Adjustment of Upper Extremity Joint Subluxations-Fixations
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Upper Extremity Technique”
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Introduction Terminology: Subluxation-Fixations Upper Extremity Pain Screening Tests for the Upper Extremity as a Whole Lateral Clavicular Subluxations Shoulder Subluxations, Fixations, and Dislocations Elbow Subluxations, Fixations, and Dislocations Wrist and Hand Subluxations, Fixations, and Dislocations
Chapter 2: Adjustment of Upper Extremity Joint Subluxations-Fixations
This chapter describes adjustive therapy as it applies to articular malpositions of the lateral clavicle, shoulder, elbow, wrist, and hand. Manipulations to free areas of fixation are also covered.
From a biomechanical viewpoint, a kinematic chain extends from the cervical and upper thoracic spine to the fingertips. Only when certain multiple segments are completely fixed can these parts possibly function independently in mechanical roles (essentially, the placement of the hands).
The term subluxation technically refers to an incomplete or partial dislocation in which the articular surfaces have not lost contact. Partial malpositions may be extremely slight (beyond palpatory perception), yet be the focus for initiating a chain reaction in a kinematic chain that may express itself acutely in another joint or for establishing numerous adverse proprioceptive reflexes that may find expression in either the soma or viscera, or both.
In states of articular malposition (subluxation), a certain degree of fixation exists, else the malalignment would readily reduce itself during joint function because the direction of least resistance would be towards normalization (congruent surfaces). Thus, it is just as important to determine what is holding the joint in malalignment (eg, spasm, shortened ligaments, adhesions, mineral deposits, entrapped cartilage, neogenic bone, neoplasm, degenerated joint surfaces, fracture, etc) as it is to determine that a joint is subluxated-fixated to some extent,
While it is likely that some degree of fixation always accompanies a subluxation, it is also likely that a dynamic subluxation also accompanies a fixation even when the fixation is found in the joint's position of rest. For, example:
(1) joints fixated unilaterally tend to encourage compensatory contralateral joint laxity, and
(2) joints fixated bilaterally tend to encourage compensatory joint laxity in the adjacent movable joints of the kinematic chain.
It is for this reason that the site of fixation is typically asymptomatic, with symptoms expressing at the site of compensatory hypermobility where activity is likely to produce irritation and inflammation due to reduced structural support. A fixation in the elbow, for example, may exhibit as symptoms in the hand, shoulder, or cervical and/or thoracic spine, or vice versa. It is for this reason that the entire kinematic chain must be evaluated in any extremity neuromusculoskeletal disorder. Localized evaluation at the site of pain offers limited information in itself and can readily lead to false conclusions.
The term fixation, as used in chiropractic, rarely means ankylosis (complete immobility). Rather, it implies a state of reduced mobility, essentially due to soft-tissue changes, and commonly found within the range of 20%–90%. This degree of reduced mobility may be a gradual increasing resistance, as commonly encountered in passive motion against taut muscles, or normal motion up to a point that meets a firm "rubbery" motion block, as commonly found when ligament straps have shortened or a piece of dislodged cartilage serves as a barrier to motion.
Once the possibilities of fracture and underlying pathology have been eliminated, antalgic spasm is probably the only type of fixation involved in an acute subluxation syndrome. However, with chronic subluxations, concern must be given to the mobilization of degenerated para-articular and intra-articular tissues that have lost much of their elasticity and plasticity.
Although subluxations and fixations commonly accompany each other, each requires a different therapeutic rationale. Subluxations, being bony malpositions, are usually corrected with an adjustment that employs a high-velocity thrust within a short range of motion. This can usually be accomplished instantly and only need be repeated on a subsequent office visit if the adjustment does not "hold." Such a force, however, would usually be contraindicated with most types of soft-tissue fixations if bleeding is to be avoided, as even minute hematoma would encourage further soft-tissue fibrosis and calcification.
Thus, most fixations are treated by using a slow repetitive stretching maneuver applied (up to patient tolerance) against the resistance, which may extend through a relatively long range of motion. It may take many months (eg, frozen shoulder) to achieve the optimal results possible when the joint has been in a prolonged state of hypomobility. Both techniques require firm stabilization of adjacent joints that could possibly be adversely stressed during adjustment or mobilization maneuvers.
Other important clinical paradoxes are those of posttherapy immobilization and heat versus cold. Following the correction of an acute subluxation, short-term immobilization tends to offer the affected tissues a period of rest to promote healing and prevent further inflammation from activity. Cold would usually be indicated within the first 72 hours to reduce pain and swelling.
On the other hand, extended immobilization tends to weaken para-articular muscles (disuse atrophy), encourage circulatory stasis and the accumulation of metabolic debris, and promote shortened ligaments and stiff capsules, which would encourage the formation of soft-tissue fixation. Heat and exercise would usually be indicated to soften taut tissues and enhance circulation.
Following any manual therapy, the common procedure is to recheck joint mobility, apply any adjunctive therapy or rehabilitative procedure that would be appropriate, counsel the patient as to adverse activities, and prescribe necessary home exercises.
The technics described in this manual should not be considered as rigid disciplines. There are many ways in which the same result can be achieved. Once the reason for any specific technic is understood, the method used is a matter of personal preference. For example, if a joint is jammed, it usually does not matter which bone is stabilized and which is the subject of traction. In either case, the result will be articular separation (distraction). The goal of any adjustive or mobilizing technic is only to restore normal functional and structural relationships with minimal discomfort to the patient. How this is accomplished is a matter of clinical judgment.
Upper Extremity Pain
Pain in an upper extremity may be the result of any disorder within the involved limb or a disturbance elsewhere in which sensory phenomena are referred to the limb. The pain may be of mechanical, chemical, thermal, toxic, nutritional, metabolic, or circulatory origin, or a combination of some of these factors depending upon the nature of the pathologic process involved, and the pain will often reveal the point of origin by its peculiar location, quality, and affect on function. The most important clues toward determining cause (type of pain, its distribution, and its associated symptoms) are the result of a carefully taken case history.
Symptoms may be referred to the wrist or hand from the cervical spine, shoulder, or elbow such as from cervical disc disorders, osteoarthritis, brachial plexus syndromes, and shoulder and elbow entrapments. In addition, cervical pathology and subluxation syndromes, rheumatoid arthritis of the wrist, a cervical rib, and neurovascular compression syndromes frequently involve or refer pain to the shoulder. Upper rib and upper thoracic syndromes may also involve or refer pain to the upper extremity.
The origin of nerve root lesions may be traced to trauma, compression or irritation of the nerve root, hypertrophic changes in the vertebrae, entrapment neuropathy, or a neoplasm. Differentiation should be made from rare nutritional disorders resulting in a polyneuropathy because of unfavorable metabolic activities within the nerve cells. Peripheral neuritis is less common than peripheral neuropathy.
As a rule of thumb, it is widely held that mobile and ankylosed joints are functionally painless and that partially fixated joints become increasingly painful with activity.
Screening Tests for the Upper Extremity as a Whole
The Shoulder Girdle
As with other areas of the body, it is good procedure during observation to first note the general characteristics and then inspect for details. Visualize the anatomy involved while observing the overall bilateral symmetry, rhythm of motion, swing during gait, smoothness in reach, patterns of pain, and general circulatory and neurologic signs. Inspect for gross abnormal limb rotation or adduction. Note skin discolorations, masses, scars, blebs, swellings and lumps, abrasions, and overt signs of underlying pathology. Carefully note the biomechanical relationship of the neck with the shoulder girdle and both with the thorax. Observation should be conducted on all sides.
With the patient sitting, inspect the anterior aspect of the shoulder girdle starting with the clavicle. A fracture or dislocation at either the medial or lateral end of the clavicle is usually quite obvious by the apparent change in contour and exaggerated round shoulders to protect movement. Note the normally symmetrical fullness and roundness of the anterior aspect of the deltoid as it drapes from the acromion over the greater tuberosity of the humerus. Unusual prominence of the greater tuberosity of the humerus suggests deltoid atrophy, while a sharp change in contour unilaterally suggests dislocation. A forward displacement of the tuberosity exhibits an indentation under the point of the shoulder and a loss of normal lateral contour. The most common points of abnormal tenderness are at the acromioclavicular joint and in the rotator cuff.
To test the general integrity of the shoulders, have the patient place the hands on top of the head and pull the elbows backward. This will be painful, if not impossible, in shoulder bursitis, arthritis, and rotator-cuff strains. Apley's scratch test is another good screening procedure. Note if the scapula and humerus move in harmony.
Branch points out that spasm above or over the scapula will be readily recognized if the examiner observes the patient from the back during horizontal abduction. If such spasm exists (eg, from cervical radiculitis), horizontal abduction of the arm will occur with little motion of the scapula. However, if the origin of pain is within the shoulder, a "shrugging" motion occurs, in which the apex of the scapula sharply swings laterally but glenohumeral motion is restricted.
The Elbow and Forearm
The normal carrying angle of the elbow is about 5 for men and 12 for women. An increase in the angle (cubitus valgus), commonly results from a lateral condyle fracture; a decrease in the angle (cubitus varus), which is more common, portrays a characteristic "gunstock" deformity, which is likely the result of a supracondylar fracture or malunion during youth.
Inspect for deep burn scars that may have resulted in contractures, needle-puncture marks, overall contour abnormalities, lumps, skin texture changes, and other signs of pathology. A localized soft bump on the olecranon process points toward olecranon bursitis, while the first considerations in widespread diffuse swelling about the elbow are an elbow crush injury or fracture of the distal humerus.
If the patient can hold the arms at the sides of the body and comfortably pronate/supinate the forearms with the palms open and fingers extended through a full range of motion, the elbows can initially be considered functionally normal.
The Wrist, Hand, and Fingers
The hands, being the least protected and most active parts of the upper extremity, are easily injured. Observe the hands in their rest attitude and during functioning such as in writing, undressing, and shaking hands. Note the bony framework, contours, finger webbing, muscle development, and color and texture of the skin. Inspect for abnormal skin temperature, swellings, nodes, asymmetrical development or deformities, scars, contractures, and nail abnormalities or discolorations.
What first appears to be a deep erythema prominent over the heel of the hand that spreads laterally over the thenar eminence, may be deep spider-like telangiectases that are commonly associated with pregnancy, hepatic cirrhosis, and rheumatic heart disease. Check for Bouchard's nodes and swan-neck deformity (rheumatoid arthritis) or Heberden's nodes (osteoarthritis). Inspect the fingertips and nails for signs of infection such as felons or hangnails that may complicate the picture. Allen’s' test can quickly appraise the general vascular integrity of the radial and ulnar arteries in the hands.
If the patient can extend the hands and fingers and then make a fist with each hand and flip the wrists back and forth, the wrists and hands can initially be considered functionally normal. Almost any wrist, metacarpal, or phalangeal disorder will interfere with these maneuvers to some degree.
Active and Passive Range of Motion
Active range of joint motion should be tested for the shoulder girdle, elbow, wrist, and fingers. If active motion is normal, there is usually no need to test passive motion unless unusual circumstances exist which make active motion difficult. Complete patient relaxation is necessary to obtain an accurate judgment of range of motion because tension will produce considerable motion restriction. As in all range of motion tests, passive motion should not be attempted if there is any possibility of fracture, dislocation, or severe tears. It is important during all tests that the examiner form a mental picture of the underlying anatomy and normal motion.
The most common causes of motion restriction are muscle weakness, spasm, contractures, fracture, or dislocation. In muscle weakness, a joint will move through its normal range passively but not actively. Consistent active and passive restriction is likely to be the result of a bony or soft-tissue block, and the atrophy present will most likely be from disuse. With passive movement, bone blocks will feel as abrupt inflexible stops in motion, while extra-articular soft-tissue blocks will be less abrupt and slightly flexible when additional pressure is applied.
LATERAL CLAVICULAR SUBLUXATIONS
For the glenohumeral joint to move freely, the clavicle must be free to pivot and rotate up to 40 in accommodation for the wide range of motion of the shoulder joint. Any limitation of movement at either the acromioclavicular joint or the sternoclavicular joint will severely limit glenohumeral motion. Sternoclavicular fixation (eg, shortened interclavicular ligament) is an often overlooked cause of restricted shoulder motion.
Dynamic Palpation of the Acromioclavicular Joint
Neither the acromioclavicular joint nor the sternoclavicular joint (which contains an articular disc) can be moved by voluntary action, yet they play a vital involuntary role in all motions of the shoulder girdle. Dynamic palpation to evaluate the normally small but necessary joint play at both the lateral and medial aspects of the clavicle can sometimes be achieved if the patient is able to achieve full relaxation. The joint play elicited at the acromioclavicular articulation is felt as a slight inferior and superior glide. Although the clavicle rotates on its axis several degrees during humeral flexion and extension, this movement is difficult to perceive unless the patient has abnormally flexible joints (eg, a contortionist) or the joint is unstable.
Anterosuperior Lateral Clavicular Subluxation
Acromioclavicular subluxations commonly result from falls, blows, and contact injuries and are usually accompanied by new or old joint ligament separations. An anterosuperior subluxation is by far the most common subluxation of the lateral clavicle.
Significant Features. The patient will complain of an ache within the joint, tenderness at the lateral end of the clavicle, and loss of some arm function. A partial ligament tear, which will complicate the clinical picture, will be demonstrated by looseness of the joint during Schultz's test. The subluxation can be detected by bilateral palpation of the lateral end of the clavicle for the characteristic down step. Bilateral comparison is necessary because some people normally have enlarged clavicle ends laterally that can be mistaken for subluxated clavicles. When subluxated, the clavicle tends to displace to the superior and anterior. In chronic cases, a degree of soft-tissue shortening will inevitably exist that can be determined by placing two finger pads upon the acromioclavicular joint and circumducting the patient's abducted arm.
Schultz's Test. Standing behind the sitting patient with acromioclavicular separation, face the affected side. Place one hand under the flexed elbow and push up while the other hand, which is placed over the acromioclavicular joint, applies firm pressure. The more "give" that is felt in the joint, the greater the separation.
Adjustment. The patient is asked to sit on a low stool. The palm of the patient's hand on the involved side is placed on the back of the neck or occiput. Stand behind the patient and place the web of your medial contact hand on the superior aspect of the patient's lateral clavicle. Stabilize the patient's elbow with your lateral hand by cupping your palm underneath the patient's lower humerus (medial aspect) and apply as much traction as possible short of patient discomfort. Apply pressure inferiorly with your contact hand. Then, with your active medial hand, make a short thrust directed inferiorly and posteriorly, while simultaneously elevating the patient's elbow superiorly and medially with your stabilizing hand. Conclude the adjustment by maintaining contact pressure and gently circumducting the abducted humerus.
Burns points out that if the arm is just abducted, the greater tuberosity of the humerus will be forced against the acromion and increase patient discomfort. He suggests that mild external rotation be added to a pure abduction position as this will produce much less discomfort to the patient during the maneuver.
Alternative Technic. The doctor-patient position and the doctor's contact are the same as described above. With this technic, however, the patient's arm is abducted, the elbow is flexed, and the patient's hand points inferiorly and medially towards the floor. Rather than stabilizing the patient's elbow, place your stabilizing forearm under the patient's abducted arm and grasp the dorsal surface of the patient's forearm. Apply pressure directed inferiorly with your contact hand, and then make a short thrust directed to the inferior and posterior while simultaneously elevating the patient's elbow to the superior and medial with your stabilizing forearm.
SHOULDER SUBLUXATIONS, FIXATIONS, AND DISLOCATIONS
Subluxations of the glenohumeral joint may be primary conditions after intrinsic overstress or extrinsic trauma, or they may occur weeks or months after reduction of a primary dislocation. Thus, in cases of chronic shoulder pain, the history should be probed for possible shoulder dislocation and spontaneous reduction.
Most shoulder subluxations are nonacute and exhibit little or no swelling, but they present with chronic (often episodic) pain, stiffness or "blocks," and other signs of local tissue fibrosis and joint gluing. Mild-to-moderate local muscle weakness and possible atrophy are characteristic. Postural distortions of the lower cervical and upper dorsal spine and musculoskeletal abnormalities of some aspect of the shoulder girdle are invariably related.
As a peripheral vascular disorder may be involved, it is usually good policy to palpate the tone of the brachial and radial pulses, measure upper-limb blood pressure, and compare findings bilaterally.
Tendon inflammation is not as common in the shoulder as it is in the elbow and wrist. However, because all tendons are relatively avascular, all are subject to chronic trauma, microtears, slow repair, and aging degeneration.
The regional anatomy of the shoulder offers little to resist violent shoulder depression, and the shoulder tip itself has little protection from trauma. The length of the arm offers a long lever with a large head within a relatively small joint. This allows a great range of motion with little stability. The stability of the shoulder is derived entirely from its surrounding soft tissues.
The glenohumeral (shoulder) joint, a ball-and-socket joint, is freely movable and lacks a close connection between its articular surfaces. Mennell points out that although only two bones comprise the glenohumeral joint, it is dependent upon the synchronous normal movement of the:
(2) sternoclavicular, and
(3) scapulothoracic articulations.
Although the latter is not a synovial joint, it acts as one in many respects. For example, motion can be restricted by scapulothoracic contractures or adhesions and this will restrict shoulder motion.
During articular correction of a shoulder subluxation, dynamic thrusts should be reserved for nonacute situations. When subluxation accompanies an acute sprain, attempts at articular correction should be more in line with gentle traction forces after the musculature has been relaxed. Obviously, the probability of an underlying bone tumor, fracture fragments, osteoporosis, abscess, etc, must be eliminated before any form of manipulation.
Because the shoulder readily "freezes" after injury, treatment must strive to maintain motion as soon as possible without encouraging recurring problems. The key to avoiding prolonged disability is early recognition; articular correction; early mobilization; normalization of neural, arterial, venous, and lymphatic circulation; and the elimination of contributing extrinsic contributions.
Dynamic Palpation of the Glenohumeral Joint
Because the shoulder joint has such a wide range of motion in flexion, extension, abduction, adduction, internal rotation, external rotation, and circumflexion, five joint plays must be evaluated to determine the point of possible fixation. These are:
- Anterior glide of the humerus relative to the glenoid cavity.
- Posterior glide of the humerus relative to the glenoid cavity.
- Lateral glide of the humerus relative to the glenoid cavity.
- Medial glide of the humerus relative to the glenoid cavity.
- Downward separation from the glenoid cavity.
Inasmuch as pure internal and external rotations occur as spinning actions without shear or glide, joint play is difficult to perceive. The standard procedures for judging passive ranges of internal and external rotatory motion will accurately reflect the integrity of joint play. From a practical standpoint, if all the above joint play movements are normal, internal and external rotation joint play can be assumed to be normal.
Keep in mind that the motions of the distal and proximal humerus are reciprocally opposite in rotation. For example, when the arm is raised forward and up, the head of the humerus rotates downward on the posterior aspect of the glenoid cavity. When the arm is extended laterally and raised, the head of the humerus rotates downward on the medial aspect of the glenoid cavity.
Likewise, the site of articular fixation will determine the motion restricted. For example:
- Anterior glenohumeral fixation restricts extension but not flexion.
- Posterior glenohumeral fixation restricts flexion but not extension.
- Lateral glenohumeral fixation restricts adduction but not abduction.
- Medial glenohumeral fixation restricts abduction but not adduction.
Downward (normal distraction) glenohumeral fixation of this important motion restricts all ranges of motion to some degree.
Shoulder pain has a high incidence. Cailliet states that it is third only to low-back and neck pain.
Shoulder pain may have its origin in either local or systemic causes. Jaquet points out that about 95% of all shoulder disorders are due to four conditions:
(1) adhesive capsulitis
(2) simple tendinitis,
(3) tendinous perforation and rupture, and
(4) hyperalgesic calcareous tendinitis. Note that three of these four conditions are tendinous in origin. A wide range of common causes of shoulder pain is shown in Table 2.1
Table 2.1. Typical Causes of Shoulder Girdle Pain
Traumatic Endocrine or Inflammatory Neurologic Vascular Metabolic Cervical IVD syndrome
Cervical IVD syndrome
Lateral clavicle subluxation
Aseptic bone necrosis
Reflex sympathetic dystrophy
Thoracic outlet syndrome
Neoplastic Degenerative or Deficiency Congenital Allergic or Autoimmune Toxic
Carcinoma Cord tumor
Scalenus anticus syndrome
Effects of Activity
Most shoulder syndromes involve a degree of either overuse or underuse:
Overuse of poorly conditioned tissues is the most common cause of shoulder pain. The shoulder tendons are wide bands of collagen fibers, and if stress roughens a tendon, its tensile strength decreases. This leads to fibrinoid degeneration in and between the collagen fibers and later fibrosis. With necrosis and the initial inflammatory reparative process, the local tissues become alkaline, which induces precipitation of calcium salts. This deposition may invade an overlying bursa.
Excessive postinjury immobilization leads to muscle atrophy and loss of capsular elasticity, a predisposing factor to capsulitis and periarthritis. Lack of joint movement fosters retention of metabolites, edema, venous stasis, and ischemia leading to fibrous adhesions and trigger-point development. It is for this reason that rehabilitation procedures should be instigated immediately after immobilization.
Effects of Active vs Passive Motion. Several shoulder disorders can be differentiated by the pain characteristics associated with active and passive motion. See Table 2.2.
Table 2.2. Differentiation of Common Shoulder Disorders by Motion
Disorder Active Motion Passive Motion Acromioclavicular arthritis Acutely painful abduction above 110 degrees Crepitus may be noted. Adhesive capsulitis Mild to moderate pain Passive motion is limited in all directions. Bicipital tendinitis More painful than passive motion at all levels of horizontal abduction. Painful when the tendon or bursa becomes compressed beneath the acromion during abduction (approx. 60º). Arm pain increased by forearm pronation and supination against active resistance. Rotator cuff tear (Grade 3 strain) Able to hold horizontal abduction above 90 degrees but not below 90 degrees. Unlimited motion without pain after the acute stage has subsided. Synovitis Acutely painful, increased by humeral rotation in the rotation in the resting position. Acutely painful at all levels of abduction.
Referred Pain. As the shoulder lies between the neck and the hand, pain from the neck or distal upper extremity may be referred to the shoulder, and a shoulder disorder may refer pain to the neck or hand. In shoulder disorders, differentiation should include cervical problems, superior pulmonary sulcus tumor, and referred pain from viscera. Pain can also be referred to the shoulder by brachial plexus involvement, pectoralis minor syndrome, anterior scalene syndrome, claviculocostal syndrome, suprascapular nerve entrapment, dorsal scapular nerve entrapment, cervical rib, spinal cord tumor, arteriosclerotic occlusion and other vascular disorders.
In cases of a herniated cervical disc (most common at C5–C6), pain may radiate from the neck into the arm, forearm, hand. The head and neck will be deviated to the affected side with marked restriction of movement. The shoulder will usually be elevated on the same side, with the arm slightly flexed at the elbow (protective position). Biceps and triceps reflexes will be lost or diminished. Paresthesias and sensory loss in the dermatome will be found corresponding to the disc involved.
The examiner should also keep in mind that both referred pain and tenderness may be of a visceral nature, especially from:
(1) the liver, gallbladder, and right diaphragm to the right shoulder and
(2) the stomach, left diaphragm, and heart to the left shoulder. Referred pain and tenderness, however, are not always predictable. If you are able to easily reproduce pain during joint motion, the condition is most likely structural or neuromuscular in origin. Pain that cannot be readily reproduced suggests a visceral origin. Note, however, that it is not true that visceral reflexes do not affect local joint function. They may or may not produce musculoskeletal symptoms and signs.
According to Mercier, referred shoulder pain (unilateral or bilateral) often courses via the phrenic nerve (ie, the cutaneous branches of C4). For example, pain perceived on top of the shoulder, in the supraspinous or subclavicular fossa or over the acromion or clavicle, may be the only outward signal of a liver abscess that is threatening to perforate the diaphragm. Likewise, a perforated gastric ulcer might allow escaping stomach contents to cause irritation or pressure on the lower surface of the diaphragm. The same type of phrenic reflex can be set up by diaphragmatic pleurisy, subphrenic abscess, gallstones, acute pancreatitis, ruptured spleen, and the Fitz-Hugh-Curtis syndrome.
In many instances of localized referred pain, the location of the perceived pain correspondingly reflects the portion of the diaphragm being affected. For instance, it is generally thought that pain on top of both shoulders indicates a broad or median irritation of the diaphragm; pain on top of the left shoulder only, a left diaphragmatic irritation; and pain on top of the right shoulder only, a right diaphragmatic irritation. In upper-abdominal irritations, for example, a pyloric or duodenal ulcer or gallstones often refers pain to the right shoulder (often right supraspinous fossa); a ruptured spleen, which may be spontaneous, will refer pain to the left shoulder; and an anterior gastric perforation or mid-line diaphragmatic hernia will refer pain to both shoulders.
Differentiating Points in Diagnosis. The differentiation of various causes of shoulder girdle pain can sometimes be made solely by its associated symptoms such as cough and expectoration, a neck or shoulder mass, swelling and tenderness, fever, or radiating ache. See Table 2.3
Table 2.3. Shoulder Girdle Pain and Associated SymptomsSyndrome: Shoulder Pain + Primary Suspect Disorders Swelling and Arthritis Fracture tenderness Cellulitis Sprain (neck or shoulder) Contusion Strain Dislocation Subluxation (acute) Radiating ache Angina pectoris Rib subluxation Bursitis Scalenus anticus syndrome Capsule adhesions Shoulder-hand syndrome Fracture Spinal cord tumor IVD syndrome Spondylosis Pancoast's tumor Subluxation Periarthritis (cervical or shoulder) Cough and Pancoast's tumor Pneumonia expectoration Pleurisy Tuberculosis Mass Actinomyocosis Hydradenitis suppurativa (neck or Carcinoma Lipoma shoulder) Cellulitis Lymphadenitis Cyst Ruptured biceps Epithelioma Sebaceous cyst Hodgkin's disease Tuberculosis Pyrexia Cholecystitis Purulent arthritis Pericarditis Subphrenic abscess Pneumonia Tuberculosis
Shoulder Dislocations: General Concerns
The glenoid cavity covers only a small part of the head of the humerus. In extreme degrees of abduction, extension, or flexion, any force transmitted through the humeral shaft is applied obliquely to the surface of the glenoid and upon the capsule of the joint, through which the head of the humerus is then forced.
Falls and collisions causing shoulder dislocation are frequent in contact sports, representing about 50% of all major joint dislocations and the most commonly dislocated area of the body. The typical mechanism is an extension force against an abducted arm that is externally rotated.
The various types of shoulder dislocations (and subluxations) may be classified according to the direction in which the humeral head leaves the socket, and these can be subclassed according to the point at which the head of the humerus comes to rest or according to limb position. These four major types are anterior, inferior, posterior, and superior dislocations. Most shoulder dislocations involving the shoulder girdle complex are anterior dislocations of the glenohumeral joint (85%), followed by acromioclavicular separations/dislocations (10%), sternoclavicular dislocations (3%), and posterior glenohumeral dislocations (2%).
True dislocations must be differentiated from pseudosubluxations where the humerus is displaced inferiorly by hemarthrosis. Poor muscle tone is usually related in the poorly conditioned individual.
Significant Features. In primary glenohumeral dislocation, symptoms may be severe even if the para-articular soft tissues and capsule are not greatly damaged. Heroic emergency reductions should be avoided. A number of commonly applied tests can be used in screening the possibility of shoulder dislocation or fracture. These are shown in Table 2.4.
Pertinent Roentgenographic Findings. Careful evaluation of the glenohumeral articulation is necessary to judge alignment congruity. An axillary (bird's eye) view to clearly expose the glenohumeral relationship is often quite helpful. A tangential view of the scapula may be an aid in exhibiting a fracture of the coracoid process or glenoid margin or to find evidence of defects in the humeral articular margin following chronic dislocation. In approximately 20% of cases of shoulder dislocation, fractures of the glenoid are related. Lesser tuberosity fractures are often associated to a posterior dislocation of the shoulder. Vigorous contractions of the triceps muscle, as seen in throwing, may produce avulsion injuries to the inferior aspect of the glenoid. Thus, roentgenography is necessary to analyze possible complications before any considered reduction.
Table 2.4. Common Tests in Screening for Shoulder Dislocation/Fracture
Apprehension test If chronic shoulder dislocation is suspected, the patient's arm is slowly and gently abducted and externally rotated so that the patient's elbow is flexed toward a point where the shoulder might easily dislocate. If shoulder dislocation exists, the patient will become quite apprehensive, symptoms may be reproduced, and the maneuver is resisted if an attempt is made for further motion. Bryant's sign A posttraumatic ipsilateral lowering of the axillary folds (anterior and posterior pillars of the armpit), with level shoulders, is indicative of dislocation of the glenohumeral articulation. Calloway's sign The circumference of the proximal arm of a seated patient is measured at the shoulder tip when the patient's arm is laterally abducted. This measurement is compared to that of the uninvolved side. An increase in the circumference on the affected side suggests a dislocated shoulder. Consider- ation must be given to the individual who occupationally uses the involved arm almost exclusively (eg, a tennis player). Dugas' test The patient places the hand (on the involved side) on the opposite shoulder and attempts to touch the chest wall with the elbow and then raise the elbow to chin level. If it is impossible to touch the chest with the elbow or to raise the elbow to chin level, it is a positive sign of a dislocated shoulder. Hamilton's sign Normally, a straight edge (eg, a yardstick) held against the lateral aspect of the arm cannot be placed simultaneously on the tip of the acromion process and the lateral epicondyle of the elbow. If these two points do touch the straight edge, it almost always signifies a dislocated shoulder.
General Management Direction of Shoulder Dislocations
Techniques for reducing long-duration dislocation or those with complications requiring anesthesia or surgery are orthopedic procedures that require referral to an appropriate specialist. However, the reductions of dislocations are within the chiropractic scope of practice in some states; thus, commonly applied techniques for these conditions will be briefly described in this book. Only techniques to reduce simple, uncomplicated dislocations are described in this text. These will usually be recurring dislocations where only mild or moderate force is necessary for correction.
Some authorities report that, when possible, reduction should be made within 10 minutes after injury when local numbness is present and severe spasm has not occurred. A firm gentle manipulation will usually result in reduction. If not, avoid persistent attempts and refer to an orthopedist. Such rapid reduction is rarely possible unless the doctor is an on-field athletic physician or just happens to be near the scene. Other authorities believe that prior x-rays should always be taken before attempting reduction to avoid possible problems associated with a fracture.
There is always a great danger of forcing a bone chip into the joint that would require surgery. Thus, a decision must be made to either offer immediate relief with some risk by making one good attempt or leaving the patient in severe pain until films can be taken, processed, and analyzed. The longer reduction is delayed, the greater muscle spasm will make reduction difficult.
Following reduction, strapping and a sling should be used to rest the joint and a harness employed to restrict shoulder abduction and exterior rotation. Such a sling should have a controlling swath around the thorax to stabilize the joint such as incorporated within a modified Velpeau bandage. Local soreness will subside within a few days as the soft tissues heal. Cold can be applied initially to reduce pain and swelling, followed by the usual treatment for severe sprain. The typical athlete is excessively eager to have the sling removed; thus, strong warnings must be given. Professional opinion differs as to the length of immobilization. The average is 4 weeks. Some feel prolonged immobilization (over 3 weeks) produces more harm (atrophy) than good, while many others feel that at least 6 weeks are necessary to avoid recurring problems. Regardless, the shoulder should be allowed to heal thoroughly before progressive exercises are initiated. The fingers and wrist, however, should be actively exercised early during immobilization.
The older patient is more prone to later stiffness problems than recurrence problems. Mild circumduction exercises may be initiated after about 4 days and progressive range-of-motion regimens after 3 weeks. Full external rotation and abduction should be avoided for 6 weeks in older patients, 9 weeks in younger patients. Isometric exercises of all involved muscle groups are always recommended while the shoulder is immobilized.
Humeral Head Hypomobility
The head of the humerus is frequently flexed and abducted in most lifestyles and occupations, but it is less often used in adduction and rarely used in backward extension. Likewise, internal rotation of the humerus is made much more frequently than is external rotation. Lack of exercise in any range of normal motion can readily lead to uncomfortable or painful motion restriction when unaccustomed movements are made with or without external loading. Mobilizing such points of restriction can often relieve functional shoulder complaints as well as symptoms referred from the site of restriction. Data on the normal range of shoulder motion vary several degrees among the authorities. Below are general averages that are adequate for clinical practice:Abduction 180° Adduction 50° Fllexion 180° Extension 50° Internal rotation 90° External rotation 90°
Restricted Upward Elevation
Spastic and Painful Jammed Shoulder Joint. A proximal humerus can be jammed into the glenoid by a fall on the outstretched hand or simply by severe periarticular muscle spasm. Almost any type of axial traction will help to relieve this condition. One common technique is to place the patient supine (to stabilize the scapula) with the involved limb resting comfortably at the side, elbow extended, and wrist pronated. Stand at the side and face the patient. Cup your stabilizing hand (medial) on the patient's shoulder so that your fingers extend around the shoulder, your thumb enters the axilla, and the web of your hand contacts the inferior neck of the glenoid below the lateral aspect of the clavicle. Firmly grasp the patient's arm just above the elbow and apply axial traction directly caudad. The patient's extended forearm can be tucked between your stabilizing arm and medial hip. While applying traction, it sometimes helps to rotate your hips and shoulders clockwise for added leverage. Slowly stretch to patient tolerance, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of abduction as can be tolerated by the patient.
Freeing Restricted Inferior Glide During Abduction. Place the patient supine, and stand almost perpendicular to the patient but turn your body slightly away from the patient's face so that your medial hip is firm against the table. Partially flex the patient's elbow, and slowly move the limb into abduction up to patient tolerance. The fingers of your stabilizing hand grasp the patient's arm distally, just above the elbow, and the patient's elbow rests in your palm. The patient's hand can be tucked between the elbow and trunk of your lateral (stabilizing hand) side. The heel of your supinated active hand (medial) is placed against the lateral aspect of the patient's upper arm. While holding a firm contact with your stabilizing hand, apply a pushing force (directed caudally) to patient tolerance, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of horizontal abduction by moving the patient's elbow progressively toward the head of the table. This technique is especially effective when impingement is found under the greater tuberosity of the acromial arch during horizontal abduction (a common finding).
Freeing Restricted Inferior Glide During Flexion. Place the patient supine, fully flex the elbow, and lift the patient's arm so that the elbow points toward the ceiling. The patient's fingertips should come near to the shoulder tip. Stand at the side and face the patient. Grasp your hands around the patient's proximal humerus, fingers intertwined. If your treatment table is low enough, you will be able to stabilize the patient's elbow with your chest. While maintaining firm contact with your stabilizing hand, slowly apply a pulling force (to patient tolerance) toward your body with your active hand, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of internal and external rotation by moving the patient's elbow laterally and medially.
Restricted Horizontal Adduction
Freeing Restricted Lateral Glide During Flexion. This technique is similar to that described for restricted inferior glide during flexion, except that the pulling force is directed laterally rather than caudally.
Restricted Internal Rotation
Freeing Restricted Anterior Glide During Internal Rotation. Place the patient in the lateral recumbent position with the uninvolved side against the table. Stand at the side of the table (anterior to the patient) so that you are facing obliquely to the head of the table. Extend the patient's involved limb, pronate the wrist so that the back of the patient's hand rests near the buttock, and then slowly flex the patient's elbow to tolerance. Firmly cup the patient's elbow with your stabilizing (caudad) hand. Lean over the patient, and with your active (cephalad) hand, take a pisiform contact over the posterior aspect of the head of the humerus. Maintain firm contact with your stabilizing hand, apply a pushing force (to patient tolerance) with your active hand that is directed toward your body, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of internal rotation by moving the patient's hand progressively cephalad.
Freeing Restricted Posterior Glide. During Abduction. Place the patient supine, stand at the side and face the patient, and abduct the patient's involved arm of the partially flexed limb to tolerance. The patient's hand can be tucked between the elbow and trunk of your lateral (stabilizing hand) side. The palm of your stabilizing hand cups the patient's elbow while the fingers grasp the lower arm. The heel of your pronated active hand (medial) is set against the anterior surface of the patient's upper arm, as cephalad as possible without losing contact with the humerus. The greatest pressure should be felt on your pisiform. Bend over the patient so that your active hand is perpendicular to the patient's arm, and extend your elbow. Maintain firm contact, apply a pushing force (to patient tolerance) toward the floor hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of internal and external rotation by moving the patient's elbow laterally and medially.
Restricted External Rotation
Freeing Restricted Anterior Glide During External Rotation. Place the patient in the supine position, and stand at the side of the table obliquely facing the patient on the involved side. Partially flex the elbow of the involved limb, and grasp the patient's lower humerus with your stabilizing (lateral) hand. From the medial aspect, reach under the superior aspect of the patient's upper arm with your active (medial) hand so that the posterior aspect of the upper arm rests in your palm. Bend forward, maintain firm contact with your stabilizing hand, and slowly lift the head of the humerus toward the anterior (towards the ceiling). After the slack in the shoulder girdle is removed, continue the pulling force to patient tolerance, hold, and slowly release. Repeat several times, gradually moving the patient's arm into greater degrees of internal and external rotation by moving the patient's hand (elbow partially flexed) progressively medially and laterally.
Freeing Restricted Posterior Glide During External Rotation. Place the patient in the supine position, stand at the side of the table, and face the head of the table on the involved side. With your lateral hand, grasp the patient's wrist. Flex the patient's elbow and abduct the humerus as close as possible to 90. With your medial hand, take a broad contact with the heel of the hand against the anteromedial surface of the proximal humerus and your fingers wrapped around the deltoid. Very slowly produce external rotation by moving the patient's wrist slightly towards the tabletop with your lateral hand and rotating the proximal humerus externally with your medial hand. Extreme caution must be used with this maneuver to avoid dislocating the joint.
Orthopedic Subluxation Orthopedic Subluxation of the Humeral Head
This acute condition is probably a dislocation that has partially reduced itself spontaneously. It usually occurs when the greater tuberosity has been displaced upward as a whole so that it lies between the humeral head and the glenoid. The capital part rotates to a degree but does not completely escape from its capsular envelope. Films will show that the outer border of the shaft is impacted firmly into the cancellous tissue of the head of the humerus.
The chief obstacle in obtaining reduction is in the difficulty of removing the tuberosity from within the joint and overcoming the extremely firm impaction of the two main fragments. It is rarely possible to overcome these obstacles by conventional manipulation, especially without anesthesia, thus referral for orthopedic attention should be seriously considered.
Anterior Humeral Head Subluxation
This is a frequently seen shoulder subluxation. The mechanism of injury is generally similar to that of anterior humeral dislocation; ie, forces that involve a combination of abduction, extension, and external rotation of the shoulder.
Significant Features. There is difficulty in raising the arm overhead. A fullness will be noted on the upper anterior arm that will be tender during palpation. The deltoid will feel taut and stringy. A sensitive coracoid process will be found that is higher than the head of the humerus. Signs of acute or chronic sprain will likely be found, depending upon the history.
Adjustment of an Externally Rotated Anterior Humerus. If the patient's humeral head is fixated in an anteriorly and externally rotated position, stand behind the patient (seated on a low stool). The patient's hand on the involved side should be placed on the patient's opposite shoulder near the neck to internally rotate the involved humerus. The patient's elbow is then fully flexed so that the arm will be almost horizontal to the floor and the elbow is positioned approximately over the sternum. The patient's other hand can rest loosely in the lap. Reach around the patient with both arms and clasp your fingers over the patient's flexed elbow. Brace your chest against the patient's dorsal spine for counterpressure. Ask the patient to relax, and when this is done, lift the patient's elbow slightly and apply firm pressure. This maneuver is followed by a short quick thrust (pull) that is directed posteriorly and slightly superiorly. As with many adjustive procedures conducted with acute conditions, this adjustment should be followed with sprain therapy and rehabilitation measures to assure against future joint looseness or restrictions.
Adjustment of an Internally Rotated Anterior Humerus. The procedure to correct a humerus that is fixated in an internally rotated anterior position is essentially the same except that, prior to the adjustment, the patient is instructed to grasp the back of the neck on the ipsilateral side with the palm of the hand on the affected side to externally rotate his humerus.
Simple Anterior Humeral Head Dislocations
Subcoracoid (most common), intracoracoid, and subclavicular types of anterior dislocation of the head of the humerus may be found. The typical mechanism of injury involves a combination of abduction, extension, and external rotation of the shoulder. The three most common means of injury are:
(1) a fall on the outstretched arm where the force drives the humeral head forward against the anterior capsule;
(2) a fall or blow to the lateral shoulder from the rear; and
(3) forced abduction with the humerus in internal rotation or forward flexion with the humerus in external rotation, limited by the acromial arch. In this latter type, if forceful elevation is applied when the point of impingement is reached, the arch is used as a fulcrum to dislocate the head of the humerus anterior and inferior. In many instances (eg, an unexpected jolt), only a relatively trivial force is necessary to produce an anterior dislocation.
In subcoracoid luxation, the head of the humerus lies under the coracoid process, either in contact with it or at a finger's breadth distance at most below it. The dome of the humerus may be displaced inward until three-fourths of its diameter lies to the medial side of the process or be simply balanced on the anterior edge of the glenoid fossa. The humeral axis passes to the medial side of the fossa. Inspection will note that the elbow hangs away from the side, the lateral deltoid bulge is flat, and the acromion is prominent. The glenoid cavity is relatively empty. Palpation will reveal the absence of the usual bony resistance below the lateral aspect of the acromion and the presence of abnormal resistance below the coracoid process or in the axilla. Voluntary movement is lost, and assisted abduction is strongly resisted by the patient. Dugas' test is positive. That is, the arm can be passively adducted but not to the degree that the elbow can touch the chest with the fingers resting on the opposite shoulder. Linear limb measurement in abduction, compared to the uninvolved side, shows shortening.
Before any reduction technique is utilized, the integrity of the circumflex nerve should be established by checking the dermatome (C5) with a pin or pinwheel, and signs of possible fracture should be sought. As a rule, early reduction of a mild shoulder dislocation may not require an anesthetic except in the highly apprehensive patient or if complications are suspected. Reassurance, warmth, and a quiet area help to enhance relaxation. Occurrence, the absence of complications, and reduction should always be confirmed by x-ray and other diagnostic procedures
Classic (Hippocratic) Method. This crude but effective method is accomplished by the seated doctor placing a shoeless foot in the supine patient's axilla for counterpressure and applying straight axial traction with both hands on the patient's arm. The slow gentle pull is towards the inferior and slightly lateral, never upward and outward as there is danger of lacerating vessels. After a long steady pull (never a jerk), the muscles may yield and allow the head of the humerus to slip back into the socket as the arm is slowly internally rotated. If successful, relief is immediate. During the traction, some doctors attempt to push the humeral head into the socket with the ball of the stockinged foot.
The doctor-patient position described above will frequently be referred to in subsequent portions of this chapter as simply the classic position. A less effective but more "sophisticated" approach can be used by applying a padded counterpressure strap beneath the axilla rather than using a foot.
If replacement is not complete, remove your foot from the patient's axilla, and flex the patient's elbow. Stabilize the elbow with one hand while applying gently pressure downward on the forearm to cause slight internal rotation of the humeral head to complete the reduction. Place the flexed arm over the patient's chest and instruct him to hold it there until the joint can be secured with tape.
Note: Muscle spasm may be difficult to overcome in the highly musculatured athlete. Regardless, never use severe leverage against the chest as it will undoubtedly break a rib if the thorax is used as a fulcrum. However, some doctors are skilled at applying forceful adduction over a padded closed fist placed in the patient's axilla.
Kocher's Method of Reduction. This procedure is performed by:
(1) applying gentle downward traction to the flexed elbow and pressing it closely to the patient's side;
(2) most carefully, easing the arm into full possible external rotation by moving the patient's arm away from the trunk (a sudden motion may fracture the humerus);
(3) while maintaining the external rotation, carrying the elbow well anterior and superior to gently adduct the elbow across the patient's chest; then
(4) reduction can be felt (and often heard) when adduction is complete. The patient's arm is then rotated internally so that the hand rests on the patient's opposite shoulder. The elbow is simultaneously lowered. If this method fails, the classic method may be attempted. Keep in mind, however, that failure in reduction may indicate a complicating fracture that would make further attempts contraindicated.
Stimson's Method. A gentle alternative to the technics described above is to place the patient prone on a cot or table with the affected limb hanging towards the floor. Fix about a 10-lb weight to the padded wrist with tape. Frequently, this gentle continuous traction will reduce the dislocation within 20 minutes. It works best with the patient not presenting with highly developed musculature.
If one of these methods is not successful, referral for reduction during general anesthesia should be considered. Open reduction is rarely required.
Complications of Anterior Humeral Head Dislocations
When the humerus dislocates anteriorly, its posterolateral margin is often forced against the rim of the glenoid to produce a compression fracture (Hill-Sachs deformity). The malpositioned humerus frequently tears the cartilaginous labrum and capsule from the glenoid rim (Bankhart lesion) with an avulsed fragment of bone. If there is fracture of the anatomical neck, the humeral head (if it can be felt) will not participate in passive movement of the shaft. Crepitus can usually be felt. Fracture of the greater tuberosity and tears of the rotator cuff are common complications. Anterior fracture-dislocations are usually related with displacement of the greater tuberosity, but the capsule is not displaced. Any anterior luxation can do great harm to the brachial artery, vein, or nerves. Circulation should always be checked and contraindications eliminated before in-office reduction is attempted.
Intracoracoid and Subclavicular Dislocations
In intracoracoid and subclavicular luxations, the head of the humerus is displaced and fixed further medially. The symptoms and signs are similar to those of the subcoracoid type of dislocation except that the head of the humerus is felt further displaced and the lateral aspect of the shoulder appears to be more flattened. The arm may be fixed in horizontal abduction. Severe capsule laceration is usually involved, which allows for the greater displacement.
Intracoracoid or Subclavicular Dislocation Reduction Technique. Outward traction usually has no difficulty in reducing these types of dislocations unless the subscapularis or a torn capsule intervenes. If this is the case, surgery is the only recourse. Angelvin's method of reduction is applied by placing the hand of the dislocated extremity about your neck. Then, in intracoracoid luxation, direct the head of the humerus with your hands by applying extension, counterextension, and lateral traction pressure as need be. In subclavicular luxation, the same forces applied more energetically will force the head of the humerus into the socket.
Inferior Humeral Head Subluxation
Significant Features. A slight hollowness may be found at the joint space, indicating that the head of the humerus has dropped from its normal position. The deltoid will often feel firm and stringy, suggesting a chronic disorder. Physical signs are often vague; thus suspicions should be confirmed by bilateral roentgenography and other appropriate diagnostic procedures.
Adjustment. First, determine if correction is necessary for any associated internal or external rotation in addition to the superior displacement. The patient is then placed supine if there is any internal rotation, prone if there is any external rotation. Stand obliquely (facing the patient's affected side), and take contact on the patient's medial proximal humerus with the web of your medial (active) hand. Grasp your stabilizing (lateral) hand around the patient's distal humerus from above. Pressure is applied cephalad with your active hand, and then a short thrust is made while your lateral hand firmly stabilizes the patient's humerus.
Alternative Technic. In this technic, correction is induced by abduction, moderate traction, and then superior pressure. The patient is placed supine. Sit perpendicular to the affected side, and flex the patient's elbow. The forearm of the affected extremity can be placed in your axilla for control. Grasp the patient's humerus high with both hands and pull the head of humerus first laterally towards yourself and then cephalad in one smooth quick movement. Counterpressure is applied by your knee firmed against padding placed in the patient's axilla. This "reseating" procedure should be followed by short-term immobilization to encourage the lax tissues to tighten, and then rehabilitation procedures to strengthen weakened musculature and lax supporting tissues.
Inferior Humeral Head Dislocation
Subglenoid and luxatio erecta types are infrequently seen in which the head of the humerus lies below the glenoid fossa. The typical cause is forcible abduction followed by rotation or impulsion. The mechanism of injury is usually a leverage force on an abducted arm such as in a football arm tackle.
Significant Features. There is severe pain and disability. The arm is fixed at about 45 in abduction. A hollowness will be found at the joint space, with the head of the humerus found to be inferior to its normal position and often palpable within the axilla. The deltoid is flattened and extremely spastic. In subglenoid luxation, the major physical feature is marked subcoracoid flattening. The upper part of the greater tuberosity is often torn. In rare instances of luxatio erecta, forcible elevation of the arm causes the head of the humerus to be displaced so far downward that the extremity remains in an erect position.
Inferior Dislocation Reduction Technique. In subglenoid dislocation, treatment is by moderate abduction with direct pressure. This is a difficult type of dislocation to reduce without anesthesia, and usually requires an orthopedist. To reduce mild to moderate displacements, the patient is placed supine. Sit perpendicular to the affected side, and, if possible, place the patient's flexed elbow in your axilla for stabilization. The head of humerus must be first pulled laterally towards you and then cephally in one smooth movement. Counterpressure is applied by your knee against a pillow placed in the patient's axilla. Reduce any degree of luxatio erecta by upward traction until the head of the humerus slips into place.
Posterior Humeral Head Subluxation
Significant Features. Physical signs of this rare malposition are often negative. Stress films, taken bilaterally for comparison, are required for confirmation. In some cases, the posterior area may feel fuller than the unaffected side. An unusually prominent coracoid process may be felt, and a slight hollow may be felt above the humerus. Signs of taut tissues on the posterior aspect of the humeral head and lax tissues on the anterior aspect are often found.
Adjustment. In many instances, simple axial traction of the humerus in the classic position will reduce a posterior humeral head subluxation (or uncomplicated dislocation). If not, the following procedure is suggested.
The patient is placed prone with the involved extremity resting loosely at the side. Stand on the side of involvement, obliquely facing the patient's shoulder. Take a pisiform contact on the patient's posterior proximal humerus, as far cephalad as possible, with your medial hand. Your lateral hand then stabilizes your contact hand. Direct pressure toward the floor, and then make a short thrust to complete the correction.
Alternative Technic. Correction of a humeral head that has become fixated in a posterior position can also be made in the same doctor-patient position as for the alternative adjustment procedure of an inferior humerus subluxation. Traction is applied to the humerus first laterally towards yourself and then anteriorly towards the ceiling. A slow steady lateral pull should be concluded with an anterior tug to stretch the contracted tissues and "reseat" the humeral head in its normal position. Follow with standard therapy for acute or chronic sprain, depending upon the history.
Simple Posterior Humeral Head Dislocation
This type of dislocation is often a diagnostic challenge in the young well-muscled athlete because all joint motions may be unrestricted, yet disability is acute. Two types are seen that differ only in the extent of displacement; ie, subacromial and subspinous types. The cause is direct pressure that has been applied laterally and posteriorly, or pressure that has been exerted in the same direction along a flexed, adducted, and internally rotated humerus. It is sometimes produced during a convulsion.
Significant Features and Common Complications. The patient's arm is abducted and rotated internally, and the elbow is directed slightly forward. The shoulder is flat in front and full behind, where the head of the humerus may be felt. The coracoid process is prominent. The head of the humerus lies on the outer edge of the glenoid fossa or further posterior to lie under the scapular spine or on the infraspinatus. These features are not as obvious as those of anterior dislocation. Passive abduction and external rotation motions are restricted. In severe cases, the lateral side of the capsule is usually torn, and there may be associated rotator cuff tear or an avulsion fracture of the greater tuberosity resulting in persistent pain. The internal and external scapular muscles are usually torn and may contain fragments of the avulsed tuberosities.
Posterior Dislocation Reduction Technic. In uncomplicated cases of posterior luxation, reduction can usually be accomplished by inferior and lateral traction with direct anterior pressure. Unreduced dislocations exhibit an unusual amount of disability. When viewed from the lateral, the posterior area may appear fuller than the unaffected side. An unusually prominent coracoid process may be palpated, and a hollow may be felt above the humerus. Tearing of the subscapularis makes recurrence probable unless appropriate muscle rehabilitation regimens are not instituted.
In contrast to the management of anterior dislocations, a posterior dislocation should be immobilized after reduction with the arm in external rotation and abduction. This usually requires the use of an abduction splint.
Superior Humeral Head Subluxation
Because of its bony arch, the humerus cannot dislocate much superiorly unless there is severe traction involved. However, some authorities believe that superior subluxation can often be demonstrated on bilateral roentgenography. Schultz feels this is the most common shoulder subluxation seen. This author, however, believes the term to be a misnomer as the suprahumeral joint is not an articulation in the true sense of the word but is solely a structure that serves as a protective and supportive mechanism. Most likely what is referred to as a superior humeral subluxation is the result of contractures within the superior humeral area that prevent the greater tuberosity from gliding smoothly under the coracoacromial ligament during abduction. The result is chronic compression, irritation, and ischemia of the enclosed tissues. Keep in mind that the acromioclavicular meniscus progressively thins with age. It is quite thick in the young but may be completely gone by the 5th or 6th decade.
Adjustment. Determine if correction is necessary for any associated internal or external rotation besides the superior displacement. The patient is then placed supine if there is any internal rotation; prone if there is any external rotation. Position yourself above the affected limb, oblique to the patient's affected side. The patient's elbow is flexed, and the patient's shoulder is abducted to near 90. With the web of your active medial hand, take contact on the lateral aspect of the patient's proximal humerus. With your lateral stabilizing hand, grasp the medial aspect of the distal humerus. Apply pressure against the proximal humerus in a caudad direction (transverse to the humeral shaft), and then make a thrust while your lateral hand stabilizes and slightly abducts the patient's distal humerus.
Alternative Technic. As above, determine if correction is necessary for any associated internal or external rotation along with the superior displacement. This technic is a variation of the Hippocratic method of reducing subcoracoid dislocations, which has been previously described.
Sit near the affected side, and face the head of the supine patient. Place a shoeless foot in the patient's axilla for counterpressure and stabilization of the shoulder girdle. Apply straight axial traction with both hands grasped around the patient's arm. Direct the traction toward the inferior and slightly lateral. After a few seconds and with steady traction, rotate the patient's arm internally (usually) or externally, as need be, and then make a short tug towards your body to correct any rotational deficit that exists.
Superior Humeral Head Dislocation
A supraglenoid luxation is extremely rare except in sports and severe accidents. A routine A-P view may show narrowing of the space between the head of the humerus and the acromion, indicating a tear. In many cases, arthrography should be recommended. Care should be taken not to confuse the growth plate of the proximal humerus with that of a fracture line.
Superior Dislocation Reduction Technic. Superior dislocation may be reduced by the same methods described for superior humeral head subluxation.
Internally Rotated Humeral Head Subluxation
This type of malposition is frequently associated with a fixation that restricts external rotation of the humerus. Rotator cuff tendinitis and inferior humerus subluxation may be associated.
Adjustment. This technic is almost identical to the previously described adjustment of an internally rotated anterior humerus.
Alternative Technic. With the patient placed supine on the adjusting table, stand facing the patient's shoulder on the side of involvement. The patient's elbow is flexed and the arm is allowed to rotate externally somewhat by its own weight. With your contact hand, firmly grasp the patient's proximal humerus just below the acromion process. Slide your other (lateral) hand under the patient to stabilize the scapula. It is helpful if a thumb contact can also be made upon the clavicle. A deep, but not severe, rotary thrust is then made with the line of correction directed to produce external rotation of the humerus.
Externally Rotated Humeral Head Subluxation
An external subluxation of the humerus is usually related to restricted internal rotation of the humerus. Supraspinous tendinitis, bicipital tendinitis, tendon displacement from the bicipital groove, and inferior humerus subluxation are common complications.
Adjustment. This technic is almost identical to the previously described adjustment of an externally rotated anterior humerus.
Alternative Technic. Place the patient prone on the adjusting table, and stand facing the patient's shoulder on the side of involvement. The patient's elbow is flexed and the supinated hand is placed under the patient so that the palm comfortably rests against the patient's chest and the back of the hand is in contact with the table. This "sling position" will allow some internal rotation tension that will assist the forthcoming adjustment. In this position, your stabilizing hand should cup the patient's shoulder so that the heel of your hand holds the patient's clavicle while your fingers stabilize the patient's scapula. Your contact hand should firmly grasp the patient's humerus just below the acromion process. A deep, but not severe, rotary thrust is then made that is directed to produce internal rotation of the humerus.
Recurring Displacements of the Humeral Head
Several factors influence recurrent dislocation. The younger the patient is with a glenoid-rim fracture, the size of the capsular deformity (Hill-Sachs deformity), and the range of normal lateral motion all increase the chances for recurrent dislocation. If the humeral head is driven directly forward during injury, the cartilaginous labrum glenoidale is torn from its anterior attachment. This leaves a potential cavity into which the head can repeatedly slip. Another cause is too early mobilization following a primary dislocation. Incidence is highest in males 20–40 years of age. In the nonathlete, recurrences appear in over 90% of patients under the age of 20 after a primary dislocation. This rate drops to about 12% in patients over 40 years old. However, proper treatment and rehabilitation procedures can reduce this rate in any age group.
A recurring dislocation is a different problem from that of a primary dislocation. Recurring luxations are almost always of the subcoracoid type. Recurring posterior dislocations are usually not as painful and may be of the snapping variety. Regardless of the type, the dislocating force is usually mild and reduction is easy in comparison to reducing primary dislocations. As with primary dislocations, the pain may be severe and unrelieved until reduction is made. After reduction, symptoms disappear in 1 or 2 days whereupon progressive strengthening exercises can be initiated. Prolonged immobilization is ill-advised. In some cases of a permanently loose joint, surgical fixation may be the only solution, and this is an orthopedic decision.
The Lax Joint. Repeated subluxations without clinical dislocation often produce a loose joint. The history will reveal frequent episodes of mild trauma, each incorporating a period of pain and limited motion, followed by an audible "click" as the head of the humerus slips painfully back into the fossa. After reduction, examination reveals little except residual tenderness and a lax capsule. If episodes are frequent, external support should be provided. It is doubtful that strength-building exercises will be effective. The patient should be advised of the risks involved in repeated subluxation.
Lax Capsule Test. To determine a lax capsule, have the patient clasp his fingers behind his head and laterally abduct his elbows. Palpate high in the axilla over the glenohumeral capsule while applying posterior force on the patient's flexed elbow. While laxity of the anterior capsule can always be demonstrated by this maneuver, care must be taken not to dislocate the humerus within its loose capsule.
ELBOW SUBLUXATIONS, FIXATIONS, AND DISLOCATIONS
The majority of forearm injuries are the result of direct blows or falls. The most commonly seen injuries are avulsion-type trauma of the elbow as a result of acute or chronic strain at a site of tendon or ligament attachment.
The proximal ulna forms the most important articulation in the elbow, while the distal radius forms the most important articulation in the wrist.
Most subluxations in the elbow area will offer dramatic relief upon correction. Generally, correction is made with a quick, short thrust or pull on the stabilized adjacent segment to minimize the pain (and time) of relocation. It is essential that the patient's muscles be relaxed or correction will be inhibited and extremely painful. Naturally, quick thrusts are contraindicated in arthritic and sclerotic conditions or if adhesions are advanced.
Dynamic Palpation of the Elbow
The elbow has long been considered a simple hinge joint. Soderberg, however, points out that biomechanical and kinesiologic studies have shown that this viewpoint is an oversimplication of the actual conditions required for normal elbow motion.
The relatively strong elbow complex consists of three joints:
(1) the radiohumeral joint,
(2) the ulnohumeral joint, and
(3) the superior radioulnar joint.
Because the elbow has such a wide range of motion in flexion, extension, supination, and pronation, freedom of joint play must be evaluated to determine the point of possible fixation. These are:
- Lateral glide of the olecranon on the distal humerus when the elbow is flexed.
- Medial glide of the olecranon on the distal humerus when the elbow is flexed.
- Glide of the coronoid process of the ulna into the coronoid fossa of the humerus during elbow flexion.
- Glide of the olecranon process of the ulna into the olecranon fossa of the humerus during elbow extension.
- Upward glide of the head of the radius on the head of the ulna.
- Downward glide of the head of the radius on the head of the ulna.
Internal and external rotation of the head of the radius on the head of the ulna and capitulum of the humerus and internal and external rotation of the olecranon of the ulna on the trochlea of the humerus are spinning actions that are readily reflected in standard procedures for evaluating passive ranges of motion.
The most common afflictions of the elbow are elbow bruises leading to bursitis and strain/sprain leading to subluxation and arthritis. A large number of functional and pathologic disorders (local or remote) may manifest within the elbow area (Table 2.5).
Table 2.5. Typical Causes of Lower Arm, Elbow, and Forearm PainEndocrine Traumatic Inflammatory Neurologic Vascular or Metabolic Dislocation Bursitis Carpal tunnel Angina Diabetic Fracture Cellulitis syndrome pectoris neuropathy Muscle or nerve Herpes zoster Cervical Arterial Gout contusion Local infection subluxation embolism Pseudogout Spinal cord Lymphadenitis Cervical IVD Dissecting injury Osteomyelitis syndrome aneurysm Sprain Rheumatoid Cubital tunnel Myocardial Strain arthritis syndrome infarction Tendon rupture Septic arthritis Elbow subluxation Thrombophlebitis Upper extremity Tendinitis Lateral clavicle or cervical Tennis elbow subluxation subluxation Tuberculosis Peripheral neuritis Scalenus anticus syndrome Shoulder subluxation Thalamic syndrome Trigger point Degenerative Allergic or Neoplastic or Deficiency Congenital Autoimmune Toxic Lymphoma Osteoarthritis Cervical rib Dermatomyositis Septicemia Metastasis Spondylosis Multiple sclerosis Toxicosis Myoma Pancoast's tumor
Branch lists the most common causes of extrinsic elbow pain as medial or lateral epicondylitis and olecranon bursitis and of intrinsic elbow pain as synovitis, loose bodies, elbow subluxations, dislocations, and fractures.
Freeing Restricted Distraction. The humeroulnar joint can be jammed by a fall on the outstretched hand or simply by severe para-articular muscle spasm. It is sometimes seen in patients whose occupations require repeated violent pushes with the heel of the extended hand (eg, football linemen, carpenters). Almost any type of axial traction will help to relieve this condition. A common procedure is to first place the patient supine, and sit at the side of the table on the involved side (obliquely facing the patient). Abduct the patient's shoulder to 90º, flex the elbow to 90º, and pronate the forearm. Place your medial knee in the patient's antecubital fossa to stabilize the humerus, grasp the under surface of the proximal forearm with both hands, slightly abduct the forearm so that more pressure will be applied to the ulnar than the radius, and apply axial traction toward your body. Slowly stretch to patient tolerance, hold, and gradually release. Repeat several times.
Freeing Restricted Medial-Lateral Tilt. Place the patient supine, and sit or stand at the side of the table on the involved side (obliquely facing the patient). The patient's involved limb should be resting loosely at the side, near the body, with the elbow extended and the wrist supinated. This is a two-phase procedure:
The first maneuver is to stabilize the patient's distal forearm with your medial hand and grasp the lateral surface of the patient's proximal ulnar with your active (lateral) hand. This position will allow you to apply a horizontal shearing force across the humeroulnar joint, from the lateral to the medial. Slowly apply force to patient tolerance, hold, and gradually release. Repeat several times.
The second maneuver is just the reverse. Stabilize the patient's distal forearm with your lateral hand and grasp the medial surface of the patient's proximal ulnar with your active (medial) hand. This position will allow you to apply a horizontal shearing force across the humeroulnar joint, from the medial to the lateral. Slowly apply force to patient tolerance, hold, and gradually release. Repeat several times.
Proximal Radioulnar Hypomobility
Freeing Restricted Distraction. This technic is a variation on that described for a jammed humeroulnar joint. Place the patient supine, and sit at the side of the table on the involved side (obliquely facing the patient). Abduct the patient's shoulder to 90, flex the elbow to 90, and supinate the forearm. Place your medial knee in the patient's antecubital fossa to stabilize the humerus, grasp the upper surface of the proximal forearm with both hands, slightly adduct the forearm so that more pressure will be applied to the radius than the ulna, and apply axial traction toward your body. Slowly stretch to patient tolerance, hold, and gradually release. Repeat several times.
Freeing Restricted A-P Glide. Place the patient supine, sit at the side of the table on the involved side, and face the head of the table. Abduct the patient's shoulder to 90º, flex the elbow to 90º, supinate the forearm, and lift the arm so that the patient's hand points towards the ceiling. Place your thumb (lateral side) on the head of the radius (which will serve as a fulcrum) and cup the patient's elbow with the palm of your stabilizing hand. With your active hand (medial), move the patient's distal forearm toward the shoulder (elbow flexion). Once resistance is felt, slowly apply force to patient tolerance and release. This is essentially a rocking-type motion. Repeat several times. The patient must completely relax the arm as any contraction of the patient's biceps against your thumb will produce pain.
Freeing Restricted Pronation (Internal Rotation). Place the patient supine, and sit at the side of the table on the involved side (obliquely facing the patient). Abduct the patient's shoulder to 90, flex the elbow to 90, and supinate the forearm. Place your medial knee in the patient's antecubital fossa to stabilize the humerus, grasp under the patient's distal forearm with both hands, pronate the patient's forearm to tolerance by rotating your hands, and apply axial traction toward your body. Slowly stretch to patient tolerance, hold, and gradually release. Repeat several times, progressively increasing the degree of pronation possible.
Posterior-Medial Radial Head Subluxation
This "pulled elbow" injury results from the radial head being jerked from under the annular (orbicular) ligament, manifesting pain and tenderness in the area of the radial head. A "snap" is usually heard and felt at the time of trauma. It was once called "Nursemaid's elbow" because it was frequently found after young children were quickly lifted up by the wrist or hand when the child's elbow was extended and the forearm was pronated. This classic form rarely occurs after the age of 6 years.
Motion is severely limited in pronation and supination, but flexion and extension are normal. The arm is held motionless at the side in slight flexion and pronation, and pain is fairly localized at the elbow. X-ray films are usually negative. This type of subluxation is commonly associated with tennis elbow or wrist trauma, lateral elbow pain, and restricted anterolateral radial head motion.
When manipulation is indicated, hold the patient's affected elbow with one hand so that your thumb rests on the back of the head of the involved radius. With your other hand, grasp the patient's hand and move the forearm into a position of slight flexion at the elbow, full forearm pronation, and full flexion at the wrist. The adjustment (Mills' movement) consists of fully extending the patient's elbow while maintaining pronation and flexion of the wrist. The maneuver is made gently but quite sharply; thus, it is essential that the patient's elbow muscles be relaxed. The manipulation usually causes no pain to a normal elbow, but there is sharp pain that is quickly followed by relief when a tennis elbow is "freed." After correcting malposition, treat the condition as a severe sprain and offer rest in a flexion sling for several days.
An alternative manipulative procedure to re-establish a slipped radial head is to grasp the hand of the sitting patient and extend the patient's wrist. Support the elbow firmly with your contact hand. Flex the patient's elbow to a right angle. Maintain axial compression along the radius, and firmly alternate forearm supination and pronation in a "screwing" manner until the head of the radius slips back into its normal seat. The thumb of your hand holding the patient's elbow can be used to apply manual pressure against the head of the radius. A click can usually be felt and heard on replacement, which is followed by immediate relief.
Medial Olecranon Subluxation
Subluxation of the olecranon medially is often seen in association with wrist or elbow trauma that is followed by ulna nerve paresthesias, medial elbow pain, triceps weakness, a decreased distance between the olecranon and the medial epicondyle, and/or restricted lateral olecranon joint motion.
Face cephalad on the affected side of the supine patient. The patient's arm is slightly abducted with the elbow extended. The heel of your medial contact hand should be placed over the medial aspect of the patient's olecranon, while your stabilizing hand grasps the patient's forearm. The patient's involved elbow is then gently brought into full extension. A short thrust is then made from the medial to the lateral with your contact hand while your stabilizing hand applies lateral to medial pressure.
The positions for both doctor and patient are similar to those described above, but the doctor stands more parallel to the patient's arm when applying this technic. Abduct the patient's arm so that the arm is in front of you, pronate the patient's wrist, and extend the elbow. Firmly grasp the patient's olecranon with the 1st and 2nd fingers of your contact hand, and stabilize the patient's distal forearm with your other hand. A short, brisk, pronating, medial to lateral pull and full elbow extension is then made with your contact hand as your stabilizing hand tends to supinate the patient's forearm.
Lateral Olecranon Subluxation
This type of subluxation is often related to elbow or wrist trauma that is followed by lateral elbow pain, triceps weakness, a decreased distance between the olecranon and the lateral epicondyle, and/or restricted olecranon motion.
Adjustment. Face cephalad on the affected side of the prone patient. Abduct the patient's involved arm, extend the elbow, and internally rotate the extremity. Take a soft pisiform contact with your medial hand on the lateral aspect of the patient's olecranon, and stabilize the patient's lower forearm with your other hand. A short, brisk, thrust is made caudally to shift the olecranon medially as your stabilizing hand pronates the lower forearm.
Anterior Olecranon Subluxation
Subluxation of the olecranon anteriorly is often found associated with hyperextension sprains and restricted posterior olecranon motion.
Adjustment. Stand on the involved side and face the sitting patient. Slightly abduct the patient's arm, and flex the elbow. Grasp your medial (active) hand around the patient's distal forearm. Cup the medial aspect of your lateral (stabilizing) hand deep within the antecubital fossa, and wrap your fingers around the proximal aspect of the patient's forearm so that your thumb points upward. Make a short, brisk thrust with your contact hand towards the patient's shoulder, using your stabilizing hand as a fulcrum to bring the olecranon out of its depressed position.
Posterior Olecranon Subluxation
This type of subluxation is associated with elbow or wrist trauma, epicondyle and bursa tenderness, triceps weakness, and restricted anterior olecranon movement.
Adjustment. Stand on the affected side of the supine patient so that you are facing cephally. Extend the patient's elbow, and slightly externally rotate the patient's forearm. Cup the patient's elbow with your medial hand, and place your thumb against the epicondyles for leverage. With your lateral hand, grasp the patient's lower forearm. A short, brisk, thrust (downward) is made toward the tabletop on the distal forearm as your medial hand applies mild counterpressure upward.
Superior Ulna Subluxation
Subluxation of the ulna superiorly is related to elbow or wrist trauma. It is often a consequence of a falling person protecting the head by an outstretched hand, resulting in the proximal aspect of the ulna being jammed against the distal aspect of the humerus.
Adjustment. The patient is seated next to a narrow table and instructed to lean forward to slightly forward-abduct the arm and extend the forearm horizontal to the table's surface. The elbow should never be fully extended as this will subject the tip of the olecranon process to injury. Stand on the opposite side of the table and face the patient. With your contact hand, grasp the patient's lower forearm and slightly rotate it externally. Place the web of your other hand around the patient's lower anterior humerus and extend your elbow to stabilize the patient's arm. Apply traction with your contact hand, and then make a short, quick pull to bring the ulna inferiorly (towards your body).
Alternative Technic. Stand on the affected side of the supine patient. Abduct the patient's arm, and flex the elbow. Grasp the patient's lower forearm with both hands, with emphasis on the ulnar aspect, and place your knee in the patient's antecubital fossa for stabilization. Traction is applied, followed by a strong upward pull.
Elbow Dislocations and Determining Associated Fractures
The majority of forearm bone injuries are from falls or direct blows. Fractures of the bones in the forearm usually involve both bones. Sometimes, however, these bones do not fracture at the same level. When a midarm blow fractures the radius or ulna, both ends of each bone must be evaluated for possibly associated subluxation, dislocation, and rotational abnormality.
Dislocations of the Elbow Area
Elbow dislocations are usually the result of excessive stress where the olecranon and/or radial head are displaced. Severe soft-tissue damage is associated, usually resulting in subperiosteal hematoma. Comminuted or marginal fracture fragments from the radial head are frequently related with elbow dislocations. In uncomplicated cases, gentle forward traction on the forearm with the humerus stabilized can be conducted to ease pain prior to referral.
Dislocation of the proximal radius accompanies midulna fracture in Monteggia injury, while midradius fracture is accompanied by distal ulnar subluxation in the Galeazzi fracture. In radial or ulnar fractures, ulnar rotational abnormalities may be a complication. Malposition of the bicipital tubercle proximally and the ulnar styloid distally are helpful clues to rotational abnormalities.
Reducing and Managing Simple Dislocations
Reduction of uncomplicated posterior elbow dislocations can usually be performed without anesthesia if they are presented soon after they occur and spasm has not become severe.
Classic Reduction Technic. All that might be necessary is gentle steady longitudinal traction on the wrist on the supine patient, with countertraction on the shoulder. This countertraction is easily accomplished by a long towel looped around and under the patient's arm pit, with the loose ends of the towel held cephalad by an assistant while the doctor performs the reduction. Slight manual extension pressure may be necessary to unlock the olecranon during wrist traction.
Parvin's Method. An alternative procedure is conducted with the patient prone. The involved limb is allowed to hang so that the fingers point toward the floor. A 5-lb weight can be applied to the patient's padded wrist by tape or manual downward traction can be used. After several minutes, when any spasm has subsided, gently place your medial hand in the involved antecubital fossa and grasp the patient's wrist with your lateral hand. Gently lift the patient's wrist upward to produce elbow flexion. This simple maneuver will often reduce the dislocation.
General Management Direction. After reduction, the elbow should be immobilized for 3 weeks in a molded posterior plastic splint at 90 flexion. This time should be sufficient for adequate ligamentous and capsular healing to take place before mild unsupported activity is resumed. Gentle passive stretching and active range-of-motion exercises should be initiated immediately after the splint is removed. Motion should never be forced, because it will only lead to greater swelling and joint stiffness. Moist heat should be applied by the patient at home at least once daily for 20–30 minutes and continued until residual stiffness resolves. It may take several months for full recovery to occur, and a minor nondisability stiffness may remain permanently.
Fractures of the Elbow Area
The most common elbow fracture is a line running from the anterior to the posterior surface of the humeral shaft (supracondylar) with the proximal fragment shifted anteriorly. Fractures in the area of the elbow usually involve the joint. In the order of frequency, the most common fractures are supracondylar, fractures of the humerus, olecranon, head of the radius, and coronoid process. A fracture line between the condyles (intercondylar) or through one or both of the condyles (diacondylar) may be found. Fracture of the ulnar shaft with dislocation of the radial head (Monteggia injury) and fracture of the radial head may also occur.
WRIST AND HAND SUBLUXATIONS, FIXATIONS, AND DISLOCATIONS
The wrist is composed of 16 synovial joints. The distal radius enlarges to form the seat of the articulation of the proximal row of carpals. The proximal rows of carpals articulate with the ulna only during extreme wrist adduction (ulnar deviation).
As with any adjustive procedure, fracture, dislocations, and other contraindications to manipulation must be previously ruled out. If signs of swelling or inflammation are not evident, mild heat is frequently helpful before correction is made to allow maximum patient relaxation and rapid physiologic response to correction. Comparative bilateral P-A, oblique, and lateral x-ray films are helpful to diagnosis.
Extension of the wrist occurs primarily between the carpal rows, and flexion of the wrist occurs essentially at the radiocarpal joints.
Dynamic Palpation of the Wrist
Joint play in the wrist should be evaluated to determine the point of possible fixation. These are:
- A-P and P-A glide of the radiocarpal joints.
- A-P and P-A glide of the ulnocarpal joints.
- A-P and P-A glide between the carpal rows.
- Lateral tilt of the navicular (scaphoid) on the radius.
- Lateral tilt of the triquetrum on the ulna.
- Long-axis traction separation between the carpal rows.
- Long-axis traction separation of the radiocarpal joint.
- Long-axis traction separation of the ulnotriquetrum joint.
- Long-axis rotational glide of the distal radioulnar joint.
- Approximation shear (induced by compression) of the distal radioulnar joint.
Dynamic Palpation of the Hand
Independent flexion, extension, abduction, and adduction motions of the bases of the metacarpals upon the distal row of carpals are usually impossible to determine unless there is gross instability. Joint play occurs at the metacarpal heads as anteroposterior glide and rotation. These joints function during finger and thumb flexion, extension, abduction, and adduction. The interphalangeal and distal phalangeal joints have essentially only anterior-posterior joint play to provide for normal flexion-extension function.
When possible, joint play in the hand and fingers should be evaluated to determine the point of possible fixation. These are:
- Abduction and adduction glide of each proximal phalange on its apposed metacarpal head.
- Anterior and posterior glide of each metacarpal head on the proximal phalanges.
- Anterior and posterior glide of each proximal phalange on the middle phalanges.
- Anterior and posterior glide of each middle phalanges on the distal phalanges.
- Long-axis traction separation of metacarpophalangeal joints.
- Long-axis traction separation of interphalangeal joints.
Note: A degree of interphalangeal side tilt and internal-external rotation normally exists, but this is most difficult to perceive.
Wrist, Hand, and Finger Pain
Certain pain syndromes concerning the hands offer cardinal symptoms, especially those involving the ulnar, median, or radial nerves. Pain radiating to the ulnar aspect of the hand extending to the ring and little fingers is characteristic of an ulnar nerve disorder. The median nerve supplies the radial side of the palm and the thenar muscles, and the origin of pain in this area may be at any point from the thumb to the cervical spine. In carpal tunnel syndrome where the median nerve becomes entrapped in its canal at the wrist, pain may be at the wrist or radiated up the forearm to the shoulder, and it is aggravated by wrist hyperextension. The radial nerve is excluded when pain is combined with weakness because this nerve has no sensory functions in the hand.
Table 2.6 lists the major causes of pain in the hand and fingers.
Table 2.6. Typical Causes of Hand or Finger PainEndocrine Traumatic Inflammatory Neurologic Vascular or Metabolic Contusion Abscess Cervical IVD Arteriosclerosis Acromegaly Dislocation Arthritis syndrome Gangrene Diabetes melitus Fracture Cellulitis Cervical Ischemic neuritis Gout Hematoma Felon subluxation Macroglobulinemia Menopause Laceration Folliculitis Elbow Myocardial Myxedema Sprain Gonorrhea subluxation infarction Strain Herpes Lateral clavicle Reflex sympathetic Subluxation Myositis subluxation dystrophy Cervical Pneumonia Neuritis Scalenus anticus Elbow Shoulder or Peripheral syndrome Finger elbow neuralgia Vasculitis Wrist bursitis Trigger Point Vasospasm Shoulde Spondylitis Subacute bacterial endocarditis Syphilis Tendinitis Thrombophlebitis Tuberculosis Ulcer Degenerative Allergic or Neoplastic or Deficiency Congenital Autoimmune Toxic Dermal carcinoma Cervical Amyloidosis Allergic dermatitis Arsenic Multiple myeloma spondylosis Buerger's Erythema multiforme Lead Pancoast's tumor Osteoarthritis disease Lupus erythematosus Vasoconstrictors Spinal cord tumor Stenosing teno- Cervical rib Periarteritis nodosa Subcutaneous synovitis Rheumatoid arthritis sarcoma Syringomyelia Scleroderma
Associated Stiffness. The hands also express the effects of several of the arthritides. Early rheumatoid arthritis is often explained by the patient as morning stiffness of the hands and fingers. This stiffness, especially in the younger person, is often relieved with activity, while an older person with osteoarthritis will complain that activity aggravates the pain.
Associated Weakness. A complaint of progressive weakness in the hands points toward myasthenia gravis. The picture may progress to paralysis associated with repetitive muscle contractions because of the effect upon the intrinsic muscles of the hand. Neuropathic hand weakness is sometimes associated with diabetes mellitus. Increasing difficulty in releasing the grip is characteristic of amyotonia congenita that is a rare genetic disease associated with premature cataracts, nasal speech, hypogonadism, frontal baldness, and this type of handgrip abnormality.
When interosseous atrophy, numbness, or restricted shoulder motions are associated with hand and/or finger pain, differentiation as to cause is aided. See Table 2.7.
Table 2.7. Hand/Finger Pain and Associated SymptomsSyndrome: Finger/Hand Pain + Primary Suspect Disorders Numbness Angina pectoris Pancoast's tumor Carpal tunnel syndrome Reflex sympath. dystrophy Cervical IVD protrusion Scalenus anticus syndrome Cervical rib Spinal cord tumor Cervical spondylosis Stenosing tenosynovitis Diabetic neuropathy Subluxation complex Restricted shoulder Adhesive capsulitis Humeral dislocation motion Biceps tendinitis Humeral fracture Brachial neuritis Humeral subluxation Clavicular fracture Scalenus anticus synd. Glenoid arthritis Subacromion bursitis Interossei atrophy Arthritis Shoulder-hand syn. Diabetic neuropathy Stenosing tenosynovitis
An absence of hand weakness when there is weakness elsewhere may also be an important clue. For instance, selective proximal weakness excluding the hands, forearms, and lower legs points toward a neoplasm or one of the endocrine myopathies such as hyperthyroidism, hypothyroidism, adrenal hypofunction, or Cushing's syndrome.
Screening Wrist Fractures and Dislocations
The roentgenographic study of the wrist usually consists of A-P, lateral, and oblique projections in which the wrist is flexed at a 45 angle to the plane of the film with the ulnar side of the wrist placed against the x-ray table. Because of the complexity of the carpal system, special views are often necessary to disclose fractures that are hidden in routine views.
Fracture of the distal radius is the first consideration in wrist injuries, but the close relationship of both forearm and wrist bones and all articulations must be evaluated in detail. The radiocarpal articulation should be evaluated on the lateral view. The radial longitudinal axis normally extends through the lunate's midpoint.
The joint spaces between the carpal bones are normally uniform. Epiphyseal fractures and fractures through the growth plate with or without shifting are not uncommon in youth. The typical deformity in this injury is a compression of the posterior margin of the radius, resulting in a posterior tilt of the anterior surface as viewed in the lateral view. The articular margin of the radius will be disturbed, and the distal radius may be fragmented and impacted.
On the P-A view, disruption of the distal radio-ulnar articulation is seen as joint widening or narrowing. During an impacted fracture of the radius, bone fragments are frequently telescoped and both styloid processes are seen at the same but more distal level; ie, the radial styloid is normally seen 1-cm distal to the ulnar styloid process.
In cases where a fracture of the distal radius is difficult to view on film, careful inspection of the pronator muscle fat pad should be made just proximal to the wrist. Fat pad alteration may be the only radiologic sign present. This fat pad, which separates the pronator quadratus muscle and tendons of the flexor digitorum profundus, is normally viewed on lateral films of the wrist. Blurring, bowing, or obliteration of the fat pad may be a consequence of injury or disease of the radius or volar soft tissues.
Any carpal may be a potential site of fracture or dislocation. In order of frequency, the bones usually involved are the scaphoid (wrist navicular), lunate, and capitate —all of which may be associated with injuries of the radius or ulna. Of the carpals, the lunate is the most frequently dislocated and the scaphoid is the most frequently fractured. The scaphoid is the most lateral of the four bones in the proximal row of carpals; the lunate is the second carpal from thumb side in the proximal row.
If scaphoid injury is suspected, a special view is usually required: The patient's palm is directed toward the surface of the film with the thumb and index finger separated, and the tube is angled toward the patient's elbow. This angle tends to give an elongated appearance of the scaphoid, but it does offer a clear view of the bone. Most scaphoid fractures will be found in the midportion of the bone.
Even slight tenderness in the anatomical snuffbox and swelling obliterating the space between the thumb's extensor tendons suggest the danger of scaphoid fracture that may not appear on film for 10–14 days. Axially directed percussion on the knuckle of the patient's index finger when the patient's fist is closed will often elicit scaphoid pain if it is fractured. Bone necrosis and nonunion of the scaphoid are always a danger as this bone is reported to have a poor arterial supply, with resulting poor nourishment, in a third of the population.
If a fracture-dislocation is found, assess motor and sensory function of the hand and note circulation by capillary filling of the fingernails with finger pressure. Pad, splint in the position of function, and refer for immediate orthopedic attention.
Distal Radioulnar, Radiocarpal, and Ulnocarpal Hypomobility
Freeing Restricted Radioulnar A-P Glide. Sit or stand facing the patient. Straighten the involved limb, and pronate the patient's forearm. Place one thumb on the most distal dorsal aspect of the radius and the other thumb on the most distal aspect of the ulna. Flex your fingers so that the lateral surfaces of your respective index fingers are opposite your thumbs on the ventral side of the distal forearm. With the distal aspect of the radius and ulnar pinched between your thumbs and index fingers, slowly lift upward with one hand while pushing downward with the other and then reverse the maneuver in an alternating fashion.
Freeing Restricted Radiocarpal, Ulnocarpal, Intercarpal, and Carpometacarpal Distraction, Flexion, Extension, Abduction, and Adduction Mobility. While some authorities describe specific maneuvers for correcting each of these various fixations, it has been this author's experience that they all can be corrected by using one simple procedure. The doctor-patient positions are the same as described above with the exception that the contacts are taken approximately 1-1/2 inches more distal so that they are just beyond the last row of the carpals (over the metacarpal heads). Axial traction to patient tolerance is applied to the extended limb and the limb is slowly maneuvered through a small "figure 8" while holding the patient's hand firm with your fingers to prevent motion of the patient's metacarpals. This maneuver will produce extension, flexion, abduction, and adduction within the radiocarpal, ulnocarpal, intercarpal, and carpometacarpal articulations. Repeat 20–30 times, progressively increasing the size of the "figure 8" to patient tolerance. This is a slow stretching maneuver, not a snapping or jerking procedure.
Closing Separated Distal Radius and Ulna. This type of subluxation is commonly seen in association with carpal tunnel syndrome, chronic wrist pain, and the posttraumatic effects of wrist sprain. Stand on the side of involvement, and face the standing or sitting patient. Grasp the patient's semipronated wrist with both hands so that your overlapping thumbs are crossed against the lateral aspect of the distal radius and your interlaced fingers cup the medial aspect of the patient's ulna. Apply a strong squeeze with your hands to approximate the distal radius and ulnar while simultaneously making a quick downward thrust with your thumbs by extending and adducting your elbows.
Opening Approximated Distal Radius and Ulna. Approximated distal radius and ulna are often found in cases of chronic wrist pain or following wrist and hand trauma. Stand on the side of involvement, and face the standing or sitting patient. Grasp the patient's pronated wrist with both hands so that your overlapping thumbs cross between the dorsal aspects of the distal radius and ulna and your interlaced fingers cup under the lower forearm. Apply a strong thumb thrust inward and outward by extending your elbows while simultaneously using your fingers to separate the distal radius and ulna.
Inferior Radius Subluxation
An inferiorly subluxated radius is often a consequence of wrist sprain from a fall on the outstretched hand.
Adjustment. Stand on the side of involvement, and face the supine patient. Flex the patient's elbow, and be sure that the patient's arm and elbow are firmly against a padded table or firm cushion. Grasp just proximal to the patient's wrist so that your thumbs grip near the styloid process of the lateral distal radius and your fingers cup the medial aspect of the patient's distal ulna. Apply thumb pressure against the radius, directed towards the patient's elbow, and then make a short, quick, downward thrust using moderate body weight.
Anterior Carpal Subluxation
Subluxation of a carpal anteriorly is commonly related to carpal tunnel syndrome, chronic wrist pain, extension sprain, and restricted posterior wrist flexion. The lunate is the most common carpal involved.
Adjustment. Stand on the side of involvement, and face the supine or sitting patient. Grasp the patient's supinated wrist with both hands so that a double-thumb contact is made upon the volar aspect of the carpal involved and the rest of your fingers wrap under the wrist to support the other carpals. Lift the patient's forearm slightly, flex the wrist a few degrees, and place traction on the wrist. Relax the joints with mild sideward movements. The correction is made by holding firm contact pressure and traction with your thumbs and fingers and briskly snapping the wrist into mild extension against your thumb contact. Never forcibly flex the wrist as this will often cause sprain.
Note: Students should take care that the contact is directly over the involved carpal and fixed there. If the contact thumb slips proximally during the adjustment, there is chance of injuring one or more of the various arteries, veins, nerves, and tendons that course in the distal radioulnar space.
Alternative Technic. Supinate the involved wrist. Make overlapping thumb contact against the involved carpal and overlap fingers under the wrist to support the patient's hand (dorsal aspect). Apply firm traction, slightly flex the wrist, and make firm posteriorly-directed thumb pressure while rolling the wrist through alternated rotation, extension, flexion, and lateral flexion by describing a wide figure 8. This is a much gentler manipulation than described above and is recommended for the less experienced clinician. It is also recommended for anterior carpal subluxations found in children or the elderly.
Posterior Carpal Subluxation
This type of subluxation is frequently associated with wrist trauma, chronic pain upon motion, carpal tunnel syndrome, and restricted wrist extension. It is sometimes seen following a blow with the fist when the wrist is in flexion or following a fall on the dorsum of the hand. Any hyperflexion force to the wrist tends to subluxate the carpals as a whole, especially the distal row, posteriorly. Besides the angle of force being a determining factor, the specific carpal most affected (sometimes called the "major") is usually that which is normally the most mobile and free to subluxate. That is, adjacent fixated joints (eg, osteoarthritic) may help to determine the most mobile segment of the group.
Adjustment. Stand on the side of involvement, and face the supine or sitting patient. Grasp the patient's pronated wrist with both hands so that an overlapping thumb contact is made on the involved carpal, with your fingers supporting the volar aspect of the patient's wrist. Apply firm traction to the patient's wrist, and make a quick downward thumb thrust by extending and adducting your elbows while simultaneously extending the patient's wrist a few degrees.
Alternative Technic. This is the reverse of the alternative adjustment procedure for an anterior carpal, varied by turning the involved wrist palm down and taking thumb contact on the dorsal aspect of the carpal.
Metacarpal Base Posterior Subluxation
A metacarpal base subluxated posteriorly is related to wrist pain that is especially increased by wrist flexion, excessive wrist stress, wrist ganglion, and restricted wrist extension. Any blow to the heel of the hand (such as catching a baseball low in the palm) may produce an acute subluxation. The more common causes, however, are chronic contractures and other soft-tissue shortening along the anterior surface of one or more metacarpals that tends to force the metacarpal base posterior relative to its carpal articulation. Thus, unless these shortened tissues are properly treated, the secondary subluxation will tend to resubluxate shortly after an adjustment because its cause still remains.
Adjustment. Stand on the side of involvement of the seated or supine patient. Although not always necessary, it is best that the patient's pronated wrist be placed on a firm pillow. Grasp the patient's involved digit with your contact hand so that your thumb rests on the proximal head of the metacarpal and your fingers wrap around the involved finger for stability. With your other hand, apply a pisiform contact on top of the distal phalanx of your contact thumb (bottom). Apply moderate distal traction with your contact fingers and make a short, quick thrust downward by extending and adducting your elbows. As the thrust is made, the patient's wrist will dorsiflex.
Flexion, extension, abduction, and adduction mobility restrictions may be found at the metacarpophalangeal joints and flexion-extension restrictions at the interphalangeal joints. Correction can be achieved simply by stabilizing the proximal bone and slowly moving the distal segment against the resistance, gradually attempting to increase the range of motion up to patient tolerance.
Note: From this author's viewpoint, it is not advisable to attempt to release any chronic fixation that is the product of degenerative/inflammatory pathology (eg, rheumatic, gouty, or septic arthritis). In these conditions, any form of passive manipulation tends to increase the inflammatory reaction and the patient's pain. However, slow active stretching exercises (without resistance) conducted within a warm whirlpool bath or immediately after the application of any form of therapeutic heat tends to increase mobility somewhat. In most of these conditions, the local expression in the hand(s) is only a manifestation of a systemic disorder that must be given priority concern during therapy.
Finger Subluxations and Simple Dislocations
All contact sports and heavy-labor occupations have a high incidence of metacarpal fractures, but severe displacement is not common. Many finger dislocations often spontaneously reduce themselves or present as subluxations. Dislocation of the proximal interphalangeal joint usually entails severe injury of the collateral ligaments and is likely to heal with an instable, swollen, stiff joint unless proper rehabilitative therapy is applied.
Significant Features. During initial evaluation, judge bone length of a suspected fracture or dislocation by comparing with the uninjured hand. Check joint integrity by palpating the joint's capsule and applying axial and leverage pressure to patient tolerance. Keep in mind that incomplete and impacted fractures may be present, yet associated tendon, nerve, and vascular damage are quite rare except in lacerating or crush injuries. Comparative x-ray views of the sound limb are frequently helpful. Depending on one's expertise, roentgenography may or may not be required to analyze possible complications prior to considered reduction of finger subluxations or uncomplicated dislocations.
Complicated dislocations in which there is considerable soft-tissue separation are rarely possible to treat effectively by closed methods. In such situations, the surrounding soft tissue is usually penetrated by bone that prevents complete reduction during adjustment. Open reduction is the only solution.
Adjustment. After ruling out fracture and complications requiring referral, correction of uncomplicated (simple) finger dislocations is simply made by stabilizing the patient's hand with one hand, grasping the involved digit distal to the lesion, and applying a quick traction force (pull) distally to allow repositioning.
Any acute finger joint malalignment is extremely painful; thus, care must be taken to assure that one attempt at correction is sufficient. Do not use prior traction as is done in many other adjustments; the pain is too great. For good control and to avoid slippage, place the patient's phalanx, distal to the injured joint, between your flexed index finger and extended thumb, then gently close your hand into a fist. Stabilize the patient's hand with your free hand.
Simple dislocations may be reduced by slightly increasing the deformity and using leverage to slip the distal articulation into normal position. In metacarpophalangeal dislocations, hyperextend the phalanx and apply pressure and traction at its base to quickly slip it over the metacarpal head. This is often better procedure than straight axial traction. If the displacement is superior-medial or superior-lateral, the pull and pressure should be varied accordingly. Note that the index finger's metacarpophalangeal joint is extremely resistant to closed reduction and often requires surgery.
General Management Direction. Postreduction radiographs should be taken to assure correction and exclude avulsion fractures. Treat as a severe sprain. Follow articular correction immediately with a finger splint that is strapped to an adjoining finger, or apply a molded splint, for 3–5 weeks.
Screening Finger Fractures. A fracture of a proximal phalanx tends to displace anteriorly in an angular fashion because of lumbrical pull. A rotated phalanx, often noted by a nail's relationship with its neighbors, is an indication of fracture. Fracture symptoms mimic severe sprain plus abnormal bone or joint contour. Crepitus is not always exhibited in finger fractures.
Fistfighter's Dislocation-Fracture. A complex fracture of the 4th and/or 5th metacarpal, especially at the neck, is often referred to as a "fighter's" dislocation-fracture. The bone's head and neck are often pushed into the palm. This is most often seen in the bare-knuckled fighter or during riots rather than with the gloved boxer who more commonly presents a fracture at the proximal third of the 1st metacarpal.
Thumb Subluxations and Dislocations
Malposition of the thumb often occurs between the 1st metacarpal and carpal joint, which is often difficult to detect, or between the 1st metacarpal and phalangeal joint. The reduction of simple dislocation and its general management is the same as for finger dislocations. Most thumb dislocations, however, are complex; thus, orthopedic referral is recommended.
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