones are healing correctly.

You might need a sling to hold your shoulder and arm in place, especially if your humerus is fractured at the proximal end near your shoulder.

 

Closed reduction

More severe breaks require a closed reduction to set (realign) your bones. During this nonsurgical procedure, your provider will physically push and pull your body on the outside to line up the broken bones inside you. To prevent you from feeling pain during the procedure you’ll receive one of the following:

• Local anesthetic to numb the area around your fracture.
• Sedatives to relax your whole body.
• General anesthesia to make you sleep through the procedure.

After the closed reduction, your provider will put you in a splint or cast.

 

Internal fixation surgery

Your surgeon will realign (set) your bones to their correct position and then secure them in place so they can heal and grow back together. They usually perform what’s called an internal fixation, which means your surgeon inserts pieces of metal into your bone to hold it in place while it heals. You’ll need to limit how much you use your arm to make sure your bone can fully heal.

Internal fixation techniques include:

• Rods: A rod inserted through the center of your bone that runs from top-to-bottom.
• Plates and screws: Metal plates screwed into your bone to hold the pieces together in place.
• Pins and wires: Pins and wires hold pieces of bone in place that are too small for other fasteners. They’re typically used at the same time as rods or plates.

Some people live with these pieces inserted in them forever. You might need follow-up surgeries to remove them.

 

Arthroplasty

If you fracture your elbow or shoulder joint, you might need an arthroplasty (joint replacement). Your surgeon will remove the damaged joint and replace it with an artificial joint. The artificial joint (prosthesis) can be metal, ceramic or heavy-duty plastic. The new joint will look like your natural joint and move in a similar way.

 

Elbow Dislocation

The elbow is dislocated when the joint surfaces of the elbow separate. Elbow dislocations can be full or partial, and they generally develop as a result of a trauma, such as a fall or an accident. The joint surfaces are entirely separated in a complete dislocation. The joint surfaces are only partially separated in a partial dislocation. A partial dislocation is often referred to as a subluxation.

• Cause of elbow dislocation.

Elbow dislocations are unusual. Elbow dislocations are most commonly caused when a person falls onto an outstretched hand. The force is transferred to the elbow when the hand strikes the ground. This force usually has a rotating motion. This has the potential to drive and rotate the elbow out of its socket. Elbow dislocations can also develop in automobile accidents when the passengers extend forward to brace for impact. The force transmitted through the arm, as in a fall, has the potential to dislocate the elbow.

Because of the combined stabilizing actions of bone surfaces, ligaments, and muscles, the elbow is stable. Any or all of these structures can be harmed to varying degrees when an elbow dislocates.

The blood vessels and nerves that run through the elbow may be affected in the most severe dislocations. If this occurs, the arm may be removed.

Some persons are born with more laxity or looseness in their ligaments than others. These folks are more likely to dislocate their elbows. Some people are born with a shallow groove in the ulna bone for the elbow hinge joint. They are slightly more prone to dislocation.

• Symptoms & Signs.

A full elbow dislocation is both painful and visible. The arm will appear deformed, with an unusual twist at the elbow.

A partial elbow dislocation or subluxation is more difficult to detect. It usually happens after an accident. Because the elbow is only slightly dislocated, the bones might spontaneously reposition themselves and the joint may seem normal. The elbow should be able to move freely, but there may be some discomfort. Where ligaments have been strained or torn, there may be bruising on the inside and outside of the elbow. If the ligaments do not mend, partial dislocations might reoccur over time.

• Doctor Examination:

Your doctor will evaluate your arm during the physical examination, looking for pain, edema, and deformity. He or she will examine the skin and the blood circulation in the arm. Wrist pulses will be measured. If the artery is wounded during the dislocation, the hand will be chilly to the touch and may be white or purple in color. The absence of warm blood reaching the hand causes this.

It is also critical to examine the nerve supply to the hand. If nerves are damaged during the dislocation, some or all of the hand may become numb and immobile.

An x-ray is necessary to determine if there is a bone injury. X-rays can also help show the direction of the dislocation.

X-rays are the best way to confirm that the elbow is dislocated. If bone detail is difficult to identify on an x-ray, a computed tomography (CT) scan may be done. If it is important to evaluate the ligaments, a magnetic resonance image (MRI) can be helpful, however, it is rarely required.

First, however, the doctor will set the elbow, without waiting for the CT scan or MRI. These studies are usually taken after the dislocated elbow has been put back in place.

• Treatment:

An elbow dislocation should be considered an emergency injury. The goal of immediate treatment of a dislocated elbow is to return the elbow to its normal alignment. The long- term goal is to restore function to the arm.

 

Nonsurgical Treatment:

The proper alignment of the elbow may generally be restored in a hospital emergency room. Sedatives and pain relievers are frequently used before to this procedure. A reduction maneuver is the act of restoring elbow alignment. It is done slowly and delicately.

Simple elbow dislocations are treated by immobilizing the elbow in a splint or sling for 1 to 3 weeks before beginning early mobility exercises. If the elbow is maintained stationary for an extended period of time, the ability to completely move the elbow (range of motion) may be compromised. During this stage of rehabilitation, physical therapy might be beneficial.

Some people will never be able to fully open (extend) the arm, even after physical therapy. Fortunately, the elbow can work very well even without full range of motion. Once the elbow's range of motion improves, the doctor or physical therapist may add a strengthening program. X-rays may be taken periodically while the elbow recovers to ensure that the bones of the elbow joint remains well aligned.

 

Surgical Treatment:

Surgery may be required to restore bone alignment and repair ligaments in a complicated elbow dislocation. It might be challenging to correct and keep a complicated elbow dislocation in line.

An external hinge may be used to protect the elbow after surgery. This gadget prevents the elbow from dislocating once again. If blood vessel or nerve damage are linked with the elbow dislocation, further surgery to repair the blood vessels and nerves as well as bone and ligament injuries may be required.

Some stiff elbows can be effectively restored to mobility with late reconstructive surgery. Scar tissue and excess bone growth are removed during this procedure. It also reduces barriers to mobility.

Over time, there is an increased risk for arthritis in the elbow joint if the alignment of the bones is not good; the elbow does not move and rotate normally; or the elbow continues to dislocate.

 

Conclusion

Upper-extremity injuries will probably be seen on a frequent basis by primary care and sports medicine specialists. Athletes most typically get injuries to their shoulder, elbow, wrist, and hand as a consequence of a fall onto an outstretched arm.

Even a minor upper-extremity problem can dramatically impact quality of life if not treated properly for hand and upper extremity injuries.