Orthopedic Pathology 300 (Upper extremity pathologies)

Question 1

Glenohumeral hypermobility

Answer 1

“Hypermobility is when the humeral head translates to a greater degree” ????

Due to physiological laxity of the CT

Question 2

Glenohumeral instability

Answer 2

Instability is the inability to maintain the humeral head in the glenoid fossa

Question 3

instability (and hypoermobility?) can be described as

Answer 3

Can be classified as Anteriorly, Posteriorly, or Multi-directional

Question 4

instability can also be classified as…

Answer 4

Can be further classified as Traumatic or Atraumatic

Atraumatic is seen as either: Congenital or Repetitive injury (overhead activities)

Question 5

repetitive stress instability

Answer 5

…

Question 6

static vs dynamic stabilizers

Answer 6

Static Stabilizers:

Superior Glenohumeral Lig
Middle Glenohumeral Lig
Inferior Glenohumeral lig
Glenoid Labrum
Negative intra-articular pressure

Question 7

static vs dynamic stabilizers 2

Answer 7

Dynamic Stabilizers:

Rotator Cuff muscles
Deltoid
Long head of Biceps Brachii

Question 8

negative intraarticular pressure

Answer 8

“is the pressure in the synovial fluid (not that between the contact areas of the articulating surfaces)”

“Negative intra-articular pressure (IAP) is a passive stabilizer during joint movement.”

“In humans, negative intra-articular pressure is a considerable factor in the maintenance of shoulder stability.”

“In particular, it helps to prevent inferior displacement and keep the humeral head positioned in the center of the glenoid.”

Question 9

gh instability clinical presentation

Answer 9

Clinical Presentation

Pain
Clicking

Dead arm syndrome

Feeling of instability/apprehension/possible dislocation

Sulcus sign (multidirectional instability)

Question 10

dead arm syndrome

Answer 10

“Description. “Dead Arm” is characterized by a sudden sharp or ‘paralyzing’ pain when the shoulder is moved forcibly into a position of maximum external rotation in elevation or is subjected to a direct blow.”

“Dead arm syndrome is a condition that affects the shoulder. It’s caused by repeated movements, which place stress on the joint.”

“Dead arm syndrome is pain or weakness that occurs in the upper arm when doing a throwing movement.”

Question 11

sulcus sign

Answer 11

“The sulcus sign tests for inferior glenohumeral instability. With the patient sitting or standing, the examiner grasps the patient’s arm and pulls inferiorly. The test is positive if a dimple or sulcus appears beneath the acromion as the humeral head is translated inferiorly.”

Question 12

GH instability tx

Answer 12

Rehab; strengthening shoulder stabilizers
Surgery

Question 13

AC joint separation (shoulder separation)

Answer 13

Separation of the acromioclavicular joint

Technically a dislocation/subluxation

also considered ligament sprain/tear

Question 14

how ACJ sep

Answer 14

Usually from a traumatic fall/hit to the shoulder

Direct: Hit to acromion; hockey, rugby, football

Indirect: FOOSH, fall on elbow

Question 15

ACJ sep grades

Answer 15

Graded by the extent of damage to AC jt and surrounding ligaments

Grade 1: tearing of the AC joint capsule

Grade 2: tear of the AC joint capsule and acromioclavicular ligaments

Grade 3: tear of the joint capsule, the acromioclavicular ligaments, and coracoclavicular ligaments (conoid and trapezoid ligaments)

Question 16

3 grades, other definition (mistake on slides @ previous card???)

Answer 16

“The original grading system had three grades; non-displaced sprain (type 1), partially dislocated joint (type 2) and completely dislocated (type 3).”

Question 17

GH dislocation

Answer 17

Most commonly dislocated joint in the body

Anterior dislocation
= most common

MOI: excessive abduction and external rotation or hyperextension

Question 18

GH posterior dislocation

Answer 18

MOI: excessive flexion, adduction and internal rotation

Question 19

GH dislocation tx

Answer 19

Reduction (tractioning?)

Rest/sling

Rehab

Question 20

reduction define

Answer 20

“the action of remedying a dislocation or fracture by returning the affected part of the body to its normal position.”

Question 21

bicipital tendinitis (bicep tendinitis)

Answer 21

Degenerative changes in the tendon of the long head of the biceps muscle

Common with overhead activities

Question 22

bicep tendinitis – SSx

Answer 22

Local tenderness in the groove

Resisted elbow flexion

Pain with passive abduction
(LONG HEAD DOES ABD)

Question 23

rupture of biceps tendon

Answer 23

Due to pre-existing degenerative changes in the proximal tendon of the long head of the biceps muscle

(COULD ALSO BE DISTAL TENDON)

Question 24

how rupture (bb tend)

Answer 24

May rupture during active flexion against a resistance

Question 25

bb tendon rupture -- SSx

Answer 25

Immediate pain and “give away” Long head of the BB contract into a ball that is more distal than normal ---> (IN PROXIMAL TENDON RUPTURE) ---> in distal tendon rupture, ball is more proximal

Question 26

frozen shoulder (adhesive capsulitis)

Answer 26

A painful and significant restriction of active and passive range of motion at the shoulder joint.

Question 27

which movement most affected (adhesive capsulitis)

Answer 27

Usually affects all movements of the shoulder Most significant are abduction and external rotation

Question 28

adhesive capsulitis -- who?

Answer 28

2 - 3% of the population may experience frozen shoulder 10 – 20% of the diabetic population

Question 29

adhesive capsulitis -- gender

Answer 29

Women are more likely to be affected than men

Question 30

adhesive capsulitis -- age?

Answer 30

Most commonly occurs between 40 – 70 years of age

Question 31

adhesive capsulitis -- etiology

Answer 31

Largely unknown/unclear

Question 32

adhesive capsulitis -- primary vs secondary

Answer 32

Can be classified as Primary or Secondary Primary: idiopathic

Question 33

secondary adhesive capsulitis

Answer 33

Secondary: Intrinsic: impingement, bursitis, rotator cuff pathology, etc. Extrinsic: myocardial infarction, pulmonary disorders, breast surgery Systemic: Diabetes, Thyroid disease

Question 34

secondary adhesive capsulitis and blood flow (?)

Answer 34

may have something to do with reduced bloodflow ?? E.g. diabetes, MI, impingement

Question 35

why breast cancer and frozen shoulder?

Answer 35

"Why would breast cancer treatment predispose women to frozen shoulder syndrome? Because inactivity predisposes patients to developing frozen shoulder, and inactivity is common in breast cancer patients: Patients are recommended to limit use of the arm following surgery."

Question 36

why limit movement of arm in breast cancer patients?

Answer 36

"Protecting the arm on the side of the surgery is very important after breast surgery. Poor drainage of the lymphatic system can cause that arm to be more at risk of infection and less sensitive to extreme temperature. Be aware of activities that put too much pressure on the affected arm."

Question 37

frozsen shoulder vs collagen production?

Answer 37

"The exact cause of frozen shoulder is unknown. However, the condition is thought to be related to an overproduction of collagen in the shoulder" "It is thought to be caused by scar-like tissue (adhesions) forming in the shoulder joint."

Question 38

adhesive capsulitis pathogenesis

Answer 38

Disagreement over underlying pathological condition: ---> Inflammatory, fibrosis, neurological (?)

Question 39

frozen shoulder --- which structures invovled

Answer 39

Joint capsule is primarily involved with secondary involvement of surrounding structures Affects the anteriosuperior joint capsule, axillary recess and coracohumeral ligament Contracture of rotator cuff interval

Question 40

frozen shoulder phases

Answer 40

acute, subacute, chronic

Question 41

acute frozen shoulder phase

Answer 41

aka freezing phase or painful phase This stage can last 2 – 9 months Gradual onset of pain ---> @ Lateral area of shoulder Pain may be more severe at night; can’t lay on that side. Inflammation is present in joint capsule Muscle spasms may be present in rotator cuff

Question 42

subacute frozen shoulder phase

Answer 42

aka frozen phase or stiffening phase This stage can last 4 – 12 months Severe pain begins to diminish and stiffness becomes the main complaint ---> Pain is still present at the end ranges of motion. Atrophy may be seen in surrounding muscles d/t disuse ---> Deltoid, rotator cuff

Question 43

chronic frozen shoulder phase

Answer 43

aka thawing phase or resolution phase May resolve spontaneously after two years Some studies show as long as 5 – 10 years Full range of motion is not always regained Length of the acute phase corresponds to the length of the overall recovery time

Question 44

chronic phase prognosis/resolution (?)

Answer 44

Motion and function gradually return to normal Lateral shoulder pain and night pain continue to diminish

Question 45

adhesive capsulitis Treatment (MEDICAL MANAGEMENT)

Answer 45

Corticosteroids Manipulation under anesthetic (E.g. high velocity chiropractic adjustments) ---> can lead to possible iatrogenic complications Surgery ---> arthroscopic capsular release Nerve blocks ---> Suprascapular nerve Distention arthography NSAIDs

Question 46

nerve block?

Answer 46

the production of insensibility in a part of the body by injecting an anesthetic close to the nerves that supply it.

Question 47

arthroscopic capsular release (?)

Answer 47

Arthroscopic capsular release is a minimally-invasive surgery used to help relieve pain and loss of mobility in the shoulder from adhesive capsulitis (frozen shoulder). "Capsular release is an arthroscopic (keyhole) procedure to cut the tight capsular tissues surrounding the shoulder joint" "A radiofrequency (RF) probe is inserted into the shoulder. The probe uses RF waves to cut the tissue capsule that surrounds the shoulder joint, allowing the shoulder to move more freely."

Question 48

distention arthography (?)

Answer 48

"Arthrographic distension is a procedure where fluid is injected into the shoulder joint to break up the adhesions that might be restricting the shoulder's movement and causing disability."

Question 49

adhesive capsulitis Treatment (CONSERVATIVE MANAGEMENT)

Answer 49

Patient education Massage Modalities ---> US, electric stim, laser Manipulation/mobilization Pain free ROM/stretching Rehab

Question 50

is there a definitive treatment for adhesive capsulitis ??

Answer 50

The definitive treatment for adhesive capsulitis remains unclear even though multiple interventions have been studied "Previously published prospective studies of effective treatment have demonstrated conflicting results for improving shoulder range of motion in patients with this condition" "There is little evidence to support or refute the use of any of the common interventions listed for adhesive capsulitis" "There are also no studies with objective data supporting the timing of when to switch to invasive treatments"

Question 51

impingement syndrome

Answer 51

Inflammation, pain and edema in the tissues of the subacromion space Within the coracoacromial arch and between the acromioclavicular and glenohumeral joints

Question 52

NOTE CORACOACROMIAL ARCH (vs coracoacromial lig)

Answer 52

"The coracoacromial ligament (CAL), which restrains superior displacement of humeral head, is a component of coracoacromial arch"

Question 53

impingement syndrome and rotator cuff tendons (esp supraspin)

Answer 53

Painful compression of the rotator cuff tendons may occur when the humerus is abducted against the acromion ---> Most commonly supraspinatus tendon ---> May also affect subacromial bursa ---> and long head tendon of biceps brachii

Question 54

impingement syndrome can be classified as

Answer 54

structural vs functional

Question 55

structural impingement syndrome

Answer 55

Reduction of the subacromial area *** Can be caused by: ---> thickening of coracoacromial ligament, ---> osteophytes from degeneration of AC joint ---> or hooked acromion process

Question 56

functional impingement syndrome

Answer 56

Caused by shoulder instability or muscle imbalances

Question 57

Impingement syndrome -- clinical presentation

Answer 57

..

Question 58

impingement syndrome -- age

Answer 58

Typically seen in 40-60 year old age group Can also be seen in younger individuals: usually athletic population

Question 59

impingement syndrome --- SSx

Answer 59

Aching sensation in the shoulder ---> May go down arm along biceps Pain when abducting arm ---> @ Anterior and lateral shoulder Catching sensation when lowering arm (like catching @ medial meniscus injury) Worse with overhead activities Pain at night when lying/rolling on shoulder

Question 60

shoulder impingement test

Answer 60

painful arc test (70-120 degrees)

Question 61

three stages of shoulder impingement

Answer 61

Stage 1 – edema and hemorrhage of subacromial bursa Stage 2 – tendinitis and fibrosis Stage 3 – complete or incomplete tendinous rupture (surgery)

Question 62

which stages reversible?

Answer 62

Stage 1 and 2 are reversible with conservative care

Question 63

ELBOW

Answer 63

...

Question 64

elbow dislocation

Answer 64

Posterior dislocation of the elbow

Question 65

how elbow disl?

Answer 65

Can be due to a fall on hand with the elbow slightly flexed or severe hyperextension of the elbow(foosh, sports, mva) Usually requires significant amount of force (elbow is quite stable) Radius and ulna dislocate posteriorly and always with severe soft tissue injuries Frequently associated with fractures

Question 66

olecranon bursitis

Answer 66

Aka “Student’s elbow” Can be due to a hard impact on the elbow or constantly leaning on the elbow ---> over-use vs trauma Constant pain at olecranon Painful swelling Limited mobility

Question 67

what is other mechanism of olecranon bursitis -- other than trauma and over-use (elbow on table)

Answer 67

May also be d/t infection or inflammatory conditions (RA, PA, Gout)

Question 68

lateral epicondylitis

Answer 68

Aka tennis elbow Thought to be a premature degeneration in the flat tendinous origin of the forearm extensor muscles from the lateral epicondyle of the humerus Cause: ---> Local injury ---> Repetitive overuse of extensors

Question 69

lateral epicondylitis features

Answer 69

Pain over or near the lateral aspect of the elbow Radiation of pain down forearm Aggravated by use or stretch of extensor muscles origin Discrete point of local tenderness is present just distal to the lateral epicondyle

Question 70

medial epicondylitis

Answer 70

Aka golfer’s elbow Involves the common flexor tendon near the medial epicondyle Cause: Repetitive flexion movements of the wrist ---> Golfing, pitching a ball, grasping, lifting heavy objects

Question 71

medial epicondylitis is associated with...

Answer 71

Often associated with ulnar nerve problems (due to proximity)

Question 72

WRIST AND HAND

Answer 72

...

Question 73

lunate dislocation

Answer 73

Anterior dislocation is common Result of falling on a dorsiflexed wrist (FOOSH)

Question 74

lunate dislocation -- what happens? Sx

Answer 74

Lunate is squeezed out of place towards the palmar surface into the floor of the carpal tunnel Wrist is swollen, experience pain when trying to extend fingers, can compress median nerve

Question 75

lunate dislocation -- Tx

Answer 75

Traction with strong force on lunate (reduction?) Surgery

Question 76

lunate dislocation -- COMPLICATIONS

Answer 76

Avascular necrosis Median nerve compression DJD

Question 77

Dequervain's tenosynovitis

Answer 77

Inflammation of the abductor pollicis longus and extensor pollicis brevis tendon sheaths. Usually caused by repetitive use microtrauma from repeated thumb use, repetitive radial/ulnar deviation and forceful gripping. More common in women. Usually 30 – 50 years of age

Question 78

Dequervain's tenosynovitis -- management (Conservative)

Answer 78

Bracing (6 weeks) Avoid aggravating activities NSAIDS, Ice Massage, stretching, strengthening Corticosteroid injection

Question 79

Dequervain's tenosynovitis -- management (Surgical)

Answer 79

Endoscopic release of 1st dorsal compartment

Question 80

Trigger Finger

Answer 80

Excessive thickening of common fibrous sheath that surrounds deep and superficial flexor tendons flexor digitorum profundus/superficialis Idiopathic and spontaneous Most common in middle-aged women Thickening produces a constriction in the tunnel (stenosis)

Question 81

trigger finger -- what happens

Answer 81

Tendons become secondarily enlarged Unable to actively extend Passive finger extension “snaps” Active flexion “snaps”

Question 82

trigger finger -- Tx

Answer 82

Treatment includes immobilization in extension, steroid injections, surgery

Question 83

trigger finger -- "finger snaps"

Answer 83

"Overview. Trigger finger makes a finger get stuck in a bent position. It may straighten suddenly with a snap. The fingers most often affected are the ring finger and the thumb, but the condition can affect any finger." "Trigger finger occurs when the pulleys that help bend your fingers become too thick, leading to a popping or catching feeling as well as pain."

Question 84

trigger finger -- pathologies linked to progression/development

Answer 84

RA, PA, gout

Question 85

Mallet finger

Answer 85

Injury to the distal IP joint Commonly occurs during sporting injury

Question 86

mallet finger -- MOI

Answer 86

Active finger extension and forced distal phalange flexion (when extending, tendon contracting and tight, so when distal phalanx hyperflexion, more likely to avulse bone)

Question 87

mallet finger -- i.e.

Answer 87

Ext. Digitorum Avulsion fracture

Question 88

mallet finger -- features / SSx

Answer 88

Failure of active extension Can extend entire fingers except affect DIP Painful, swollen around DIP joint

Question 89

mallet finger -- Tx

Answer 89

Splinting 6 weeks ---> Removal before healed = finger perm. Bent Tendon will self heal

Question 90

Gamekeeper's thumb

Answer 90

A tear or complete rupture of the ulnar collateral ligament at the 1st MCP joint Due to abduction and extension of the thumb Treatment – immobilization or surgery

Question 91

Jersey Finger

Answer 91

Aka rugby finger Rupture of the flexor digitorum profundus tendon Occurs when DIP is actively flexed and is then forced into extension

Question 92

Volkmann’s Ischemic Contracture

Answer 92

Permanent flexion contracture of the hand and fingers Typically caused by fractures of the arm/forearm, leading to ischemia and necrosis of the distal tissues

Question 93

Dupuytren’s Contracture

Answer 93

Contracture of the palmar fascia Leads to permanent flexion of one or more digits ---> Most commonly the 4th digit Idiopathic: "It may be linked to cigarette smoking, alcoholism, diabetes, nutritional deficiencies, or medicines used to treat seizures"