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Clin Med 1 - MSK/ HEENT exam 2 > MSK Upper and Lower Extremity Injuries > Flashcards

MSK Upper and Lower Extremity Injuries Flashcards

1
Q

Where is the most common site for clavicle fx?

A

Middle 1/3

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2
Q

MOI of a clavicle fx?

A
  • Fall onto shoulder – 87%
  • Direct blow from an object
  • Fall on outstretched hand
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3
Q

List the clinical manifestations of a clavicle fx:

A
  • Pain
  • Deformity
  • Skin ‘tenting’
  • (+) ecchymosis (bruising)
  • (+) crepitus, palpable tenderness
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4
Q

How would we tx a non-displaced clavicle fx?

A
  • Sling
  • Limited shoulder ROM
  • Frequent ROM at elbow to prevent stiffness
  • Ice
  • Analgesics
  • NSAIDs (controversial)
  • Narcotics x 3-5 days
  • PT
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5
Q

WHat procedure would we do to fix a displaced clavicle fx?

A

•ORIF – plate/screws

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6
Q

What injury would result from a direct blow/force to lateral shoulder with arm adducted?

A

AC Joint separation

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7
Q

Describe how we would conduct a Cross-Arm test?

What injury is this test used to help dx?

A
  • Pt flexes shoulder to 90 degrees, then actively adducts it
  • (+) test if pain produced at AC joint

AC Joint separation

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8
Q

Define the Grading criteria for AC joint separation:

A
  • Grade I – ‘sprain’ of AC ligament (conservative tx)
  • Grade II – tearing AC ligament (conservative tx)
  • Grade III – tearing both AC and CC (coracoclavicular) ligaments (surgical tx)
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9
Q

When would we surgically treat an AC joint separation?

A

> Grade III injuries based on age and activity level

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10
Q

Pt arrives at clinic after a fall from standing. On immediate assessment you see:

Most likely Dx?

A

Proximal Humerus Fx

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11
Q

What images would we order when looking for a proximal humerus fx?

A
  • X-rays – 2v-3v
  • CT (non-contrast)
  • Evaluate joint/articulation
  • Rule in/out surgery
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12
Q

Pt presents to clinic in severe pain: she is holding involved arm adducted to side, you notice swelling and ecchymosis. She reports loss of ROM and has almost no shoulder movement at all.

Dx?

A

Proximal Humerus Fracture

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13
Q

Identify the fx:

A

Proximal Humerus Fracture

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14
Q

Is a Proximal Humerus Fracture an indication for narcotics?

A

yes

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15
Q

conservative tx for Proximal Humerus Fracture

A

~ 80% are impacted/Nondisplaced

Sling, cuff and collar

Ice

Analgesics

(+) indication for narcotics

Suggest ‘recliner chair’ for rest/sleep

ROM elbow/wrist/hand

PT/OT at 2-week mark

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16
Q

What is the most common cause of shoulder pain visits in primary care

A

shoulder impingement

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17
Q

Most common cause of shoulder pain?

A

rotator cuff disease (supraspinatus)

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18
Q

Pt presents w/ diffuse tenderness anterolateral shoulder and decreased Active ROM. The rotator cuff is in tact but shows some weakness.

What test could you perform to add to your suspected dx?

A

Impingment test

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19
Q

Which variation in acromion shape is most likely to lead to an impingment?

A

Type III

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20
Q

Images to look at shoulder impingement?

A

3vshoulder X-ray

  • AP (Grashey), Axillary, Outlet or Y scapular
  • “Type” of acromion

MRI- not indicated

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21
Q

Pt presents with pain with overhead activities, Sleeping on shoulder and has difficulty putting on jacket.

Suspected dx?

A

Shoulder impingement

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22
Q

surgical tx for shoulder impingement:

A

Arthroscopic ‘acromioplasty’

Removal of the ‘hook’/spur under the acromion

Type III → Type I

Bursectomy

Debridement of rotator cuff

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23
Q

Name the 3 grades of rotator cuff tears:

A
  • Intra-substance
  • Partial thickness
  • Full thickness **
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24
Q

What image/test would we order when you suspect a complete tear od the rotator cuff?

A

•MSK Ultrasound

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25
Q

NSAIDs appropriate for rotstor cuff tears:

A

Meloxicam 15mg 1 po qd x 3 weeks

Aleve 440mg po bid with meals x 3 weeks

Advil 400-600mg po tid with meals x 3 weeks

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26
Q

Name the muscles of the rotstor cuff?

which is the most likely to tear?

A

ubscapularis, teres minor, supraspinatus, and infraspinatus

supraspinatus

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27
Q

Pt comes into clinic and yells “I think I broke my shoulder” you ask the pt how they fell and they reply that they have not fallen, they “woke up like this”.

the patient is in obvious pain and holding the affected shoulder.

probable dx?

A

Calcific Tendonitis

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28
Q

Calcific Tendonitis is the deposition of _____ ________ within substance of tendon

A

calcium hydroxyapatite

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29
Q

Tx for calcific tendonitis

A
  • Analgesic/anti-inflammation (PO)
  • Steroid Injection (cortisone inj)
  • Local + steroid (Depomedrol)
  • Subacromial
  • PT, modalities
  • A/scope
  • Failure to make meaningful improvements
  • Recurrence
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30
Q

imaging for calcific tendonitis?

A
  • 3-view X-ray
  • AP, axillary, outlet (Y-scapular)
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31
Q

Are the majority of shoulder dislocations anterior or posterior?

A

anterior

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32
Q

causes of traumatic shoulder dislocations →

A
  • Chronic instability
  • OA
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33
Q

causes of atraumatic shoulder dislocations

A

•Often related to ligament laxity

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34
Q

What is the Labrum?

A
  • Fibro-cartilaginous ring
  • Attached to outer rim of glenoid
  • Provides added depth to the joint socket
  • Improved stability
  • ‘Gasket’ of the GH joint
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35
Q

Function of the labrum?

A
  • Attachment point for GH ligaments
  • Origin of the long head of biceps tendon
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36
Q

A baseball pitcher comes to clinic and tells you they hear a clicking / popping sound when moving their shoulder.

You ask if they can demonstrate the sound and they can.

Dx?

what images would you want to order to confrim dx?

A

Labral tear

  • MR Arthrogram (MRA)
  • Preferred
  • Intra-articular Gadolinium
  • Improved accuracy
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37
Q

Shoulder condition associated w/ endocrine disorders

A

Adhesive Capsulitis “frozen shoulder”

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38
Q

what are the hallmark clinical presentations of Adhesive Capsulitis “frozen shoulder”?

A
  • Pain
  • Stiffness (freezing)
  • Decreased AROM and PROM
  • Normal motor exam
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39
Q

Condition referred to as “tennis elbow”?

what tendons is this usually present on?

A

Lateral Epicondylitis

•Extensor tendons of the forearm at insertion at lateral epicondyle

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40
Q

Lateral Epicondylitis presents with pain upon resisted wrist _____. While Medial Epicondylitis shows pain with resisted wrist _____>

A

extension

flexion

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41
Q

Medial Epicondylitis is also referred to as?

what tendons does this affect?

A
  • Golfer’s elbow”
  • Flexor ‘wad’ tendons at insertion at medial epicondyle
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42
Q

Tx for Cubital Tunnel Syndrome (Ulnar neuropathy)?

what splint/brace do we use?

Surgical?

A
  • Night splint/brace X 3-4 weeks
  • Surgical Release
  • Stop the process
  • “Transposition” vs. release
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43
Q

Most common cause of septic bursitis

A

S. aureus

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44
Q

Describe a septic olecranon bursitis:

A

•Painful, warm to touch, erythematous

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45
Q

Pt presents to clinic w/ a fluctuant mass. He states it is painless w/ no warmth or eythema.

Dx?

A

Aseptic olecranon bursitis

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46
Q

Do elbows more frequently dislocate anterior or posterior?

A

posterior

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47
Q

Most common MOI in a posteriorly dislocated elbow?

A
  • typically occur with fall onto extended arm
  • Hyperextension
  • Posterolateral rotary
48
Q

Tx of elbow dislocation

A
  • Closed reduction
  • Long arm splint with sling
  • Refer to Ortho
  • Brace
  • PT/OT after period of immobilization
49
Q

What nerve is most commonly injured w/ a humerus fx?

50
Q

tX for humerus fx?

A
  • Hanging cast
  • Displaced/unstable ORIF
51
Q

Complications associated w/ a humerus fx?

A

mal-union

non-union

infection

52
Q

How do we tx a Radial Head Fx

A

ED/UC: long arm posterior splint until seen by Ortho

Sling for comfort x 1-2 weeks

Analgesics

Gentle ROM

Encourage Flex/Ext

Serial X-rays in 1-2 weeks

PT/OT if not FROM by 3-week mark

53
Q

What is this also called?

is it physiologic or pathologic?

A

Anterior Fat pad Sign

  • Can be normal ‘physiologic’ fluid
  • See as a thin strip
54
Q

You notice a posterior fat pad sign on a child. What does this indicate?

A

•Supracondylar fx → children

55
Q

You notice a posterior fat pad sign on an adult. What does this indicate?

A

•Radial Head fx → adults

56
Q

Is it normal to see a posterior fat pad sign?

what does it indicate about the intra-articular space?

A

no

  • Intra-articular hemorrhage/effuse
  • Distension of synovium making it visible on X-ray
57
Q

Name the fx:

Tx?

A

Olecranon Fracture

  • ORIF
  • Plate and screws
  • Tension band wire
58
Q

Why are pts unable to extend / straighten elbow when they have an olrcranon fx?

A

site of tricep tendon attachment

59
Q

How would we tx Both Bones Forearm Fracture in kids?

adults?

A

Non-displaced- LA cast

•Displaced/Adults- ORIF

60
Q

define a colles fx and the MOI

A
  • Fx of Distal radial metaphyseal region with Dorsal angulation and impaction
  • FOOSH in Dorsiflexion (palm side down)
  • Extra-articular
61
Q

Pt arrives with a “dinner fork deformity” what are we suspicious of?

62
Q

define Smith fx and MOI:

A
  • Fx of the distal radius with associated volar angulation of distal fracture fragment
  • Fall on a flexed wrist
  • Direct blow to back of wrist
63
Q

How would we tx a nondisplaced smiths fx?

64
Q

How would we tc a displaced smith fx?

A

plates and screws

splint post-op

65
Q

Identify fx

and the usual MOI

A

5th Metacarpal Fracture “Boxer’s Fracture”

  • Fracture through 5th Metacarpal neck
  • Occurs when a closed fist strikes a hard surface
66
Q

Tx for boxer’s fx

A
  • If >45 deg volar angulation, reduce fx to anatomic position
  • Ulnar Gutter Cast Immobilization for 3-4 weeks, then transition to splint
  • Surgical repair
  • Unstable, or reduction fails
  • Followed by cast immobilization for 3-6 weeks
67
Q

What fx is this???

68
Q

Pt arrives to ER after a FOOSH. They tell you they are experiencing arm pain.

Upon examination you notice a dinner fok deformity and the X-rays show a fx of distal radial metaphyseal region with dorsal angulation and impaction.

Dx?

69
Q

MOI of both Smith’s and Colles fx:

A

Colles: FOOSH, palmar surface of hand hits floor

Smith: dorsal surface (back of hand) hits the ground

70
Q

Pt presents to clinic with a Boxer’s Fx after failing the first clin med exam and punching the wall. The fx has a 50 volar degree angulation:

How do we tx?

what type of cast do we use?

A

reduce fx to anatomic position

Ulnar Gutter Cast Immobilization for 3-4 weeks, then transition to splint

71
Q

Pt arrives to ED with an intra-articular fx at the base of the 1st carpometacarpal joint. On X-rays you note a 2-piece fracture dislocation of base of 1st metacarpal with Intra-articular extension.

The Fracture has 2 mm displacement.

Tx?

A

CRPP fixation

IF >3mm ORIF w/ cortical screw

(this was a bennett fx)

72
Q

What is the name of the fx that shows an intra-articular fracture of the 1st metacarpal that is comminuted?

Does this have a better/worse prognosis?

A

Rolando fracture

worse! :(

73
Q

What type of case do we use on a Bennet Fx?

A

Thumb Spica 4-6 wks

74
Q

What is the most frequently fractured carpal bone?

75
Q

Pt arrives to ED holding wrist. She compains of pain on the radial side of wrist and with forced dorsiflexion.

They tell you they had a FOOSH, upon examination you notice tenderness w/ axial compression of thumb toward the snuff box.

Likely dx?

What cast are we using?

A

scaphoid fx

thumb spica 6-8 wks

76
Q

Why is there such a high incidence of AVN with a proximal 5th metacarpal fx?

A
  • Blood Supply:
  • Major source: dorsal carpal branch of radial artery
  • 80% of scaphoid via retrograde blood flow
77
Q

What is arthritis of the 1st CMC joint called?

A

Basal Joint arthritis

78
Q

65 year old woman arrives to clinic complaining of opposition pain. She says writting has become very difficult nd she can no longer open jars.

Upon examination she reports pain at both the trapeziometacarpal joint and the scaphotrapezial joint.

Dx?

FIRST line tx?

A

Basal joint arthritis

NSAIDs / Tylenol

79
Q

A 70 year old pt arrives to clinic with a hx of Basal Joint Arthritis. She has recieved 2 intraarticular cortisone injections and has no relief when taking tylenol and NSAIDs.

What is our next step in tx?

A
  • Joint Arthroplasty
  • Using half of the Flexor Carpi Radialis (FCR tendon) for ligament reconstruction combined with excision of trapezium
  • “anchovy technique”
80
Q

Artery that supplies 80% of scaphoid via retrograde blood flow??

81
Q

Pt with a history of RA presents w/ flexion contracture of (PIP) joint extension of (DIP) joint.

what is this deformity called?

A

Boutonniere Deformity

Manifestation of RA!!

82
Q

Swan neck deformit shows _________ of proximal interphalangeal (PIP) joints and compensatory ________ of distal interphalangeal (DIP) joints.

A

hyperextension / flexion

boutonniere is opposite

83
Q

When tx a Boutonniere deformity it is IMPORTANT to tell the pt they must wear the splint CONTINUOUSLY:

__ wks for a young pt

___ wks for an adult pt

A

6 wks child

3 wks elderly

84
Q

What deformity is repaired with silver or other Ring-type splints (Oval 8)?

A

Swan neck deformity

85
Q

what deformity is tx w/ with K-wire?

A

Boutonniere Deformity

86
Q

what is the most common compressive neuropathy of upper extremity??

A

carpal tunnel

87
Q

pt presents w a positive Tineal sign and positive Phalen’s sign.

Dx?

A

carpal tunnel

88
Q

what is a positive phalens sign??

A

the occurrence of pain or paresthesias in at least one finger innervated by the median nerve

index finger, thumb, middle finger, and half the ring finger, and the nail bed

89
Q

Stenosing tenosynovitis of 1st dorsal compartment of wrist??
Dx?

A

deQuervain’s Tenosynovitis

90
Q

what are the 2 tendons that are affected in deQuervain’s Tenosynovitis?

A
  • Abductor pollicis longus (APL)
  • Extensor pollicus brevis (EPB)
91
Q

define Gamekeepers thumb:

A
  • Injury to ulnar collateral ligament of thumb at MCP joint
  • Results in instability of MCP joint and decreased thumb grip strength
  • AKA Skier’s Thumb
92
Q

Pt arrives to ED after an injury resulting from falling on outstretched hand while gripping ski pole. You identify a partial tear.

Dx?

Tx?

A

Gamekeepers thumb

  • Conservative (partial tear)
  • Thumb spica cast/splint immobilization for 4-6 weeks
93
Q

Tx for finger dislocations:

A
  • Recheck NV status
  • Volar Alumafoam splint
  • Buddy-tape
  • Tylenol, NSAIDs, and Ice
  • Follow up with Hand/Ortho
94
Q

A baseball player arrives to clinic after an injury to his finger. He reports most of his pain is located distally. he is unable to extend DIP joint.

You get an X-ray:

Dx?

A

Mallet finger

95
Q

when would we use a DIP joint splint?

and what is most important to educate pt about this spint?

A
  • Used for Mallet Finger
  • Puts DIP in approx 10 degrees of hyperextension for tissue contact
  • Explain to patient that this is NOT TO BE REMOVED for approx. 8 weeks
96
Q

MOI of Bennett Fracture-Dislocation

A

Forced abduction of 1st metacarpal

97
Q

Compare clinical presentation of Mallet vs Jersey finger in regards to MOI and position of affected finger.

A

Jersey: MOI- hyperextension –> Inability to flex finger at DIP joint

Mallet: MOI struck (trauma) Inability to extend DIP joint

98
Q

What is injured in Jersey finger?

Which finger is almost ALWAYS affected?

A
  • Avulsion injury of Flexor Digitorum Profundus tendon from insertion at base of distal phalanx
  • Ring finger involved 75% of cases
  • During grip, ring fingertip is 5 mm more prominent than other digits in ~90% of patients
  • FDP insertion into ring finger anatomically weaker than middle finger
99
Q

Can you dx Jersey Finger via X-ray?

A

No - usually appear normal

MRI: will show disruption of FDP at volar base of distal phalanx ± avulsion fragment

100
Q

Pt arrives at clinic and reports of frequent hand pain and she is having a difficult time straightening or bending her finger, she describes this as a “locking” feeling.

Dx?

Tx?

A

Trigger finger

NSAID

Splinting

Glucocorticoid injection

101
Q

Trigger finger results in the thickening of the ___ ______ ____ _______. In serious cases this must be treated surgically where we would release the ___ _____

A
  • Flexor tendon and sheath
  • A1 pulley
102
Q

Pt complains of inability to extend hands and fingers. Upon examination you see this.

You also note a firm nodularity on volar surface of hand with coalescing cords of soft tissue on the webs and digits.

Dx?

Tx?

A

Duytren’s Contracture (•Palmar Fibromatosis)

  • Cortisone injections into sheath
  • Collagenase injections- reduces contractures improves ROM
103
Q

Which fingers are affected earliest in Dupuytren’s Contracture?

A

Fourth and fifth fingers affected earliest

104
Q

what is the most common soft tissue tumor of hand?

A

ganglion cyst

105
Q

Pt presents to clinic with joint pain in her wrist. Upon examination you note a fluid filled swelling overlying a joint or tendon sheath.

Dx?

what is this fluid most likely (2 options)

A

Ganglion Cyst

•Contains mucinous or gelatinous fluid

106
Q

Pt w/ a hx of OA presents with visible swelling on the dorsal side of finger. You also note a groove in the fingernail?

Dx?

Tx?

A

Mucous Cyst (remember usually assoc. w/ OA!)

  • Intralesional corticosteroid injectionst riamcinolone
  • Surgical excision—Hand surgeon
107
Q

where do mucous cysts normally appear?

A
  • Benign cysts usually at DIP
  • Dorsal surface
108
Q

what is an Infection of fingertip pulp called?

109
Q

Tx for felon?

A

I&D

Antibiotics directed at Staph and MRSA

  • Dicloxacillin
  • Cephalexin
  • Bactrim
  • Clindamycin
  • Nafcillin
  • Doxycycline
110
Q

Pt presents with a nail laceration, in order to fix you must provide a finger block.

When choosing your local anesthsia would you grab:

Lidocaine

Lidocaine + epi 1%

A

Lidocaine

NO EPI W FINGER LACS

111
Q

Pt presents to clinic w what they believe is a rash. upon examination you note grouped vesicles on an intensely erythematous base.

You ask them if it is itchy and they report that it is much more painful then itchy. You also note axillary lymphadenopathy.

Dx?

What fingers are most common to find this dx?

A

Herpetic Whitlow

thumb and index

112
Q

Pt presents to clinic w/ a painful, edematous fingertip with vesicular lesions.

What tests would you ude to confirm your dx?

(there are 3)

A

Herpetic whitlow

Tzank smear

  • Viral culture
  • Serum antibody titers
113
Q

Tx for herpetic whitlow?

A
  • Self-limited
  • Symptomatic relief
  • Acyclovir may be beneficial- PO and Topical
  • Famciclovir
  • Valacyclovir

unroof tense vesicles

114
Q

When assessing for a boxer’s fx what degree of volar angulation is acceptable?

A

up to 40 degrees

Clin Med 1 - MSK/ HEENT exam 2 (4 decks)

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