Injury prevention and treatment for the Shoulder, Arm and Hand © 2011 McGraw-Hill Higher Education. All rights reserved.

The shoulder is an extremely complicated region of the body Joint which has a high degree of mobility but not without compromising stability Involved in a variety of overhead activities relative to sport making it susceptible to a number of repetitive and overused type injuries © 2011 McGraw-Hill Higher Education. All rights reserved.

Prevention of Shoulder Injuries Proper physical conditioning is key Develop body and specific regions relative to activities Strengthen through a full ROM Warm-up should be used before explosive arm movements are attempted May involve tubing exercises, particularly for throwers © 2011 McGraw-Hill Higher Education. All rights reserved.

Mechanics versus overuse injuries Contact and collision sport athletes should receive proper instruction on falling Protective equipment Mechanics versus overuse injuries Proper instruction on mechanics is critical to limit overuse type injuries © 2011 McGraw-Hill Higher Education. All rights reserved.

Recognition and Management of Specific Injuries Clavicular Fractures MOI Fall on outstretched arm, fall on tip of shoulder or direct impact Occur primarily in middle third (greenstick fracture often occurs in young patients) Signs and Symptoms Generally presents w/ supporting of arm, head tilted towards injured side w/ chin turned away Clavicle may appear lower Palpation reveals pain, swelling, deformity and point tenderness © 2011 McGraw-Hill Higher Education. All rights reserved.

Clavicular Fractures (continued) Management Closed reduction - sling and, immobilize w/ figure 8 brace for 6-8 weeks Removal of brace should be followed w/ joint mobes, isometrics and use of a sling for 3-4 weeks May require surgical treatment © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 22-21 A-C © 2011 McGraw-Hill Higher Education. All rights reserved.

Scapular Fractures Figure 22-22 MOI Signs and Symptoms Management Result of direct impact or force transmitted up through humerus Signs and Symptoms Pain during shoulder movement as well as swelling and point tenderness Management Sling immediately and follow-up w/ X-ray Use sling for 3 weeks w/ overhead strengthening beginning at week 1 Figure 22-22 © 2011 McGraw-Hill Higher Education. All rights reserved.

Fractures of the Humerus MOI Humeral shaft fractures Occur as a result of a direct blow, or fall on outstretched arm Proximal fractures occur due to direct blow, dislocation, fall on outstretched arm May pose danger to nerve and blood supply Epiphyseal fractures are more common in young patients Occurs due to direct blow or indirect blow travelling along long axis of humerus Signs and Symptoms Pain, swelling, point tenderness, decreased ROM © 2011 McGraw-Hill Higher Education. All rights reserved.

Fractures of the Humerus Management Immediate application of splint, treat for shock and refer Humeral fractures- remove from activity for 3-4 months Proximal fracture - incapacitation 2-6 months Epiphyseal fracture - quick healing - 3 weeks © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 22-23

Acromioclavicular Sprain MOI Result of direct blow (from any direction), upward force from humerus, Can be graded from 1-6 depending on severity Signs and Symptoms Grade 1 - point tenderness and pain w/ movement; no disruption of AC joint Grade 2 - tear or rupture of AC ligament, partial displacement of lateral end of clavicle; pain, point tenderness and decreased ROM (abduction/adduction) Grade 3 - Rupture of AC and CC ligaments Grade 4 - posterior separation of clavicle © 2011 McGraw-Hill Higher Education. All rights reserved.

Management Ice, stabilization, referral to physician Grades 1-3 (non-operative) will require 3-4 days and 2 weeks of immobilization respectively Grades 4-6 will require surgery Aggressive rehab is required w/ all grades Joint mobilizations, flexibility exercises, & strengthening should occur immediately Progress as patient is able to tolerate w/out pain and swelling Padding and protection may be required until pain-free ROM returns © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 22-25 & 27 © 2011 McGraw-Hill Higher Education. All rights reserved.

Rotator cuff tear Management Occurs near insertion on greater tuberosity Partial or complete thickness tear Full thickness tears usually occur in those athletes w/ a long history (generally does not occur in athlete under age 40) Primary mechanism - acute trauma or impingement Involve supraspinatus or rupture of other rotator cuff tendons Management Analgesics, electrical stimulation for pain, NSAID’s and ultrasound for inflammation Restore appropriate mechanics and strengthen rotator cuff to depress and compress humeral head to restore space Strengthen lower extremity and trunk to reduce stress on shoulder Stage III and IV cases may require immobilization and rest and potentially surgery © 2011 McGraw-Hill Higher Education. All rights reserved.

Biceps Brachii Rupture MOI Result of a powerful contraction Generally occurs near origin of muscle at bicipital groove Figure 22-30 © 2011 McGraw-Hill Higher Education. All rights reserved.

Signs and Symptoms Management Patient hears a resounding snap and feels sudden and intense pain Protruding bulge may appear near middle of biceps Definite weakness with elbow flexion and supination Management Ice for hemorrhaging, place arm in sling and refer to physician Patient will require surgery Older individual may not require surgery as brachialis serves as primary elbow flexor and most can function without biceps © 2011 McGraw-Hill Higher Education. All rights reserved.

Elbow and Forearm © 2011 McGraw-Hill Higher Education. All rights reserved.

Recognition and Management of Injuries to the Elbow Subject to injury due to broad range of motion, weak lateral bone structure, and relative exposure to soft tissue damage Many activities place excessive stress on joint Locking motion of some activities, use of implements, and involvement in throwing motion make elbow extremely susceptible © 2011 McGraw-Hill Higher Education. All rights reserved.

Contusion MOI Signs and Symptoms Management Vulnerable area due to lack of padding Result of direct blow or repetitive blows Signs and Symptoms Swelling (rapidly after irritation of bursa or synovial membrane) Management Treat w/ RICE immediately for at least 24 hours If severe, refer for X-ray to determine presence of fracture © 2011 McGraw-Hill Higher Education. All rights reserved.

Muscle Strains MOI MOI is excessive resistive motion (falling on outstretched arm), repeated microtears that cause chronic injury Rupture of distal biceps is most common muscle rupture of the upper extremity Signs and Symptoms Active or resistive motion produces pain; point tenderness in muscle, tendon, or lower part of muscle belly Management RICE and sling in severe cases Follow-up w/ cryotherapy, ultrasound and exercise If severe loss of function encountered - should be referred for X-ray (rule out avulsion or epiphyseal fx) © 2011 McGraw-Hill Higher Education. All rights reserved.

Ulnar Collateral Ligament Injuries MOI Injured as the result of a valgus force from repetitive trauma Can also result in ulnar nerve inflammation, or wrist flexor tendinitis; overuse flexor/pronator strain, ligamentous sprains; elbow flexion contractures or increased instability Signs and Symptoms Pain along medial aspect of elbow; tenderness over MCL Associated paresthesia, positive Tinel’s sign Pain w/ valgus stress test at 20 degrees; possible end-point laxity X-ray may show hypertrophy of humeral condyle, posteromedial aspect of olecranon, marginal osteophytes; calcification w/in MCL; loose bodies in posterior compartment © 2011 McGraw-Hill Higher Education. All rights reserved.

Ulnar Collateral Ligament Injuries (cont.) Management Conservative treatment begins w/ RICE and NSAID’s W/ resolution, strengthening should be performed; analysis of the throwing motion (if applicable) Surgical intervention may be necessary (Tommy John procedure) Involves reconstruction using palmaris longus autograft and occasionally transposition of the ulnar nerve Throwing athlete can return to activity 22-26 weeks post surgery with full-recovery taking 18-24 months © 2011 McGraw-Hill Higher Education. All rights reserved.

Lateral Epicondylitis (Tennis Elbow) MOI Repetitive microtrauma to insertion of extensor muscles of lateral epicondyle Tendinosis with degeneration of tendon without inflammation Signs and Symptoms Aching pain in region of lateral epicondyle after activity Pain worsens and weakness in wrist and hand develop Elbow has decreased ROM; pain w/ resistive wrist extension © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 23-19 Lateral Epicondylitis (continued) Management RICE, NSAID’s and analgesics ROM exercises and PRE, deep friction massage, hand grasping while in supination, avoidance of pronation motions Mobilization and stretching in pain free ranges Use of a counter force or neoprene sleeve Mechanics and skills training in order to avoid recurrence Figure 23-19 © 2011 McGraw-Hill Higher Education. All rights reserved.

Repeated forceful flexion of wrist and extreme valgus torque of elbow Medial Epicondylitis MOI Repeated forceful flexion of wrist and extreme valgus torque of elbow May involve pronator teres, flexor carpi radialis and ulnaris, and palmaris longus tendons Can be associated with ulnar nerve neuropathy Signs and Symptoms Pain produced w/ forceful flexion or extension Point tenderness and mild swelling Passive movement of wrist seldom elicits pain, but active movement does © 2011 McGraw-Hill Higher Education. All rights reserved.

Sling, rest, cryotherapy or heat through ultrasound Management Sling, rest, cryotherapy or heat through ultrasound Analgesic and NSAID's Curvilinear brace below elbow to reduce elbow stressing Severe cases may require splinting and complete rest for 7-10 days © 2011 McGraw-Hill Higher Education. All rights reserved.

Elbow Dislocation © 2011 McGraw-Hill Higher Education. All rights reserved.

Management Cold and pressure immediately w/ sling Refer for reduction Neurological and vascular fxn must be assessed prior to and following reduction Physician should reduce - immediately Immobilization following reduction in flexion for 3 weeks Hand grip and shoulder exercises should be used while immobilized Following initial healing, heat and passive exercise can be used to regain full ROM ROM and strengthening should be performed and initiated by patient (forced stretching should be avoided) © 2011 McGraw-Hill Higher Education. All rights reserved.

Fall on flexed elbow or from a direct blow Fractures of the Elbow MOI Fall on flexed elbow or from a direct blow Fracture can occur in any one or more of the bones Fall on outstretched hand often fractures humerus above condyles or between condyles Condylar fracture may result in gunstock deformity Direct blow to olecranon or radial head may result in fracture Signs and Symptoms May not result in visual deformity Hemorrhaging, swelling, muscle spasm © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 23-22 Elbow Fractures (continued) Management Decrease ROM, neurovascular status must be monitored Surgery is used to stabilize adult unstable fracture, followed by early ROM exercises Stable fractures do not require surgery Removable splints are used for 6-8 weeks Figure 23-22 © 2011 McGraw-Hill Higher Education. All rights reserved.

Recognition and Management of Injuries to the Forearm Contusion MOI Ulnar side receives majority of blows due to arm blocks Can be acute or chronic Result of direct contact or blow Signs and Symptoms Pain, swelling and hematoma If repeated blows occur, heavy fibrosis and possibly bony callus could form w/in hematoma © 2011 McGraw-Hill Higher Education. All rights reserved.

Contusion (continued) Management Proper care in acute stage involves RICE and followed up w/ additional cryotherapy Protection is critical - full-length sponge rubber pad can be used to provide protective covering © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 24-4 Colles’ Fracture MOI Occurs in lower end of radius or ulna MOI is fall on outstretched hand, forcing radius and ulna into hyperextension Less common is the reverse Colles’ fracture (Smith fracture) Anterior displacement of distal fragment Intraarticular fracture is referred to as a Barton fracture Figure 24-4 © 2011 McGraw-Hill Higher Education. All rights reserved.

When no deformity is present, injury can be passed off as bad sprain Signs and Symptoms Forward displacement of radius causing visible deformity (silver fork deformity) When no deformity is present, injury can be passed off as bad sprain Extensive bleeding and swelling Tendons may be torn/avulsed and there may be median nerve damage Management Cold compress, splint wrist and refer to physician X-ray and immobilization Severe sprains should be treated as fractures In children, injury may cause lower epiphyseal separation © 2011 McGraw-Hill Higher Education. All rights reserved.

Recognition and Management of Injuries to the Wrist, Hand and Fingers Wrist Sprains MOI Most common wrist injury Arises from any abnormal, forced movement Falling on hyperextended wrist, violent flexion or torsion Multiple incidents may disrupt blood supply Signs and Symptoms Pain, swelling and difficulty w/ movement © 2011 McGraw-Hill Higher Education. All rights reserved.

Refer to physician for X-ray if severe RICE, splint and analgesics Management Refer to physician for X-ray if severe RICE, splint and analgesics Have patient begin strengthening soon after injury Tape for support can benefit healing and prevent further injury © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 24-25 Scaphoid Fracture MOI Caused by force on outstretched hand, compressing scaphoid between radius and second row of carpal bones Often fails to heal due to poor blood supply Signs and Symptoms Swelling, severe pain in anatomical snuff box Presents like wrist sprain Pain w/ radial flexion Figure 24-25 © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 24-25 Scaphoid Fracture Management Must be splinted and referred for X-ray prior to casting Immobilization lasts 6 weeks and is followed by strengthening and protective tape Wrist requires protection against impact loading for 3 additional months Figure 24-25 © 2011 McGraw-Hill Higher Education. All rights reserved.

Generally appears following wrist strain Signs and Symptoms Wrist Ganglion MOI Synovial cyst (herniation of joint capsule or synovial sheath of tendon) Generally appears following wrist strain Signs and Symptoms Appear on back of wrist generally Occasional pain w/ lump at site Pain increases w/ use May feel soft, rubbery or very hard © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 24-27 Wrist Ganglion Management Old method was to first break down the swelling through distal pressure and then apply pressure pad to encourage healing New approach includes aspiration, chemical cauterization w/ subsequent pressure from pad Ultrasound can be used to reduce size Surgical removal is most effective treatment method Figure 24-27 © 2011 McGraw-Hill Higher Education. All rights reserved.

Figure 24-29 Extensor Tendon Avulsion (Mallet Finger) Etiology Caused by a blow to tip of finger avulsing extensor tendon from insertion Also referred to as baseball or basketball finger Signs and Symptoms Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx Unable to extend distal end of finger (carrying at 30 degree angle) Point tenderness at sight of injury Management RICE and splinting for 6-8 weeks © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 24-29

Flexor Digitorum Profundus Rupture (Jersey Finger) Etiology Rupture of flexor digitorum profundus tendon from insertion on distal phalanx Often occurs w/ ring finger when athlete tries to grab a jersey Signs and Symptoms DIP can not be flexed, finger remains extended Pain and point tenderness over distal phalanx Management Must be surgically repaired Rehab requires 12 weeks and there is often poor gliding of tendon, w/ possibility of re-rupture © 2011 McGraw-Hill Higher Education. All rights reserved.

Immediate follow-up must occur Management Immediate follow-up must occur If instability exists, athlete should be referred to orthopedist If stable, X-ray should be performed to rule out fracture Thumb splint should be applied for protection for 3 weeks or until pain free Splint should extend from wrist to end of thumb in neutral position Thumb spica should be used following splinting for support If a complete tear occurs, surgical repair is necessary to allow normal function to return © 2011 McGraw-Hill Higher Education. All rights reserved.