16 Clinical Correlation of Upper Extremity

Question 1

most commonly fall directly onto shoulder
Pain with overhead motions, deformity of superior
shoulder

Answer 1

Acromioclavicular (AC) sprains

Question 2

Pain with cross body adduction of arm (positive cross-chest
test)
Painful arc of abduction over 150°

Answer 2

Exam finding for AC sprain

Question 3

Exam finding for AC sprain

Answer 3

pain with cross body adduction, painful overhead motions, deformity of superior shoulder

Question 4

Grade I for AC

Answer 4

AC ligament stretch

Question 5

Grade II for AC

Answer 5

AC ligament tear and coronoid-clavicular (CC)

ligament stretch

Question 6

Grade III for AC

Answer 6

complete tears of both AC & CC ligaments

Question 7

Grades IV+ for AC

Answer 7

complete tears + clavicular displacement

Question 8

Tx options for AC Grades
I and II
III
IV

Answer 8

Non-operative – grades I & II

b) Operative grade IV+
c) Either – grade III

Question 9

most common dislocation of shoulder

Answer 9

anterior dislocatoin

Question 10

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

Answer 10

Will cause anterior shoulder dislocation

Question 11

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

Answer 11

Shoulder dislocation

Question 12

What would you expect the shoulder to look like on shoulder dislocation

Answer 12

(1) Prominent acromion
(2) Humeral head anterior to acromion and adjacent to
coracoid

Question 13

How can you test a patient for shoulder dislocation?

Answer 13

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)

Question 14

What neurovascular structures should we worry about in a shoulder dislocation?

Answer 14

axillary & musculocutaneous nerves -sensation

Question 15

How do we tx a non-surgical acute shoulder dislocation?

Answer 15

Non-operative - immobilization with sling and
watch for 3 to 4 weeks for young adult; for older adult
sling for comfort and gentle mobilization

Question 16

When would we consider surgical measures for a shoulder dislocation?

Answer 16

consider for adolescent athlete and high

level athletes

Question 17

Radiology for shoulder dislocation?

Answer 17

multi-planar x-rays

Question 18

Pt comes in with pain on overhead arm movement

Answer 18

Rotator cuff injury

Question 19

What 3 impingement tests can we do if we expect a rotator cuff injury?

Answer 19

(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

Question 20

What is a Neers test

Answer 20

pain when arm is elevated through forward flexion

–for rotator cuff injury

Question 21

What is an Empty Can test?

Answer 21

arms (vertically) abducted
to 90°; 30° horizontally adducted; thumbs down to
floor; push downward to floor against resistance
–for rotator cuff injuy

Question 22

Hawkins Test -

Answer 22

pain with resisted external rotation
with elbow flexed and across body
–for rotator cuff injury

Question 23

Rotator cuff weakness; patient has profound weakness when abducting their arm; may even drop it

Answer 23

possible complete tear of rotator cuff: via drop arm test

Question 24

What degree of abduction is painful for rotator cuff injuries?

Answer 24

Painful arc of abduction (80° to 120°)

Question 25

Tender at insertion of supraspinatus tendon on greater | tuberosity of humerus

Answer 25

rotator cuff injury

Question 26

Treatment for rotator cuff injuries

Answer 26

a) Non-operative for small tears and tendonopathies | b) Surgical for large tear or in a younger athletic patient

Question 27

Pt comes in complaining of painful, stiff shoulder

Answer 27

Adhesive capsulitis; frozen shoulder

Question 28

Etiology of frozen shoulder -

Answer 28

complication of many injuries including dislocation, | rotator cuff tendinitis, reflex sympathetic dystrophy and fractures

Question 29

What do we expect to see on exam with a pt with a frozen shoulder?

Answer 29

``` limited passive (& active) ROM – especially noted in external rotation ```

Question 30

Treatment for adhesive capsulitis

Answer 30

- time - often resolve in 1-2 years | younger patients better prognosis of spontaneous resolution

Question 31

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

Answer 31

Medial epicondylitis “golfer’s elbow”

Question 32

Etiology of medial epicondylitis

Answer 32

overuse of the wrist flexors - (especially - pronator teres | and flexor carpi radialis)

Question 33

– overuse from repetitive extension (especially - extensor | carpi radialis brevis)

Answer 33

Lateral epicondylitis

Question 34

pain over lateral elbow radiating into forearm; late - | weakness

Answer 34

lateral epicondylitis or tennis elbow

Question 35

Signs of lateral epicondylitis:

Answer 35

tenderness over lateral epicondyle; pain with resisted wrist dorsiflexion & middle finger extension

Question 36

tenderness over lateral epicondyle; pain with resisted wrist dorsiflexion & middle finger extension

Answer 36

Lateral epicondylitis

Question 37

Pt had a fall on outstretched hand and is experiencing tenderness in anatomic snuffbox

Answer 37

scaphoid frx

Question 38

What radiology tests do we order when we expect a scaphoid fracture?

Answer 38

Radiology – often need to consider MRI, CT or bone scan

Question 39

Etiology of carpal tunnel

Answer 39

irritation of the median nerve in carpal tunnel

Question 40

Tingling & pain in median nerve distribution (1) Especially at night - frequently accompanied by numbness

Answer 40

carpal tunnel syndrome

Question 41

Early Signs of carpal tunnel

Answer 41

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

Question 42

Late findings of carpal tunnel

Answer 42

thenar eminence atrophy and loss of 2 point discripination

Question 43

overproduction of fluid by a joint of tendon sheath | a) Filled with thick gelatinous material

Answer 43

wrist ganglion

Question 44

pt has a firm but mobile lump in her wrist, what's the tx

Answer 44

wrist ganglion: a) Typically clinically observation b) Aspiration – if painful, but often reoccurs c) Surgery – for definitive treatment, but still may recur

Question 45

Recommend tx for fractures

Answer 45

1. immobilization | 2. avoid NSAIDs: may interfere with bony healing via PGs

Question 46

Initial tx of patient with broken scaphoid

Answer 46

immobilization

Question 47

What is a worry with a scaphoid frx

Answer 47

its a watershed region and can disrupt blood supply and become necrotic. certain areas are more sensitive to blood loss then others

Question 48

What are the contents of the snuffbox

Answer 48

Radial nerve and artery; parathesis on back of thumb Cephalic vein scaphoid bone

Question 49

What do we worry about with a femoral head fracture

Answer 49

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

Question 50

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

Answer 50

pt has arthritis (crepitus and history of dislocations) if it was rotator cuff tendinitis she wouldn't have FROM

Question 51

What would we see in the history of pt with arthritis?

Answer 51

stiffness, especially after rest and worse after prolounged use

Question 52

What would the exam findings would you expect from someone with arthritis

Answer 52

joint line tenderness, mild swelling, deformity, symptoms with both passive and active motions see damage to articular cartiledge

Question 53

Capsulitis history

Answer 53

Limited ROM Painful earl with decreased ROM (freeze phase) non-painful with stable, decreased ROM (frozen phase) Non-painful with improving ROM (thawing phase)

Question 54

Risk factors for capsulitis

Answer 54

injury, diabetes, thryoid disease

Question 55

What to look for on MRI of capsulitis

Answer 55

see brighter white signal in the inferior aspect of joint capsule signifying joint inflammation

Question 56

Tx for capsulitis

Answer 56

reassurance, educate and set expecation, maintain ROM and pain control takes 2-3 years to get back to normal, keep using the arm

Question 57

Pt hear their shoulder pop and now has a bulge in biceps area, most likely diagnosis

Answer 57

Long head biceps tendon rupture

Question 58

Key signs in exam of long head biceps rupture

Answer 58

see a furrow by the deltiod where the tendon usually is and the bulge is more distal on the arm

Question 59

Best tx for a tx of long head biceps tendon rupture

Answer 59

do nothing Ask: what impact does missing muscle action have, are there altenative muscles, what are the functional requirements of my patient

Question 60

disorder of muscular or tendinous bony attachment

Answer 60

enthesopathy; type of musculoskeletal injury

Question 61

technically acute inflammation of tendon | --often dt a blow or pull

Answer 61

Tendinitis

Question 62

chronic degenerative condition of tendon; seen with submaximal repetitive irritation

Answer 62

Tendinosis

Question 63

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

Answer 63

Lateral epicondylitis

Question 64

Causes of Muscle strain

Answer 64

``` muscle fiber damage from overstretching: eccentric loading (muscle lengthening during firing) ```

Question 65

Syptoms of muscle strain

Answer 65

stiffness, bruising, swelling, soreness

Question 66

What situations are NSAIDS most favorable

Answer 66

Acute patellar tendinitis

Question 67

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

Answer 67

Acromioclavicular (AC) sprain

Question 68

Microscopic damage with no increased laxity, but pain with stress

Answer 68

Grade I Sprain

Question 69

Partial tear with increased laxity and pain

Answer 69

Grade II sprain

Question 70

Complete tear with significant laxity

Answer 70

Grade III sprain

Question 71

What structures do we worry about getting damaged in anterior shoulder dislocation?

Answer 71

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

Question 72

What is our most effective passive stabilizer

Answer 72

vacuum phenomena