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Upper Extremity Pain: Where's the pathology—Neck or Shoulder?

Teaser:

Andrew Trenholm, MD, MSc, FRCSC,¹
Fred Xavier, MD, PhD,²
Sean Christie, MD, FRCSC,³

Authors' Affiliations

¹ Associate Professor Orthopaedics (Upper Extremity and Trauma) Dalhousie University, Halifax, NS.
²Fellow, Combined Spine Program, Department of Surgery, Dalhousie University, Halifax, NS.
³ Associate Professor, Dalhousie University, Department of Surgery (Neurosurgery), Halifax, NS.

CLINICAL TOOLS

Abstract: Neck and shoulder disorders are among the leading causes of pain and disability. History and physical examination are key components to clinical diagnosis and to determining whether the source of the arm pain is the neck or the shoulder. When consistent with the history, it is recommended to perform targeted provocative tests or manoeuvers. Several studies have shown that using a test item cluster improves diagnostic accuracy more than any single test item alone. Imaging, electrophysiological and laboratory studies are usually unnecessary unless there are clear clinical indications.

Key Words: Cervical radiculopathy, Neck pain, Shoulder pain, Clinical diagnosis, Provocative tests.

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Pre-test CME Quiz Post-test CME Quiz

1. Sinister pathology is rarely produces completely intermittent pain.

2. Neck pain is frequently associated with psychosocial stress and heightened emotional response.

3. The first step in taking the history is to establish the site of the dominant pain.

4. A neurological examination should include tests for spinal cord involvement causing cervical myelopathy.

5. Neck dominant pain can include pain felt in the face, upper back, top of the shoulder, anterior chest and headache.

The best way to differentiate between the neck and the shoulder as the source of upper limb pain is to assess the effect of movement in each area on the patient's typical pain.

The provocative tests should be chosen to confirm a suspected diagnosis. By themselves they are not a reliable guide to the specific pathology.

Neck and shoulder problems may coexist particularly in older patients and the examination of one should always include a screen of the other.

Radicular arm pain is more often caused by boney foraminal nerve root entrapment than by a new "soft" disc herniation.

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Editor's Note, Volume 8 Issue 2

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D’Arcy Little, MD, CCFP, FRCPC Medical Director, JCCC and HealthPlexus.NET

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Insufficiency Fractures of the Femur and Sacrum

Teaser:

Dr. M.S. Alam, MD, MBBS, CCFP, FCFP

Authors' Affiliations

Clinical Lecturer, Cumming School of Medicine, Calgary, University of Calgary, Family Medicine Department, Calgary, AB.

CLINICAL TOOLS

Abstract: Insufficiency Fractures (I.F) are non-traumatic fractures that occur in abnormal bone (low density bone). Usually occurs in elderly post-menopausal women and is non-traumatic. X-rays are unremarkable and MRI showed extensive bone marrow oedema and subchondral fracture.
Ms. Shirley Cooke, a 61 year old with a background of low bone mass, breast cancer, Diabetes Melitis type 2, HTN, splenic artery thrombosis came in with a dull pain on her left knee and occasionally some sharp element, with unremarkable examination on knees.
Recently, she was diagnosed with left ankle avulsion fracture of lateral maleolus and is wearing an ankle boot for healing.
It is important to make the correct diagnosis in order to avoid complications."

Key Words: Insufficiency Fracture (I.F), low bone mass, management.

1. With regard to I.F of femoral Condyle—Although the knee symptoms will always be unilateral, on the side of the meniscal tear, and are more frequent in older woman, the pain of an insufficiency fracture can easily be confused with that of other joint pathologies and therefore be easily missed.²

2. With regard to I.F of Femoral Neck—This fracture is seen in the elderly osteoporotic patient, often following a trivial event such as a slip without a fall. The resultant boney defect may be a compression fracture, which is inherently stable, or a transverse fracture, more common in older patients and is potentially much more serious.

3. With regard to I.F of Sacrum—The possibility of an insufficiency fracture should be considered in elderly osteoporotic patients, particularly women, following evenly seeming innocuous trauma to the posterior pelvis who exhibit constant buttock pain which may radiate to the thigh or groin and is unaffected by spinal movement.

MRI is the gold standard for Dx. I.F.

Symptoms and conventional tests may not be helpful, High Index of suspicious is needed.

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