Ortho- Upper Flashcards
1
Q
Normal elbow rom degrees
A
Flexion 140
Extension 0
Pronation and supination 90
2
Q
Normal wrist ROM degrees
A
Extension and flexion 90
Ulnar and radial deviation 30
3
Q
Manual muscle grading
A
5/5 complete ROM against max resistance 4/5 complete ROM w moderate resistance 3/5 against gravity 2/5 complete ROM w gravity removed 1/5 no ROM, isometric muscle contraxn 0/5 no muscle contraction
4
Q
Can have impingement of….
A
Subacromial bursa
Rotator cuff
(Compressed between humeral head and acromion)
5
Q
Epidemiology of impingement/bursitis/tendonitis
A
Middle aged adults
Atraumatic onset
Repetitive overhead work
Gradual progression
6
Q
Impingement symptoms
A
Pain w overhead reaching, lifting Night pain Ache Catching at about 80-120 degrees, painful arc No acute onset
7
Q
Generalized tenderness, rarely point tender
Possible slight decrease in AROM
Full PROM
Manual muscle testing normal (possible slight decrease secondary to pain)
A
Impingement
8
Q
Pos impingement sign
Pos Hawkins maneuver
A
Impingement
9
Q
Impingement diagnostics
A
Physical exam
X Rays- a/p, axillary lateral (may show subacromial spur)
10
Q
Impingement treatment
A
Relative rest…eliminate aggravating factors
NSAIDS
Cortisone injection
Physical therapy…RC strengthening
Surgery..arthroscopic subacromial decompression
11
Q
4 muscles of rotator cuff
A
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
12
Q
Rotator cuff tear
A
Complete or partial disruption of musculotendonous complex
13
Q
Seen in older adults, rarely younger than 30
Rarely traumatic
May result from prolonged impingement
A
Rotator cuff tear
14
Q
May or may not have specific MOI
Pain or weakness w elevation/rotation
Progressive in nature
Pain at night
A
Rotator cuff tear
15
Q
Possible muscle atrophy, tenderness w palpation, crepitus w PROM
Decreased AROM
Pain w AROM (elevation, ext rotation)
Minimal pain w PROM
Weakness and pain w manual muscle testing
A
Torn rotator cuff physical exam
16
Q
Special tests with torn rotator cuff
A
Impingement sign Hawkins maneuver Drop arm tst Empty can test Lift off test
17
Q
X Rays with rotator cuff tear
A
May show subacromial spur
May show calcific tendonosis
18
Q
MRI with rotator cuff tear
A
Definitive but not 100%
Expensive!!
19
Q
Conservative rotator cuff tx
A
PT
cortisone injections
NSAIDs
20
Q
Surgery w rotator cuff tear
A
Arthroscopic or open repair of RC
21
Q
Possible consequences of RC tears
A
RC arthritis and or arthropathy
22
Q
Normal shoulder ROM degrees
A
Forward flexion 180 Abduction 180 Adduction 60 Extension 60 Internal and external rotation 90
23
Q
Shoulder separation
A
Acromioclavicular stress or disruption
May involve other structures
24
Q
Can occur at any age, but usually young adults to middle aged
History of specific trauma..fall on “point of shoulder”
A
Shoulder separation
25
```
Sudden onset of pain after trauma
Felt pop or crunch in shoulder
Pain w or without motion
Decreased ROM
Arm "went dead"
```
Shoulder separation
26
Can have obvious deformity depending on grade
Depressed affected shoulder
Unwillingness to move arm
Decreased AROM and PROM secondary to pain
Shoulder separation
27
Shoulder separation special tests
Cross arm test
Pain w horizontal abduction
Spring test
28
X ray of shoulder separation
A/P
| Possible bilateral
29
Conservative shoulder separation tx
For grades 1-3
Immobilization in sling for 1-3 weeks then PT
Rest
NSAIDs
30
Surgical tx for shoulder separation
For grades 3-6
| Needed if unstable or cosmetic
31
Degenerative arthritis of AC joint
Usually in middle aged men
Manual laborers, weight lifters, athletes
May have initial traumatic event
AC degenerative joint disease
32
Rarely known moi
Pain at AC joint
Pain w pushing, horizontal adduction
Pain laying on shoulder
AC DJD
33
```
May have AC hypertrophy
Tenderness at AC joint
May have crepitus
Normal AROM and PROM
MMT normal
```
AC DJD
34
Special test for AC DJD
Cross arm test
35
X Ray with AC DJD
A/P and axillary lateral
| Will show evidence of degenerative changes
36
Conservative tx of AC DJD
Rest
NSAIDs
Cortisone injection
37
Surgical tx of AC DJD
Excision of distal clavicle (Mumford procedure)
38
Clavicle fracture
Very common among active
Usually between middle and lateral third of clavicle
Great variability in size, deformity
39
History of trauma
Pt feels crepitus at fx site
Pain w AROM/PROM and at rest
Clavicle fracture
..pt often knows and will tell you "I broke my collar bone"
40
Clavicle fracture physical exam findings
```
Obvious deformity
Pain over fx site on palpation
Possible crepitus w palpation
Pain with AROM and PROM
MMT intact but painful
```
41
X Rays in clavicle fracture
A/P
Usually easily seen
Bone fragments usually overlap
42
Treatment of clavicle fx
Conservative...sling 3-4 weeks
Gradual return to rom, activity
...if unstable, surgery may be required
43
Generalized laxity of glenohumeral joint
Dislocation..full disarticulation of GH joint
Subluxation..partial disarticulation
Shoulder instability
44
Most common in younger patients..overhead athletes
Can be Traumatic (95% are anterior dislocations)
90% will reoccur
Can be atraumatic.."voluntary dislocators"
Shoulder instability
45
```
Usually traumatic event
May or may not relocate spontaneously
Dead arm
Pain and apprehension w ROM
Sense of instability
May sense clicking in GH joint
```
Shoulder instability
46
```
PE reveals...
Flattened deltoid
Prominent acromion
Pain
Arm held in splinted position
Dramatically reduced AROM/PROM
```
Shoulder dislocation
47
```
PE shows...
Normal shoulder appearance
Non tender palpation
Near full ROM
MMT normal
```
If shoulder dislocation has been reduced
48
```
Anterior/posterior humeral drawer
Sulcus sign (inferior instability)
Anterior apprehension w passive ext rotation
Relocation test
Ant/post load and shift test
Active compression test (labral tear)
```
Special tests for shoulder dislocation
49
X Ray for shoulder instability/dislocation
A/P, axillary lateral, Y view
**always X-ray first time dislocators!!!!
Always x ray post reduction
Must suspect fx and or Hill-Sach lesion
50
Best diagnostic way to assess in Bankart lesion in shoulder dislocation
MRI
51
Conservative tx for shoulder instability
Modify activity
Physical therapy-RC strengthening
NSAIDs
52
Surgical tx for shoulder instability
Bankart (labral) tear
| Capsulorrhaphy
53
Frozen shoulder
Insidious onset
Unknown cause..probably inflammatory
Most common among middle aged women
Adhesive capsulitis
54
```
No known injury or onset
Gradual progression
Gradually limited ROM
Pain at limits of motion
Pain at night
```
Adhesive capsulitis
55
```
PE shows..
Normal appearance
Minimal tenderness on palpation
Decreased PROM/AROM
Pain at limits of motion
MMT normal
```
Adhesive capsulitis
56
Diagnosis of adhesive capsulitis made by...
History and physical exam
| Take x ray to rule out other bony pathology
57
Adhesive capsulitis treatment
```
Physical therapy
NSAIDs
Cortisone injection
Manipulation under anesthesia
**may take over a year to resolve!!!**
```
58
Most common dislocation in children
50% are result of sports
Fall on out stretched hand is MOI
Most (98%) are posterior
Elbow dislocation
59
Traumatic event
Arm held at side in splints position
Immediate pain
Inability or unwillingness to move elbow
Elbow dislocation
60
```
PE shows...
Obvious deformity..prominent olecranon
Swelling
Pain w palpation
Decreased AROM
```
Elbow dislocation
****MUST ASSESS NEUROVASCULAR STRUCTURES WITH AN ELBOW DISLOCATION
61
X ray with elbow dislocation
Not initially necessary
Must perform post reduction
*high incidence of associated injury or fx
62
Elbow dislocation tx
Reduction
Splint/cast for 1-3 weeks
Initiate early ROM exercise to reduce chance of flexion contracture
NSAIDs
63
"tennis elbow"
Inflammation or degeneration of wrist extensors
Usually in middle aged adults
Overuse injury (golf, tennis, construction workers)
Lateral epicondylitis
64
Gradual onset, no MOI
Pain w repetitive wrist flexion/extension
Possible localIzed swelling
Pain may radiate down forearm
Lateral epicondylitis
65
```
PE shows..
Normal inspection of elbow
Point tenderness at lateral epicondyle
Normal ROM
Pain w passive wrist flexion
Pain w active wrist extension
```
Lateral epicondylitis
66
Lateral epicondylitis treatment
```
Eliminate aggravating factors
NSAIDs
Ice and heat
PT
Tennis elbow strap
Cortisone injection
Surgical release/fasciotomy
```
67
Inflammation of olecranon bursa
Usually precipitated by traumatic event
Any age
Olecranon bursitis
68
```
Quick onset
May have known MOI
Pain w pressure on elbow
Variable swelling
Tightness with ROM
May have fever, erythema if infected
```
Olecranon bursitis
69
Obvious olecranon swelling
May have erythema and intense pain on palpation (suspect infection!)
May not be tender on palpation if chronic
Slight decrease in ROM
Strength in tact
Olecranon bursitis
70
Treatment in olecranon bursitis
```
Aspirate fluid! (Send for analysis..culture, crystals)
Compression wrap/padding
NSAIDs
Heat and or ice
Cortisone injection
```
71
If olecranon bursitis is infectious...
Treat cultured pathogens
| Incision, drainage and packing
72
Entrapment of median nerve under transverse carpal ligament
Most common nerve entrapment syndrome
May result from inflammation, fluid retention, trauma, overuse
Carpal tunnel syndrome
73
```
No known MOI
Pain w typical static ADLs
Pain and numbness into median distribution
Night pain is common
Weakness of thumb, grip strength
```
Carpal tunnel
74
```
PE shows...
Thenar atrophy
Tenderness at palmar wrist area
ROM normal
Decreased thumb opposition strength
Decreased/abnormal sensation in median distribution
```
Carpal tunnel
75
Special tests for carpal tunnel
Phalens test
Tinels sign
Decreased 2 pt discrimination
76
Diagnostics in carpal tunnel
Nerve conduction studies
77
Carpal tunnel conservative treatment
Night splints
NSAIDs
Activity modification
Cortisone injection
78
Carpal tunnel surgical treatment
Release of transverse carpal ligament
79
Inflammation of tendon sheath (synovium) surrounding tendons of thumb (tenosynovitis)
DeQuervians disease
80
Which muscles/ tendons involved in DeQuervains disease
Extensor pollicus brevis
| Abductor pollicus longus
81
Pain with repetitive motion of thumb
Possible swelling
Stiffness
Weakness
DeQuervain disease
82
```
PE shows...
Possible swelling
Point tender over tendons at CMC joint
Pain w resisted thumb opposition
Pain w thumb flexion
```
DeQuervain
83
Special test for DeQuervain disease
Finkelstein
84
Diagnostics for DeQuervains disease
X ray to rule out bony pathology like OA
| Labs if diagnosis is in doubt (?gout)
85
DeQuervain conservative tx
NSAIDs
Splint
Cortisone injection
*symptoms usually resolve by 1 year
86
Surgical treatment for DeQuervain
Fasciotomy of 1st dorsal compartment
87
```
Most commonly fractured carpal bone
Blood enters distal third of bone
High rate of non unions (50-90%)
20-40 year old men most common
Rare in children
```
Scaphoid fracture
88
MOI falling on out stretched hand
Pain at base of thumb and or wrist
Pain w rom and gripping
Scaphoid fx
89
```
PE shows...
Possible swelling
Pain w palpation of snuffbox
Decreased rom due to pain
Pain with MMT
```
Scaphoid fx
90
X-rays w scaphoid fx
Scaphoid views (ulnar deviation and oblique)
Most likely negative initially!!
**must repeat X-ray 2 weeks post injury
Look for fx or signs of healing
91
Bone scan with scaphoid fx
Shows evidence of generalized metabolic activity
92
Tx of scaphoid fx
Cast at least 2 weeks (even if no fx seen initially)
Total cast time can be up to 12 weeks
Re X-ray at 2 weeks to assess healing
93
If scaphoid fx is healing at 2 week X-ray....
Recast for at least another 4 weeks
94
If X-ray after 2 weeks of scaphoid shows no fx...
Splint for 2 weeks
95
If X-ray after 2 weeks after scaphoid fx shows displacement..
Refer to surgeon
96
Rupture of extensor tendon at distal phalynx
| Most common extensor injury
Mallet finger
97
Hyper flexion injury
Pain and swelling at distal fingertip
Inability to extend fingertip
Mallet finger
98
```
PE shows...
Swelling and ecchymosis at DIP
pain on palpation
DIP at slight flexion
Cannot actively extend DIP
```
Mallet finger
99
Mallet finger tx
Splint DIP in full extension
Wear splint for 4 weeks
Initiate gentle ROM after splint removed
100
Rupture of flexor digitorum profundus
Jersey finger
101
Known moi
Pain and swelling at distal finger
Inability to flex fingertip
Jersey finger
102
PE shows..
Swelling and ecchymosis at dip
Pain at DIP joint
Unable to actively flex DIP
Jersey finger
103
Jersey finger treatment
Initially splint finger in flexed position
Refer for surgical eval
**all flexor tendon injuries require surgical repair****
104
Tear of the central slip (median band) of extensor tendon at PIP level
PIP flexes due to unopposed action of FDS
DIP joint extend due to pull of intact lateral bands
Boutonnière deformity
105
Hx of trauma
Inability to extend PIP joint
Pain w any active motion
Boutonnière deformity
106
PE shows...
Pain and swelling at pip joint
Inability to actively extend PIP
Boutonnière deformity
107
Boutonnière treatment
Splint PIP joint in extension
May leave DIP joint free for motion to avoid stiffness
Splint for at least 6 weeks
Gradually initiate ROM exercises after splint removed
