ED 2 Upper Extremity

Question 1

where do most clavicle fractures occur? what is the typical MOI?

Answer 1

distal 1/3 of clavicle

“shoulder first” injuries

Question 2

what carries the worst prognosis in terms of clavicle fractures?

Answer 2

tenting – can convert to open fracture (push that thing down)

Question 3

if you note pain at the SC joint in your patient with a clavicle fracture, what do you worry about?

Answer 3

additional, deeper injury – it takes a LOT of force to dislocate there

Question 4

management of clavicle fractures? what will your patient typically have following healing process?

Answer 4

sling and ortho referral

bayonette deformity following healing process

Question 5

what should you advise your patient to do for the first few nights following clavicle fracture?

Answer 5

sleep upright

Question 6

your patient presents to your office with a “low hanging” shoulder. he says he fell on his shoulder. what do you suspect?

Answer 6

AC separation

Question 7

how do we manage AC separations?

Answer 7

sling them

should heal on their own

Question 8

in which population is a shoulder fracture most common? what is the typical MOI?

Answer 8

elderly, osteoporotic

fall with arm locked, driving humeral head straight up into glenoid

Question 9

if you notice a scapular fracture on your patient’s x-ray, what should you be thinking?

Answer 9

consider other fractures and injuries, it takes a LOT to fracture a scapula

Question 10

treatment for shoulder fractures?

Answer 10

sling, refer to ortho (don’t do much for them)

Question 11

which way do shoulders typically dislocate? in which two circumstances would we see the other direction?

Answer 11

typically anterior

posterior = electrocution, epilepsy

Question 12

MC mechanisms of shoulder dislocation?

Answer 12

FOOSH, abduction and external rotation (reaching backward in car)

Question 13

what special test will be positive on PE of a shoulder dislocation?

Answer 13

+ sulcus sign

Question 14

what might you notice on x-ray of patient who has had multiple shoulder dislocations?

Answer 14

hill-sach’s deformity

Question 15

what x-ray view must your order to see a shoulder dislocation?

Answer 15

lateral (y view) x-ray

Question 16

4 reduction techniques for shoulder dislocation? what must you always ensure pre and post-reduction?

Answer 16

1) traction/countertraction
2) stinsons
3) scapular manipulation
4) external rotation

ensure neurovascular fxn intact

Question 17

when do we get post-reduction films with shoulder dislocations?

Answer 17

for the first dislocation or with obvious trauma

Question 18

management of shoulder dislocations?

Answer 18

sling and swath

ortho FU

Question 19

patient presents with very little ROM of their arm, with the inability to bring arm above their head while held out anteriorly. DX?

Answer 19

rotator cuff injury

sling em

Question 20

which elbow injury carries the worst prognosis due to risk of malalignment?

Answer 20

supercondylar elbow fracture

Question 21

most common type of elbow injury?

Answer 21

radial head fracture; usually a FOOSH

Question 22

most common direction of elbow dislocation? how do we reduce?

Answer 22

posterior

pull lower arm towards you while pts arm is flexed and you are pushing back on their humerus

Question 23

why are elbow injuries a real concern?

Answer 23

BIG risk of neurovascular injury, don’t tolerate abuse well

Question 24

even if you can’t see a break on x-ray, what may you notice that will clue you into presence of a fracture?

Answer 24

sail sign, posterior fat pad

Question 25

your patient has broken their distal radius and ulnar styloid, what MUST you do before you manage them?

Answer 25

ALWAYS palpate anatomic snuffbox to r/o scaphoid fracture

Question 26

what type of splint does a wrist fracture get? who gets surgery?

Answer 26

volar splint

angulated, displaced = ortho needs to come in

Question 27

if you have ANY concern for scaphoid injury, what type of splint do you place?

Answer 27

thumb spica splint

refer to ortho

Question 28

what are patients with hx of a scaphoid fracture at risk for?

Answer 28

chronic arthritis due to non-unions (half heals, half doesn’t because of terrible blood flow)

Question 29

a positive finkelstein’s sign (ulnar deviation) is pathognomonic for what?

Answer 29

dequervian’s tenosynovitis

Question 30

how does one develop dequervian’s tenosynovitis?

Answer 30

repetitive hammering type motion; ie. in carpenters

Question 31

which two tests may be positive in a patient with carpal tunnel syndrome? how do we manage them?

Answer 31

tinnel’s and phalen’s

splint at night and at work!
release if bad

Question 32

how do we diagnose and manage gamekeeper’s thumb?

Answer 32

DX: can’t see anything on x-ray, take thumb and yard sideways (positive is crepitus or too lax)

TX: splint and ortho referral

Question 33

why can we not miss gamekeeper’s thumb?

Answer 33

we have torn the medial collateral ligament; if they fall, there is nothing protecting the joint anymore and it will explode