Upper Limb Assessment

Also written as Upper Extremity.

The upper limb includes the shoulder, arm, elbow, forearm, wrist and hand. Understanding anatomy, common injuries and infections helps clinicians diagnose and manage problems efficiently, especially where resources are limited.

Overview

The upper limb is a functional unit that moves the hand for tasks. It is supplied by the brachial plexus, major vessels (subclavian, axillary, brachial) and muscles that cross each joint.

• Shoulder: glenohumeral joint, rotator cuff, suprascapular nerve
• Elbow: hinge joint, median/ulnar/radial nerves
• Wrist/hand: complex carpometacarpal joints, digital nerves

Key concepts

Clinicians must link history (trauma, infection, systemic disease) to localisation of pain, weakness or swelling, then use a focused exam to narrow differential diagnoses.

• Pain localisation → joint vs. soft‑tissue vs. nerve
• Red flag symptoms → vascular compromise, infection, compartment syndrome
• Common tropical contributors: HIV‑related neuropathy, TB osteomyelitis, malaria‑related myalgia

Clinical relevance

Upper‑limb problems are frequent in low‑resource settings due to road traffic injuries, manual labour, and infections. Early recognition of compartment syndrome, septic arthritis and neurovascular injury can prevent permanent disability.

• Plain radiograph: Does the bone show fracture or dislocation? → Guides immobilisation or surgery; if unavailable, rely on clinical alignment and neurovascular exam
• Joint aspiration: Is the joint fluid purulent? → Confirms septic arthritis; if unavailable, treat empirically if clinical picture fits
• Nerve conduction study (if available): Is there demyelination or axonal loss? → Helps differentiate compressive vs. systemic neuropathy

• Compartment syndrome: pain out of proportion, pain on passive stretch, tense swelling
• Septic arthritis: acute mono‑articular pain, fever, limited active motion
• Peripheral neuropathy: sensory loss in a nerve distribution, often HIV‑related

Exam pearls

Examination proceeds from proximal to distal, assessing skin, bones, joints, muscles and nerves. Compare both sides.

• Inspect for swelling, bruising, deformity
• Palpate bony landmarks and tender points
• Active and passive range of motion at each joint
• Strength testing of deltoid, biceps, triceps, wrist extensors/flexors, hand grip
• Sensory testing in median, ulnar and radial distributions

Common mistakes

Errors often arise from incomplete localisation, overlooking vascular status, or assuming infection without joint aspiration.

• Missing a pulse deficit in a supracondylar fracture
• Treating presumed tendonitis without ruling out fracture
• Relying on normal white cell count to exclude infection in immunocompromised patients

Questions an examiner may ask

• A 28‑year‑old farmer presents after a fall on an outstretched hand with a swollen, painful wrist. What is your immediate management? — Assess distal pulses, obtain a wrist X‑ray, immobilise in a splint if fracture suspected.
• A patient with known sickle cell disease has sudden hand pain, swelling and fever. How do you differentiate vaso‑occlusive crisis from septic arthritis? — Examine for joint effusion, obtain joint aspiration; vaso‑occlusive pain is diffuse, aspiration yields sterile fluid.
• During a routine exam you note weakness of wrist extension but normal sensation. Which nerve is likely involved and what injury mechanism is common? — Radial nerve; often injured in humeral shaft fractures or compression from a tight cast.
• A child presents with a swollen elbow, limited motion and a fever of 38.5 °C. What investigations are essential and why? — Plain X‑ray to rule out fracture, joint aspiration to detect septic arthritis; both guide urgent treatment.
• In a resource‑limited clinic you suspect TB osteomyelitis of the humerus. Which clinical clues support this and what is the treatment principle? — Chronic pain, low‑grade fever, weight loss; start anti‑TB therapy for 6‑9 months after confirming with biopsy if possible.
• A patient on antiretroviral therapy develops a painful, tender forearm swelling after a minor injury. What complication must you rule out and how? — Compartment syndrome; assess pain on passive stretch and consider urgent fasciotomy if pressure high.
• Why is NSAID use cautioned in a patient with a known peptic ulcer presenting with shoulder bursitis? — NSAIDs increase gastric bleeding risk; consider paracetamol or intra‑articular steroid injection instead.
• A manual worker complains of gradual shoulder pain worsened by overhead activity. What is the most likely diagnosis and first‑line management? — Rotator cuff tendinopathy; advise activity modification, physiotherapy and NSAIDs if no ulcer risk.

When to seek help

• Rapidly expanding swelling with pain on passive stretch (compartment syndrome)
• Absent distal pulses after trauma
• Fever with joint swelling and limited motion (suspected septic arthritis)

Quick questions

What is the first step when a patient presents with a painful swollen elbow?

Check neurovascular status, then obtain a plain X‑ray before any manipulation.

How does HIV increase the risk of upper‑limb neuropathy?

HIV can cause distal symmetric polyneuropathy and opportunistic infections that affect peripheral nerves.

Why is compartment syndrome an emergency?

Elevated pressure compromises blood flow, leading to irreversible muscle and nerve loss within hours.