Extremities Pathology Final

Question 1

Middle Finger Test Positive Sign

Answer 1

pain in lateral elbow

Question 2

Middle Finger Test

Answer 2

Resisted middle finger extension test
Patient is seated
The wrist is extended
The patient is asked to spread the fingers apart and hold this position
Downward pressure is placed on the middle finger while the patient resists this movement

Question 3

Medial Epicondylitis

Answer 3

• chronic overuse
• Repetitive wrist flexion/forearm pronation
• Microtrauma to common flexor tendon or FCR tendon
• Pain worse on wrist flexion and pronation
• Tenderness just distal to the medial humeral epicondyle
• golfer’s elbow test

Question 4

Golfer’s Elbow Test

Answer 4

Patient is seated
Ask the patient to extend and supinate the forearm
Ask the patient to flex the wrist and hold that position
While you push down on the wrist
+= pain in the medial epicondyle

Question 5

Little Leaguer’s Elbow

Answer 5

Chronic repetitive valgus loading
Associated with throwing curve balls
Causes tension overload on the medial structures-medial anterior oblique ligament or the medial epicondyle epiphysis
Young pitchers [10-16 years]
Decreased throwing speed and accuracy
Tenderness over the medial humeral epicondyle
X-ray or MRI

Question 6

Cubital Tunnel Syndrome

Answer 6

Chronic or acute
Compression of the ulnar nerve as it passes between the medial and lateral heads of Flexor Carpi Ulnaris (FCU)
Second most common entrapment neuropathy in the upper limb
Medial aspect of the hand and 4th and 5th digits
Nerve Velocity Conduction tests

Question 7

Orthopedic Tests for Cubital Tunnel Sydrome

Answer 7

Wartenberg, Tinel, Froment and elbow flexion tests

Question 8

Wartenberg Test

Answer 8

Patient is seated
Instruct the patient to place the tested hand flat on the table
Separate the fingers
Ask the patient to bring all the fingers together
+= failure to bring the little finger in [adduct]

Question 9

Tinel’s Tap Test (Elbow)

Answer 9

Stand behind the seated patient
Passively abduct the shoulder and allow the elbow to hand down
Tap the Cubital Tunnel
+= reproduction of pain radiating along the ulnar aspect of the hand and 4th and 5th digits

Question 10

Elbow Flexion Test

Answer 10

Patient is seated
Ask the patient to fully flex the elbow and hold this position for 5 minutes
+= paresthesia along the ulnar border of the hand and 4th and 5th digits

Question 11

Ulnar Collateral Ligament Sprain

Answer 11

Acute or chronic
Repetitive throwing motions
Pitchers and javelin throwers
Or a fall on the outstretched arm
Tear in the Ulnar Collateral Ligament
Medial elbow pain worse with forceful abduction
Abduction stress test
MRI

Question 12

Orthopedic Test for Ulnar Collateral Ligament Sprain

Answer 12

abduction stress test

Question 13

Abduction Stress Test

Answer 13

The patient is seated
Ask the patient to fully extend the elbow
Stabilize the lateral aspect of the patient’s elbow with one hand
Grasp the distal forearm of the patient
Pull the distal forearm laterally
+= pain over the medial elbow

Question 14

Olecranon Bursitis

Answer 14

Acute or chronic
Inflammation of the olecranon bursa which lies between the skin and the olecranon
Traumatic or prolonged pressure on the olecranon or associated with RA or gout
Swelling [size of a goose egg] and pain worse on elbow flexion
If it is red and warm, then the bursa is infected
Ultrasound

Question 15

Triceps tendonitis

Answer 15

Chronic or acute
Repetitive or prolonged activity placing strain on the triceps tendon
Pushups, punching, throwing the shot put or excessive hammering
Non-traumatic
Pain at the back of the elbow
Patient supports involved arm in elbow flexion
Tenderness and perhaps swelling in the olecranon fossa
Pain worse with extension against resistance
MRI may be needed

Question 16

Posterior Impingement Syndrome

Answer 16

Acute or chronic
Excessive or repetitive hyperextension often with abduction
The windup or cocked position just prior to throwing
Intra-articular lesion or reactive synovitis
OA in the older patient
Pain at the back of the elbow
Tenderness when palpating the olecranon fossa
MRI may be needed

Question 17

Occult Elbow Fracture

Answer 17

Acute traumatic injury
Swollen elbow
Inability to fully extend the elbow
X-ray may appear to be normal
Posterior fat pad [90% chance of an intra-articular fracture] or an anterior sail sign [75%] may be seen on the lateral x-ray
Another view may show an intra-articular fracture

Question 18

Bicipitoradial bursitis

Answer 18

Repetitive supination and pronation
More common in males
Mid-elbow pain and swelling lateral to insertion of the bicipital tendon
Limited supination and pronation
Ultrasound and MRI

Question 19

Bicipital Tendon Tear

Answer 19

Acute
Trauma
Older men
Smoking and use of anabolic steroids
Sudden jerky lifting of a heavy object
Bruising in front of the elbow
Mid-arm bulge
Unable to flex the elbow or supinate the forearm against resistance
MRI

Question 20

Pronator Syndrome

Answer 20

Insidious
Repetitive pronation
Median nerve entrapment 
Pain worse on pronating the flexed wrist against resistance
X-ray may show a bony spur
Nerve conduction velocity studies

Question 21

Resisted Pronation test

Answer 21

The patient is seated
The forearm is in supination and the elbow in extension
Stabilize the proximal forearm with one hand
Hold the distal forearm
Ask the patient to pronate the forearm while you resist this movement
+= reproduction of pain

Question 22

Nerves that innervate the wrist joint

Answer 22

Anterior interosseous branch of the median nerve
Posterior interosseous branch of the radial nerve
Articular branches of the ulnar nerve

Question 23

Ranges of Motion for Wrist

Answer 23

Flexion: 0-80 degrees [FCR and FCU assisted by FDS and FDP]
Extension: 0-70 degrees [ECRL, ECRB and ECU assisted by ED and EI
Radial deviation: 0-20 degrees [ECRL, ECEB and FCR]
Ulnar deviation: 0-30 degrees [FCU and ECU]
Pronation and supination are allied to the elbow joint

Question 24

Orthopedic Tests for Carpal Tunnel Syndrome

Answer 24

Tinel, Phalen, Reverse Phalen and Wrist Compression

Question 25

Carpal Tunnel Sydrome

Answer 25

Insidious Repetitive flexion and extension of the wrist and/or fingers Females > 45 years Hypothyrodism, diabetes and pregnancy Pain or paresthesia in the thumb, index, middle and radial aspect of the ring fingers

Question 26

Tinel's Test

Answer 26

The patient is seated The forearm is supinated Using a reflex hammer or your finger, tap one inch distal to the distal skin crease at the wrist += reproduction of pain or paresthesia along the thumb, index, middle and the radial half of the ring fingers

Question 27

Phalen Test

Answer 27

The patient is seated Instruct the patient to hold both hands in the flexed position for 1 minute += reproduction of pain or paresthesia along the thumb, index, middle and the radial half of the ring finger

Question 28

Reversed Phalen Test

Answer 28

The patient is seated Ask the patient to hold both hands as if in prayer for 1 minute += reproduction of pain or paresthesia along the thumb, index, middle and the radial half of the ring fingers

Question 29

Wrist Compression Test

Answer 29

aka Durkan’s test The patient is seated Compress with both thumbs an area 1 inch beyond the distal skin crease at the wrist for 30 seconds += reproduction of pain or paresthesia along the thumb, index, middle and the radial half of the ring finger within 30 seconds

Question 30

Cheiralgia Paresthetica aka Wartenberg’s syndrome

Answer 30

Acute or chronic Compression of the superficial branch of the radial nerve as it lies between the ECRL and brachioradialis tendons More common in females Pain or paresthesia over the dorsolateral aspect of the wrist

Question 31

Orthopedic Test for Cheiralgia Paresthetica

Answer 31

Tinel's sign

Question 32

Tinel's Sign

Answer 32

The patient is seated With a reflex hammer or your finger tip, tap over the lateral aspect of the wrist About 9 cm proximal to the radial styloid process += pain or paresthesia along the dorsal aspect of the thumb and index fingers

Question 33

de Quervain’s tenosynovitis

Answer 33

Chronic Inflammation of the tendon sheaths of APL and EPB caused by microtrauma Pain over the radial styloid process and the tendons of APL and EPB Finkelstein test may be positive

Question 34

Orthopedic Test for de Quevain's Tenosynovitis

Answer 34

Finkelstein Test

Question 35

Finkelstein Test

Answer 35

The patient is seated Ask the patient to make a fist with the thumb on the palm Ask the patient to bend the wrist towards the little finger += pain over the styloid process of the radius

Question 36

Ganglion

Answer 36

Soft tissue swelling arising from the joint capsule of tendon sheath May be a history of repetitive wrist activities Dorsal wrist pain worse with passive dorsiflexion Tense cystic swelling MRI may be helpful

Question 37

Guyon’s Canal Syndrome

Answer 37

Acute or chronic Compression of the ulnar nerve as it passes through Guyon’s canal Compressive injury-cyclists or associated with hamate fractures Pain or paresthesia along the 5th and the ulnar aspect of the ring finger Tinel’s test, Froment’s and Wartenberg’s sign Nerve Conduction Velocity studies

Question 38

Orthopedic Tests for Guyon's Canal Syndrome

Answer 38

Tinel's test, Froment's and Wartenberg's sign

Question 39

Tinel's Test

Answer 39

The patient is seated With a reflex hammer or your finger tip, tap over the pisiform bone += Pain or paresthesia along the little finger and the medial half of the ring finger

Question 40

Froment’s sign

Answer 40

The patient is seated The elbows are flexed Ask the patient to grasp a piece of paper between the thumb and index fingers in both hands Attempt to pull the paper out +=the patient flexes the interphalangeal joint of the thumb to get a better grip on the paper

Question 41

Intersection Syndrome

Answer 41

Insidious onset Repetitive activities involving the tendons of APL and EPB crossing over the tendons of ECRL and ECRB Weight lifters and rowers Pain over the dorsolateral aspect of the wrist 5 cm proximal to the wrist Pain with resisted wrist and thumb extension and abduction Crepitus over the affected tendons Finkelstein’s test may be positive

Question 42

Kienbock’s disease

Answer 42

Insidious Avascular necrosis of the lunate bone Stress or compression fracture or repetitive trauma Stiff wrist with pain over the dorsum of the wrist Pain on passive extension of the middle finger X-ray or MRI

Question 43

Osteoarthritis

Answer 43

``` Primary or secondary Wear and tear degeneration F>M in primary M>F in secondary Morning stiffness < 1 hour Bilateral Heberden’s [DIP] and Bouchard’s [PIP] nodes ```

Question 44

Psoriatic Arthritis

Answer 44

Autoimmune disorder F>>M 10% of patients with psoriasis will develop pain and swelling of the small joints in the hands Pitted nails and sausage digits

Question 45

Rheumatoid Arthritis

Answer 45

``` Autoimmune disorder F:M 9:1 Small joints mainly Bilateral Early morning stiffness > 1 hour Rheumatoid Factor + in 70% of patients Bouchard and Haygarth’s nodes Bracelet and wringing tests X-ray ```

Question 46

Bracelet Test

Answer 46

The patient is seated Grab the wrist of the patient with one hand Squeeze mild lateral compression to the lower ends of the radius and ulna += pain on lateral compression of the wrist

Question 47

Wringing Test

Answer 47

The patient is seated Give the patient a towel Ask the patient to wring the towel with both hands += pain in the elbow, wrist or hand on wringing the towel

Question 48

Scapholunate dissociation

Answer 48

Acute Falling on the thenar eminence Tear of the scapholunate and radioscaphoid ligaments Presents with radial or dorsal wrist pain Watson test X-ray-David Letterman [Terry Thomas] sign [large space between the scaphoid and lunate bones

Question 49

Watson’s Test

Answer 49

The patient is seated Stabilize the radius and ulna with one hand holding the hand in slight ulnar deviation Grasp the scaphoid and move in anteriorly and posteriorly += reproduction of pain, crepitus or increased laxity

Question 50

Triangular Fibrocartilage Complex Tear

Answer 50

Acute or chronic Fall on the outstretched hand with wrist in extension and forearm pronated or Chronic wear and tear associated with a positive ulnar variance Pain over the ulnar aspect of the wrist Fovea sign and the Press test MRI of the wrist

Question 51

Fovea sign

Answer 51

The patient is seated | += Tenderness in the soft spot between the ulnar styloid and flexor carpi ulnaris tendon

Question 52

Press Test

Answer 52

The patient is seated in a chair with arms Ask the patient to place both hands on the arms of the chair and push off as to suspend the body using only the hands += reproduction of wrist pain while pushing up

Question 53

Triquetrohamate Instability

Answer 53

Acute Disruption of the osseous coupling between the hamate and triquetrum Injury to the ulnar side of the hand with excessive pronation Ligamentous tear Active pronation with ulnar deviation causes a click and may reproduces the pain Videofluoroscopy is diagnostic