Shoulder to hand in orthopedic

Shoulder

ดู: ดูทั้ง 4 ทิศ deltoid mass, clavicle, AC joint, scapular position, muscle atropy
คลำ: bony landmark (clavicle, AC joint, acromion, coracoids, spine of scapular, lesser/greater tuberosity, bicipital groove), tone, contraction, trigger point
ขยับ-วัด: active/passive ROM

Special test:
• Anterior shoulder dislocation: Dugar’s test (จับไหล่ฝั่งตรงข้าม ศอกติดอก), Hamilton’s ruler test (ไม้บรรทัดทาบจาก acromion ไป Lat epicondyle ได้), Callaway’s test (เส้นรอบวงรอบรักแร้มากขึ้น)
• Others: impingement test, rotator cuff test (SITS), bicipital tendinitis (Speed’s test, Yergason’s test), glenohumeral instability (sulcus test, load and shift test, apprehension test)

Elbow

ดู: carrying angle (ปกติ 11°), infralateral condylar recess, olecarnon process, medial epicondyle
คลำ: bony landmark (medial/lateral epicondyle, radial head, lateral supracondylar ridge), Heuter’s triangle, joint space (ระหว่าง radial head, Lat epicondyle, olecarnon process), radial nerve (ต่ำกว่า radial neck 2 นิ้วมือ), cubital tunnel, antecubital fossa(structure เรียงจาก medial ไป lateral คือ MAT = median n, brachial a, biceps tendon, musculocutanerous n.)
ขยับ-วัด: full ROM

Special test:
• Tennis elbow: Cozen test (ต้านแรงขณะเหยียดแขน กำมือ กระดกข้อมือขึ้น), Middle finger extension test (ต้านแรงกดนิ้วกลางขณะเหยียดศอก ข้อมือ นิ้วมือออก), Mill’s manever (ทำ stretching กำมือ งอข้อมือลง)
• Golfer elbow ต้านแรง flex, pronate wrist and forearm
• Cubital tunnel syndrome: elbow flexion test (งอศอกมากที่สุด จะชาภายใน 1 นาที), compression test (กดโดยตรง)

Forearm, wrist & hand

ดู: texture, color, atropy, mass, resting position (เมื่อ extend MCP แล้ว PIP จะงอ 40-50-60-70° DIP จะงอ 10-15-20-25° จากนิ้วชี้ไปนิ้วก้อย)
คลำ: bony landmark (ด้าน dorsal: radial/ulnar tuberosity, Lister’s tubercle, scapholunate joint, lunotriquetral joint, scapho trapeziotrapezoid joint, EPL, anatomical snuff box, EPB; ด้าน palmar: scaphoid tuberosity, hook of hamate (จุดตัดเส้นที่ลากจาก 1st web space ขนานกับ proximal palmar crease (Kaplan’s line) กับ เส้นที่ลากจากขอบ ulnar ของนิ้วนาง), pisiform, FCR, PL, FCU), muscle, tenson, joint
ขยับ-วัด: active/passive ROM, test tendon with resistant of extensor/flexor digitorum profundus/ flexor digitorum superficialis

Neurovascular test
• Screening motor: กำมือ (ดู orientation-rotation); แบมือ; เอาปลายนิ้วมารวมกัน (median/ulnar/radial nerve intact); นิ้วโป้งกับนิ้วชี้ ”OK” หนีบกระดาษ (pincer function-median nerve or ulnar collateral ligament), grip strength
• Sensory ตรวจ touch, pinprick test ที่ autonomous zone(palp ของนิ้วชี้/ก้อย, 1st web space); sensibility ตรวจ 2 point discrimination ปกติ < 6 mm

Median n.	Pronation,  MCP flexion,  thumb-little PIP, index-long DIP flexion, thumb adbuction
Ulnar n.	Index-ring abduction/adduction, thumb adduction,  flexion MCP of little finger, ring-little DIP flexion
Radial n.	Supination; wrist extension, ulnar/radial deviation

**Axillary n.: arm abduction/external/internal rotation; sensation lateral shoulder
**Musculocutaneous n.: forearm flexion; sensation lateral forearm

Special test
• De Quervain’s disease: Finkelstein’s test (กำนิ้วโป้งแล้วทำ ulnar deviation)
• Carpal tunnel syndrome: Phalen’s test (palmar flexion < 1 min)
• Ulnar nerve: Newspaper’s test ทำ Lat pince นิ้งโป้ง adduction หนีบกระดาษ ถ้า IP flexion เรียกว่า Forment’s sign

Imaging

Film shoulder AP, Lateral scapular (Y view), others (axillary, posterior oblique (Grashey view), internal/external rotate, Stryker notch, West point view)
• AP: humeral head อยู่ใน glenoid fossa, ห่างจาก anterior glenoid rim < 6 mm, ดู cortex/trabecular pattern, acromio-humeral distance 9-10 mm, calcification รอบข้อหรือไม่
• Lateral scapular: humeral head วางอยู่ตรงกลาง glenoid cavity
• Finding: Hill-sachs lesion, Bankart lesion; posterior dislocation: “light bulb on a stick”,”trough line”,”empty glenoid cavity”; proximal humeral fx แบ่งเป็น 4 part ถือว่าเคลื่อนเมื่อแยก > 1 cm เอียง > 45°; Rotator cuff tear: acromio-humeral distance < 7 mm

Film clavicle straight AP, angled AP, stress; sternoclavicular view; scapular AP, transscapular Y, axillary view
• Clavicle: AC joint < 8 mm(เทียบสองข้างต่างกัน < 2 mm), ขอบล่างของ clavicle อยู่แนวเดียวกับ acromion, CC joint < 13 mm
• Sternoclavicular: ดูเทียบกัน 2 ข้าง ถ้า anterior dislocation จะเห็น clavicle อยู่ต่ำกว่าปกติ; posterior dislocation จะอยู่สูงกว่าปกติ
• Scapular: เทียบระยะห่างจาก spinous process ทั้ง 2 ข้าง มักมองเห็นใน Y view เท่านั้น

Film elbow AP, Lat
• Lateral: ต้องให้ capitellum ซ้อนทับกับ trochlea จึงจะเป็น true lateral
• ดู Fat pad sign (anterior ปกติเห็นเป็นเส้นบางๆ, posterior ปกติจะไม่เห็น), supinator fat strip < 1 cm, radiocapitellar line, anterior humeral line จะตัดผ่าน middle 1/3 ของ capitellum

Capitellum Radial head Internal(medial) epicondyle Trochlea Olecranon External(lateral) epicondyle

Ossified ประมาณ 1 ปี Ossified ประมาณ 3 ปี Ossified ประมาณ 5 ปี Ossified ประมาณ 7 ปี Ossified ประมาณ 9 ปี Ossified ประมาณ 11 ปี

Film wrist PA, lateral, others: oblique (scaphotrapezium joint, pisiform), scaphoid (scaphoid fx, scapholunate dissociation), carpal tunnel (pisiform, lunate fx), grip compression/motion studies (scapholunate, triquetrolunate instability)
• AP film proper position: distal radius & ulnar ไม่ overlap กัน; axis ของ 3rd metacarpal ขนานกับ radius
          (1) Gilula lines (2) carpal bone ห่างกัน 1-2 mm (3) scaphoid elongated shape (4) radius: ulnar inclination 13-30° (5) radial height 8-18 mm (6) Lunate articulate กับ radius & ulnar อย่างละครึ่ง
• Lateral film proper position: radius & ulnar overlap กันสนิท(dorsal surface ของ ulnar อยู่ 1-3 mm dorsal to radius), radial styloid อยู่ตรงกลาง distal radial articular surface
          Axis ของ radius, lunate, capitate เป็น collinear (three C's sign), capitolunate angle <10-20°, scapholunate angle 30-60°, radial volar tilt 10-15°
• Soft tussue sign ได้แก่ pronator quadrates fat strip sign (film Lat เงา fat line ด้าน volar ของ radius จะบวมออกเมื่อ fx), scaphoid fat stripe (film PA เป็นเงาดำข้าง scaphoid จะหายไปเมื่อมี fx)

Film hand AP, Oblique view
• Supination oblique (ball-catcher view): กระดูก metacarpal 4th-5th จะไม่ซ้อนกัน

Treatment

Sternoclavicular dislocation

Anterior: Patient supine, place a rolled towel between the scapulae, apply lateral traction to the abducted arm and push the clavicle back into place
Posterior: Patient supine, place a rolled towel between the scapulae, apply lateral traction to the abducted arm, grasp the clavicle with towel clip and pull back into position after infiltrating local anesthesia

Acromioclavicular injury

Type	Radiograph	Treatment
I	Normal	Sling immobilization
II	Clavicle elevated < 50% above acromion
III	AC dislocation, CC widened
IV	III + posterior dislocation	Surgical fixation
V	Marked dislocated
VI	Clavicle displaced inferiorly

Clavicle fx: sling and referral; consult if NV injury, skin tenting, displaced lateral third, concurrent fx of shoulder girdle, nonreducible displacement, open fx

Shoulder dislocation:
Anterior:
• Scapular manipulation: mild anterior traction to the arm, inferior tip of scapula is rotaled medially
• Milch method: flex elbow 90°, slowly externally rotate the humerus, abduct the arm and traction after full external rotation
• Traction-countertraction
• Stimson: patient prone with affected arm hanging off the side, suspend 10-lb weight from the wrist 20-30 min
Posterior: traction-countertraction or stimson method
Inferior: traction-countertraction, rotate the arm inferiorly in an an toward position of complete adduction
• Postreduction film, shoulder immobilization (3wk; 1wk if > 30 yr)

Scapular fx: shoulder immobilizer, sling, consult if severely displaced fx

Humerus fx
Head/neck: Neer classification 4 part (anatomical neck, surgical neck, greater tuberosity, lesser tuberosity)
• One-part: shoulder immobilization; two-four part: consultation
Shalf
• Non-displaced fx: Sugar-tong, shoulder immobilization
• Consultation if segmental fx, spiral, bilateral, pathogic, comminuted, open, failed closed reduction, ipsilateral elbow dislocation/forearm fx, multisystemic trauma, vascular compromise

Elbow dislocation “terrible triad”(dislocation + coronoid & radial head fx)
Posterior
• Palm-palm technique: grasp patient's hand with palm to palm and fingers interlocked, place examiner's elbow in patient's antecubital fossa, pushing downward on patient's distal humerus with examiner's elbow
• Hanging technique: place prone on stretcher with the elbow hanging over side with 2 kg and increase as needed
• Traction-countertraction technique: apply traction along the long axis followed by progressive flexion to 90°
Anterior: partial extension and distal traction of the wrist with backward pressure on forearm
• Immobilize in long arm splint with elbow in 90° flexion for 1 wk

Condylar fx

Transcodylar fx: long arm posterior splint; consult if displaced fx
Lateral condylar fx: long arm posterior splint with elbow ftexed at 90°, forearm supination. wrist extension; consult if displaced fx
Medial condylar fx: long arm posterior splint with elbow ftexed at 90°, forearm pronation. wrist flexion; consult if displaced fx
Intercondylar fx: admit if severe edema or displaced fx; Non displaced: long posterior splint

Suprecondylar fx: Non displaced(angulation < 20°): posterior long arm splint + frequent pulse check; consult if displaced fx

Radial head fx: Non displaced fx (< 1 mm separation, < 1/3 of articular surface): sling; consult if displaced fx or restricied ROM

**Essex Lopresti fx: comminuted radial head fx with distal radioulnar joint dislocation (interosseous membrane tear)

Olecranon fx: Non displaced fx: posterior long arm splint with elbow in 90° flexion and forearm neutral; consult if displaced fx

Proximal biceps rupture	anterior shoulder pain, swelling; pain with flexion of the elbow & arm abducted and externally rotated; midarm "ball"
Distal biceps rupture	antecubital fossa swelling, pain, ecchymosis; inability to palpate the distal biceps tendon, mid-arm "ball” ;strength loss in supination; "biceps squeeze test"(forearm on patient’s lap and loss of supination when compress bicep)
Tricep rupture	Posterior elbow pain, swelling, proximal mass, modified Thomson test(hanging forearm 90°, loss of extension when squeeze tricep)
Lateral epicondylitis	"tennis elbow”, pain with forced extension and supination of the forearm against resistance
Medial epicondylitis	"golfer's elbow”, pain with forced flexion and pronation of the forearm, wrist, digits

Radius fx
Proximal-mid shalf: Non displaced fx: long arm splint with elbow in 90° flexion and forearm supinated; consult if displaced fx
Distal shalf: Non displaced fx: long arm splint with elbow in 90° flexion and forearm pronation; consult if displaced fx
Galeazzi fracture/dislocation: consultation
Ulnar fx: Non displaced distal 2/3: long arm volar splint; consult if displaced fx, fx proximal1/3
Monteggia's fracture/dislocation: consultation
Combined radius/ulnar fx: Non displaced fx: long arm splint with elbow 90° flexion and forearm neutral; consult if displaced fx

Distal forearm fx
Non displaced radius or ulnar fx: immobilization, short arm cast

Wrist

Injury	Finding	Treatment
Ligamentous injury
scapholunate ligament	PA: scaphoid-lunate seperation > 3 mm, scaphoid shorter & show "cortical ring sign"; Lat: dorsal intercalated segment instability	Radial gutter splint, short arm volar posterior mold, referral
Triquetrolunate ligament	PA: triquetrolunate widening, obliteration of capitolunate joint; Lat: volar intercalated segment instability	Ulnar gutter 6-8 wk
Perilunate dislocation	Third C, displaced dorsal to the lunate	Emergency consultation
Lunate dislocation	PA: triangular shape of the lunate (piece-of-pie); Lat: middle C pushed off the radius into the palm (spilled teacup sign)

Bone	Examination	Management
Trapezium	Painful thumb movement, weak pinch strength; snuffbox tenderness	Short arm thumb spica  splint
Trapezoid	Tenderness over the radial aspect of the base of the index metacarpal	Short arm thumb spica splint
Capitate	Tenderness over the capitate just proximal to the third metacarpal	Short arm, volar wrist splint
Hamate	Tenderness at hook of the hamate, just distal and radial to the pisiform	Short arm, volar wrist splint, 4th-5th MC joint flexion
Scaphoid	Snuffbox tenderness. Pain with radial deviation and flexion	Short arm, thumb spica, in dorsiflexion with radial deviation
Lunate	Tenderness at shallow indentation of the mid-dorsum of the wrist, ulnar and distal to Lister tubercle	Short arm, thumb spica splint
Triquetrum	Tenderness at the dorsum of the wrist, distal to the ulnar styloid	Short arm, sugar tong splint
Pisiform	Tender pisiform, prominent at the base of the hypothenar eminence	Short arm, volar splint in 30° of flexion and ulnar deviation
Colles	Closed reduction if > 5 mm loss in radial height, > 10° dorsal tilt; hematoma block, attach fingertraps and apply counterweight (10-20 lb) hanging, manipulate pressure dorsally to restore the normal length and volar tilt, immobilize with wrist in slight flexion and ulnar deviation Surgical fixation if after closed reduction then remains > 5 mm loss in radial length, > 15° dorsal tilt, open/comminuted fx, intracellular fx > 2 mm articular offset
Smith	Reverse coller; consultation
Barton	Dorsal or volar rim fx of distal radius; consultation
Radial styloid fx (Chauffeur's fx)	consult if displace > 3 mm; Non displace fx: short arm splint positioning the wrist in mild flexion and ulnar deviation
Ulnar styloid fx	Consult if triangular fibrocartilage complex injury (ulnocarpal stress test: compression load to the wrist in ulnar deviation will pain or clicking; or pain with pronation and supination); If stable:  ulnar gutter splint in slight ulnar deviation and neutral positioning of the wrist.
Distal radioulnar joint disruption	Pain at the distal radioulnar joint, weak grip, restricted ROM(pronation, supination), prominent ulnar head; Film PA: narrowing and overlap of the distal radioulnar joint; Lat: volar or dorsal displacement of the ulnar (True Latn); Immobilizing the wrist in supination(dorsal dislocations) or pronation(volar dislocation)

Hand: Acceptable angulation of metacarpal neck fx: 2nd-3rd < 15°; 4th < 20°; 5th < 40°

Injury	splint
Thumb MCP ulnar collateral ligament	Thumb spica (F/U 1wk if partial tear < 40° radial angulation); Gamekeeper's thumb, skier's thumb
Mallet finger	Dorsal splint, full extension at DIP
Flexor tendon laceration	Dorsal splint, 30° wrist flex, 70° MCP flexion, 30-45° PIP flexion
Dislocations
DIP joint	Dorsal splint, full extension
PIP joint	Dorsal splint, 30° PIP flexion (F/U 2-3 d if unstable)
MCP joint	Buddy-taping
Carpometacarpal joint	Dorsal–volar splint
Thumb IP joint	Dorsal splint, full extension
Thumb MCP joint	Thumb spica
Fracture
Distal phalanx	Volar or hairpin splint not immobilizing PIP
Middle /proximal phalanx	Nondisplaced: Buddy-taping/dynamic splinting Displaced: Radial/ulnar gutter, 90° MCP flexion, < 15-20° PIP flexion, < 5-10° DIP flexion
Thumb proximal phalanx	Thumb spica
Metacarpal	Radial gutter/ulnar gutter, 20° wrist flexion, 90° MCP flexion, PIP left mobile
Thumb metacarpal	Thumb spica (F/U 2-3 d if intraarticular fx or Rolando fx)