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Lateral
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collateral
ligament
Annular
ligament
Chapter 23 • Upper Extremity Limb Pain
279
Heat over the affected joint can indicate inammation or infection. Evaluate the joint for crepitus, both
palpable and auditory. Tendonitis can produce a grat-
Humerus
ing sensation on palpation of the ligament or a grating
sound with movement.
Perform Passive/Active Range of Motion
of All Limbs
Range of motion (ROM) may be limited because of
pain, weakness, or deformity.
e
l
y
d
n
o
c
i
p
e
l
a
Articular
r
e
t
capsule
a
L
e
l
y
d
n
o
c
i
p
e
l
a
i
d
e
M
Medial
collateral
ligament
Test for Muscle Strength
Test for upper extremity exor and extensor strength
against resistance of both the proximal and distal
muscle groups. Proximal muscle weakness is seen in
myopathic disorders. Distal muscle weakness is seen
secondary to a neuropathic process. Generally, if the
opposite side is normal, strength should be compared
with it. A scale of 0 to 5 is used to rate muscle strength
(Table 23-1).
Oblique cord
UlnaRadius
Anterior view
FIGURE 23-2 Bony and ligamentous anatomy of the elbow.
(From Neumann D: Kinesiology of the musculoskeletal system,
St. Louis, 2010, Mosby.)
Palpate Extremities and Joints
Palpate those areas that are painful last and then compare with the unaffected limb.
Determine if there is edema (e.g., presence of interstitial uid). Induration is interstitial swelling that has
progressed and is now rm. An effusion is a collection
of uid in the joint capsule, which can be the result of
rupture of a vascular structure or a synovial secretory
response to an inammatory process. The consistency
of the uid is noteworthy. Pus has a thick consistency
and is less uctuant than synovial uid. Hematoma has
a more gelatinous consistency.
Perform a Neurological Examination
Assessment of sensory and motor function and deep
tendon reexes should be done on the affected and
contralateral limbs. If systemic illness is suspected,
perform a neurological examination.
LABORATORY AND DIAGNOSTIC STUDIES
Complete Blood Count
A complete blood count (CBC) is obtained to evaluate
for anemia associated with chronic disease, infection,
or neoplasm. An altered white blood cell (WBC) count
may indicate infection or leukemia.
Erythrocyte Sedimentation Rate
An erythrocyte sedimentation rate (ESR) is elevated
when inammation is present. It is a nonspecic test.
Joint Aspiration
Joint aspiration is performed to assess synovial uid
for elevated WBC count, Gram stain, culture and sensitivity, crystal analysis, presence of glucose, and consistency or “string test.” This procedure is performed
using local anesthesia under sterile technique. Synovial uid will ow easily when the joint capsule is
penetrated.
Radiography
Obtain at least two radiographic views, anteroposterior
and lateral, because injuries are not always apparent on
280
Capitate
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Chapter 23 • Upper Extremity Limb Pain
Trapezoid
Scaphotrapezial
Radial collateral
A
Capitotriquetral ligament
Transverse carpal
Lunotriquetral ligament
Ulnocarpal
complex
B
ligament
Trapezium
Scaphoid
ligament
Dorsal radiocarpal
ligament
Radius
ligament (cut)
Hamate
Ulnar collateral
ligament
Palmar ulnocarpal
ligament
Articular disc
Ulna
Hamate
Short dorsal ligaments
of distal row
Capitate
Dorsal intercarpal
ligament
Ulnar collateral
ligament
Articular disc
Ulna
Short palmar ligaments
of distal row
Trapezoid
Capitate
Transverse carpal ligament (cut)
Lunate
Radial collateral ligament
Scaphoid
Radiocapitate
Radiolunate
Radioscapholunate
Radius
Palmar radiocarpal
ligament
5th Metacarpal
Hamate
Pisiform
Triquetrum
Lunate
Triangular
fibrocartilage
complex (TFCC)
Ulna
C D
FIGURE 23-3 Bones and ligaments of the wrist. A, Ligaments, dorsal view. B, Ligaments, palmar view. C,
Bones, dorsal view. D, Close-up view of triangular fibrocartilage complex. (From Magee D: Orthopedic
physical assessment, St. Louis, 2008, Mosby.)
Trapezoid
1st metacarpal
Trapezium
Scaphoid (navicular)
Radiocarpal
joint
Distal
radioulnar
joint
Radius
Ulna
Radius
Ulnar
styloid
Triangular
fibrocartilage
complex
(TFCC)
FIGURE 23-4 Osteoarthritis of the hand. Heberden nodes are
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shown at the distal interphalangeal joints. (From Waldman S:
Pain management, Philadelphia, 2007, Saunders.)
Chapter 23 • Upper Extremity Limb Pain
281
Rheumatoid Factor
Rheumatoid factor (RF) is the single most useful test to
conrm a diagnosis of RA and is positive in 80% of
patients with this disease.
C4 Complement
C4 complement determines serum hemolytic complement activity, a protein that binds antigen-antibody
complexes for the purpose of lysis. Complement is
increased in active inammatory disease and in autoimmune disorders such as juvenile RA.
C-reactive Protein
C-reactive protein (CRP) indicates the presence of abnormal plasma protein or a nonspecic response to
inammation caused by both infectious and noninfectious processes. CRP is elevated in RA and infection.
DIFFERENTIAL DIAGNOSIS
Table 23-1
GRADE MUSCLE STRENGTH TERM
0 No palpable contraction Zero
1 Muscle contracts but part does not
2 Muscle moves part but not against
3 Muscle moves part through range
4 Muscle moves part even with
5 Normal strength against resistance
Muscle Strength Test
Trace
move
Poor
gravity
Fair
against gravity
Good
resistance
Excellent
present
a single view. Any evidence of fracture or dislocation
will require orthopedic attention. Sometimes radiographic comparisons with the opposite limb may be
useful. Magnetic resonance imaging (MRI) is usually
used in spine, joint, and soft tissue imaging. Computed
tomography (CT) scans are usually performed for bone
visualization. An MRI can conrm a chronic or acute
rotator cuff tear in tendons and bone swelling after an
acute injury.
Antinuclear Antibodies
Antinuclear antibody (ANA) tests are positive with
high titers in RA and SLE; however, other factors such
as aging, medications, and other connective tissue disease can produce positive antibody titers.
Musculoskeletal Inflammation
Tenosynovitis (Tendinitis)
Soft tissue disorders of tendinitis, bursitis, and brositis tend to occur together. Tenosynovitis is inammation of the tendon and tendon sheath. In an acute
inammation, usually caused by trauma related to recreational or occupational activities, effusion may accumulate and result in swelling. With chronic inammation, ROM will be limited by brosis of the tendon
sheath.
Pain is worse with movement. Occupational and
recreational history will provide vital clues to differentiate between overuse and trauma as the cause of pain.
People with arthritis may have tendinitis secondary to
joint disease. Crepitus may be felt on palpation of the
tendon.
Bursitis
Bursitis is inammation of a sac lined with synovial
uid, most often secondary to traumatic tenosynovitis
of the shoulder and elbow. Numerous bursae lie over
bony prominences and reduce friction from motion of
fascial planes. Bursitis is caused by overuse and
trauma and may be associated with RA. If isometric
contraction of a group of muscles causes pain, the
muscles or tendons, or both, may be involved. Bursitis causes an aching pain that radiates to points of
tendon insertion or further along the limb. Muscle
weakness may also be present. Palpation reveals local
tenderness and swelling without full range of joint
motion.
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Chapter 23 • Upper Extremity Limb Pain
Fibrositis (Myofascitis, Fibromyositis)
Fibromyositis is a response to underlying conditions,
such as polymyalgia rheumatica, RA, ankylosing spondylitis, hypothyroidism, neuritis, and viral infection,
which generate major muscle tension around a large,
weight-bearing proximal joint. Fatty and brous nodules may be palpable, and painful trigger sites can be
located throughout the shoulder and pelvic girdle or
lower extremities. Patients complain of stress and
anxiety, sleep disturbance, painful trigger points, and
joint stiffness.
Osteomyelitis
The presentation of osteomyelitis, a pyogenic infection
of bone, depends on the patient’s age as well as the
bone involved. The hallmark is a constant, local pain
that progressively worsens. The slightest motion of the
limb aggravates the pain. Laboratory ndings show
increased WBC counts, ESR, and CRP. Radiographs
may show bone destruction or deep soft tissue swelling
at the site of infection.
Joint Inflammation
Osteoarthritis
Osteoarthritis (OA) is the most common form of arthritis and is present to some extent in all elderly people.
Patients report joint stiffness, pain, and limited movement. Symptoms may be asymmetric. Patients at increased risk have a history of performing repetitive
weight-lifting tasks, have sustained some form of joint
trauma, are obese, or have been diagnosed with diabetes mellitus. Acute arthritis is associated with an increased ESR, and radiographs will show spurs, joint
deformity, and erosive changes.
Rheumatoid Arthritis
RA is a chronic inammatory disease characterized by
joint swelling and tenderness and destruction of synovial joints, leading to severe disability and premature
mortality. There is a wide clinical presentation of RA
and symptoms include morning stiffness of symmetrical small joints in the hands and feet, swelling, and
progressive fatigue. Rheumatoid nodules are soft and
spongy and appear on the elbows, forearms, and hands.
Pericarditis, pleuritis, and vasculitis are associated
conditions. Laboratory data may disclose a normochromic/normocytic anemia, an elevated ESR, and a
positive rheumatoid factor (RF) in 75% to 90% of patients. A positive RF test result may precede symptoms
by many years. Radiographs may show bony erosion at
the joint margins and joint deformities.
Musculoskeletal Pain Related to Trauma
or Overuse
Shoulder
Dislocation (glenohumeral joint instability). A
patient with shoulder dislocation presents with anterior
and/or posterior joint pain, periarticular muscle spasm,
anxiety, and limited movement. An anterior dislocation
causes inability to internally rotate and abduct the humerus. Posterior dislocation causes limitation of external rotation, arm abduction, and hand supination with
the shoulder exed forward. Radiographs of the shoulder (anteroposterior, lateral, and axillary views) will
exclude fracture of surrounding bones.
Acromioclavicular joint injury. Acromioclavicu-
lar joint injuries usually result from sports injuries or
motor vehicle accidents. Injury occurs when the acromion, scapula, and upper extremity are driven inferiorly, and the supporting ligamentous structures are
sprained or torn. There are three grades of severity:
(1) partial tear (dislocation) of the acromioclavicular
ligament; (2) partial tear of the acromioclavicular and
coracoclavicular ligaments; and (3) complete rupture
of the acromioclavicular and coracoclavicular ligaments and joint separation. History will reveal the
nature of the injury. The patient will have pain and
limited shoulder movement and may present with
obvious deformity if there is a severe injury.
Bicipital tendinitis. Bicipital tendinitis is an over-
use syndrome of the biceps brachii muscle that ends in
two tendons; one attached to the radial tuberosity (arm
adduction) and one to the forearm fascia (arm abduction and internal rotation). The syndrome may be associated with other shoulder disorders, such as impingement syndrome. Children may have anomalies
of the intertubercular groove when presenting with
repeated trauma from swimming, volleyball, baseball,
or golf. Pain is localized to the intertubercular groove,
is aggravated by the offending movement, and subsides with rest. A Yergason test can indicate bicipital
tendinitis. A positive test is characterized by pain in
the intertubercular groove with resistance to supination of the forearm while the elbow is exed 90 degrees. A Fisk radiographic view enables the examiner
to determine the size of the intertubercular groove.
Rotator cuff tear. Rotator cuff tears are acute inju-
ries in children and young adults but occur as chronic
injuries in older adults. In acute tears, the shoulder pain
is severe, and the patient is unable to raise the arm
sideways because of pain. In a complete tear, attempts
to raise the arm laterally will produce a shoulder shrug.
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283
In a partial tear, the patient can raise the arm but cannot
maintain the position with any resistance. Inammation
secondary to injury can cause rotator cuff tendinitis that
produces shoulder and upper arm pain, weakness, and a
grating sound with movement.
Chronic rotator cuff tears are most common in people
older than 50 years; they result from cumulative and repeated impingement processes. The onset of pain is insidious and is made worse with the arm in an overhead
position. Patients experience shoulder pain with sleep and
tenderness over the acromioclavicular joint. Examination
may reveal minimal restriction in movement, crepitus, and
weakness in external rotation of the shoulder. Radiographs
will show any bony abnormality, such as an acromial spur.
Elbow
Olecranon bursitis. Olecranon bursitis is commonly
seen in people who engage in contact sports, repetitive
motion, rubbing or placing pressure on the elbow, or
overuse. Pain is localized over the bursae, and swelling
may be the result of hemorrhage in a traumatic injury.
The joint’s ROM is usually normal. The joint may be
warm and red. When these signs are present, carefully
examine the skin over the elbow to ensure intactness,
because a penetrating injury may cause septic bursitis.
Radiography will exclude underlying bone infection
and show the plane of soft tissue swelling.
Lateral humeral epicondylitis (tennis elbow).
Epicondylitis is an aseptic inammation of the bonetendon junction, resulting from repetitive concentric
contractions that transmit force via the muscles to the
origin on the lateral epicondyle. People most at risk for
tennis elbow are nonathletes who have occupations
that require repeated contractions of extensor and supinator muscles. Athletes at risk are tennis players, bowlers, and hockey players. Patients present with gradual
onset of pain and tenderness over the lateral epicondyle that progresses in intensity. Palpation over the
lateral epicondyle produces point tenderness, although
elbow movement is not limited. Resisted forearm supination with the elbow exed at 90 degrees will intensify symptoms.
Subluxation of the radial head (nursemaid
elbow). A rapid upward pulling of a child’s hand or
wrist causes subluxation of the radial head. The radial
head is pulled out of the annular ligament. This ligament then becomes caught between the radial head
and the joint, causing the elbow to be exed and pronated. The child cries at the event and then refuses to
move the arm and may complain of pain in the elbow.
Radiographs are normal.
Wrist and Hand
Wrist fracture. Wrist fractures usually result from
falling on an outstretched hand and may involve a
number of types of fracture. Patients present with a
painful, swollen distal forearm and wrist and may report numbness if the median nerve is involved. Gently
palpate to locate the site of maximal pain, particularly
the navicular (“snuffbox”) area located between the
extensor pollicis longus and the extensor pollicis brevis tendons when the mechanism of injury is hyperextension of the wrist. Pain localized here indicates a
scaphoid (navicular) fracture. Assess pulses, pain sensation, and motor function (range and strength). Radiographic views (posteroanterior, lateral, and oblique)
will reveal the bone involved. In a Colles fracture, the
distal radius is displaced dorsally and shows up as a
“silver fork” deformity on lateral view radiographs.
Finger fracture. Fractures of the phalanges (n-
gers) and metacarpals (hand) are common sports injuries. Older people usually sustain fractures as a result
of falls. Correct diagnosis of a fractured nger is important in preventing long-term functional disability.
Patients will present with a history of trauma or injury. Physical examination includes assessment of
vascular and neurological function, tenderness and
swelling, ROM of each joint, and signs of joint instability or deformity. Three radiographic views (posteroanterior, lateral, and oblique) are needed for a
complete evaluation.
Ganglion. Ganglions are cysts that contain a ge-
latinous uid formed by an “outpouching” of a joint
capsule or tendon sheath. They most often occur on
the dorsum of the wrist. A ganglion can be distinguished from a tumor by its soft consistency and
transillumination.
Muscle Pain (Myalgia)
Viral Infections
Viral infections can produce diffuse myalgias that are
usually associated with fever, chills, upper respiratory
tract symptoms, and malaise. A patient with inuenza
will have intense myalgia and high fever and appear
quite ill. A paraviral immunoglobulin M (IgM) titer is
diagnostic of an acute parvovirus B19 infection.
Psychogenic
Pain that is diffuse, variable in pattern, and unaffected
by activity or rest may be psychogenic in origin. A careful history may reveal any secondary gain the patient
may derive from the pain and suggest the presence of
an anxiety or depression disorder. On examination, the
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Chapter 23 • Upper Extremity Limb Pain
patient may display facial expressions and descriptions
of discomfort to palpation and movement that are inconsistent. This diagnosis involves excluding other causes.
Fibromyalgia
Fibromyalgia is a syndrome characterized by chronic
fatigue, generalized musculoskeletal pain, and multiple
trigger points of pain on physical examination (see
Chapter 22).
Systemic Disorders
Sickle Cell Disease
Sickle cell disease is a genetic disorder characterized
by production of hemoglobin S, an anemia secondary
to short erythrocyte survival, and sickle-shaped erythrocytes. It affects mainly African American, Mediterranean, and Southeast Asian population groups. Sickle
cell disease manifests itself after the rst 6 months of
life. The child presents with painful or vaso occlusive
crises characterized by symmetrical, painful swelling
of the hands and feet. Older people report pain in long
bones and joints, abdominal pain, decreased appetite,
fever, and malaise. The laboratory ndings reveal a
hemoglobin S genotype and anemia, but ndings can
vary depending on the hemoglobin genotype, age,
gender, and presence of other organ involvement.
Systemic Lupus Erythematosus
SLE is a systemic inammatory condition that occurs
most often in women. It is characterized by arthritis
that commonly involves the small joints of the hands,
wrists, ankles, knees, and hips as well as malar rash,
oral ulcers, glomerulonephritis, hematological disorders, and psychological symptoms. The pain is transient but severe. Laboratory ndings show leukopenia
with neutrophils predominating the peripheral count,
and the antinuclear antibody test result is positive.
Nerve Entrapment Syndromes
Thoracic Outlet Syndrome
Thoracic outlet syndrome is the result of compression of nerve and vascular structures in the neck
area. Arterial compression creates pallor and decreased pulses and weakness, with eventual skin and
nail atrophy in the affected extremity. Nerve compression creates paresthesias, dysesthesias, and pain.
History may disclose that the patient sleeps with
the arm extended against the head, causing morning
symptoms of pain and paresthesias. Reaching, working with the arm raised, and lifting exacerbate pain.
Other risk factors include a rounded, sagging shoulder posture and shoulder muscle deformities. A
common compression occurs with the cervical rib
compressing the subclavian artery. A bruit may be
heard over the supraclavicular fossa. Electromyographic studies help to delineate the specific nerve
involvement; although they may not identify the
vascular involvement.
Carpal Tunnel Syndrome
Carpal tunnel syndrome involves entrapment of the
median nerve in the dominant hand, resulting from
repeated strain that causes thickening of the exor
tendon sheath. A dull, achy pain is felt across the wrist
and forearm with paresthesia, weakness, or clumsiness of the hand; atrophy; dry skin; and skin color
changes of the hand secondary to impaired nerve innervation. Symptoms are often worse at night. History
reveals repetitive activity of the upper extremity. Carpal tunnel syndrome most often occurs in women and
in people older than 30 years. Examination discloses
dry skin on the thumb, index nger, and middle nger
(median nerve distribution). Thenar atrophy may be
present. Tinel sign and Phalen test results are positive
(Table 23-2).
Neuritis
Vascular metabolism affected by systemic disorders
such as diabetes mellitus can cause a nerve to become
ischemic, producing toxins that can directly damage
the nerve. The nerve axon, myelin sheath, or both, can
be inamed. Soft tissue inammation contributing
to neuropathy can be caused by collagen disorders
(e.g., SLE, scleroderma).
Chapter 23 • Upper Extremity Limb Pain
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285
Table 23-2
Selected Tests Used to Assess for Upper Extremity Musculoskeletal Disorders
TEST DESCRIPTION FINDINGS
SHOULDER
Yergason test Have patient supinate forearm
Rotator cuff tear Ask patient to externally rotate and
ELBOW
Tennis elbow Have patient resist forearm supina-
WRIST
Finkelstein test Have patient flex fingers over a
Tinel sign Tap over median nerve (palmar
Phalen test Ask patient to maintain palmar flex-
DIFFERENTIAL DIAGNOSIS OF
against resistance.
abduct shoulder.
tion with elbow flexed 90 degrees.
clenched thumb; then passively
deviate wrist ulnarly.
surface of wrist) to assess for
compression neuropathy.
ion for 1 min with dorsal surfaces
of each hand pressed together.
Common Causes of Upper Extremity Limb Pain
A positive test produces pain in bicipital groove and is
suggestive of bicipital tendinitis.
In a partial tear, patient can raise arm but cannot main-
tain position against resistance; in a complete tear,
attempts to abduct arm will produce a shoulder shrug.
Pain with this movement indicates lateral humeral
epicondylitis.
Movement produces pain in de Quervain disease (first
dorsal compartment tenosynovitis).
In a positive test, patient reports a tingling or prickling
sensation distal to site tapped along first three digits,
wrist pain, and weak grip.
Test is positive if maneuver produces numbness and
paresthesia in fingers innervated by median nerve.
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
MUSCULOSKELETAL INFLAMMATION
Tenosynovitis
(tendinitis)
Bursitis History of overuse; aching pain
Fibrositis
Osteomyelitis Presentation depends on age,
JOINT INFLAMMATION
Osteoarthritis
Rheumatoid arthritis Morning stiffness of small joints;
Repetitive trauma activities; pain
with movement
over affected bursae that
radiates along limb
Pain in trigger sites throughout
body, joint stiffness, disturbed
sleep
location of infection; history of
infection, trauma, penetration,
invasive procedure; refusal to
bear weight (hip); constant pain
Older adults; asymmetrical joint
pain and stiffness that improves
throughout day; history of
repetitive joint trauma; obesity
symmetrical involvement;
anorexia, weight loss
Swelling over tendon,
crepitus
Local tenderness, swelling;
limited joint motion;
muscle weakness
Fatty, fibrous nodules in
muscles; palpation of
trigger points elicits pain
Fever, chills, vomiting; pain
localized over affected
area but progressively
worsens; soft tissue
injury or abscess
DIP, PIP joints enlarged;
Heberden nodes; limited
cervical spine ROM
Fever, rheumatoid nodules,
ulnar deviation of wrists
None
None
None
Increased WBCs,
ESR, CRP; radiographs
ESR; radiograph may
reveal osteophytes,
loss of joint space
Increased ESR,
positive rheumatoid
factor, anemia on
CBC count; radiograph shows bony
erosion
Continued
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Chapter 23 • Upper Extremity Limb Pain
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Upper Extremity Limb Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
JOINT INFLAMMATION—cont’d
Septic arthritis History of systemic infection, mal-
aise, diaphoresis, refusal to bear
weight (hip), acute joint pain
MUSCULOSKELETAL PAIN RELATED TO TRAUMA OR OVERUSE
Shoulder dislocation History of trauma, pain Limited rotation, arm
Acromioclavicular
joint injury
Bicipital tendinitis History of overuse of biceps; pain
Rotator cuff tear Acute: younger people, history of
Olecranon bursitis Repetitive motion of or pressure to
Lateral humeral
epicondylitis
Subluxation of radial
head
Wrist fracture History of fall on an outstretched
Finger fracture History of trauma or fall, joint
Ganglion Noticeable lump on dorsal surface
History of trauma, pain Limited shoulder move-
worse with movement
trauma, severe pain; chronic:
older, pain worse with overhead
movement, sleep disturbance
elbow; localized pain
History of repetitive contraction of
extensor and supinator muscles;
pain over lateral epicondyle that
progresses
Occurs in children; pain in elbow
or arm
hand; pain and swelling of
forearm and wrist
tenderness
of wrist
Fever; red, swollen joint;
limited range of motion
abduction, and hand
supination
ment; obvious deformity
Positive Yergason test; pain
localized over intertubercular groove
Acute: inability to raise arm
laterally, shrug shoulders;
chronic: tenderness over
AC joint, crepitus, weakness in external shoulder
rotation
Warmth, redness, and swell-
ing over joint; full ROM
Tenderness over lateral epi-
condyle; palpation produces pain, motion does
not; supination against
resistance worsens pain
Affected arm is flexed; child
cries when attempts are
made to move joint
Palpation of snuffbox in-
creases pain; observe for
joint deformity
Joint swelling, instability Three-view radio-
Gelatinous filled nodule,
soft, transilluminates
WBCs, culture of joint
aspirate, ESR, CRP,
ultrasound of joint
Radiograph of shoulder
with AP view and
internal/external
rotation
Radiograph of shoulder
with AP view and
internal/external
rotation
Radiograph (Fisk
view)
Radiograph may
reveal humeral
displacement
or spurs; MRI
Radiograph to rule
out fracture of
olecranon process
None
Radiograph of elbow
Three-view radio-
graphs to determine
scaphoid or Colles
fracture
graphs (PA, lateral,
and oblique)
None
MUSCLE PAIN (MYALGIA)
Viral infections History of upper respiratory tract
Psychogenic Diffuse pain; varies in pattern
infection; malaise, chills, cold
symptoms, general muscle aches
of activity, setting; history
of depression or anxiety
Fever, ill-appearing adult or
child
Normal examination or pa-
tient response to examination maneuvers disproportionate to physical
findings or subjective
complaints
Viral serum titer
None
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287
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Upper Extremity Limb Pain—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Fibromyalgia Female 20-50 yr old; history of
depression, sleep disturbance,
chronic fatigue, general muscle
and joint aches
SYSTEMIC DISORDERS
Sickle cell disease African American, family history;
appears after age 6 mo; acute
pain with swelling of hands and
feet, abdominal pain, decreased
Systemic lupus
erythematosus
NERVE ENTRAPMENT SYNDROMES
Thoracic outlet
syndrome
Carpal tunnel
syndrome
AC, Acromioclavicular joint capsule; AP, anteroposterior; CBC, complete blood cell count; CRP, C-reactive protein; CT, computed tomography; DIP,
distal interphalangeal; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging; PA, posteroanterior; PIP, proximal interphalangeal;
ROM, range of motion; WBC, white blood cell.
appetite, malaise
Female; transient arthritis of small
joints, malar rash
History of sleeping with arm
against head; morning shoulder
pain; pain worse with lifting;
paresthesia, weakness, or
clumsiness of hand; symptoms
worse at night
History of repetitive upper extremity
motion; paresthesia, weakness,
or clumsiness of hand; symptoms worse at night
Palpation of trigger points
will produce pain; normal
physical examination
Normal examination Hemoglobin S
Normal examination may
have joint tenderness on
palpation
Bruit over supraclavicular
fossa; pallor, decreased
pulses of upper extremity, weakness, skin and
nail atrophy
Positive Phalen test and
Tinel sign; weakness of
hand; dry skin over distribution of median nerve
None
genotype
Kidney function tests,
antinuclear antibody, CBC
None
None
References and Readings
Aletaha D, Neogi T, Silman AJ, et al: 2010 Rheumatoid arthritis
classication criteria: An American College of Rheumatology/
European League Against Rheumatism collaborative initiative,
Arthritis Rheum 62:2569, 2010.
Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J: Chronic
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CHAPTER
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24
report of acute low back pain (ALBP), although
A
quite common, requires a thorough evaluation.
The underlying pathophysiology of back pain is frequently multifactorial and includes both physiological and psychological components. The most common causes of ALBP relate to musculoligamentous
injuries and age-related degenerative processes.
About 90% of ALBP episodes in adults are related
to mechanical causes that resolve within 4 weeks
without serious sequelae. A smaller percentage of
patients will continue to have chronic symptoms
without organic pathology or will have underlying
disease.
In children, the prevalence of back pain increases
with age and with involvement in sports. Anthropometric variations in children place them at risk for excess strain on the spine, producing back pain. These
variations include reduced hip mobility, decreased
lumbar extension and increased lumbar exion, poor
abdominal muscle strength, tight hamstring muscles,
and lumbar hyperlordosis.
ALBP is dened as activity intolerance producing
lower back or back-related leg symptoms of less than
3 months’ duration. The Agency for Healthcare Research and Quality (AHRQ) guidelines provide the
following framework for causes of ALBP:
l
Potentially serious conditions (e.g., spinal fracture,
tumor, infection, or cauda equina syndrome)
l
Sciatica, or leg pain and numbness of the lateral
thigh, leg, and foot, suggesting nerve root compression (Figure 24-1)
l
Nonspecic back problems such as musculoskeletal
strain, diskogenic pain, or bony deformity secondary
to inammatory disease
l
Nonspinal causes secondary to abdominal involve-
ment (e.g., gallbladder, liver, renal, pelvic inammatory disease, prostate tumor, ovarian cyst, uterine broids, aortic aneurysm, or thoracic disease)
l
Psychological causes such as stress related to work
environment (e.g., disability, workers’ compensation,
secondary gains).
Low Back Pain (Acute)
When evaluating ALBP, the goal of the clinician is
to rst identify signs and symptoms of potentially serious conditions through a careful history and physical
examination. A holistic approach to the patient is needed
to appreciate the extent to which pain affects the patient’s daily routine or work-related activities. Because
ALBP is a common occupation-related complaint and a
cause of disability and lost productivity, the clinician
must gain insight into the patient’s psychosocial and
economic situation to help arrive at a correct diagnosis.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is this a potentially serious cause of ALBP?
Key Questions
l
Do you have a fever?
l
Have you experienced any trauma to the spine or
back?
l
Do you have any other health problems?
l
Have you been treated for cancer?
l
What is your age?
l
Have you had loss of control of your bowels or
bladder?
l
Are you taking any medications?
Fever
The presence of a fever indicates an inammatory condition such as spondyloarthropathy or systemic infection. Infection is a likely diagnosis when there are
chills and fever, weight loss, a recent history of bacterial infection, intravenous drug use, or immunosuppression. Ewing sarcoma is a malignant tumor and can
mimic spinal infection, occurring as back pain that can
be accompanied by fever. Children with diskitis will
have a fever and refuse to walk because of back pain.
Trauma
Acute trauma to the spinal cord can result in fracture,
dislocation, or misalignment of muscles, ligaments,
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