2.3.3 Upper Extremity Injuries

Question 1

What test does Dr. Fox use to ellicit the pain from tennis elbow in the office?

Answer 1

Laptop test

-have patients act like they are grabbing their chart out of a bag

Question 2

What is the treatment sequence for trigger finger?

Answer 2

splints, steriod injections, surgery (cutting of A1 pulley/sparing the A2 pulley)

Question 3

What are some of the risk factors for carpal tunnel syndrome?

Answer 3

female, pregnancy, diabetes, obesity

Question 4

What is the scientific name for trigger finger?

Answer 4

stenosing flexor tenosynovitis

Question 5

What is the typical presentation of rotator cuff tears?

Answer 5

Age > 40 y/o

anterolateral shoulder pain worsened by reaching and overhead activity (like taking a jug of milk out of the fridge)

Night pain

Weakness with attempted overhead activity

Question 6

What two tests can be used to identify cubital tunnel?

Answer 6

Tinel’s over cubital tunnel

2-point discrimination

Question 7

Which is normal? which is abnormal?

Answer 7

Question 8

Which pulleys in the finger are used to keep the flexors from fish poling?

Answer 8

A4 and A2 pulley

Question 9

How does the position of the nodule in trigger finger change in response to the change in positon of the finger?

Answer 9

Question 10

What are two tests (used to stimulate symptoms) that can be used to diagnose carpal tunnel?

Answer 10

Tinel’s sign (tapping on tranverse carpal ligament)

Phalen’s test (hold for up to 30 seconds)

Question 11

What is the standard presentation of cubital tunnel syndrome?

Answer 11

Numbness and tingling in the ring finger and little finger

Nocturnal paresthesias

Worsening symptoms while driving or resting medial elbow on hard surfaces

Question 13

Why is an x-ray taken in a patient with tennis elbow symptoms?

Answer 13

Rule out other causes of pain

May see some bony changes on x-ray

Question 14

What are the treatment steps for carpal tunnel?

Answer 14

Night splints -> steriod injections -> surgery (endoscopic or open)

Question 15

What is the scientific name for tennis elbow?

Answer 15

Lateral epicondylitis

Question 16

Describe the tract of the ulnar nerve.

Answer 16

Note the branch heading towards the thumb (helps explains the atrophy seen with cubital tunnel)

Question 17

What are the two signs seen on exam with ulnar pathology?

Answer 17

Wartenburg sign: ask come to ADductor fingers (bring them together), little finger stays abducted - shows dyfunction of palmar interossei, other fingers come together because of the extensor tendon

Fromment’s Sign: Person is trying to compensate for the first palmar interosseus muscle and thumb adductor (positive shown on right)

Question 18

Which tendon is most commonly torn in the rotator cuff?

Answer 18

Supraspinatus tendon

Question 19

What are two ways to identify the neuropathy and structure changes as a result of carpal tunnel syndrome?

Answer 19

Sensory testing (2-point discrimination)

Thenar atrophy (severe atrophy can be irreversible)

Question 20

From which bones does the transverse carpal ligament arise?

Answer 20

The hook of the hamate and the trapezium

Question 21

What is the standard presentation of tennis elbow?

Answer 21

Middle aged

lateral elbow pain

worsed by repetitive gripping/forearm rotation activities

(cannot grip without flexing extensor tendons)

Question 22

What is the treatment sequence for tennis elbow?

Answer 22

steriod injections -> PT -> surgery (Dr. Fox not keen on)

There also is a brace that is supposed to help

Question 23

What ligament is incised during cubital tunnel surgery?

Answer 23

Osborn’s ligament

Question 24

What three things must be elicted during an exam?

Answer 24

reproduction of locking and release that is pathogenic

Tenderness over A1 pulley

Look for other potential causes of contracture (dupuytren’s and arthritis

Question 25

What are some elements of the presentation that could lead to the diagnosis of carpal tunnel syndrome?

Answer 25

Nocturnal paresthesias (night tingling) Parasthesias worsened by gripping activities - holding phone, steering wheel, writing Weakness of grip

Question 26

Name a risk factor for trigger finger

Answer 26

Diabetes

Question 27

What is cubital tunnel syndrome?

Answer 27

Peripheral compression neuropathy of the ulnar nerve as it passes through the cubital tunnel (tightness from osborn's ligament)

Question 28

What muscle is typically affected most by lateral epicondylitis?

Answer 28

Extensor carpi radialis brevis (ECRB)

Question 29

What two hand deformities can be seen on physical examination of a patient with an ulnar nerve injury?

Answer 29

Claw hand (not normally seen with cubital tunnel) and intrinsic atrophy (lose thickness of first interosseus muscle

Question 30

compression of the median nerve within the carpal tunnel?

Answer 30

Carpal tunnel syndrome

Question 31

What is the test used to measure/quantify neuropathy in a patient?

Answer 31

EMG/NCS - nerve conduction study

Question 32

ID

Answer 32

Question 33

Which is normal RCT, small RCT, and massive RCT

Answer 33

Just a little more imaging review. A normal MRI on the left, An MRI showing a small supraspinatus tear in the middle. You can see the small area of detachment of the tendon insertion to the greater tuberosity without much in the way of retraction. Now contrast that to the MRI on the right where the supraspinatus is detached entirely and the tendon isnt really even appreciable anymore. You couldnt say it just from one cut, but this patient likely has a massive rotator cuff tear. The humeral head is also no longer centered on the glenoid and sits in a superiorly migrated position to rest against the undersurface of the acromion.

Question 34

What is the standard presentation of trigger finger?

Answer 34

Locking/catching sensation w/ finger flexion (worst in AM) Pain in palm at the entrance of flexor tendon sheath

Question 35

What is the origin of the extensor carpi radialis brevis?

Answer 35