16 Clinical Correlation of Upper Extremity Flashcards
most commonly fall directly onto shoulder
Pain with overhead motions, deformity of superior
shoulder
Acromioclavicular (AC) sprains
Pain with cross body adduction of arm (positive cross-chest
test)
Painful arc of abduction over 150°
Exam finding for AC sprain
Exam finding for AC sprain
pain with cross body adduction, painful overhead motions, deformity of superior shoulder
Grade I for AC
AC ligament stretch
Grade II for AC
AC ligament tear and coronoid-clavicular (CC)
ligament stretch
Grade III for AC
complete tears of both AC & CC ligaments
Grades IV+ for AC
complete tears + clavicular displacement
Tx options for AC Grades
I and II
III
IV
Non-operative – grades I & II
b) Operative grade IV+
c) Either – grade III
most common dislocation of shoulder
anterior dislocatoin
a) Forced extension, abduction and external rotation of the
arm (e.g. open arm tackle or fall onto abducted arm
b) Direct blow to posterior shoulder
Will cause anterior shoulder dislocation
Pt comes in with arm held in opposite hand in slight abduction and external rotation. He doesn’t want to abduct his arm and doesn’t want to internally rotate
Shoulder dislocation
What would you expect the shoulder to look like on shoulder dislocation
(1) Prominent acromion
(2) Humeral head anterior to acromion and adjacent to
coracoid
How can you test a patient for shoulder dislocation?
Positive apprehension test – feeling of instability with
stressing of the joint (note – feeling of pain is not a positive test; this test is done when patient is currently reduced/in normal anatomical alignment – not when dislocated)
What neurovascular structures should we worry about in a shoulder dislocation?
axillary & musculocutaneous nerves -sensation
How do we tx a non-surgical acute shoulder dislocation?
Non-operative - immobilization with sling and
watch for 3 to 4 weeks for young adult; for older adult
sling for comfort and gentle mobilization
When would we consider surgical measures for a shoulder dislocation?
consider for adolescent athlete and high
level athletes
Radiology for shoulder dislocation?
multi-planar x-rays
Pt comes in with pain on overhead arm movement
Rotator cuff injury
What 3 impingement tests can we do if we expect a rotator cuff injury?
(1) Neer’s test – pain when arm is elevated through
forward flexion
(2) Empty can test (Jobes) - arms (vertically) abducted
to 90°; 30° horizontally adducted; thumbs down to
floor; push downward to floor against resistance
(3) Hawkins Test - pain with resisted external rotation
with elbow flexed and across body
What is a Neers test
pain when arm is elevated through forward flexion
–for rotator cuff injury
What is an Empty Can test?
arms (vertically) abducted
to 90°; 30° horizontally adducted; thumbs down to
floor; push downward to floor against resistance
–for rotator cuff injuy
Hawkins Test -
pain with resisted external rotation
with elbow flexed and across body
–for rotator cuff injury
Rotator cuff weakness; patient has profound weakness when abducting their arm; may even drop it
possible complete tear of rotator cuff: via drop arm test
What degree of abduction is painful for rotator cuff injuries?
Painful arc of abduction (80° to 120°)
Tender at insertion of supraspinatus tendon on greater
tuberosity of humerus
rotator cuff injury
Treatment for rotator cuff injuries
a) Non-operative for small tears and tendonopathies
b) Surgical for large tear or in a younger athletic patient
Pt comes in complaining of painful, stiff shoulder
Adhesive capsulitis; frozen shoulder
Etiology of frozen shoulder -
complication of many injuries including dislocation,
rotator cuff tendinitis, reflex sympathetic dystrophy and fractures
What do we expect to see on exam with a pt with a frozen shoulder?
limited passive (& active) ROM – especially noted in external rotation
Treatment for adhesive capsulitis
- time - often resolve in 1-2 years
younger patients better prognosis of spontaneous resolution
Pt comes in with pain on medial elbow and secondary weakness. ON exam, they state tenderness over medial epicondyle and pain with resisted wrist flexion and forearm pronation
Medial epicondylitis “golfer’s elbow”
Etiology of medial epicondylitis
overuse of the wrist flexors - (especially - pronator teres
and flexor carpi radialis)
– overuse from repetitive extension (especially - extensor
carpi radialis brevis)
Lateral epicondylitis
pain over lateral elbow radiating into forearm; late -
weakness
lateral epicondylitis or tennis elbow
Signs of lateral epicondylitis:
tenderness over lateral epicondyle; pain with resisted wrist
dorsiflexion & middle finger extension
tenderness over lateral epicondyle; pain with resisted wrist
dorsiflexion & middle finger extension
Lateral epicondylitis
Pt had a fall on outstretched hand and is experiencing tenderness in anatomic snuffbox
scaphoid frx
What radiology tests do we order when we expect a scaphoid fracture?
Radiology – often need to consider MRI, CT or bone scan
Etiology of carpal tunnel
irritation of the median nerve in carpal tunnel
Tingling & pain in median nerve distribution
(1) Especially at night - frequently accompanied by
numbness
carpal tunnel syndrome
Early Signs of carpal tunnel
a) Tinel’s sign - percussion over the carpal tunnel reproduces symptoms
b) Phalen’s sign - wrists are held in maximal flexion for 1
minute reproducing symptoms
c) Sensory loss of the radial 31/2 fingers
Late findings of carpal tunnel
thenar eminence atrophy and loss of 2 point discripination
overproduction of fluid by a joint of tendon sheath
a) Filled with thick gelatinous material
wrist ganglion
pt has a firm but mobile lump in her wrist, what’s the tx
wrist ganglion:
a) Typically clinically observation
b) Aspiration – if painful, but often reoccurs
c) Surgery – for definitive treatment, but still may recur
Recommend tx for fractures
- immobilization
2. avoid NSAIDs: may interfere with bony healing via PGs
Initial tx of patient with broken scaphoid
immobilization
What is a worry with a scaphoid frx
its a watershed region and can disrupt blood supply and become necrotic. certain areas are more sensitive to blood loss then others
What are the contents of the snuffbox
Radial nerve and artery; parathesis on back of thumb
Cephalic vein
scaphoid bone
What do we worry about with a femoral head fracture
medial circumflex supplies most of femoral head. we worry with a frx to femoral head that we will impede the blood supply from this area: key for head and neck of femur
Pt presents with significant crepitus, pain with motions but has almost FROM, stregth WNL and positive apprehension sign… shes 16 yo with recurrent shoulder pain and self reduced her dislocated shoulder at home
pt has arthritis (crepitus and history of dislocations) if it was rotator cuff tendinitis she wouldn’t have FROM
What would we see in the history of pt with arthritis?
stiffness, especially after rest and worse after prolounged use
What would the exam findings would you expect from someone with arthritis
joint line tenderness, mild swelling, deformity, symptoms with both passive and active motions
see damage to articular cartiledge
Capsulitis history
Limited ROM
Painful earl with decreased ROM (freeze phase)
non-painful with stable, decreased ROM (frozen phase)
Non-painful with improving ROM (thawing phase)
Risk factors for capsulitis
injury, diabetes, thryoid disease
What to look for on MRI of capsulitis
see brighter white signal in the inferior aspect of joint capsule signifying joint inflammation
Tx for capsulitis
reassurance, educate and set expecation, maintain ROM and pain control
takes 2-3 years to get back to normal, keep using the arm
Pt hear their shoulder pop and now has a bulge in biceps area, most likely diagnosis
Long head biceps tendon rupture
Key signs in exam of long head biceps rupture
see a furrow by the deltiod where the tendon usually is and the bulge is more distal on the arm
Best tx for a tx of long head biceps tendon rupture
do nothing
Ask: what impact does missing muscle action have, are there altenative muscles, what are the functional requirements of my patient
disorder of muscular or tendinous bony attachment
enthesopathy; type of musculoskeletal injury
technically acute inflammation of tendon
–often dt a blow or pull
Tendinitis
chronic degenerative condition of tendon; seen with submaximal repetitive irritation
Tendinosis
Pt presents with pain in left elbow, got hit with golf ball, has 2 cm area of pain over distal humerus and lateral proximal radius.
pain persists with wrist and middle finger extension and with supination
no pain with varus or valgus stress
Lateral epicondylitis
Causes of Muscle strain
muscle fiber damage from overstretching: eccentric loading (muscle lengthening during firing)
Syptoms of muscle strain
stiffness, bruising, swelling, soreness
What situations are NSAIDS most favorable
Acute patellar tendinitis
Pt fell right onto shoulder. Has pain with overhead motions and deformity of superior shoulder.
On exam has pain and deformity of AC joint, pain with cross body adduction of arm and painful arc of abduction over 150 degrees
Acromioclavicular (AC) sprain
Microscopic damage with no increased laxity, but pain with stress
Grade I Sprain
Partial tear with increased laxity and pain
Grade II sprain
Complete tear with significant laxity
Grade III sprain
What structures do we worry about getting damaged in anterior shoulder dislocation?
Axillary nerve: deltoid is innervated by axillary so check for abduction past 30 degrees (supraspinatous does first 30 degrees of abduction)
also have the musculocutaneous: check skin over deltiod and the skin on arm
What is our most effective passive stabilizer
vacuum phenomena
