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CLIN MED- Upper Extremity Disorders
what is the true term for a "separated shoulder" - acromioclavicular separation elevation of the clavicle (step off deformity) and point tenderness and pain with cross chest testing is indicative of: - acromioclavicular separation how are acromioclavicular separation appropriately graded? - x-ray is taken with the patient holding a weight to assess the level of injury to the joint how are acromioclavicular separations initially managed? - Conservative management is possible for mild to moderate injuries because they can be managed with a sling and analgesia. More severe injuries usually will require operative repair how are acromioclavicular separations categorized? - 1st, 2nd, and 3rd degree what degree of AC joint involves stretching of the joint? - 1st degree what degree of AC joint involves complete separation of the AC joint, but the ligaments that attach the shoulder blade and collarbone are still intact? - 2nd degree what degree of AC joint involves complete separation, gap is usually 1-2 inch wide? - 3rd degree how is 1st degree AC separation treated? 3rd degree? - 1- sling for at least 3 days, joint repairs self in one week 3- surgical repair what is an inflammatory disorder of the bursa (a thin-walled sac lined with synovial tissue)? - bursitis Pain on motion and at rest can cause fluid to accumulate, discomfort at end of ranges of motion, significant pain when shoulder in 90 degrees flexion then internally rotate: all these indicate what condition - bursitis
how should bursitis be treated? - prevention of the precipitating factors, rest, and NSAIDs. Cortisone injections can be helpful Aspirate if fever, diabetic or immunocompromised. Elbow swelling, can be red and tender inflammation can indicate what condition - Olecranon Bursitis (Scholar's Elbow) acute trauma or repetitive trauma causes inflammation of the olecranon bursa is what kind of olecranon bursitis? - nonseptic bursitis infection from microorganisms transferred via trauma to the skin overlying the bursa, resulting in pain or fever is what kind of olecranon bursitis? - septic bursitis what is an overuse syndrome that results in pain in the myotendinous junction between the wrist flexors and medial epicondyle - Medial Epicondylitis (Golfer's Elbow) Pain with resisted wrist/elbow flexion and pronation, tenderness upon palpation of medial elbow; pain at the medial elbow epicondyle that may radiate to the wrist: - Medial Epicondylitis (Golfer's Elbow) how are lateral and medial epicondylitis treated? - activity modification, physical therapy, corticosteroid injections - orthopedic surgery in patients who failed physical therapy for 4-6 months. along with counterforce bracing for lateral epicondylitis! An overuse syndrome that results in pain in the myotendinous junction between the wrist extensors and lateral epicondyle; [ain with wrist extension or forearm supination, increased with activity: - Lateral Epicondylitis (Tennis Elbow) Overuse injury in lateral epicondylitis specifically what muscle? - extensor carpi radialis brevis
what images should be taken if shoulder dislocation is suspected? - Anteroposterior (AP) and axillary lateral or scapular Y-views in x-rays must be taken how are shoulder dislocations treated? - Reduce, postreduction films, sling, and swath, physical therapy what are 5 associated conditions with shoulder dislocation? - Bankart lesion Hill-Sachs lesion Axillary nerve injury Rotator cuff tear Labral tear what complication of shoulder dislocations is a fracture of the anterior inferior glenoid following impaction of the humeral head against the glenoid? - Bankart lesion what complication of shoulder dislocations involves compression chondral injury of the posterior superior humeral head following impaction against the glenoid? dent in the humeral head! - Hill- Sachs what complication of shoulder dislocations involves cartilage that surrounds the glenoid? - labrum tear present with pain with reaching or lifting, and pain with overhead motions should be suspected of: - shoulder impingement syndrome what are 3 tests to look for impingement? - Neer test Hawkins test Drop arm test
what test for impingement involves arm fully pronated (thumbs down) with pain during forward flexions while shoulder is held down to prevent shrugging? - Neer test what test for impingement involves elbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with internal rotation? - Hawkins what test for impingement involves pain with inability to lift arm above shoulder level or hold it or severe pain slowly lowering arm after shoulder abducted to 90 degrees? - Drop arm test how should impingement syndrome be treated? - Treatment involves rest, ice, activity modification, NSAIDs, and corticosteroid injections. Symptoms refractory to conservative treatment or if subscapularis tearing secondary to impingement - arthroscopic surgery is indicated crepitus with range of motion and a subacromial spur on x-ray may be associated with what condition - impingement syndrome what condition generally occurs with a pulling upward type of motion while the child has an outstretched arm? - nursemaid's elbow (radial head subluxation) infant / young child presents with lateral elbow pain, the child will hold the elbow in slight flexion and the forearm pronated. Pain and tenderness localized to the lateral aspect of the elbow, and refuses to move arm on presentation: - Nursemaid's Elbow (Radial Head Subluxation) what is a classic method of reducing a subluxed radial head? / nursemaid's elbow - supination- flexion technique what are the 4 muscles of the rotator cuff? - Supraspinatus Infraspinatus Teres minor Subscapularis what nerves innervate the 4 rotator cuff muscles? - C5 and C what 3 tests can be done to test for supraspinatus tear or inflammation? - Empty can test
what is inflammation of the tendons that connect the biceps muscle, at the front of the arm, to the shoulder and the elbow? - biceps tendonitis Patient will present with pain at the biceps groove (between greater and lesser tubercle with palpation): along with anterior shoulder pain - may have pain radiating down the region of the biceps, pain with resisted supination of the elbow. - biceps tendonitis what special tests can be done for biceps tendonitis? - speed test Yergason's test "Popeye" deformity - indicates a rupture of what muscle? - biceps muscle what test for biceps tendonitis involves pain elicited in the bicipital groove when the patient attempts to forward elevate shoulder against examiner resistance while elbow extended and forearm supinated? - speed test what test for biceps tendonitis involves elbow flexed 90 degrees, wrist supination against resistance?
- Yergason's test what test for biceps tendonitis can show thickening and tenosynovitis of proximal biceps tendon? what does it show? - MRI increased T2 signal around biceps tendon how is biceps tendonitis treated? - Treat with NSAIDS, PT strengthening, and steroid injections. Surgical release reserved for refractory cases for bicep pathology seen during arthroscopy. what is a condition of the shoulder characterized by a severely limited range of motion? - Adhesive Capsulitis (Frozen Shoulder)
Insidious onset of shoulder stiffness and pain at rest and with movement. Decreased active and passive range of motion all indicate: - Adhesive Capsulitis (Frozen Shoulder) what test involves the patient tries to bring hands together on the back while one hand comes from above and the other from below? - Apley scratch test what test can be performed for patients suspected of Adhesive Capsulitis (Frozen Shoulder)? - Apley scratch test how is Apley scratch test treated? - Treat with NSAIDs, physical therapy, and intra-articular steroid injections. Surgery if failure to respond to conservative treatments - arthroscopic surgical release, manipulation under anesthesia (MUA). what tests can be done for patients of carpal tunnel syndrome? - Phalen test and Tinel test what test for carpal tunnel syndrome involves pushing backs of hands together? - Phalen test what test for carpal tunnel syndrome involves tapping over nerve? - Tinel test how is carpal tunnel syndrome diagnosed? - nerve conduction studies how is carpal tunnel syndrome treated? - Splint (particularly at night), corticosteroid (oral or injection), surgical decompression for severe median nerve injury Pain or paresthesia in the median nerve distribution - the first 3 digits and radial half of 4th digit. Symptoms are typically worse at night - carpal tunnel syndrome what condition involves pain and swelling at the base of the thumb often radiates into the radial aspect of the forearm - De Quervain's Tenosynovitis what muscles does De Quervain's Tenosynovitis mainly involve? - abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
whaat is the most common site of radial nerve injuries? - humerus fractures immediate pain in affected arm after trauma/accident is indicative of: - humerus fracture posterior fat pad or sail sign is associated with what kind of injury: - humerus fractures how are humerus fractures treated? - Treat with sugar tong splint (distal) coaptation splint (shaft) with ortho follow up in 24-48 hours. what is the usual dislocation of an elbow look like? - posterior and closed what is the largest concern with elbow dislocation? - ulnar nerve entrapment what is the most common pediatric elbow fracture - supracondylar fracture what is indicated when X-ray demonstrates anterior fat pad sign = dark area either side of the bone?
- supracondylar fracture what should you be sure to check for with supracondylar fracture? why? - neurologic or vascular involvement - may cause median nerve and brachial artery injury, as well as radial nerve injury. how is supracondylar fracture treated? - Long arm posterior splint followed by long arm casting - open reduction with internal fixation for all displaced fractures. Patient will present with pain and tenderness along the lateral aspect of the elbow, limited elbow or forearm motion, particularly supination/pronation: - radial head fracture how is radial head fracture? - Treat with sling, long arm splint at 90 degrees, open reduction, and internal fixation what is isolated fracture of the ulna? - nightstick fracture
how should nightstick fractures be treated? - Functional brace with good interosseous mold for isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx). ORIF if displaced Proximal ulnar shaft fracture with radial head dislocation: - Monteggia Fracture Patient presents with elbow pain and swelling, tenderness to palpation along the elbow, decreased elbow range of motion due to pain, and radial head may be palpable if significantly dislocated: - Monteggia Fracture what nerve is injured in some Monteggia Fractures? - radial nerve injury Fracture of radial shaft (between middle and distal 1/3's) with dislocation of the radioulnar joint: - Galeazzi Fracture what direction is the dislocation in a Galezzi fracture? - dorsal Patient presents with wrist pain and swelling, pain with wrist flexion/extension and forearm pronation/supination, a deformity may be noted depending on fracture severity: - Galeazzi Fracture what are dorsally angulated extra-articular distal radius fractures: - Colles fractures what is the most common forearm fracture/injury of the wrist? - Colles Fracture what condition is associated with a "dinner fork" deformity? - Colles fracture what is needed to diagnosed Colles fracture? - lateral X-Ray to make the correct diagnosis, may cause extensor pollicis longus tendon rupture. how is Colles fracture treated? - sugar tong splint/cast what fracture is sometimes referred to as reverse Colles fracture? - Smith's Fracture
what is an ulnar collateral ligament injury resulting from a fall on an abducted (hitchhiker) thumb. - Gatekeeper's Thumb what is an acute injury for Gatekeeper's Thumb? chronic injury? - A- Skier's thumb C- Gamekeeper's thumb Laxity and pain with valgus stress would be present in what injury? - Gatekeeper's thumb Pain and swelling at ulnar aspect of thumb at MCP joint, can progress to difficulty moving thumb, may have palpable mass along ulnar aspect of MCP joint: - Gatekeeper's thumb how is Gatekeeper's thumb treated? - Immobilization (thumb spica splint) for 4 to 6 weeks for partial tears or ligament repair what is also known as baseball finger? - Mallet finger Patient is unable to straighten distal finger (flexed at DIP joint) commonly associated with an avulsion fracture of the distal phalanx: - mallet finger bony avulsion of distal phalanx on x-ray is indicative of: - mallet finger how is mallet finger treated? - Splint DIP uninterrupted extension x 6 weeks or surgical pinning. what is a tear at PIP joint (jammed finger) - Boutonniere Deformity deformity characterized by PIP flexion and DIP extension - Boutonniere Deformity how is Boutonniere Deformity treated - Splint PIP in extension x 4-6 weeks with hand surgeon evaluation what is bleeding/bruising under the nail - subungual hematoma
throbbing pain initially followed by discoloration of the nail: - subungual hematoma Stenosing tenosynovitis is commonly called: - trigger finger when the pulley of the finger becomes too thick, so the tendon cannot glide easily through it: - trigger finger ain, popping, catching feeling, limited finger movement: - trigger finger how can trigger finger be treated? - Night splints Anti-inflammatory medication Activity modification Steroid injection Surgery (after failed tx including at least 2 injections)
