091014 clinical upper extr injury Flashcards
types of fracture mechanisms
acute fracture : suddent impact of large force exceeding the strength of bone
stress fracture : repeititive submaximal stresses
pathologic: normal forces to diseased bone
fracture hx
acute-sudden blow
chronic-repetitive activity; increase in activity duration, intensity, or frequency
fracture exam
deformities (if bleeding with or w/o a fragment, you should suspect open fracture, which is an orthopedic emergency. NEEDS to be washed out ASAP)
bony point tenderness (just at one spot)
pain w/ loading the bone (indirect loading is very useful-like the axial loading test, bump test, fulcrum test, hop test)
how to treat a fracture?
in general, immobilization
avoidance of NSAIDs (some animal studies show NSAIDs interfere w bony healing through prostaglandins)
fall on an outstreched hand-what are you concerned about?
scaphoid fracture
bones with vulnerable blood supply
scaphoid
talus
femoral head
what blood vessel supplies to scaphoid?
radial artery’s branch called the palmar carpal branch
what can a scaphoid fracture cause in terms of damage?
can disrupt blood supply going to distal ends of scaphoid, as the fracture is usually mid-scaphoid
then you would get necrosis
snuffbox contents
radial nerve
cephalic vein
radial artery
scaphoid bone (deepest)
how would you be able to tell its a scaphoid frac?
if pressure on anatomic snuffbox elicits pain
can have radial nerve paresthesia
what to do for scaphoid frac
need to put on splint b/c these fractures (due to tenuous blood supply) won’t heal very well if you don’t protect them. if it were a sprain, you may just watch and observe, but here, it’s critical to immobilize
can follow w/ MRI to see the blood supply
which artery supplies the femoral head?
medial circumflex femoral artery
with full range of motion, you can rule out
dislocation (w/ acute dislocation, it will be painful and the pt wouldn’t let you move it around much)
when can you have accelerated arthritis at an early age?
with trauma (ex-with repeated dislocations, articular cartilage will be damaged and worn away)
arthritis pt hx
stiffness, especially after rest
worse after prolonged use
exam findings of arthritis
joint line tenderness
mild swelling
deformity
KEY: symptoms with BOTH passive and active mvmt
physical therapy may be good for arthritis b/c
teaches how to use body in right manner
and also, build stronger muscles so can absorb shock better
what can you use for OA?
cortisone (for acute flares, or if someone has special occasion coming up)-can cause chondrocyte cell death though
NSAIDs
surgical replacement
physical therapy
dietary supplements (glucosamine, chondroitin-they make up articular cartilage)
viscosupllement (injections w/ hyaluronic acid, a building block of articular surface)
frozen shoulder is due to
capsulitis (joint capsule thickening, giving rise to inflam and scarring)
cause of capsulitis
idiopathic or post injury
capsulitis hx
limited range of motion (hurts to raise arm overhead)
early stage: painful w/ decreased ROM (freeze phase)
then later, frozen phase: non painful with decreased ROM
then later, thawing phase: non painful with improving ROM (the condition reverts on its own)
capsulitis exam findings
decreased ROM
gradually tightening endpoint
otherwise consistent with underling etiology
diagnosis of adhesive capsulitis
difficult w/o clinician giving background; usually radiology can say it’s consistent with but not that this IS capsulitis
capsulitis treatment
maintain ROM (what they came in with)
pain control
reassure and and educate
popped shoulder 2 weeks ago in a construction worker two wks ago when pulling on a bolt
full ROM, normal muscle strength,
diagnosis?
long head biceps tendon rupture (refer back to picture in slides)
differentiating btwn long head and short head biceps tendon tears at the proximal end
short head would result in muscle lump that is higher
treatment of long head of biceps tendon rupture?
NSAIDs can be used for the pain
platelet rich plasma or autologous blood injection can be used
physical therapy
or do nothing (can do fairly well with this)
to cinsider when treating musclotendinous ruptures
impact of absence of muscle
presence of alternative muscles
functional requirements of pt
enthesopathy
disorder of muscular or tendinous bony attachment
tendinitis
acute inflam of tendon (traumatic-blow or pull)
tendinosis
chronic degeneration of tendon
many injuries may be acute on a chronic underlying condition
40 year old golfer feels pain on left elbow; recently was hit by a golf ball in this area
exam shows 2 cm area of pain over distal humerus and lateral proximal radius, pain with resisted wrist and middle finger extension and with supination, no pain with varus or valgus stress
lateral epicondylitis
can’t be fracture b/c it’s diffuse (2 cm)
strains usually happen with what mechanism?
eccentric muscle contraction
strain is
muscle fiber damage from overstretching
symptoms of stiffness, bruising, swelling, soreness
for what case is the risk vs benefit ratio of NSAIDs most favorable?
acute patellar tendinitis
NOT chronic condition (b/c less inflam there). NOT immediate post-op pain (use stronger drugs and also NSAIDs have bleeding side effect). NOT stress fracture
with joint sprain, what can you observe?
pain and limited ROM
AC sprain most commonly caused by
fall directly onto shoulder
presentation of AC sprain
pain w/ overhead motions
deformity of superior shoulder
exam findings of AC sprain
pain and deformity at AC joint
pain with cross body adduction of arm (postive cross chest test)
painful arc of abduction over 150 degrees
AC injury grading
grade I-stretched AC ligament
grade II- torn AC ligament and coracoclavicular ligament stretched
grade III-torn both ligaments
sprain
ligamentous damage from overloading
symptoms are instability or laxity, swelling
sprain grades
grade I: microscopic damage. on exam, no increased laxity but get pain with stress
grade II: grossly see a partial tear. on exam, has increased laxity (opening and looseness) and pain
grade III: complete tear. exam shows significant laxity.
anterior shoulder dislocation possible sequelae
chip fractures in humeral head or glenoid b/c humeral head bumps into glenoid (coranoid process is in the way so it comes inferior and anterior)
what nerve can get copmressed with anterior shoulder dislocation
axillary nerve (which innervates deltoids and brings sensory info from area over deltoids)
joint stability types
dislocation-complete displacement
subluxation-transient, partial displacement and then slips back into proper place (never loses contact with the joint)
laxity-normal variant in joint looseness
shoulder disolocation causes
forced extension, abduction, and external rotation of arm (open arm tackle or fall onto abducted arm)
direct blow to posterior shoulder
diff btwn ligament sprain and dislocation
sprain-limited ROM
dislocation-won’t want to move
exam findings for shoulder dislocation
arm hand by opposite hand in slight abduction and exterrnal rotation
asymmetry-altered shoulder contour including prominent acromion; humeral head anterior to acromion and adjacent to coracoid
check sensation of axillary and musculocutaneous nerves
positive apprehension test- a feeling of instability with stress
paresthesia
tingling sensation
carpal tunnel syndrome
median nerve problem as it goes through carpal tunnel-if have activities that increase pressure within the tunnel, resulting in nerve compression
will cause paresthesia in volar aspect of hand distal thumb, index finger, middle finger, and half of ring finger
rotator cuff injuries-why can you still ability to move against resistance?
b/c deltoid is still good
rotator cuff injuries-will surgery be needed?
no, unless you want it. you can still have function w/o surgery
if you do want surgery (like if you were an assembly line worker and needed it for repetitive work), though, it should be done soon because otherwise the muscle scars down and you can’t bring it back to full length
acute complete rotator cuff tear will present with
maybe some weakness initially, but w/ physical therapy, get back to function
pain w/ overhead motions
most common rotator cuff muscle tear
supraspinatus
if subacromial space is obliterated, suggests?
rotator cuff tear
