B6.085 - Common Pathologic Conditions of Upper Extremity Flashcards
Dupuytrens contracture
relatively common disorder characterized by progressive fibrosis of palmar fascia with an unknown etiology
associations with dupuytrens contracture
northern european genetics smoking drinking DM thyroid disease >50 yo M>F repetitive palmar trauma w vibration
clinical dx of dupuytrens contracture
gradual onset begins as one or more smaller tender lumps on palm pain resolves w time, nodules thicken and contract tough bands of tissue may form may result in loss of full extension 4th and 5th fingers commonly affected
dupuytrens contracture
tx for dupuytrens contracture
mild - padding, steroid injection
progressive - surgical removal of fibrotic adhesions, steroid injection
injection of clostridia histolyticum collagenased <50 degrees
minimal surgical lysis of adhesions has also been done
mallet finger deformity
injury frequentyl acquired when attempting to catch a ball and impact causes sudden flexion of DIP of an extended finger
most common closed tendon injury of finger
mechanically what is mallet finger
traumatic disruptio of terminal slip of extensor tendon at distal interphalangeal (DIP) joint
treatment of mallet finger
splinting 6-8 weeks if uncomplicated, immobilization with slight hyperextension 5-15 degrees
comlicated injuries require referral and likely surgical repair
mallet finger
jammed finger
prolonged swelling of proximal interphalangeal joint after an axial loading force
diagnosis of exlusion
signs of more serious injury than jammed finger
deformity
significant swelling
significant bruising
treatment of jammed finger
conservative management, early ROM important
trigger finger
the flexor tendon catches in what is called the first annular (A1) pully of the MCP causing a snapping, catching or locking when flexing finger
features of trigger finger
pain in palm at entrance to flexor tendon sheath
usually worse in AM improving throughout day
risk factors of trigger finger
DM, age, female
dx is clinical
treatment for trigger finger
conservative - splinting, NSAIDs, modify repetitive activity
Injection of steroids
surgery if conservative fails, release of A1 pully
trigger finger
flexor tendon catches on what is called A1 first annular MCP
gamekeepers thumb
forced abduction of the thumb can result in rupture of ulnar collateral ligament
exam for gamekeepers thumb
tenderness overlying the ulnar aspect of the MCP joint of the thumb
swelling
laxity of 30-40 degrees more than the uninjured thumb measured in neutral and 30 degrees of flexion are strongly suggestive of a complete ulnar collateral ligament tear
no end point in radial deviation of the phalanx
test for gamekeepers thumb
stressing ulnar collateral ligament of MCP joint
treatment of gamekeepers thumb
thumb spika cast or splint
may need surgical referral if there is avulsion fracture
carpal tunnel syndrome
nocturnal parasthesia worsened by gripping activities like holidng a phone, gripping steering wheel, writing
weakness of grip
risk factors for carpal tunnel
female
pregnancy
DM
obesity
RA
hypothyroid
what type of neuropathy is carpal tunnel
median nerve neuropathy
describe carpal tunnel as it relates to anatomy
unique anatomy of the median nerve as it passes through the “carpal tunnel”, increased pressure in this confined area can lead to nerve compression and subsequent neuropathy
overuse syndromes seem to cause edema and lead to compression
testing for carpal tunnel
tinel test (TAP) , phalen test (FLAP)
what is the tinel test
test for carpal tunnel
examiner taps over the wrist at the point where the median nerve passes through
tapping creates electric or sharp pain and tingling in hand, 50% sn 77% sp
what is the phalen test
patient flexes wrists with the elbows raised and the backs of the hands pressed together for 1 minute
positive is pain or tingling in median nerve distribution
sn 68% 73%sp
confrimatory testing for carpal tunnel
electromyography or nerve conduction studies
not absolutely needed until surgery is a consideration
imaging is generally not useful in providing additional information
treatment for carepal tunnel
conservative
Night bracing
ice
rest
NSAIDs
steroid injections
surgical release
sono guided techniques, open surgical
ulnar neuropathy at the wrist
compression of ular nerve at wrist
clasically seen in cyclists due to pressure from handlebars
treatment for ulnar nerve neuropathy
padding, gloves or handlebars
NSAIDs
Ice
scaphoid fracture
scaphoid most commonly fractured bone in wrist
avascular necrosis of proximal scaphoid
complication of even the smallest amount of displacement in scaphoid fracture
blood supply from scaphoid comes from radial artery, feeding the bone on the dorsal surface near tubercle and scaphoid waist. Because the proximal portion has no direct blood supply, nonunion caused by poor blood supply is an important complication of scaphoid fracture
treatment and dx of avascular necrosis of proximal scaphoid
surgical treatment recommended
can be difficult to diagnose, snuffbox tenderness most sensitive (90%)
scaphoid tubercle tenderness 87% sn, 57% sp
high index of suspicion with tenderness and negative x ray
avascular necrosis of proximal scaphoid
scaphoid fracture
nursemaids elbow
radial head dislocation usually due to pulling small childs arm
history is key
child with arm held limp and partially flexed
exam for nursemaids elbow
apprehensive
inspection frequently unremarkable
palpation shows tenderness over lateral aspect (radial head)
ROM - wait until x rays
nursemaids elbow reduction
apply pressure at radial head
grasp wrist and apply slight traction
supinate wrist while flexing elbow to 90 degrees
medial epicondylitis and lateral epicondylitis
repetitive motion with either extension (lateral) or flexion (medial)
predisposing factors to epicondylitis
age 45-50
smoking
obesity
what is the difference between tendititis and tendinosis
tendinitis is inflammation of the tendon and results from micro tears and tendinosis is a degenration of the tendons collagen in response to chronic overuse
presentation of epicondylitis
pain with tenderness at insertion of tensions on epicondyle
presentation of lateral epicondylitis
pain with resisted extension at wrist, supination of hand
presentation of medial epicondylitis
pain with resisted flexion of wrist and pronation of hand
treatment for epicondylitis
conservative
splinting, activity modification, counterforce bracing, NSAIDs, physical therapy, surgery last resort
describe examination of the shoulder
inspect symmetry
palpate Acromion, AC joint, coracoid, major bones
ROM
anatomy of rotator cuff
SItS
Supraspinatus
Infraspinatus
teres minor
Subscapularis
what does the supraspinatus do
inn by suprascapular n
abducts arm initially before action of deltoid
most common rotator cuff injury
empty can test
what does infraspinatus do
inn by suprascapular n
externally rotates arm
pitching injury
what does teres minor do
inn by axillary n
adducts and externally rotates arm
what does subscapularis do
inn by upper and lower subscapular nerves
internally rotates and adducts arm
push away test
special tests for supraspinatus
empty can test
active painful arc test - moving arm through abduction, + if pain past 90 degrees
drop arm test - lowering arm from full abduction not smooth and coordinated
special tests for infraspinatus/ teres minor
external rotation - isometric ER, patient presses against examiners hand
special test for subscapularis
internal rotation - assessed using the push off test painand weakness is positive
empty can test
supraspinatus test
arm held at 90 degrees of abduction and 30 degrees forward flexion. Then internally rotating completely with thumb pointing down
pain without weakness indicates tendinopathy
pain with weakness indicates tear
AC separation
common injury in sports resulting in player hitting shoulder while arm is adducted wiht downard force
AC joint injuries are about 10% of shoulder injuries
treatment fro AC separation
Type 1-2 managed conservtively
3 judgement call
4-6 need surgical reduction and repair
grading AC separation
type 1 AC separation - ligament sprain, joint intact
2 - AC ligament torn, CC intact
3 - Both AC and CC torn, joint dislocated
4 - 6 - above plus displacement of distal clavicle
subacromial bursitis
can be from trauma, overuse, inflammatory, infection
need to differentiate infection, aspirate bursa, imaging usually not needed
management of subacromial bursitis
infection - hospitalization
conservatively
adhesive capsulitis
frozen shoulder
condition causing pain and limited ROM of shoulder
causes largely unknown
spontaneous resolution usually
risk fx - >40, F, DM
3 stages and presentation of adhesive capsulitis
painful, adhesive, recovery
gradually increasing pain and stiffness without cause, initial phase can last 3-9 months. exam may have muslce spasms and decreased ROM without focal tenderness
tx - supportive and conservative
calcific tendinopathy
calcific tendinitis of the shoulder as an acute or chronic painful condition due to the presence of calcific deposits inside or around the tendons of the rotator cuff; more specifically, it s caused by depositon of calcium hydroxyapatite crystals commonly within the supraspinatus and infraspinatus tendons
exam for calcific tendinopathy
pain with active abduction, passive has minimal tenderness. Impingement less frequently positive
imaging is confirmatory
tx for calcific tendinopathy
supportive, conservative
steroid injection
ESWT can help break up calcifications
surgery for refractory causes
impingment
hawkins kennedy test is used to test for it as well as passive painful arc test
hawkins kennedy test
clinician stabilizes shoulder with one hand and the patients elbow flexed at 90 degrees then passiveley internally rotates the shoulder using the other hand. Pain is positive
passive painful arc test
passively raising arm in flexion while holding the shoulder from shrugging. pain is positive
rotator cuff tear dx and tx
may need imaging for dx (MRI)
trial of conservative treatment (rest, PT, NSAIDs, injection)
ortho referral for refractory cases
immediate ortho if acute traumatic injury with full thickness tears
rotator cuff exercises
once daily
start with light weights (1-2 lbs)
work up to 30 reps, warm up, ice after
supraspinatus rotator cuff tear signs
tender to palpation of subacromion tegion
supraspinatus test (empty can)
tx for rotator cuff injury
PT, steroid injection, surgery
