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Ortho > Elbow, Forearm, Hand, and Wrist > Flashcards

Elbow, Forearm, Hand, and Wrist Flashcards

1
Q

Unlike the shoulder, the elbow is more stable with 3 distinct articulations:

A
  1. Ulnahumeral joint
  2. Radiocapitellar joint
  3. Proximal radioulnar joint
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2
Q

What is a fat pad on a xray mean?

A
  • if fat pad sign, there is blood inside the elbow and ASSUME there is fracture somewhere
  • Might need a CT
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3
Q

What is the normal AROM of the elbow

A
  1. Flexion/extension: 0-140/150

2. pronation/supination of 80degrees

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4
Q

Post-traumatic elbow is commonly stiff and the least “functional ROM” of ___ flex/ext. and ___ P/S

A
  1. flex/ext of 30-130 degrees

2. P/S of 50 degrees.

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5
Q

Pain with flexion/extension is must likely from the ____ joint and pain with pron/supp must likely from the ___ joint

A

ulno-humeral join

radio-capitellar

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6
Q

Most common joint to dislocate during childhood

A

elbow joint

*and it is second only to the shoulder and finger joints in adults.

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7
Q

MOI of an elbow joint disloctaion

A

Commonly after falling off with out-stretched hands (FOOSH)

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8
Q

Always check for ___, before and after any reduction and splinting/casting.

A

neuro-vascular injuries

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9
Q

What is the most common type of elbow dislocation?

A

More than 80% are posterior dislocations

*posterolateral

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10
Q

More than 80% are posterior dislocations with ___ and ___ associated injuries

A
  • residual stiffness

- commonly with rupture of the ulnar collateral ligament*

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11
Q

-once you reduce an elbow dislocation you want to keep it in what position to keep it from going out?

A

hyperflexion and then pronate it to keep it from going out (posterolateral)

  • Reduction maneuver with steady traction with elbow flexed to 45 degrees. Splinting at > 100 degrees of flexion and hyper pronation.
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12
Q

What is the tx of elbow dislocation?

A
  1. Closed reduction ASAP with sedation, and with or without joint aspiration and intra-articular anesthetic injection (lateral approach).
  2. Reduction maneuver with steady traction with elbow flexed to 45 degrees. Splinting at > 100 degrees of flexion and hyper pronation.
  3. Surgery if unable to reduce, usually because loose bodies and/or extensive soft tissue swelling.
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13
Q

When is surgery indicated for an elbow dislocation

A

Surgery if unable to reduce, usually because loose bodies and/or extensive soft tissue swelling.

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14
Q

Neurovascular complications after dislocation of the elbow occur in up to __% of cases

A

5%

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15
Q

Symptoms of elbow dislocation

A
  1. Symptoms related to neuropraxia may occur usually involving the ulnar or median nerve (Anterior Interosseous Nerve branch) with ulnar nerve palsy much higher in pediatric dislocations with an associated medial epicondyle fracture.
  2. Most neurologic deficits are short-termed.
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16
Q

What is the follow up management of elbow dislocations after reduction

A
  1. Early motion 5-7 days post-reduction,

2. progressing for the next 3-4 wks (PT consult recommended if persistent stiffness.)

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17
Q

Possible complications of elbow dislocations

A
  1. flexion contractures,
  2. heterotrophic ossification (OH)** and
  3. post-traumatic arthritis.
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18
Q

what is heterotrophic ossification (OH)

A

HO formation calcification is somewhere else (joint, soft tissue, just NOT MUSCLES!! If inside muscle it is called myocytis)

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19
Q

Most Condylar fractures need __

A

ORIF

*open reduction and internal fixation

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20
Q

What do Xrays of elbow fractures show?

A

X-rays with AP and lateral views:

  1. non-displaced fractures may show a (+) fat-pad sign on the lateral view.
  2. Also check cortical lines “hourglass” for displacement on lateral view.
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21
Q

Adverse outcomes of elbow fractures

A
  1. residual pain
  2. stiffness
  3. deformity
  4. mal-union/non-union
  5. AVN
  6. compartment syndrome
  7. ulnar neuropathy
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22
Q

What is the MC MOI of olecranon elbow fractures

A

after FOOSH injury and posterior dislocations

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23
Q

What is the tx of olecranon elbow fractures

A
  1. ORIF for displaced fractures,
  2. with splinting in 45 degrees of flexion with
  3. follow-up x-rays after 1, 2, and 4 wks post-injury.
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24
Q

What kind of fracture commonly happens from kids hanging from monkey bars

A

supracondylar elbow fracture

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25
Q

a radial head dislocation is also called _____

A

Nursemaid elbow

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26
Q

What kind of injury commonly happens from swinging a kid by their hands?

A

radial head dislocation

*nursemaid elbow

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27
Q

What is the treatment of radial head fractures

A
  • usually non-displaced.
    1. Treated in splint/sling with early motions.
    2. May require cortisone / anesthetic injection for pain relief and mobilization.
    3. Referral to ortho if >30% comminuted fracture

*if the fragment is depressed 2mm or more then consider surgery

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28
Q

What is the magic number in ortho

A

2mm

*if the fragment in a radial head fx is depressed 2mm or more then consider surgery

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29
Q

What are types of forearm fractures?

A
  1. Monteggia’s fracture dislocation:
  2. Galeassi’s fracture dislocation:
  3. Night stick fracture:
  4. “Both bones” fracture
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30
Q

What is a Monteggia’s fracture dislocation

A

fracture of the ulna shaft w/ radial head dislocation

*must have an ulnar fx!!

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31
Q

What is a Galeazzi’s fracture dislocation

A

Fracture of distal third of Radius with associated radioulnar dislocation

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32
Q

What is a night-stick fx

A

mid-shaft ulnar fx

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33
Q

What is the tx of both-bone forearm fractures

A
  • Most DO NOT have a neurovascular injury**
  • Very hard to reduce and keep it reduce–> NEEDS SURGERY, very unstable

Most commonly in pediatrics
*arm is pointing in the wrong direction

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34
Q

What are types of elbow epicondlyitis

A
  1. Medial (Golfer’s elbow)

2. lateral epicondylitis (tennis elbow):

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35
Q

elbow epicondlyitis is best described as

A

Best described as tendinosis with the pathological process described as tissue degeneration with fibroblast hypertrophy and MINIMAL inflammation

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36
Q

What is the tx of elbow epicondlylitis (medial and lateral)

A
  1. stop what makes it worse,
  2. NSAIDs, ice/heat massage, cortisone injection and
  3. elbow strap, with >95% of cases non-surgical
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37
Q

What causes Golfer’s elbow

A

aka medial epicondlyitis

*Caused by overuse of the muscles of the forearm leading to inflammation and pain around the elbow joint

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38
Q

What are causes of olecranon bursitis

A
  • Acute vs chronic;
    1. secondary to trauma,
    2. inflammation or
    3. infection (20% acute bursitis have a septic cause);
    4. also seen secondary to Gout or RA.
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39
Q

Olecranon bursitis requires __ for definitive etiology

A

aspiration

*if it looks like cottage cheese–> gout

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40
Q

What labs should you get for an olecranon bursitis

A
  1. CBC,
  2. ESR, CRP with
  3. aspirate fluid: WBC cell count, GS, cultures/sensitivity and crystals.
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41
Q

What is the treatment of olecranon bursitis

A
  1. include NSAIDs,
  2. oral or IV antibiotics,
  3. elbow pad and/or splint (avoid splinting in hyperflexion) and surgical resection.
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42
Q

What is another name for ulnar nerve compression

A

cubital tunnel sydnrome

*Second only to carpal tunnel syndrome

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43
Q

Where is the most common site of compression for cubital tunnel syndrome

A

compression at the medial epicondyle groove

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44
Q

Cubital tunnel syndrome most commonly occurs in who

A

ages 30-60y/o

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45
Q

What are the PE findings of cubital tunnel syndrome

A
  1. tenderness over cubital tunnel and

2. a (+) Tinel’s sign (tapping over the nerve)

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46
Q

Symptoms of cubital tunnel syndrome

A
  1. aching pain,
  2. numbness and
  3. tingling in SF and RF and
  4. late findings of intrinsic muscles weakness and hypothenar compartment atrophy
  5. interosseous muscle atrophy
  6. chronic ulnar nerve atrophy
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47
Q

What is the diagnostic test of cubital tunnel syndrome

A

EMG/NCV tests with a reduction in velocity of 30% or more suggestive of significant compression

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48
Q

What are the treatment options for cubital tunnel syndrome

A
  1. activity modification,
  2. night splint keeping the elbow from flexing to 90 degrees and
  3. NSAIDs.
  4. Surgical decompression and
  5. possible nerve transposition.

*No cortisone injections recommended.

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49
Q

What is no man’s land?

A

-zone 2 of the hand (top of palm and bottom of fingers)

  • If injury in that area–> wash it but don’t go exploring for things in there bc you may damage nerves
  • STAY AWAY FROM HERE
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50
Q

Common symptoms of hand and wrist complaints

A
  1. pain
  2. instability- sensation of slipping, snapping, or clunking with certain wrist motions.
  3. stiffness
  4. swelling
  5. weakness
  6. numbness
  7. masses
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51
Q

common symptoms in OA, trigger finger and Carpal Tunnel Syndrom

A

stiffness

52
Q

Most common cuases of masses in the hand and wrist

A
  1. ganglion cyst
  2. Giant cell tumors
  3. Dupuytren’s nodules
  4. RA/OA nodules
  5. Carpal boss deformity
53
Q

What are special tests of the hand and wrist

A
  1. Finkelstein test
  2. Allen’s test
  3. Phalen’s maneuver
  4. Tinel’s sign
54
Q

What is the Finkelstein test?

A

-tuck thumb in palm and rotate wrist down

+) test indicate tenosynovitis of the first dorsal compartment (de Quervain tenosynovitis.

55
Q

What is Allen’s test

A

compression of radial and ulnar arteries and assessment of blood refill.

**Do this test prior to surgery (in no mans land) to assess blood flow

56
Q

What is Phalen’s maneuver?

A

numbness or tingling of the median nerve with wrist flexion within 60 seconds.

*for carpal tunnel

57
Q

What is Tinel’s sign

A

tapping over median nerve w paresthesia

*for carpal tunnel

58
Q

What are contributing factors to hand infections

A
  1. Diabetes
  2. Immuno-compromised patient
  3. Environmental / occupational
  4. Smoking
59
Q

What is cellulitis

A

diffuse skin involvement infection

*Beware of a septic joint or a deep space infection overlying cellulitis

60
Q

causes of cellulitis

A

trauma
ulceration
lymphedema

61
Q

How do you dx celluliits

A

primarily a clinical diagnosis

62
Q

What is tx of cellulitis

A
  1. Oral abx
    - If no resolution in 24 to 48 hrs, then IV antibiotics with 1st generation cephalosporin or Vancomycin.
  2. Immobilization/splint
  3. Elevation
63
Q

If worry about septic joint at MCP due to pain with ROM (can get MRI) but in general w/ diffuse redness not just at the site it is __

A

cellulitis!!!!

-tx w/ antibiotics

64
Q

What is paronychia

A

infection beneath eponychial fold

65
Q

What organism most commonly causes:

  1. paronychia
  2. Felon
  3. Flexor tenosynovitis
A
  1. S. aureus
  2. S. aureus
  3. S. aureus
66
Q

What is the tx of paronychia

A
  1. Abx
  2. warm soaks
  3. drainage (do a nail nerve block)
  4. elevation of nail fold

*Solution for pollution is dillution!!

67
Q

What is felon

A

digital pad infection

*Closed, poorly compliant compartment

68
Q

Sx of felon

A

intense throbbing pain (VERY PAINFUL)

69
Q

What is the tx of felon

A
  1. incision and drainage (“the solution for pollution is dilution”).
  2. spread tweezers until pus is found
    * **Stay away from the neurovascular bundle
70
Q

Complications of felon

A
  1. necrosis
  2. osteomyelitis (rare)
  3. flexor tenosynovitis
71
Q

What is herpetic whitlow and what is it commonly confused with?

A
  • Herpes virus hand infection

- Clinically confused with felon

72
Q

Sx of herpetic whitlow

A

painful cytolytic lesion 2-14 days

2. vesicle mature over 14 days

73
Q

what is the tx of herpetic whitlow

A

self limited disease, clearing in 7-10 days

74
Q

Anatomy:

  1. ___ is a closed space.
  2. Sheath of thumb contiguous with ___.
  3. Sheath of small finger is contiguous with ___.
  4. In 50-80% of pts the radial burase and ___ communicate.
A
  1. Flexor sheath
  2. radial bursa
  3. ulnar bursa
  4. ulna bursae
75
Q

What is flexor tenosynovitis and what are common causes

A

*bacterial infection of flexor tendon sheath

Causes:

  1. penetrating trauma
  2. hematogenous- gonoccal infections
  3. S. aures (MC)
76
Q

What are the 4 Kanavel cardinal signs

A
  1. FLEXED resting posture
  2. tenderness over flexor sheath
  3. fusiform swelling (sausage finger)
  4. severe pain on passive extension

*signs of infectious flexor tenosynovitis

77
Q

What is the tx of infectious flexor tenosynovitis

A

incision, irrigation and IV antibiotics

78
Q

Common causes of infections from human bites

A
  1. Group A strep
  2. S aureus
  3. Eikenella corrodens
79
Q

Bites presenting ___ hours old are usually infected.

A

over 24

80
Q

When doing a PE on a human bite on the hand it is important to ___

A

do an exam with an open and closed fist bc that is how it was injured and a closed fist can assess the tendon

81
Q

What is the tx of infected human bites

A
  1. Irrigation and debridement with delayed wound closure

2. IV antibiotics

82
Q

W/ human bites, beaware of joint involvement:

A
  1. Fight bite with clenched fist injury
  2. Examine hand with finger in full flexion
  3. With a dorsal MCP joint injury, always assume joint involvement.
83
Q

What organisms most commonly cause infected animals bites

A
  1. staph
  2. strep
  3. pasturella multocida
84
Q

___% cat bites become infected

A

30 - 50%

85
Q

What is the treatment of animal bites

A
  1. Meticulous wound irrigation
  2. Exploration and delayed wound closure
  3. Antibiotic– prophylactic treatment:augmentin /amoxicillin or with pcn allergy: clindamycin

**Any hand infection, you do not want to close all the way– can do close approximation closure

86
Q

What is the most common compression neuropathy

A

carpal tunnel syndrome

*entrapment of the median nerve at the wrist

87
Q

Carpal tunnel is most common in who

A

Most common in middle-aged or pregnant women

88
Q

Causes of Carpal tunnel syndrome

A
  1. overuse
  2. DM
  3. thryoid dz
  4. RA
  5. pregnacy
89
Q

How do you dx Carpal tunnel

A
  1. Tinel’s,
  2. Phalens and
  3. EMG/NCT
90
Q

What is the treatment of carpal tunnel syndrome

A
  1. NSAIDs
  2. night splint
  3. cortisone injection (less frequently done bc can numb the whole nerve)
  4. surgical release
91
Q

Symptoms of DeQuervain Tenosynovitis

A

Swelling or stenosis of the Abductor Pollicus Longus (APL) and Extensor Pollicus Brevis tendon sheaths.

92
Q

How do you dx DeQuervain Tenosynovitis

A

finkelstein test and x-rays

93
Q

what is the tx of DeQuervain Tenosynovitis

A
  1. Thumb spica splint,
  2. NSAIDs,
  3. cortisone injection and
  4. rarely needs surgical release.

**Does well w/ injections

94
Q

What is Dupuytren’s Disease

A
  • Nodular thickening and contraction of palmar fascia.

- Has a dominant genetic component involving northern European descent.

95
Q

Dupuytren’s Disease is most common in who

A

men older than 50

96
Q

Associated factors of Dupuytren’s Disease

A
  1. DM
  2. epilepsy
  3. COPD
  4. alcholism
  5. smoking
  6. trauma
97
Q

What are 3 common findings of Dupuytren’s Disease

A
  1. Tight cord that CANNOT extend the finger (can release it at 30 degrees)
  2. Pit on the nodule
  3. Flexion contracture
98
Q

What is the tx of Dupuytren’s Disease

A
  1. surgical release, but not recommended until flexion contracture of 30 degrees or more.
  2. Xiaflex (collagenase clostridium histolyticum) injection for cord deformity only.
99
Q

what is the etiology of Trigger finger

A

Nodule of flexor tendon entrapment at A1 pulley

100
Q

what is the treatment of trigger finger

A

cortisone injection of tendon sheath and/or surgical release

101
Q

How can you differentiate trigger finger and Dupuytren disease

A

**THIS ONE YOU CAN CAN REDUCE AND GET INTO FULL EXTENSION PASSIVELY UNLIKE Dupuytren Disease

102
Q

The most common fracture in adults

A

distal radius fx

*fractures of the distal radius accounting for one-sixth of all fractures seen in the emergency department.

103
Q

Types of distal radial fractures

A

** based off MOI

  1. Colles
  2. Smith
  3. Barton
  4. chauffeurs
  5. die-punch
104
Q

What is the tx of distal radial fx

A
  1. Closed reduction with hematoma block or conscious sedation,
  2. splint/casting or ORIF.
105
Q

What is a Barton’s fractire

A

: It is an intra-articular fracture-dislocation of the VOLAR RIM OF THE RADIUS with the displaced volar fragment taking the carpus with it

106
Q

What is Chauffeur’s fracture

A

an isolated fracture of the radial styloid process
-Displacement of the fragment is uncommon

  • also called a Hutchinson’s fracture.
107
Q

Associated injurys w/ Chauffeur’s fx

A
  1. associated injury to the scapholunate ligament

2. In most cases a fracture of the radial styloid process is part of a comminutive intraarticular fracture

108
Q

What is a Die-punch fracture

A

a depression fracture of the lunate fossa of the distal radius from a transverse load through the lunate.

109
Q

What are Triangular Fibrocartilage Complex (TFCC) tears

A
  • cartilage tissue attaching the ulna to the distal radius and creates a concave surface for articulation with the lunate and triquetrium.
  • The ulnar side of the wrist is supported by the TFCC, which articulates w/ both the lunate and the triquetrum.
110
Q

TFCC tears are commonly associated with

A
  1. an avulsion of ulnar styloid,
  2. scaphoid fracture and
  3. distal radius fracture
111
Q

TFCC is prone to injury due to

A

the axial and shear forces that are applied to it as the carpi rotate over the radius and ulna

112
Q

What is the most common fx of the metacarpals and phalanges

A

Boxers fx (5th MC)

113
Q

what is the tx of a boxer’s fx

A
  1. closed reduction with hematoma block or sedation,

2. splint/casting or ORIF

114
Q

w/ Boxer’s fx, __ indicates unstable fracture

A

Malrotation

  • Have the pt close the hand (all fingers should point to the scaphoid– if one does not, there is malrotation)
  • Document no rotational defomrity noted
115
Q

What is a Boxer’s fx

A

a break through the bones of the hand that form the knuckles.

116
Q

Most commonly fracture of a carpal bone

A

Scaphoid fracture

*20% of fractures in the proximal pole, 60% in the middle and 20% distal pole

117
Q

Complications associated w/ scaphoid fractures

A

High incidence of non-union and osteonecrosis

118
Q

why do scaphoid fractures have a high incidence of non-union and osteonecrosis

A
  • 80% of this bone has articular cartilage and blood supply is commonly interrupted with injury.
  • Therefore, displaced fractures have up to 90% rate of non-union
119
Q

What is the treatment of scaphoid fractures

A
  1. Casting may be needed for 8-12 weeks.

* *If there is a non-union you need to restart the clock so try to catch it early!

120
Q

What are common signs of scaphoid fracturs

A

snuff box tenderness

121
Q

Xray: empty cup sign

A

Perilunate dislocation

122
Q

common causes of prox. carpal row instability

A
  1. perilunate dislocation

2. scapho-lunate disassociation

123
Q

What are common finger deformities

A
  1. Mallet finger
  2. Swan neck deformity
  3. Boutonniere deformity
124
Q

What is the difference between swan neck deformities and boutonniere deformities

A

Swan neck deformity: PIP is hyperextended

Boutonniere deformity: PIP is hyperflexed

125
Q

Common cysts seen on the wrist

A

Volar/dorsal ganglion cyst

Ortho (6 decks)

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