Myelopathy most often occurs in patients with a presumptive congenital narrowing of the cervical spinal canal. Symptoms related to myelopathy include mild upper extremity weakness, atrophy, hyperreflexia in the lower extremities, and extensor plantar responses.

Patients with radiculopathy present with symptoms referable to the particular nerve root that is compressed; most commonly C6 and C7 are involved and result in neck, parascapular, and arm pain, all of which may be accentuated or precipitated by movement of the head or neck. Motor abnormalities, including weakness and diminution or loss of reflexes, may be noted in the biceps, brachioradialis, and triceps muscles. Sensory loss may involve the radial aspect of the thumb or index and long fingers (see Table 46-1).

The demonstration of cervical spondylotic changes by plain radiography cannot be considered diagnostic, given the extremely high incidence of asymptomatic patients. Such radiographic abnormalities, however, when correlated with physical findings, are suggestive. The diagnosis of cervical myelopathy requires demonstration that the cervical canal is less than 10 mm in diameter; this dimension may be measured by magnetic resonance imaging (MRI) or computed tomography imaging, which can usually be done nonemergently.

Patients in whom the diagnosis of myelopathy is considered should be discussed with the orthopaedic or neurosurgical consultant before disposition; this is particularly true when trauma has precipitated or worsened symptoms or when motor loss is suspected. Patients with cervical radicular symptoms should be treated with immobilization of the neck in a soft cervical collar and several days of activity limitations; nonsteroidal anti-inflammatory agents, local heat, muscle relaxants, and analgesics as needed are generally recommended as well. When motor abnormalities are noted, consultation before disposition is recommended.

As noted previously, isolated discomfort involving the upper or lateral shoulder, arm, or forearm may be reported as the initial and only complaint in patients with cardiac ischemia. A history of discomfort beginning or worsening with exertion is occasionally present but cannot be relied on to exclude or make less likely the possibility of cardiac pain. Diagnostically, a critically important finding is that neither movement of the extremity nor palpation elicits or worsens the patient’s discomfort; when this is the case, local causes are unlikely. Unfortunately, in most patients, the electrocardiogram (ECG) will not exclude the possibility of cardiac ischemic pain, because it is recognized that as many as half of all patients presenting to the emergency department (ED) with an acute myocardial infarction may have a normal ECG when first evaluated.

When the clinician suspects the diagnosis of cardiac ischemic pain, further workup and admission are indicated.

When these structures are inflamed, severe discomfort is described, often perceived as more severe at night and preventing sleep. Pain is clearly enhanced both by palpation and by passive or active motion of the shoulder. Discomfort commonly radiates superiorly toward the neck and distally toward the elbow. Radiologically, local deposits of calcium may be noted.

Treatment includes an initial but abbreviated period of immobilization in a sling (2-3 days at most) and the institution of anti-inflammatory agents. Patients should be instructed to remove the sling each day for bathing and at night to prevent the development of shoulder (adhesive capsulitis) or elbow stiffness. Daily, gentle range-of-motion exercises are recommended to minimize the development of adhesive capsulitis. The use of a nonsteroidal anti-inflammatory agent such as ibuprofen and an analgesic for particularly symptomatic patients is reasonable and effective treatment. If discomfort is well localized, and infection has been excluded, a local injection of a long-acting steroid preparation, such as methylprednisolone acetate, 40 mg, combined with an anesthetic agent, such as 2 mL of 1% or 2% lidocaine or 1 to 2 mL of bupivacaine, is also effective; this modality is frequently reserved for patients failing a course of anti-inflammatory agents. No more than one or two such injections (the initial injection should be given 2 weeks to be effective) should be given in the ED; orthopaedic referral is preferred at this point. Patients receiving an injection should be told that although the anesthetic will acutely alleviate discomfort, pain will recur and last for approximately 12 to 36 hours, after which time the effect of the steroid becomes apparent. Referral should be advised in 5 to 7 days to assess progress and institute range-of-motion exercises.

Patients with lateral epicondylitis usually provide a history of repetitive or excessive use of the muscles of the wrist or forearm; however, often no such history is present. On examination, tenderness of the lateral epicondyle is noted with palpation, which is accentuated by extension of the wrist, particularly against resistance. Passive range of motion of the elbow is normal.

Treatment involves prohibiting maneuvers that result in use of the forearm and wrist extensors; providing a sling, which should be removed for bathing and at night; and instituting a course of oral nonsteroidal anti-inflammatory agents. A variety of splinttype devices are available (these are referred to as “tennis-elbow bands or wraps”), which when applied result in mild compression of the muscles in the forearm, in this case the forearm or wrist extensors, thereby reducing transmitted force to the epicondyle. Radiologic assessment of the elbow is indicated in most patients to exclude displacement, which, if present, may require operative reduction and fixation. Although the local injection of corticosteroids is effective, this treatment should be reserved for patients not responding to more conservative therapy.

In most patients, an x-ray should be obtained to exclude avulsion fractures of the epicondyle or displacement. Ulnar nerve irritation is commonly associated with the above syndromes and may be symptomatic.

Treatment includes rest, by prohibiting activities resulting in symptoms, local heat, and prescribing of an anti-inflammatory agent. A variety of splint-type devices are available (“tennis-elbow bands or wraps”), which when applied result in mild compression of the muscles of the forearm, in this case the forearm flexors and major pronator, thus reducing transmitted force to the epicondyle. Patients should be referred to an orthopaedic surgeon, since refractory cases may require immobilization in a long-arm splint or cast with the forearm in pronation. Local injection with a corticosteroid may also be recommended in particularly refractory or symptomatic cases but must be undertaken with caution due to the proximity of the ulnar nerve. Patients with fractures or displacement of the epicondyle should be referred to an orthopaedic surgeon for prompt follow-up.

Patients with olecranon bursitis present with severe pain overlying the olecranon; a history of chronic overuse or recent injury to the area is often present. On physical examination, the posterior elbow is exquisitely tender to palpation and often markedly inflamed with increased warmth and erythema; the thickened, fluid-filled or “boggy” olecranon bursa is easily appreciated. Suppurative bursitis must always be considered when penetrating or other trauma has preceded the onset of symptoms or when evidence of systemic infection is present; under these circumstances, sterile aspiration of the bursa is indicated. In addition, the possibility of gouty bursitis can be addressed with the analysis of aspirated bursal fluid.

Treatment includes the use of a sling, which should be removed for bathing and at night, and the institution of a nonsteroidal anti-inflammatory agent. Patients should be advised that if symptoms have not improved in 5 to 10 days, aspiration and possible steroid injection may be required; orthopaedic follow-up at this time is therefore advised. Analgesics are often required during the initial 2 to 3 days of treatment.

Patients usually complain of a dull ache in the involved area; physical findings include local induration, erythema, and tenderness. Tenderness is often found to extend
proximally along the course of the involved, indurated vein; true fluctuance is rarely present, but when it is noted, suppurative thrombophlebitis should be suspected. In patients with idiopathic or drug-induced thrombophlebitis, the inflammatory process generally subsides within 5 to 7 days with treatment, but a firmly palpable cord remains for a longer period. Edema and deep pain involving the arm do not occur unless deep venous or suppurative thrombophlebitis coexists.

In patients with recent venipuncture, intravenous catheter placement, medication administration, or illicit intravenous drug use, the possibility of suppurative thrombophlebitis must be considered. Fortunately, in patients with recent venipuncture, intravenous catheter placement, or in-hospital medication administration, thrombophlebitis is most often irritative or chemical in nature rather than infectious. These patients require only routine symptomatic treatment as outlined below. However, because it is virtually impossible to exclude completely the diagnosis of suppurative phlebitis, a re-examination in 24 to 48 hours is indicated. Patients with high fever, leukocytosis, evidence of systemic illness, bacteremia, local fluctuance, cellulitis, or an appropriate history require that suppurative phlebitis be excluded, and to this end, general or vascular surgical consultation at the time of presentation is appropriate. If confirmed, patients will require admission, intravenous antibiotics, and early surgical intervention.

In patients with irritative or chemical phlebitis, only local and symptomatic measures, including moist heat, elevation, and a short course of an appropriate anti-inflammatory agent, are necessary.

Many patients are asymptomatic, although occasionally aching discomfort accentuated by pressure over the area is reported, often in association with minor trauma or overuse of the involved joint. By palpation, synovial cysts are somewhat firm and nodular, and when trauma or overuse has preceded or precipitated symptoms, evidence of mild inflammation may be noted. Most such lesions are small—approximately 1 cm—and may also be found in association with the tendon sheaths of the distal lower extremity. Pathologically, lesions consist of a wall of tough fibrous material, often containing synovial cells and filled with a fluid rich in glycosaminoglycans.

When evidence of inflammation is present, treatment includes reassurance, immobilization of the joint, and a course of an anti-inflammatory agent. Patients without signs or symptoms of inflammation require only orthopaedic referral at an interval determined by the patient’s symptoms. Surgical removal may be elected if significant symptoms persist.

Repetitive trauma to the area is often reported, as is an occupation or activity requiring weight bearing on this area of the forearm. In addition to symptoms related to median nerve compression, forearm pain is reported, and local tenderness to palpation is noted. Physical findings are somewhat similar to those found in patients with the carpal tunnel syndrome; however, in addition, weakness of distal thumb flexion is noted because the flexor pollicis longus derives its innervation proximal to the wrist.

Treatment depends on the extent of symptoms and whether motor function is impaired. Orthopaedic referral is recommended.

Most patients will be young to middle-aged women who report a vague or ill-defined ache involving the hand or forearm; pain is sometimes noted to involve the upper arm and neck. Symptoms are usually precipitated or exacerbated by activities requiring repetitive movements of the upper limbs, especially above the head. Accentuation of symptoms at night is common, and some patients report that the entire limb feels numb; paresthesias and weakness involving the fingers and hand are also commonly reported. A “whiplash” injury precedes the onset of symptoms in some patients.

When the arm is abducted to 90 degrees and externally rotated, patients with thoracic outlet obstruction may develop typical paresthesias and numbness with immediate resolution of symptoms once the arm is returned to the side; with abduction, a bruit may also be auscultated in the supraclavicular fossa. Loss of the radial pulse with the arm abducted (positive Adson test), once considered the diagnostic hallmark of the syndrome, is often noted in asymptomatic individuals. Nerve conduction studies are sometimes helpful in supporting the diagnosis or suggesting other cause. Arteriography is sometimes used to establish the diagnosis, most often before surgery.

Treatment is initially symptomatic, with avoidance of heavy lifting and repetitive movements of the upper extremities, particularly above the head. Patients should also be instructed not to sleep with their arms above the head. A sling can be tried on the affected arm, which should be removed for sleeping. Physical therapy and warm compresses to the shoulder are sometimes symptomatically helpful; muscle relaxants can be tried as well. Surgical treatment usually involves resection of a cervical rib or fascial bands; surgery is normally reserved for patients with severe symptoms who fail a course of conservative therapy or for those with embolization or actual arterial occlusion.

In many patients with tendinitis around the wrist or fingers, a history or occupation involving repetitive motion of the joint is elicited and has preceded the development of symptoms; this history is absent in approximately 50% of patients. Most patients report poorly localized discomfort to the area of the involved tendon or tendons; such discomfort, however, is clearly worsened by passive or active movement of the involved tendon, and this remains a key diagnostic point. Increased warmth, overlying erythema, and occasionally palpable crepitus are noted; crepitus is appreciated by palpation directly over the involved tendon with active or passive motion. Patients with de Quervain tenosynovitis report discomfort at the radial styloid often radiating into the thumb and forearm. Discomfort may be increased by flexion and apposition of the thumb and fifth finger.

Treatment of tendinitis involves immobilization of the involved joint with a splint, use of a nonsteroidal anti-inflammatory agent, and elevation. Use of the joint should be prohibited, and follow-up is suggested at 5 to 7 days to evaluate the patient’s response to treatment. Patients should be advised to remove the splint each day for bathing and gentle range-of-motion exercises to prevent the development of joint stiffness. If treatment is unsuccessful, locally administered steroids may be effective.

Carpal tunnel syndrome is most often unassociated with trauma, and patients report the gradual onset of primarily nocturnal hand, wrist, and forearm pain often accompanied by numbness or dysesthesias. Pain is sometimes better localized to the volar first or second fingers. Patients are commonly awakened from sleep and report relief of symptoms by shaking or elevating the hands. Bilateral involvement is occasionally reported, but more often only one upper extremity is involved. The incidence is increased in pregnancy and associated with birth control pill use.

On physical examination, sensation to pinprick is reduced on the volar (palmar) aspect of the index finger; frequently, a subjective difference between the two hands can be demonstrated. Mild atrophy of the thenar eminence is noted in some patients, and thumb adduction is often slightly weakened. The diagnostic impression of carpal tunnel syndrome can be further supported if holding the patient’s wrist in flexion (Phalen test) for 60 seconds reproduces symptoms and placing the wrist in the neutral position relieves symptoms. Tinel sign (light tapping over the median nerve as it crosses under the carpal ligament) may also elicit symptoms (tingling in the fingers in the median nerve distribution) and is useful diagnostically.

Radiologic assessment should be undertaken when trauma has preceded the onset of symptoms, because carpal displacement and Colles fractures have both been associated with the development of the carpal tunnel syndrome. More commonly, tenosynovitis localized to the wrist flexors is responsible. The diagnosis can be confirmed by electromyography.

Treatment is determined by the extent of symptoms and whether motor loss is present; patients with abnormalities of motor function in the distribution of the median nerve require prompt orthopaedic consultation for possible decompression. Other patients should be treated with wrist immobilization by splinting in the neutral position; patients should remove the splint once each day for bathing, but it should otherwise remain applied. Wearing the splint during sleep, particularly during the first 3 to 5 days of therapy, and keeping the involved extremity elevated as much as possible should be emphasized. An initial trial of a nonsteroidal anti-inflammatory agent is recommended; treatment with steroids or definitive repair (release of the transverse carpal ligament) or both may be undertaken subsequently in selected patients. Follow-up in patients without motor loss should be advised in 7 to 10 days.

A medical evaluation should be considered to exclude various medical conditions frequently associated with carpal tunnel syndrome; these include diabetes mellitus, rheumatoid arthritis, hypothyroidism, multiple myeloma, acromegaly, amyloidosis, nephrosis, sarcoidosis, and tuberculosis.