I.    BASIC EXAMINATION

A.  History. As with any medical problem, the history of events leading up to the patient’s visit to the physician with an upper extremity problem is critical. The history should contain family history, social history, personal medical history unrelated to the musculoskeletal system, infectious disease history, and risk behavior history. Some additional key facts to record include the following:

1. Handedness. Is the patient right- or left-hand dominant?
   
2. Work-relatedness. If the patient believes a problem is related to work or a series of events, it is the physician’s job to document the patient’s beliefs. The physician can do this by “quoting” the patient exactly. It is not the physician’s job or duty to question the veracity of a patient’s complaint.
   
3. Mechanism of onset. Record the details of the incident or accident as completely as possible. This is particularly relevant for motor vehicle accidents. Record details such as whether the patient was in the car, whether the air bags were deployed, whether the steering wheel was bent (particularly if the injured person was the driver), and the amount of damage done to the car.
   
4. Date of most recent tetanus booster. This is important with any direct trauma. Do not assume that another first examiner has resolved this issue.

B.  Physical examination

1. General. At first glance, the upper extremity is a mirror of the lower. But, several key differences are obvious:

a.  The shoulder has more freedom of motion and is consequently less stable than the hip.

b.  The “patella” of the elbow is fused to the ulna as the olecranon. However, it performs a similar function to the patella in that it increases the “lever arm” for the attached muscle (triceps in the arm, quadriceps in the leg).

c.  The elbow and wrist participate equally in guiding forearm rotation (supination and pronation). A similar motion is not available in the lower extremity.

d.  The wrist has more motion and less bony stability than the ankle.

e.  The fingers are longer in proportion to the palm than the toes in relationship to the midfoot.

f.  The thumb is longer and is opposable to the digits.

2.  Region specifics

a.  Elbow

1. The elbow joint moves in a hinge manner at its articulation between the humerus and the ulna. Thus, the ulnar–humeral articulation is uniaxial. In addition to its critical role in forearm rotation, the radius can transmit load to the humerus in “high-strength” situations. This issue is even more important if the elbow ligaments are injured. In general, the elbow gains minimal stability from muscle support and is reliant on ligament support to guide joint motion.
   
2. Examination of this joint should document the active and passive arcs of flexion and extension. Varus (lateral ligament loading) and valgus (medial ligament loading) should be assessed.
   
3. Standard radiographs include anteroposterior (AP) and lateral views.

b.  Forearm

1. Rotation of the forearm is guided by bone support at the proximal and distal radioulnar joints (PRUJ and DRUJ, respectively). Additional stability and guidance for this motion is provided by the interosseous membrane.
   
2. Examination should record the active and passive arcs of supination and pronation. Crepitance or pain at the PRUJ or DRUJ should be noted. Pain or swelling in the mid-forearm should be assessed.
   
3. Standard radiographs include AP and lateral views.

c.  Wrist

1. The wrist moves in a multiaxial manner. The carpus is divided into proximal (scaphoid, lunate, and triquetrum) and distal (hamate, capitate, trapezoid, and trapezium) rows. Some of the key intercarpal articulations have more easily described relationships (the scaphoid moves relative to the lunate in flexion and extension). However, taken as a whole, the wrist is multiaxial and its motion is highly dependent on ligament function. There is no direct attachment of an extrinsic (forearm based) muscle or tendon to the bones of the proximal wrist. Thus, these bones (scaphoid, lunate, and triquetrum) are 100% dependent on ligament integrity for function.
   
2. Examination should record passive and active arcs of flexion, extension, radial deviation, and ulnar deviation. Obvious pain or crepitance should be recorded as specifically as possible.
   
3. Standard radiographs include posteroanterior (PA) or AP and lateral views. If the scaphoid is the focus of attention, AP and lateral views of the scaphoid should be specifically requested. The AP view should be obtained with the wrist in ulnar deviation to capture the scaphoid in full profile. These are oblique to the normal PA and lateral views of the wrist.

d.  Hand

1. The hand contains uniaxial (interphalangeal), multiaxial-stabilized (metacarpal phalangeal), and multiaxial-unstabilized (first and fifth carpometacarpal [CMC]) articulations. Thus, these joints have varying degrees of ligamentous or muscle stability requirements. For example, the proximal interphalangeal joint of the index finger is dependent on ligament support. Whereas, the index finger’s metacarpophalangeal joint can be partially stabilized by hand intrinsic muscle support.
   
2. Examination should record active and passive arcs of flexion and extension for all joints. Thumb examination should additionally include ability to abduct (palmar and radial), adduct, retropulse (extend), and oppose. Joint stability should be tested and any masses or tenderness noted.
   
3. Standard radiographs include PA and lateral views. Note: To obtain a lateral view of a finger, the adjacent digits need to be moved aside. Similar to the scaphoid, “normal” thumb views are oblique to the hand.
   
4. Note: Always examine the opposite or unaffected side. This is particularly important when assessing stability.

II.   DEVELOPMENTAL DIFFERENCES

A.  Developmental birth conditions

1. Radial agenesis. Absence of the radius can be full or complete. Occasionally, this longitudinal deficiency is accompanied by thumb agenesis. An even more rare condition is presence of the radius and absence of the ulna. In either event, stability of the wrist is compromised. The deformity is often characterized with a “club hand.” The absence of the radius would then be termed a radial club hand. Full assessment of this condition requires complete assessment of the child to include renal, cardiovascular, neural, and other musculoskeletal regions (shoulder, elbow, and hand). If the child has associated anomalies, correction of the deformity at the forearm carpal articulation may actually compromise function. Thus, any direct treatment must consider the whole forearm and carpal articulation.
   
2. Syndactyly

a.  This is the most common congenital hand condition (1 in 2,000 live births). The cause is not known. It is divided into simple (soft-tissue joining of two or more digits with no associated bone or joint anomaly) and complex (joining of two or more digits to include soft tissue and bones or joints) categories. Further subdivision is possible on the basis of the length of the syndactyly. Complete syndactyly involves the whole length of the finger, whereas incomplete syndactyly does not. Simple syndactyly is often completely correctable. The complex differences, however, can occur in combination with other congenital differences (Apert syndrome).

b.  In general, surgical correction of this difference should be performed as soon as is anesthetically feasible. Correction of a multiple finger difference is done in stages. Limitations of correction are often related to digital blood supply; usually, full-thickness skin grafts are required at surgery.

3.  Polydactyly

a.  This difference is classified into preaxial duplication (involvement of the thumb), central duplication (index, middle, or ring involvement), and postaxial duplication (small finger involvement). Postaxial duplication has a clear genetic component and is seen in as many as 1 in 300 live births. Correction of this difference usually involves excision. The degree of duplication and joint involvement determines the complexity of the procedure.

b.  Treatment methods for thumb duplication generally focus on excision of an unstable duplicate thumb. Duplication of the thumb has been characterized to occur in at least seven different patterns. The outcome of thumb reconstruction depends on the ability to create a thumb of appropriate length, rotation, stability, and mobility and to integrate the thumb into the child’s daily routine. It is on this basis that earlier correction is generally recommended.

4.  Madelung deformity. First described by Malgaigne in 1855 and later by Madelung in 1878, this difference of growth related to the distal epiphysis of the radius is believed to be congenital in nature, although it is usually not noted before adolescence. It is a rare, genetic condition transmitted in an autosomal dominant pattern. Because of incomplete growth of the radius, the clinical presentation may be prominence of the ulnar head (distal ulna). Alternatively, abnormal forearm rotation may be the presenting complaint; pain may not be a component. The method of surgical correction (shortening of the ulna versus lengthening of the radius) is less important than the goal of obtaining and preserving stable, painless forearm rotation with full and unrestricted use of the wrist.

5.  Brachial plexus

a.  The brachial plexus comprises a coalescence of cervical and upper thoracic spine nerve roots. It traverses the space between the neural foramina and the infraclavicular regions where it again separates into individual nerves. Birth injuries relating to the brachial plexus are thought to represent an avulsion or stretch of the upper (Erb), lower (Klumpke), or both aspects (combined) of the brachial plexus. These injuries occur generally in the process of vaginal delivery of the child.

b.  Critical to the examination of any child with a presumed brachial plexus lesion is verification of normal shoulder bony anatomy. The physician should document this by way of physical examination, and shoulder radiographs confirming the shoulder (glenohumeral joint) is located.

c.  Occasionally, a child with nothing more than a fractured clavicle (birth related) will be mistaken to have a brachial plexus injury. Thus, it is important to include the clavicle in the physical examination of the infant. Generally speaking, a single AP chest radiograph suffices to detect such a fracture in the neonate.

d.  Management of brachial plexus injuries at birth should include the following:

1. Documentation of glenohumeral joint status (located)
   
2. Documentation of passive mobility of all upper extremity joints, including cervical spine mobility
   
3. Documentation of observed active motion in shoulder, upper arm, elbow, forearm, wrist, and hand
   
4. Initiation of twice-daily active-assisted “whole-arm” mobilization program to be completed by the care team or parents
   
5. Plan for follow-up examination on a frequent interval to verify understanding and completion of passive and active-assisted exercises and available joint motion (both passive and active—looking for change or improvement)

e.  The prognosis for many brachial plexus injuries is for complete or near complete recovery. Children whose function remains compromised are evaluated and occasionally operated upon within the first 6 to 18 months of age. The treating physician who cannot document substantial improvement early (<6 months of age) should arrange further evaluation by an upper extremity specialist.

B.  Delayed presentation of developmental differences

1. Cerebral palsy

a.  Patients with cerebral palsy constitute the largest group of pediatric patients with neuromuscular disorders. The frequency varies from 0.6 to 5.9 patients per 1,000 live births. Difficulties related to this problem persist into adulthood. However, unlike many neuromuscular disorders, this condition does not progress. Relative progression of the disorder may occur in relation to growth, weight gain, or onset of degenerative change. However, any real progression should cause review of the original diagnosis. Generally, the problem relates to prenatal, natal, or early postnatal brain injury. The injury can express itself in a wide pattern, ranging from single limb to whole body involvement. Two clinical types of injury are seen:

1. Spastic type—represents an injury to pyramidal tracts in the brain. Exaggerated muscle stretch reflex and increased tone are seen.
   
2. Athetoid type—probably a lesion in the basal ganglia. Continuous motion of the affected part is present; this type is more rare.

b.  Diagnosis is the first component of treatment. In cases with lesser involvement, diagnosis may not be obvious until the child fails to reach normal motor milestones or has difficulty with coordinated tasks. In some cases, the diagnosis is suspected because of early “under-use” of a part. For example, a child does not have a strong hand preference before 18 months of age.

c.  Treatment of cerebral palsy should always focus on functional improvement. Surgery generally has a cosmetic benefit, but the initial goal should be to improve a specific function. Intelligence and sensory awareness of the child are the two biggest determinants for functional improvement after surgery. Improvements of arm function are possible by improvement in the position of the shoulder, elbow, forearm, wrist, hand, and thumb. Three of the more successful surgeries are release of an internal rotation/adduction spastic contracture involving the shoulder, release/rebalancing of a flexed and pronated spastic wrist/forearm, and release/rebalancing of a thumb into palm deformity.

III.  ACQUIRED NONACUTE DYSFUNCTION OF THE ELBOW, WRIST, AND HAND

A.  Nerve. Nerve tissue is responsible for communication in two directions between the brain and the external environment (peripheral). Like the brain, nerve function is highly dependent on oxygen. Although depolarization of a single axon is energy independent, repolarization of the axon is dependent on adenosine triphosphate to run the Na⁺/K⁺ pump to “recharge” the axon potential. Thus, although local loss of O₂ will not cause death of the peripheral axon cell body, local loss of O₂ will affect the ability of the axon to conduct

Related posts:

Pediatric Orthopaedic Conditions Nonacute Shoulder Disorders Acute Shoulder Injuries Complications of Musculoskeletal Trauma Aspiration and Injection of Upper and Lower Extremities Operating Room Equipment and Techniques

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