EXTREMITY PAIN, UPPER EXTREMITY

Ask the following questions:

1. Is there limitation of motion of the joints? Limitation of motion of a joint would suggest not only various types of arthritis, fracture, or torn ligaments, but also inflammation of surrounding structures such as the bursa or tendons. For example, limitation of motion of the shoulder would suggest impingement syndrome, frozen shoulder, rheumatoid or osteoarthritis, subacromial bursitis, and a torn rotator cuff.
2. Is the limitation of motion both active and passive or active only? If the limitation of motion is only active, one should suspect tendinitis or bursitis. If the limitation of motion is both active and passive, one should suspect the various forms of arthritis, as well as bone tumors, osteomyelitis, and adhesive capsulitis.
3. Is there weakness or paresthesia? Weakness and especially paresthesia suggest a neurologic origin for the pain, and one should be considering brachial plexus neuritis, carpal tunnel syndrome, ulnar entrapment, and radiculopathy.
4. Are there vasomotor or trophic changes? Vasomotor changes would suggest Raynaud's phenomena and sympathetic dystrophy. Trophic changes along with vasomotor changes would suggest a peripheral neuropathy also.
5. Are there positive neurologic signs in the lower extremities? Diffuse hypoactive reflexes with stocking deficits in the lower extremities would suggest a peripheral neuropathy, whereas hyperactive reflexes in the lower extremities would suggest a cervical cord tumor, cervical spondylosis, or multiple sclerosis.
6. Is there a positive Tinel's sign at the wrist or elbow? Tinel's sign at the wrist would suggest carpal tunnel syndrome, whereas Tinel's sign at the elbow would suggest ulnar entrapment if it is over the ulnar nerve or pronator syndrome if it is over the median nerve.
7. Are Adson's tests positive? Adson's tests are positive in thoracic outlet syndrome, whether it is due to a cervical rib, scalenus-anticus syndrome, Wright syndrome (pectoralis minor syndrome), or a costoclavicular compression.

DIAGNOSTIC WORKUP

X-rays of the affected joints need to be done if there is tenderness or limitation of motion. Further workup of joint pain can be found on page 279 . When there are abnormal neurologic findings, an x-ray of the cervical spine, nerve conduction velocity studies, and EMG examinations need to be done. Referral to a neurologist should be made for these tests. If there is a typical radicular pain and a herniated cervical disk is strongly suspected, MRI of the cervical spine should be done. This is an expensive test, but when there are obvious signs of radiculopathy, it is worthwhile. Perhaps dermatomal somatosensory studies should be done when there is confusion about whether a herniated disk is pathologic. If a vascular lesion is suspected, angiography and venography should be ordered. ANA and nail fold capillary loop dilation and dropout study may diagnose Raynaud's phenomena; a small injection of lidocaine and steroids locally may be diagnostic in cases of carpal tunnel syndrome.

When there is intermittent pain, an exercise tolerance test should be done to exclude coronary insufficiency. A stellate ganglion block may be helpful in diagnosing reflex sympathetic dystrophy. Remember that other nerve blocks may be done and one should not hesitate to call an anesthesiologist for help in this area. Various forms of bursitis may be diagnosed by a therapeutic trial of lidocaine and corticosteroid injections.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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