Upper limb pain

Chapter 19 Upper limb pain



Case 19.1


While treating a 40-year-old female for an ongoing condition, you notice that she has a swollen and red index finger. On questioning, she states that it is quite painful, and started to develop about 12 hours following an incident that occurred while gardening a couple of days earlier.


She had been cutting some roses from her garden when a thorn entered the tip of her left index finger.


On inspection, the finger is inflamed, and held in a semi-flexed position. A small mark is seen on the surface of the distal phalanx where the thorn has entered. On palpation, her finger is very tender, especially along the line of the flexor tendons. When asked to move the finger, both extension and flexion are difficult.




Questions



1. Redness, swelling and pain are typical of inflammation and/or infection. What structure is likely to be infected?

2. Will the infection spread quickly into the hand? Give reasons for your answer.

3.
a If the infection had commenced in the thumb, what structure may have been rapidly infected?

b From which other digit would this happen?

She did not seek medical attention. Within 2 days, thin red streaks were seen on her upper limb, extending as far as the axilla. She was febrile. Palpation in the axilla revealed some small tender lumps.


4. What do the red streaks indicate?

5. What are the lumps in the axilla?

6. Describe the drainage of lymph from the index finger to the axilla.


Case 19.2


During a strenuous game of badminton, a 54-year-old man suddenly felt pain in the region of the right elbow joint. When he describes to you the action which precipitated the pain, it seemed that there had been excessive supination of the forearm. Since then, he has had difficulty turning doorknobs, holding his cup of coffee, and grasping any weight in the semi-pronated position of the forearm. On examination, there was tenderness over the anterolateral side of the elbow joint, immediately below the lateral epicondyle.




Questions



1. From the information given regarding the difficulties in function, name:
a the joints that may be involved

b the movements that occur at these joints.

2. Name the muscles attached to the lateral epicondyle. At which joints do they act?

3. What is the most likely diagnosis?

4. Describe how this disorder occurs.

5. Does this condition affect range of motion (ROM) at the elbow?

6. Is there a need for any imaging studies?


Case 19.3


During a social event, you meet a 42-year-old woman who you notice has red palms. She mentions that she has had pain in her hands intermittently for the last year. Her photo is shown in Figure 19.1.


image

Figure 19.1


(Source: Mir, MA. Atlas of Clinical Diagnosis [2nd edn]. Edinburgh: Saunders; 2003: 159, Fig 9.12)




Questions



1. What do you observe in this photograph?

2. What is the name given to the redness on her hands? Name the causes of this sign.

3. Can you see any evidence in the photograph which would help you determine the cause of the redness in this particular individual?

4. What other clinical features might she have or develop later?


Case 19.4



History


Vicky is a 38-year-old woman reporting to your clinic complaining of frequent episodes of pain, tingling and numbness in both of her hands, greater on the right. The hand pain may be intense at times and is described as sharp and burning. These symptoms wake her up multiple times each night, especially if she sleeps with her wrists bent. She has to get out of bed and walk around shaking her hands in order for the symptoms to resolve enough to allow her to go back to sleep. She has had these symptoms off and on for almost a year and they are progressively getting worse. Vicky works as a graphic designer and spends many hours at the computer each day using a mouse. She experiences the hand symptoms while working at the computer and has also noticed pain and stiffness throughout her neck and upper back while working. These symptoms are worse with the overtime she has been working recently. She has also noticed that she is clumsy and frequently drops things. Vicky denies any significant health history, trauma, or musculoskeletal injuries. Her only medication is birth control pills. She does report a family history of similar symptoms in her mother and brother, related to factory work.



Questions



1. Using only the information provided in Vicky’s history, list your differential diagnoses for her hand symptoms. Justify your answer.

2. Why was Vicki asked about the following:
a quality of the pain

b exacerbating and relieving factors

c timing of the pain and paresthesia

d family history?

3. The history is incomplete. What information is missing?

4. The diagrams in Figures 19.2A and 19.2B depict the area of sensory changes. What do these pain diagrams suggest in terms of a diagnosis?

5. What do you need to examine in this patient?

image

Figure 19.2A


image

Figure 19.2B



Physical examination








































Vitals •Pulse rate/min 76
  •Respiratory rate/min 12
  •Blood pressure mm Hg 118/68
  •Height (cm) 178
  •Weight (kg) 79
  •BMI 24.9
  •Temperature (degrees C) 36.5
HEENT Unremarkable  
Neck
Cervical ROM:
• flexion decreased 10 degrees with pain (2/10) noted in right cervicothoracic junction

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Upper limb pain

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