The patient with upper extremity pain

A study guide for undergraduate medical students

Lindsay Davidson, M.D., M.Sc., M.Ed., FRCSC Associate Professor, Queen’s University

Kingston, ON

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Why this is important to know: Pain in the upper extremity is a common clinical presentation. The shoulder is the most frequent source of pain while the wrist is commonly affected by both acute and repetitive trauma. It is useful to think of the cause of upper extremity pain using an anatomical framework. The source of the pain may be:

1. The shoulder 2. The elbow 3. The wrist 4. The hand 5. Referred pain (musculoskeletal, neurologic and

visceral) Relevant MCC objective: 67-1-2-2

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This is a good opportunity to review the anatomy of the upper limb. Focus on bony and articular anatomy first but don’t forget the brachial plexus and major nerves as well as major muscular origins and insertions. See if you can answer the following questions as you review your anatomy.

1. How many joints contribute to shoulder motion? 2. List the structures that lie deep to the

sternoclavicular joint. 3. Name the ligaments that stabilize the

acromioclavicular joint. 4. What anatomical features predispose the

glenohumeral joint to instability? 5. Name the muscles that make up the rotator cuff? 6. What is the function of the rotator cuff? 7. Which muscles originate from the medial

humeral epicondyle? From the lateral humeral epicondyle?

8. Which structures are found within the carpal tunnel?

9. What is the anatomic snuffbox? What bone lies deep to it?

10. What is the sensory distribution of the median nerve? … the radial nerve? … the ulnar nerve? … the anterior interosseous nerve?

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The left shoulder and acromioclavicular joints, and the proper ligaments of the scapula.

Image credit: Gray's Anatomy of the Human Body fig. 326 (www.bartleby.com)

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Case 1: Acute shoulder pain

Photo: D. Bardana

You are attending the annual Homecoming football game and witness the following injury. The player is helped off the field and does not return to play for the remainder of the game. What structures may be damaged when an individual lands forcefully on the shoulder?

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Later that day, you encounter the player as a patient in the Emergency Room where you are working. He is a right-handed fourth-year Engineering student who complains of pain in the right shoulder subsequent to this fall. He is reluctant to abduct or elevate the right arm as he reports that these motions cause pain and a "crunching" feeling. You notice an obvious deformity. The patient is most tender when you press in the location indicated by the arrow.

Photo: L. Davidson

Name two injuries that could produce this clinical picture. What test will you order to make the diagnosis?

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X-rays of the clavicle and acromioclavicular joint

Which image is most likely represents this patient’s problem?

Image 1

Image: http://en.wikipedia.org/wiki/Image:Clavicle_fracture_left.jpg

Image 2

Image: Dr. Frank Gaillard, www.Radiopaedia.org