Ortho UE- Wells- clin med exam 2 Flashcards
1
Q
List the Rotator Cuff Muscles (SITS) and their associated functions
A
Supraspinatus – Abduction, ER
Infraspinatus – ER, stabilizer
Teres Minor – ER, stabilizer
Subscapularis – IR, anterior stability
2
Q
Function of the Rotator cuff
A
- Allows you to ABduct arm (as opposed to ADDuct arm)
- Allows for IR and ER of the shoulder but mainly ER
- Pt can have pain in a “painful arc” from 60-120 degrees of abduction
3
Q
Rotator cuff MOI
A
- Allows you to ABduct arm (as opposed to ADDuct arm)
- Allows for IR and ER of the shoulder but mainly ER
- Pt can have pain in a “painful arc” from 60-120 degrees of abduction
4
Q
Diagnostic test for rotator cuff tear (gold standard imaging study)
A
**MRI
5
Q
Tx Rotator cuff injury
A
- -Partial Thickness vs. Full thickness
- Partial often presents like an impingement …pain with abduction, possible weak RC testing
- **>50% tear will need surgical repair, typically arthroscopy as opposed to an “open repair’
6
Q
Rotator cuff tear– non operative tx
A
- PT (Typically 2x week x 4-8 weeks)
- –Shoulder stabilization exercises
- -Stretching…get that humeral head down and back
- -Postural strengthening/”retraining”
- NSAIDS
- -Make sure no contraindications (CVD, PUD, pregnancy, bleeding disorders…)
-Injections (usually some form of medium acting steroid “Celestone”,and lidocaine)–> Allowed 3 injections in 1 Year –> otherwise degenerates the tendon making it prone to tearing
7
Q
If a rotator cuff is NOT surgically repaired.. this can lead to ?
A
fatty atrophy of the cuff and an irreparable tear resulting is limited treatment options
8
Q
How long can a Pt with a rotator cuff injury be in PT for?
A
8-12 weeks
9
Q
Pt with a rotator cuff injury, what is the last ROM to come back?
A
Internal rotation is the last to come back!! (ie tucking in a shirt)
10
Q
Impingement Syndrome- etiology
A
Causes:
Repetitive overhead movement
Anterior translation of the humeral head with poor posture
Acromial “hook”
Degenerative change
Trauma
Causes micro trauma to supraspinatus/bursa
11
Q
Describe an Acromial hook
A
-Type 1- Type VI
=Causes impingement, possible tearing of the supraspinatus tendon
–Typically live with it, however Types IV-VI may need to be burred down…i.e., ”acromioplasty”
12
Q
Impingement Syndrome- dx:
A
- History of painful arc
- PE shows pain with impingement testing (Neers, Hawkins…)
-Diagnostic Injection – lidocaine/steroid
- Imaging – treat first, then image, unless concern for trauma, tear, etc…
- -X-ray can show trauma/OA/acromial hook
–MRI can show fraying/degenerative change of the rotator cuff, inflammation of the bursa
13
Q
Acromioclavicular separation-hx
A
-typically from a lateral fal, FOOSH, or contact sport injjury, or MVA
14
Q
Acromioclavicular Separation-tx
A
- Grade I-III usually tx conservatively–> Sling for comfort, NSAIDs, RICE
- Grade IV-VI often require surgical repair due to instability of the shoulder
15
Q
“Frozen Shoulder” aka
A
Adhesive Capsulitis
16
Q
Adhesive Capsulitis- etiology
A
Spontaneous or Gradual onset of worsening AROM
Often after a period of immobilization such as shoulder surgery/mastectomy…
Diagnose with H+P
See in 40-60 y/o F>M, watch for with your DM pts
17
Q
Adhesive Capsulitis- tx
A
Requires PT or sometimes manipulation under anesthesia
18
Q
Adhesive capsulitis-pathophys
A
This is associated with an increased amount of collagen, fibrotic growth factors such as transforming growth factor-beta, and inflammatory cytokines such as tumor necrosis factor-alpha and interleukins. Immune system cells such as B-lymphocytes, T-lymphocytes and macrophages are also noted. Active fibroblastic proliferation similar to that of Dupuytren’s contracture is documented.
19
Q
Bicep Tendonitis-hx
A
- Hx of repetitive use, trauma, poor ergonomics, anterior translation of the humerus due to postural weakness, old age
- FLEXORS ALWAYS WIN
- Pain over the proximal long head of the bicep tendon
- Can sometimes elicit pain with flexion testing, pronation/supination of the forearm against resistance, ***Speeds Test
20
Q
Biceps tendonitis-tx
A
- PT (postural strengthening, stretching)
- cortisone/lidocaine injection into tendon sheath
- surgery (bicep tenodesis)
21
Q
Instability (or eventual dislocation)
A
- Anterior Instability is far more common than posterior or multidirectional instability
- Pt will light up with apprehension test–>.and…Can have a positive “Sulcus Sign”
- Be aware if traumatic…consider other soft tissue injury (SLAP tear)
Causes: Trauma Genetics Treatment PT Surgery if not improving with conservative treatment
22
Q
Shoulder Dislocation Reduction
-what MUST you do?
A
- **MUST do Pre-reduction/Post-reduction films (post film needed to male sure post reduction placed the humeral head back in place)
- **Look for Hill Sachs Lesion
- **Look for Bankart Lesion
- Check for Axillary nerve injury* w/ a shoulder dislocation
- Sling pt for comfort after reduction
- May need short course of PT to regain ROM, shoulder stability, inflammation reduction
- Recurrent dislocations will need stabilizing surgical procedure
23
Q
Axillary nerve lesion (describe)
A
- axillary nerve may get injured due to downward dislocation of the humeral head OR a fx of the humeral head
- ->Deltoid and teres minor become paralyzed
- Abduction of the shoulder is impaired
- loss of sensation over the lower half of the deltoid
24
Q
**Bankart Lesion
A
-results as a complication of dislocation
=an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation.
-Can have bony (glenoid) and/or soft tissue (labrum) trauma
25
Hill Sachs Lesion***
-(a complication of Dislocation)
=a cortical depression in the posterolateral head of the humerus. Caused by forceful impact of the humeral head against the glenoid rim when the shoulder is dislocated anteriorly.
26
For Dislocations of the shoulder you can use 2 methods for reduction
- Milch Method of Reduction
- Kocher’s Method of Reduction
- Stimson Maneuver of Reduction
27
Shoulder Dislocation Complications
Labral Tear
Hill Sachs Lesion
Bankart Lesion/Fracture
Axillary nerve injury
28
"SLAP Lesion=
Superior Labral Anterior Posterior
| -Occurs where the bicep tendon anchors to the labrum
29
Causes of a SLAP lesion
- A motor vehicle accident
- FOOSH
- Forceful pulling on the arm, such as when trying to catch a heavy object
- Rapid or forceful movement of the arm when it is above the level of the shoulder
- Shoulder dislocation
30
Gold standard dx test for "SLAP" tear (KNOW!!)
MRI Arthogram******
- Other sx:
- Pt will often complain of painful catching or “clicking” in the shoulder
- Usually caused from traumatic fall or forceful abduction of arm
- Can be watched if not overly symptomatic but often will require surgical repair
- ***Recovery in shoulder immobilizer, longer than RC tear recovery
31
Pectoralis Major Rupture:
- etiology
- Sx
- tx?
- Acute pain, typically with lifting, bench pressing, etc…
- Presents with bruising, **declivity(scooped out appearance) in the muscle
tx: Typically need surgical repair
32
Fracture type: stable
broken ends line up
33
Fracture type: open
bone pierces skin
34
Fracture type: transverse
horizontal fx
35
Oblique fx
angled fx
36
Comminuted
bone shatters
37
stress/overuse fx
MC in athletes
38
Intra-articular fx
fx involves the joint surface (more concerning)
39
When in doubt with a fx?
- get an X-RAY, refer
| - Peds--have low threshold for referral
40
Fx healing time
- Heal in 6-8 weeks in most healthy individuals but usually 4-6 months before pt feels “normal” depends on body part
- Look for delayed healing in smokers, high altitude, DM
- Fever, swelling, pain…think osteomyelitis
- Watch for DVT in LE fractures
- *Pain, Pallor, Pulselessness with compartment syndrome…EMERGENT SURGERY REQUIRED
41
Types of casts in Fx tx
- cast (after waiting 3-4 days)
| - functional cast (this person can still kind of move and you can take cast off)
42
Types of fx tx
- traction
| - external fixation
43
Fx of the humerus
- etiology
- demographic
- tx
- -Usually from a fall
- Think osteoporotic women
- tx: sling (self-traction) if non displaced and no concerns for bone healing
- ORIF (open reduction internal fixation) if needed
44
Bicep Muscle/Tendon:
| -Bicep tendon rupture
- MC in men
| - usually repaired surgically --let ortho make the call
45
Bicep Muscle/Tendon:
- Bicep tendon rupture
- key sx
-“Popeye” sign (can be from proximal or distal rupture)
| Can diagnose with MRI
46
Lateral Epicondylitis “Tennis elbow” (electrician’s elbow)
- Common with supination injuries (screw driver…”righty-tighty”)
- Extensor tendons of the forearm on the lateral epicondyle
- ***Hard to treat – hard to not use forearm extensors
tx: OT/iontophoresis (/tennis elbow strap/ compression sleeve, stretching/strengthening/rest/ice
cortisone injection/surgery (last resort)
-Warn your patients this will take a while to heal
47
Medial Epicondylitis – “Golfer’s Elbow”
=Irritation of where the flexor tendons of the forearm attach on to the medial epicondyle
-Pronation injury
48
Ulnar nerve can get entrapped in the _____
cubitus--> "cubital tunnel syndrome"
49
Ulnar nerve issues
- Ulnar nerve can sublux – pops in and out of the cubital tunnel
- Both can cause chronic pain, paresthesias, “electric shock”, weakness
- EMG/NCVS to determine where entrapment is occurring
- Depending on issue, tx with OT, NSAIDs, rest, injection
- May require surgical cubital tunnel release or ulnar nerve repositioning …think baseball pitchers
50
Olecranon Bursitis
- usually caused by a traumatic event
- but can be filled with fluid from gout
- Tx: conservative at first (may need to drain it, cortisone)
-Ice rest elevate NSAIDs
51
elbow fractures- which one is MC?
| -tx:
- radial head fx MC
- tx: with splint and sling vs ORIF depending on severity (comminuted, displaced)
- Be aware soft tissue (ligamentous) damage associated with elbows
52
Pediatric Fractures: MC fx?
- **Supracondylar fracture
- make sure you watch for growth plate/ nerve/vessel damage
- Elbow fractures in kids (and adults) need to heal properly or you can have permanent loss of ROM and this greatly affects ADL’s
53
Fat Pad Sign / Sail Sign= an indication of..
cortical disruption of the distal humerus fracture, caused by joint effusion due to elbow fracture
54
Distal Radius Fracture: Colles
=distal portion of fracture tilts upward
55
Distal radius fx:
- etiology?
- tx
-MC= FOOSH
-Common in young and old
You catch yourself with your hands
-Watch for nerve trauma/ ligamentous injury in the carpal area
tx: cast vs. surgery if indicated
56
Ganglion Cyst
(generally on the wrist)
-Fluid filled cyst, benign
- Often occur over a joint or area of high mobility, flexor or extensor surface
- Higher rate in females ages 30-40
- Often resolve on their own, but may require excision if compressing a structure such as a nerve or vessel (check Allen test)
57
Scaphoid Fracture:
- sx?
- Xray that you need to order?**
- complications?
sx- Tenderness over anatomic snuffbox
-xray-->Get a “scaphoid view”
Even if x-ray is “neg”, splint the pt in a thumb spica splint, have return in a week, re-x-ray
-***Avascular necrosis due to backwards vasculature
58
Wrist Ligamentous Injury
| "Terry Thomas Sign"
=Chronic pain and possible instability s/p FOOSH when pt should be healed
-scaphoid tears b/w the lunate and the scaphoid bone= terry thomas sign (aka a gap b/w those bones)
- X-ray may be neg but pt has pain over carpal ligaments…
- GET an MRI ARTHROGRAM (gold standard for soft tissue injuries)
-If disruption--> send to hand ortho
59
Carpal tunnel syndrome=
* **Median nerve impingement
sx: pain in the front of the wrist, numbness or tingling into the thumb, index, middle and 1/2 of the ring finger
- weakness in the hand with the tendency to drop objects
- increased tingling at night while sleeping
60
Carpal tunnel syndrome: key findings
-If you see atrophy, there’s no getting this back.
-key is to release the nerve prior to atrophy or nerve death
If H+P consistent with CTS, not improving with conservative tx, get an EMG/NCVS=electromyelogram nerve conduction study) to determine severity
61
Carpal tunnel syndrome- non operative tx
- Night splints to prevent chronic flexion of the wrists
- NSAIDs (Did you ask about CVD/PUD/Renal disease/Bleeding disorders?)
- Occupational Therapy
- Injections
- Ergonomic evaluation
62
Carpal tunnel syndrome: surgical tx
-surgical release (can be open or endoscopic carpal tunnel release)
63
De Quervains Tenosynovitis
=Inflammation causes thickening and stenosis of the synovial sheath
-MC in women (New Moms!!!)
- Finkelstein test positive
- Tx: thumb spica, NSAIDs,OT, injection, surgical release
64
Metacarpal fx
- Look for finger rotation
- Will need ORIF (Open Reduction Internal Fixation) if rotation or at least special casting
-Ulnar gutter splint
65
Boxer fx tx
Ulnar Gutter splint with MCPJ flexion
66
Tendon injuries: extensor vs flexor
- Flexor more concerning b/c you need it for grip
- Extensor annoying b/c fingers catch on your pockets
- Send to hand surgery
67
Mallet Finger
-Distal Extensor tendon injury
68
Mallet finger- tx *** KNOW
**Treat with a “Stack Splint” x 6 weeks for 24 hours a day hyperextension…if you remove splint and fingertip drops… you start over
(think about someone playing basketball)
69
Duputreyn’s Contracture=
=Thickening under the skin
- Affects M>F and more common in northern European descent, later decades
- -Can treat with OT, splints, injection, surgery
- MC involves the 4th and 5th fingers
70
“Trigger Finger” =
=Stenosing Tenosynovitis
-Flexor tendon “pulleys” become too thick so the tendon cannot slide through the tendon sheath, causing a catching
tx: OT, injection, tendon sheath release
May see more with repeated gripping, RA, Gout, DM
71
Boutonniere Deformity
-Typically from a “jammed” injury
-Caused by tear in part of extensor tendon causing flexion of the PIP and extension of the DIP
(think boutonniere, Button, like the Pt is pushing a button)
-Can’t flex the finger
tx: figure 8 splint
Can also be seen in Ehlers Danlos Syndrome
72
Swan Neck Deformity
=Hyperextension of the PIPJ and flexion of the DIPJ
- Seen in RA patients, trauma
- tx: splint vs. surgery
73
“No Man’s Land”
=Palm laceration
-Too much important stuff here ie Flexor tendons, Nerves/Vessels/Muscles
- Send to hand surgery emergently – ***don’t wing this
- High risk of infection (especially of tendons, which will require future surgical debridement
74
"tuft fracture"
- Smash/Crush Injury
- Treat with splint for comfort
- May need to remove nail if nail bed involvement and repair nailbed
- -Make sure tetanus is UTD
75
Bouchards Nodes
```
OA/RA – less common
More proximal (PIPJ)
```
76
Heberdons Nodes
```
OA - more common
More distal (DIPJ)
```
77
earliest place to see OA?
Basilar Joint and CMCJ of the thumb
78
CMCJ OA
-10-20x more common in females, >40 y/o
=Erosive changes of the joint
Flattening of the “cup” (Trapezius)
If conservative treatment fails (NSAIDs, OT, splinting)
**LRTI=Ligament Reconstruction and Tendon Interposition, or possible fusion
79
Thumb Injuries: “Skiers Thumb"
Stretch or tear of the Ulnar Collateral Ligament (UCL) if forceful ABDuction
- Must be splinted for healing
- May require ligament repair
80
Bennett’s Fracture
-Thumb is usually flexed when injured (such as punching)
Will usually require surgical repair
-Refer to hand ortho
-Will require OT to regain ROM and strength
81
Complications of Fractures- if surgical repair
-Infection
Limited mobility
Chronic pain
Hardware irritation
Early Arthritis with intra-articular fracture
Early intervention with PT/OT vital (especially with shoulders)
82
Complications of Fractures: non surgical fx recovery
Chronic pain
Limited mobility
Weakness of appendage
Early intervention with PT/OT vital
If intrarticular…always more complicated recovery
83
A few last thoughts on UE Ortho…
- Check above and below the joint for damage, especially after trauma
- Always check and document N/V exam
- Cast in a position of function and immobilize above and below joint
- Threaten your patients so they will quit smoking/vaping and actually heal their fracture
- When in doubt, shoot an x-ray (careful in prego pt’s) and refer
- splint fracture for 1-3 days THEN cast after swelling has gone down
- RICE Rest Ice Compression Elevation - is your friend
84
Don’t Forget the ____ could be causing this UE pain and dysfunction
C/S !!!
- Radiculopathy from an impinged nerve root can mimic joint pain
- -Impinged nerves can cause weakness in a specific myotome
- -C/S issues can present as shoulder pain
85
Other things that cause shoulder pain..
- Pancoast Tumor, rare
- Liver disease, cholecystitis
- Lung Cancer, less rare
- MI / Angina, less rare
-TOS – Thoracic Outlet Syndrome, way more common
Etc…
