29 - Upper Extremity Injury Flashcards
What are the three mechanisms of a fracture?
Acute: from suddent impact of a large force exceeding strength of the bone
Stress: from repetitive submaximal stresses
Pathologic: from normal forces to diseased bone
What is the fracture history seen with an acute or chronic fracture?
Acute: sudden blow
Chronic: repeitive activity, increase in activity duration, intensity, or frequency. Pathologic bone.
What are the components of a fracture exam?
Deformity: bleeding +/- fragement = suspect open fracture = orthopaedic emergency needs to be surgically washed out.
Bony point tenderness
Bone pain with loading- indirect loading esp. useful.
What are some indirect loading tests?
Axial loading - pushing in on the limb or digit
Bump test - bumping the injured limb to test for pain
Fulcrum test - stablize proximal part and push down on the distal part, break will be loaded and cause pain
Hop test - hopping to elicit pain
What are some ways to diagnose a fracture? What are fracture treatments?
- Plain Xrays
- CT
- Bone scan
- MRI
Treatment: immobilization, avoidance of NSAIDs - some animal model studies show they interfere with bony healing via PGs
What are some bones with “vulnerable” blood supply?
Watershed regions: central (tarsal) navicular bone
Retrograde supply: scaphoid, talus, femoral head
What are the contents of the anatomical snuff box?
- Radial nerve
- Cephalic vein
- Radial artery
- Scaphoid bone
What causes scaphoid fractures? What are clinical findings and what occurs?
Usually a fall on out-stretched hands (FOOSH) - fractures of middle third (waist) of scaphoid most common
Findings: pain, tenderness, and swelling of snuff box
Because nutrient arteries only enter the distal half, fracture often causes necrosis of the proximal portion.
What is the initial treatment of a scaphoid fracture?
Immobilize with a splint.
What is a non-union risk factor for bone healing?
Tobacco use: can lead to poor healing of a fracture.
What are three types of musculotendinous injuries? Describe each.
Enthesopathy: disorder of muscular or tendinous bony attachment
Tendinitis: technically acute inflammation of tendon; traumatic blow or pull
Tendinosis: chronic degenerative condition of tendon (chronic - submaximal repetitive irritation)
*Many injuries may be acute on chronic.
What are enthesopathies? What are examples?
Disorders involving ligamentous or tendinous attachment to bone
Epicondylitis (elbow) and shin splits
Pain with stressing structures and to palpation.
What is delayed onset of muscle soreness (DOMS)? When does it occur and why?
Weakness, tenderness, and elevated muscle enzymes about 24-72 hours after unaccusromed physical activity.
Lasts ~5-7 days
Caused by disruption of the sarcolemma, resulting in influx of intracellular Ca2+ which causes proteolytic enzyme mediated myoprotein degradation.
What is a strain? What are symptoms?
Muscle fiber damage from over-stretching: eccentric loading (muscle lengthening during firing)
Symptoms: stiffness, bruising, swelling, soreness, and weakness (with more severe injury).
A 60 yo retired assembly line worker complains of shoulder pain with overhead motions. On exam, he has pain with over 80 degrees of abduction and weak external rotation. What testing should be done?
“impingement testing”
Empty can testing: bring arms out and turn them over (like your flipping a can over)
Hawkins test: stabilize elbow and have them push arm up againt hand
Neers test: swinging their arm over their head
Children don’t get enthesopathy, they get ________. Why is this?
If a golfer has pain upon wrist extension, what type of epicontilitis do they have?
Lateral epicondylitis; the extensers of the wrist have a common attachment there.
What are enthesopathies? What are examples?
Disorder involving ligamentous or tendinous attachment to bone
Exp: epicondylitis, shin splints, pain with stressing structures and to palpation.
What type of exercise is most likelu to cause a muscle strain?
An eccentric exercise because it puts the most stress on the muscle/tendon.
Exp: quadriceps on landing a jump
What is true about the timing of rotator cuff tear repair?
If the patient has an acute tear, surgery shuld be done sooner rather than later.
Otherwise the muscle will scar down; surgical window is like 1-2 months.
What are swome clinical characteristics of someone with a rotator cuff tear?
Struggling to abduct their arm to 90 degrees.
Can’t initiate because supraspinatus is torn.
What is the etiology of an acromioclavicular (AC) sprain? What would you see on exam?
Most commonly due to a fall directly onto shoulder.
Pts presents with pain with overhead motions, deformity of superior shoulders.
On exam: pain and deformity at AC joint, pain with cross body adduction of arm (positive cross-chest test), and painful arc of abduction over 150 degrees.
Describe the grading of an AC injury?
Grade I: AC ligament injury (stretching)
Grade II: AC ligament tear and oracoclavicular (CC) ligament stretch
Grade III: complete tears of both AC and CC ligaments.
What is a sprain?
Ligamentous damage from overloading.
Symptoms: instability or laxity; swelling
What are the three grades of a sprain?
I: microscopic damage - no increased laxity, but point with stress
II: partial tear - increased laxity with pain
III: complete tear - significant laxity
Define effusion and bursitis? What are common locations?
Effusion: excessive fluid in the joint
Bursa: synovial lined sac that contains fluid and acts to reduce friction between structures
Common locations: Achilles, olecranon, subacromial, prepatellar, and other knee locations.
What isa ganglion? What is a common location?
Fluid filled soft tissue mass filled with collection of synovial or peritendinous fluid that arises from a joint or tendon sheath.
Commonly located on the wrist.
How do the tell the difference between an effusion, bursitis, and a ganglion?
Effusions: uniform and diffuse around joint; does not move independently (non-mobile) since its “attached” to joint.
Bursitis: localized, mobile. Located throughout body. Usually feels “squishable”
Ganglion: usually relatively small <2 cm, usually near joints, usually fairly tense (feel like marbles)
If you think someone may have a rotator cuff injury but aren’t sure, what would you be most concerned about?
A fracture!
This is your FIRST concern, don’t think it’s the number one cause but it’s reasonably plausable and is the most severe and would need the most acute care (don’t wanna miss)
What is a strain?
Musculotendinous injury; pain with active ROM especially resisted motions.
Weakness with increasing severeity
With complete rupture: muscle with no secondary muscles needs surgery or immobilization for healing.
What are the three types of sprains?
Ligament injury
Instability
Laxity on exam
What can dislocations cause?
Deformity (if unreduced), loss of range of motion (ROM), apprehension.
In a traumatic accident, what is your FIRST concern? What about your SECOND concern?
FIRWST: Bleeding - the most live threatening thing
SECOND: compartment syndrome - life threatening
What are the three types of bone fractures?
Traumatic: high force exceeds normal bone strength
Pathologic: normal force exceeds damaged bone strength
Stress: repetitive submaximal forces gradually damages bone
A 20yo running who recently upper her milage can in with ankle pain. On exam, she has an area of point bony tenderness over her distal fibula, full range of motion, no pain to resisted motion and normal strength, and symmetric ankle laxity. What is the most likely diagnosis?
Stress fracture of the fibula - tipped off by point tenderness.
Shin splits are more diffuse pain.
Describe the stages of bony healing?
Bleeding, clot formation, inflammatory stage.
Repair:
- osteoclasts/blasts invade clot
- Soft callus forms (2-6 weeks)
- Hard callus (4-12 weeks)
- Callus matures (6-12 mo)
- Bony gaps bridges (6-12 months)
Remodeling occur sin 1-2 years
Describe acute, stress, and pathologic bone injury?
Acute: known injury
Stress: overuse injury
Pathologic: normal forces to abnormal bone.
Point tenderness on exam, pain with indirect loading.
What should you think of when a patient complains of “locking” or “catching” of their knee?
Loose body (aka joint mice): cartilage fragment that has gotten caught in the joint.
Cartilage injury tends to cause pain with what type of motion? What is challening about cartilage injuries?
Both actie and passive (if large enough lesion or involved area stressed)
Poor healing
What are three ways to describe injuries of joint stability?
Dislocation: complete displacement
Subluxation: transient, partial displacement
Laxity: normal variant in joint looseness
What is a Maisonneuve fracture? What test can idenfity this?
When a force radiates upwards to the head of the fibula causing a fracture in the head/neck of the fibula.
Squeeze test: squeeze middle of leg to make ends of bone bow. If maisonneuve fracture is present, this test will elicit pain.
What test should rule out a high ankle sprain?
The external rotation test: external rotation of the foot should NOT hurt a lateral ankle sprain.
What is needed for ligament healing?
Needs good blood supply, needs damage section to be approximated or guided to correct area, needs relative rest.
Describe the benefits of cast vs. brace?
Cast: greater protection, non-removable (for pts you don’t trust ot leave a brace on)
Brace: limits only certain motions, removable, adjutable
What type of fracture is often seen with a high ankle sprain?
A 5th avulsion fracture: flexor halluces longus tendon wraps around this, rolling foot onto lateral aspects can rip off this tendon.
What are the two mechanisms of dislocation?
Acute: from sudden impact of large force exceeding strength of the joint restrains
PAthologic: from normal forces to weakened or anatomic variant joint/capsular restrains.
What things air in joint stability?
Muscles (stabilizers)
Capsule
Bony architecture
Ligaments
Intracapsular (negative) pressure
90% of shoulder dislocations occur in what direction? These can affect which nerve?
Anteriorly
Axillary nerve: traverses the quadrangular space and wraps around the neck of the humerus.
What are the three type sof joint stability?
Dislocation: complete displacement
Subluxation: transient, partial displacement
Laxity: normal variant in joint looseness
What is usually the cuase of shoulder dislocation?
Forced extension, abduction, and external rotation (open arm tackle or fall onto abducted arm)
Direct blow to posterior shoulder
If a biceps tendon ruptures, which one is it?
Almost always LONG head of the biceps.
This tendon should be located in the intertubercular groove of the humerus.
What is the aprehension test?
Positive apprehension test: feeling of instability with stress
Positive test if they are apprehensive - joint is dislocated.
What is loading and shirt testing?
Loading joint: pushing out or in
- Compression loading: tests joint surfaces and strucutures
- Distraction loading: tests structures surrounding joint
Shift stress: tests various structures (pulling up or down)
What are key components to treatment of musculotendinous ruptures?
- Impact of absence of muscle
- Presence of alternative muscles
- Functional requiremetns of patient
What is capsulitis? What history is often seen?
Capsular thickening, inflamamtion, scarring; Idiopathic or post-injury.
Limited ROM
- painful eary with decrease ROM (freeze phase)
- non-painful with stable, decreased ROM (frozen phase)
- non-painful with improving ROM (thawing phase)
What is seen on exam in someone with capsulitis?
Decreased ROM, gradually tightening endpoint (feels like they hit a wall at a certain point), and otherwise normal exam.
What is the treament for capsulitis?
Reassurance, educate and set expectations, maintainence of ROM, pain control.
What are the type of 5th metatarsal fracture?
Avulsion: base @ peroneus brevis insertion
Jones: traumatic fracture metaphyseal-diaphysis junction
Pseudojones: stress fracture proximal diaphyseal
Dancer’s: spiral fracture mid to distal diapysis
What is Sever’s condition?
Pain on heel in active children - due to the relative weakness of the growth plate compared to the tendon
If it was a 19yo this would have been achilles tendinitis - in adolescence you see sever’s disease
What is apophysitis? What is the pattern of pain? How should it be treated?
Pain and inflammation of ossification centers from repetitive tension
Pain:
- after activity
- at beginning of activity
- throughout activity
- all the time
Treat: activity as tolerated, stretching, ice plus or minus NSAIDs.
Complications may be bony hypertrophy or fracture (rare).
What are common sites of apophysitis?
Osgood schlatter: tibial tubercle
Sever’s: calcaneal apophysitis
Sinding-larson-johansson: distal patellar pole
ASIS: sartorius
AIIS (ant. inf. iliac spine): rectus femoris
Little leaguer’s elbow: medial epocondyle
