Elbow, Wrist, and Hand Flashcards
1
Q
What injuries may occur from a Fall on Outretched Hand?
A
- Distal Radial Fracture
- Scaphoid Fracture
- Radial Head Fracture
- AC Separation
- Glenoid Labral Tear
- Perilunate Dislocation
2
Q
What is Little League Elbow?
A
- Can refer to several overuse injuries
- Often is Osteochondritis Dissecans of the radial head and/or capitellum or Osteochondrosis of the capitellum (panners syndrome)
- May be from compressive forces through the lateral elbow during throwing
3
Q
How is Little League Elbow treated?
A
- Relative Rest
- No throwing for up to 1 year
4
Q
What Functional tests help confirm little league elbow?
A
- Bending and Flexing of the Elbow with maintenance of Valgus Stress should elicit pain
5
Q
Which Structure is most commonly affected in Lateral Epicondylitis?
A
- Extensor Carpi Radialis Brevis
- Occasionally the Extensor Digitorum
6
Q
What is the Mills Maneuver?
A
- Used in treating Lateral Epicondylitis
- Forceful and quick Extension of the forearm with wrist flexed and pronated
7
Q
What is Radial Tunnel Syndrome?
A
- Entrapment of Radial nerve in the radial tunnel
- tunnel is approx 2 inches long from the capitellum of the humerus to the supinator
- Pain can mimic Lateral Epicondylitis, but often tennis elbow strap will make pain worse due to compressive forces
8
Q
What is NurseMaids Elbow and how is it treated?
A
- Subluxation of the radial head, usually in children after traction injury
- Reduced with Supination
9
Q
How would you differentiate Ulnar Collateral Injuries and Medial Epicondylitis?
A
- If Valgus stress applied with elbow slightly flexed, wrist flexed and forearm pronated, should be painless if Medial Epicondylitis
- If UCL, would still reproduce Sx
10
Q
At what sites can the Median Nerve be compressed in the elbow and forearm?
A
- Ligament of Struthers
- Pronator Teres
11
Q
In terms of the Elbow, what does the acronym CRITOE stand for?
A
- The Order of appearance of the ossification centers of the elbow
- C - Capitellum - 1 year
- R - Radial Head- 3 years
- I- Internal (Medial) Epicondyle - 5 years
- T- Trochlea - 7 years
- O - Olecranon - 9 years
- E- External (Lateral) Epicondyle- 11 years
12
Q
What is a GreenStick Fracture?
A
- Occurs only in children
- Part of the bone is broken but not all the way through
13
Q
What is a Metaphyseal Fracture?
A
- Fracture of the Metaphysis (upper or lower part of the bone shaft)
- Does Not include the growth plate
14
Q
What is a Colles Fracture?
A
- Fractur of the distal radius and a dorsally angulated distal fragment
- usually from FOOSH
15
Q
What is a Galeazzi Fracture?
A
- Combines a fracture of the radius, with displaced pieces of bone, and a dislocation of the ulna at the wrist
16
Q
What is a Monteggia Fracture?
A
- Involves both forearm bones
- At the Proximal Forearm, the Ulna is Fractured and the Radius is Dislocated
- Sometimes presents as a night stick fracture but can be caused by FOOSH as well
17
Q
What are common sites of compression of the Ulnar Nerve at the elbow?
A
- Ligament of Struthers
- Arcade of Struthers
- Cubital Tunnel (most common)
18
Q
What is an elbow flexion test?
A
- Passive Flexion of the elbow for approx 60 seconds
- Reproduces Sx of Cubital Tunnel Syndrome
- Ligamentous roof of cubital tunnel becomes taut in flexion and compresses ulnar nerve
19
Q
What is Radial Tunnel Syndrome?
A
- Compression Neuropathy to the PIN Nerve at the Supinator or Arcade of Frohse
- Similar Presentation to Lateral Epicondylitis but approx 2-4 cm more distal
- Differs from PIN, Radial Tunnel Syndrome includes pain only
20
Q
What are the common special tests used to diagnose Radial Tunnel Syndrome?
A
- Long Finger Extension Test
- Resisted Supination
21
Q
What is Posterior Interosseous Nerve Compression Syndrome?
A
- Compressive Neuropathy of the PIN at the Supinator or Arcade of Frohse
- Differs from Radial Tunnel Syndrome, Motor Weakness only, no sensory deficits but can have pain
22
Q
What are common findings of PIN Syndrome on physical exam?
A
- Wrist Extensor Weakness
- Weakness of Finger MCP Extension
- Radial Drift
23
Q
What is Dequervains Syndrome?
A
- Stenosing Tenosynovitis of the 1st Dorsal compartment of the wrist
- Includes Abductor Pollicis Longus and Extensor Pollicis Brevis
- (+) Finkelsteins Test
24
Q
What is Anterior Interosseous Nerve Syndrome?
A
- Compressive Neuropathy of AIN at the Pronator Teres Most often
- Motor Loss Only, No Pain or sensory deficits
- Unable to make OK sign
25
What is Parsonage Turner Syndrome?
- Bilateral Anterior Interosseous Signs
- Caused by Viral Brachial Neuritis
- Be suspicious if motor loss is preceded by intense shoulder pain and viral prodrome
26
What is Pronator Syndrome?
- Compressive Neuropathy of Median Nerve at elbow
- Most commonly at Ligament of Struthers or Pronator Teres
- Differentiated from Carpal Tunnel d/t pain in volar forearm and Sensory Disturbances of palmar cutaneous branch of median nerve (palm of hand)
27
What is Cubital Tunnel Syndrome?
- Compressive Neuropathy of the Ulnar Nerve most often at cubital tunnel and arcade of struthers
- Sensory and Motor loss in ular nerve pattern distal to elbow
28
What are common Signs and Special Tests for Cubital Tunnel Syndrome?
- (+) Froments Sign
- Weakened Grasp and Grip
- (+) Tinels at cubital tunnel
29
What is Saturday Night Palsy?
- Compressive Neuropathy of the Radial Nerve at the proximal Humerus
- Often presents with Triceps and Wrist Extensor Weakness
30
What is a Bouttoniere Deformity?
- Flexion of PIP
- Extension of DIP
- Caused by Central Slip Injury
31
What is a Swan Neck Deformity?
- Hyperextension of PIP
- Flexion of DIP
- Caused by Volar Plate Laxity/Injury
32
What is Mallet Finger?
- A finger deformity caused by disruption of the terminal extensor tendon distal to DIP joint
- Lack of active DIP extension
- Painful and swollen DIP joint following impaction injury to finger
33
What is Jersey Finger?
- Avulsion injury of FDP from insertion at base of distal phalanx
- •FDP muscle belly in maximal contraction during forceful DIP extension
- No active flexion of DIP, Slight extension compared to other fingers
34
In general, what position should the MCP Joint be splinted in?
- Flexion, not extension
| - Collateral ligaments more taut in flexion and therefore easier to get ROM back after splinting
35
What is Trigger Finger?
- Locking or attempt to lock of a finger in the position of flexion
- Caused by thickening of A1 pulley and flexor tendon inflammation
36
What is Dupuytrens contracture?
- Familial disease characterized by the development of new fibrous tissue in the palmar and digital fascia of the hand
- Usually treated surgically and then with Active Splinting
37
What is Keinbocks Disease?
- Avascular Necrosis of the Lunate
38
What nerve innervates sensation to palmar triangle of the hand?
- Palmar Cutaneous Branch of the Median
39
When should Extensor and Flexor Tendon injuries be repaired?
- Extensor- injuries with >50% of the tendon lacerated
| Flexor- >60%
40
What is the benefit of pressure therapy in managment of a burned hand?
- Pressure Therapy helps prevent hypertrophic scarring after a burn
41
What is a Boxers Fracture?
- Fracture of the metacarpal neck of the ring and little finger
42
What is Gamekeepers Thumb?
- Injury to the Ulnar Collateral Ligament of the thumb
| - If completely torn, the Adductor Aponeurosis can become wedged in the lax joint space, this is called a steners lesion
43
How are Gamekeepers Thumbs Treated?
- Partial Rupture - Thumb Spica Splint x 4 weeks
| - Complete tear- Usually Surgery
44
What is an Essex Lopresti Fracture?
- Fracture of the Radial Head and Dislocation of the DRUJ Joint as well as disruption of the interosseous membrane
45
What is a Froments Sign?
- Pinch paper between thumb and index pads and examiner attempts to pull it away. Ulnar deficient hands with flex DIP to hold the thumb opposed to paper
46
What are common sites of entrapment of the Median, Ulnar, and Radial Nerves at the Elbow?
- Median- Pronator Teres
- Ulnar- Cubital Tunnel
- Radial- Arcade of Frohse/Supinator
47
Which Porton of the Ulnar Collateral Ligament (MCL) is strongest?
- Anterior Portion
48
What structure is the Greatest Restrain to Valgus stress at the elbow?
- UCL (MCL)
49
What movement flattens the roof of the cubital tunnel and can ellicit symptoms of Cubital Tunnel Syndrome?
- Elbow Flexion
50
Discuss the Management of a Simple Elbow Dislocation
- Closed Reduction
- Ligament injury present, but surgical outcomes poorer
- Immediate ROM if stable, if unstable cast or sling <14 days to prevent motion loss
51
Discuss Management of a Complex Elbow Dislocation
- Most common is terrible triad
| - Surgical Fixation is a must, if not stable enough with ORIF, External Fixator or Posterior Splint is used
52
What is a "Terrible Triad" of the elbow?
- Elbow Dislocation
- Radial Head Fracture
- Coronoid Fracture
- Surgery is a must
53
What are some signs/ symptoms that an elbow fracture may be present?
- History of Trauma
- Presence of Fat Pad Sign (Effustion over the posterior aspect of the elbow)
- Inability to fully extend the elbow
54
What are the 3 most common MOI's for Radial Head Fractures?
- Axial load on a pronated forearm
- Direct blow to the elbow
- Hyperflexion Injury
55
Describe the Mason Johnston Classification for Radial Head Fractures
- Type 1: Undisplaced
- Type 2: Large Displaced Fragment
- Type 3: Comminuted
- Type 4: Associated with elbow dislocation
56
Complications of a distal humeral fracture can result in damage to what nerve?
- Ulnar Nerve
57
What type of Neuritis is common in individuals with severe flexion contracture?
- Ulnar
58
What are some hallmark symptoms of Complex Regional Pain Syndrome?
- Intractable Pain in Non Peripheral nerve distribution
- Allodynia, Hyperalgesia
- Must be evidence of edema with sensory and motor changes
59
What are some signs and symptoms of a patient with Radial Collateral Ligament Injury or PLRI?
- Vague Elbow Discomfort
- Lateral Elbow Pain
- Clicking, Snapping, Clunking that is worse with Supination
- Feeling that "something is not right" during comined elbow extension and forerarm supination
- Giving out sensation with loading of a flexed elbow and supinated forearm
60
What are some special tests indicative of Posterolateral Rotary Instability/RLC?
- PLRI Test
- Push Up Sign
- Chair (Push) sign
- Press Up Maneuver
61
What is the most common special test used to determine RLC Laxity?
- Varus Stress Test
62
How is the UCL typically damaged?
- Acutely from FOOSH
| - Insidiously from overuse or chronic attenuation, Overhead Throwing Athletes
63
What are the 6 phases of throwing?
- Wind Up
- Stride
- Arm Cocking
- Arm Acceleration
- Arm Deceleration
- Follow Through
64
What are some signs and symptoms of Ulnar Collateral (MCL) Ligament Injury?
- Medial Elbow Pain
- May report hearing a "pop"
- Tenderness at Ulnar insertion of the UCL (2 cm distal medial epicondyle)
65
What are some special tests indicative of UCL/ MCL injury?
- Moving Valgus Stress test
- Milking Test
- Valgus Stress Test
66
What are some signs and symptoms of Valgus Extension Overload Syndrome?
- Tenderness at Posteromedial Olecranon
- Flexion Contracture
- Painful Active Motion with Crepitus
- PROM painful into Pronation, Valgus and Extension
- Treat with NSAIDs, Rest, Correction of Throwing Mechanics
67
Describe Operative management of UCL/ MCL
- Reconstruction of the UCL
- Tommy John Procedure and Newer "Docking Technique" Procedure
- First 2 weeks, very gradual ROM
- 4-6 weeks Strength
- 4 months interval throwing
- 12 months competition
68
What are some special tests indicative of Medial Epicondylitis?
- Palpation of Medial Epicondyle
- Grip Strength
- Passive Positioning Test
69
What are some special tests indicative of Lateral Epicondylitis?
- Cozen Test
- Mill Test
- Isometric contraction of wrist extension
- Third Finger Resistance Test
70
What is initial treatment progression of Lateral Epicondylitis?
- Rest
- Avoidance of Aggravating Factors
- Self Stretching
- Eccentric Strength
71
What is surgical criteria for patient with lateral epicondylitis?
- Failure of success after multiple cortizone injections
- Failure of Rehab > one year
- Constant Pain
- Associated with Intra Articular Pathology
72
What are some milestones after surgical intervention for Distal Biceps Tendon Rupture?
- Posterior Splint x 2 weeks
- Full ROM by week 4
- Strength starts weeks 6-8
- Unrestricted Activity by 8-16 weeks
73
Describe a Neuropraxia
- Least Serious Nerve Dysfunction
- No Tinels Sign
- Presenting Signs and Symptoms resolve in days to weeks
74
Describe Axonotomesis
- Mid Serious Nerve Dysfunction
- (+) Tinels and EMG
- Recovery Complete, 1mm a day, 1 inch a month
75
Describe Neurotmesis
- Most Serious Nerve Dysfunction
- (+) Tinels and EMG
- Recovery Incomplete and Surgical intervention is required
76
What are some common special tests indicative of Cubital Tunnel Syndrome (Ulnar Nerve Pathology)?
- Tinel at Cubital Tunnel
- Elbow Flexion Test
- Pressure Provocative Test
- Froment Sign
77
What are differences in Pronator Teres and Anterior Interosseous Syndromes?
- Pronator Teres Syndrome, Sensory Changes in fingers 2-4
| - No sensory changes in AIN
78
What are differences in Radial Tunnel Syndrome and Posterior Interosseous Nerve Syndrome?
- Raidal Tunnel Syndrome, Pain Only, Lateral Forearm and resisted supination painful but not weak
- PIN Syndrome Weakness of Finger Extensors and Wrist Extension with radial deviation
79
What population is Osteochondritis Dissecans most prevalent in the Elbow?
- Ages 12-17
- Adolescent Male Baseball Pitchers and young female gymnasts
- Insidious Onset
- Vague Elbow Pain
- Extension ROM loss
- Clicking, popping, locking may occur
80
What is Panners Disease?
- 7-10 year olds
- Affects Ossification centers, mostly in Capitulum
- Self Limiting and will heal with rest and avoidance of valgus stress
- May require symptomatic splinting and up to 3 years to heal fully
81
What are the 5 P's of Compartment Syndrome?
- Pain
- Pallor
- Pain with passive stretch
- Parasthesias
- Pulselessness
82
What is MOI and s/s of Dequervains Syndrome?
- Repetitive wrist and thumb motion (opening jars, scissors)
- Finkelsteins Test Positive
- RICE, NSAIDS, Forearm Based Thumb Spica
83
With a Flexor Tendon Injury in the hand, why would a surgeon choose debridement over repair?
- < 50% lacerated: Debridement
| - 60% or more: Repair
84
What is Post Op treatment of Flexor Tendon Repair in Hand?
- Dorsal Block Spint, Passive Flexion and Active Extension (0-3.5 weeks)
- Wrist Cuff and rubber band tension so finger extension and wrist extension cannot be done simultaneously (3.5-8 weeks)
- Resistive Exercise begun (8 weeks)
- All programs limit active flexion for first 3-5 weeks
85
How do you treat laceration of Extensor Tendon in Zone 1 and 2 of hand?
- Immobilization in Slight Hyperextension
| - wean from splint in 8 weeks
86
How do you treat laceration of Extensor Tendon in Zone 3 and 4 of hand?
- Surgical Repair
- PIP Splint in Extension (DIP joint Free)
- 6 weeks for complete, 3 weeks for partial
- Move DIP and MP freely and PIP begins gentle ROM at 3 weeks
- 6-8 weeks wean from splint and initiate resistance exercises
87
What is Tenolysis as it relates to Extensor/ Flexor Tendon Repair in the Hand?
- Mechanical removal of adhesions that have formed after extensor/ flexor tendon repair
- AROM Immediately
- 4-6 weeks, gentle grip
88
What is a Smith Fracture (reverse Colles)?
- Fracture of distal radius with Volar Displacement
89
What is the typical timeframe for cast immobilization with Smith, Colles, Barton Fractures?
- 6-8 weeks
90
Describe Scaphoid Fracture
- MOI of falling backward onto hand
- If initial Rads negative, immobilize for two weeks and retake
- Nondisplaced Distal Pole Fx, 8-10 weeks in Forearm Thumb Spica
- Nondisplaced Waist Fx, Long Arm Thumb Spica 6 weeks, then 6 weeks is short arm
- Displaced, surgery
91
What is MOI for Hook of Hamate Fracture?
- Force transmitted through base of palm while holding a tool gripped with force
- Using the hand to pound an object
92
What nerve can become irritated in the rare Pisiform Fracture?
- Ulnar
93
What visible defects might be noted with metacarpal fractures?
- Loss of Knuckle Contour
| - Palpable or visible Metacarpal deformity
94
How would you treat proximal and middle phalangeal fractures?
- Stable: Buddy tape
| - Unstable: Short Forearm based Orthotic or surgical fixation
95
How do TFCC Injuries Most often occur?
- Axial Load to extended and pronated wrist or twisting the ulnarly loaded wrist
- Golf Swing
96
What is a Steners Lesion?
- The Adductor Aponeurosis is interposed between the torn UCL of the thumb and the proximal phalanx
- Occurs in Gamekeepers Thumb
97
What disorders are associated with Pitting of the Nails?
- Psoriasis
| - Cyanosis
98
You Observe Nodule protruding from wrist or dorsal hand. What is your Differential?
- Ganglion Cyst
99
You Observe Palmar Nodules with or without evidence of collagenous cords in palmar fascia upon finger extension. What is your Differential?
- Dupuytren disease
100
You Observe Nodule just proximal to A1 pulley. What is your Differential?
- Trigger Finger
101
You Observe Bouchards (PIP) or Heberdens (DIP) Nodes. What is your Differential?
- Degenerative Joint Disease
102
You Observe Ape or Claw Hand. What is your Differential?
- Ape Hand: Median Nerve Lesion
| - Claw Hand: Ulnar Nerve Lesion
103
You Observe Thenar Atrophy. What is your Differential?
- CTS or Median nerve lesion
104
You Observe Hypothenar Atrophy. What is your Differential?
- Ulnar Verve Lesion
105
You Observe Wrist Drop. What is your Differential?
- Radial Nerve Lesion
106
You Observe Drooping of Distal Phalanx. What is your Differential?
- Mallet Finger
107
You Observe Loss of DIP Joint Flexion. What is your Differential?
- Jersey Finger (FDP Tendon Injury)
108
You Observe PIP Flexion and DIP Extension. What is your Differential?
- Bouttonniere Deformity (Central Slip Injury)
109
You Observe PIP Extension and DIP Flexion. What is your Differential?
- Swan Neck Deformity (Volar Plate Injury)
110
What would weakness in 3 point or tip pinch grip indicate vs Weakness in Key Pinch Grip?
- 3 point and tip pinch: Median or AIN Lesion
| - Key Grip: Ulnar Nerve Lesion
111
What does this special test indicative of: Finkelsteins Test
- De Quervain Syndrome
112
What does this special test indicative of: First CMC Grind Test
- OA of the First CMC Joint
113
What does this special test indicative of: UCL stress test of the thumb
- Gamekeepers Thumb
114
What does this special test indicative of: Scaphoid Shift Test or Watsons Test
- Scapholunate Dissociation
115
What does this special test indicative of: Scapholunate Shear of Ballotement
- Scapholunate Dissociation
116
What does this special test indicative of: Piano Key sign of the wrist?
- DRUJ Instability
117
What does this special test indicative of: Ulna Fovea Sign
- Disruption of DRUJ Ligaments
118
What does this special test indicative of: Bunnell- Littler Test
- Instrinsic Muscle Tightness or Contracture
119
What does this special test indicative of: Allen Test
- Vascular Disorder or Arterial Occlusion
120
What does this special test indicative of: Froment Sign
- Ulnar Nerve Lesion
121
What does this special test indicative of: OK Sign (Teardrop Pinch)
- AIN Lesion
