UE Flashcards
1
Q
Rotator cuff action
A
Stabilize shoulder by depressing the humeral head against glenoid
2
Q
Rotator cuff muscles and their actions
A
Supraspinatus, Infraspinatus, Teres Minor- External rotation and abduction
Subscapularis- internal rotation
3
Q
Most common cause of rotator cuff tears
A
repetitive micro-trauma (overuse)
4
Q
Most common rotator cuff tear
A
supraspinatus (tear in order)
5
Q
Sx of rotator cuff injury
A
pain over anterior & lateral aspects of should (radiates to deltoid, occurs initially with overhead activity then progresses to sx at rest); ROM decreased (abduction past shoulder level), should may catch
6
Q
Tests for rotator cuff
A
(+): Drop arm (complete tear), empty can, neers impingement, hawkpin
7
Q
Weakness tests for rotator
A
drop arm, empty can
8
Q
Pain test for rotator
A
neers, hawkins
9
Q
Types of rotator cuff injuries
A
tendonosis, tendonitis, tear (chronic/acute)
10
Q
Tendonosis
A
Chronic degneration of the muscles typically with AGE (weakness)
11
Q
Tendonitis
A
INFLAMMATION associated with repetitive trauma associated with everyday movement of the shoulder (pain)
12
Q
Chronic rotator tear
A
degeneration, impingement due to overload; overhead occupation
variations in should structure causing narrowing under outer edge of clavicle
majority start as partial tear of suprapsinatus and progress to complete (involving SITS) and biceps tendon
13
Q
Acute rotator tear
A
TRAUMA;
Suspicion with acute should pain and negative radiograph
Significant force if person <30 yo
Often seen with labral pathology
14
Q
Acute rotator tear is usually seen with
A
labral pathology
15
Q
Major risk of tendonitis/impingement
A
Repetitive overhead activity
16
Q
Sx of tendonitis/impingement of rotator
A
pain comes on GRADUALLY
deep ache in lateral shoulder that radiate to deltoid
POINT TENDERNESS
ROM painful >90 degrees, improves with analgestics
may lead to chronic tear
17
Q
Tests for impingement of rotator
A
Hawkins, neer
18
Q
Who is most likely to have a chronic tear
A
men older than 40
19
Q
Sx of chronic tear
A
pain worse with overhead activities and at night;
worsening pain followed by weakness
subacromial tenderness/bursitis
decrease in ability to move arm, especially abduction
Restricted ADL’s >90
20
Q
PE for tear
A
weakness of abduction and external rotation
loss of smoothness of overhead reaching and ability to lift 2-5 lb weights overhead
atrophy may be present in large tears
weakness does not improve with anlagesics
21
Q
Apleys scratch test
A
loss of range of motion; rotator cuff problem
22
Q
Neer’s
A
subacromial impingement
23
Q
Hawkin’s
A
supraspinatus impingement
24
Q
Drop-arm
A
rotator cuff tear
25
Cross-arm test
acromioclavicular joint arthritis
26
Spurlings test
spine extended with head rotated to affected should: cervical nerve root disorder
27
Apprehension test
anterior pressure with external rotation; anterior glenohumeral instability
28
Relocation test
posterior force on humurus while externally rotating the arm: anterior glenohumeral instability
29
Sulcus sign
inferior glenohumeral instability
30
Yergason
biceps tendon instability or tendonitis
31
Speed's
biceps tendon instability or tendonitis
32
Clunk sign
rotation from extension to forward flexion; labral disorder
33
Dx for rotator cuff
Lidocaine injuection test (10 mL to subacromial space- Neer's test)
Radiographs (elevation of humeral head >1 cm - tear)
U/S: limited use
MRI: STUDY OF CHOICE when full thickness tear is suspected or pt has failed conservative tx
MR Arthrography PREFERRED and can also evaluate labral pathology
34
Rotator cuff test of choice
MR arthrograph, or MRI
35
Acute therapy for rotator cuff
ice, NSAIDs, weighted pendulum stretching (5 min BID), restrict overhead positioning, shoulder immobilizer for SHORT TIME,, after rest consider PT
36
Tx for persistent rotator cuff sx
Subacromial steroid injection (rest several days after, no more than 3-4/year)
Surgery: arthroplasty or joint arthroplasty (pain vs. mobility trade off)
37
Shoulder impingement syndrome
compression causing pain and dysfunction: compression of rotator cuff tendons and subacromial bursa between humeral head and lateral edge of acromion process
38
Risk for shoulder impingement syndrom
anatomical variance (osteophytic changes) or previous injuries (clavicle fracture, AC separation)
39
Impingement can lead to
bursitis, rotator cuff tendonitis, degenerative changes
40
Principle cause of rotator cuff tendonitis
Shoulder impingement syndrome
41
Degree of impingement
pain reproduced by flexion-internal rotation maneuvers (neer's hawkins);
Pain at 90 degrees: mild
Pain at 60-70: moderate
Main 45 or below: severe
42
Imaging for impingement
Radiography (anatomical variance)
MSK U/S
MRI: rule out cuff tear
43
Tx for impingement
Ice, NSAIDS, activity modification (no sling)
PT referall: F/U after 2-3 weeks to confirm improvement
Possible corticosteroi; surgery if sx are severe and anatomic variant could be improved
44
Labral tear MOI
acute (FOOSH, sudden pull); repetitive overuse (throwing athletes, laborer)
45
Presentation of labral tear
acute: pain
Chronic: clicking/catching
frequently associated with other should pathology
Bankhart vs. SLAP tear
46
Bankart lesion
inferior tear of rim often associated with dislocation
47
SLAP lesion
superior labrum anterior posterior; curved fashion
48
PE for labral tear
biceps tendon: Pain
glenohumeral joint: restricted internal/external rotation
Scapula: motion dysfunction
Specialized: Anterior glide test, speeds, o'brien's
49
Specialized tests for labral tear
anterior glide test, speed's test, O'briens
50
Imaging for labral tear
1. Radiograph
2. MRA>MRI: preferred (more beneficial in pts <35 yo)
3. Arthoscopy (DEFINITIVE FOR DX)
51
Definitive dx for labral tear
Arhtroscopy
52
Tx for labral tears
nonsurgical preferred; NSAIDs or acetaminophen and PT
53
Adhesive capsulitis (frozen shoulder)
chronic shoulder pain with gradual global limitation in ROM (stiffened glenohumeral joint, may develop adhesion)
54
Etiology of adhesive capsulitis
idiopathic
| secondary to injury, trauma, overuse, bursitis or sling use
55
Dx of adhesive capsulitis
ROM testing (decreased in 2+ planes- passive and actie)
Severe shoulder pain
Mechanical restriction
Abduction and external rotation most commonly affected
Apley's scratch test (T8-T10 is normal)
Injection test: won't help
56
Imaging for adhesive capsulitis
Radiography- most are normal but routinely ordered
| MRI or MRA: not needed but may be helpful; thickening of joint capsule and ligaments
57
Tx for adhesive capsulitis
treat underlying process, stretch, restore ROM, CONSULT PT
58
Acromioclavicular injury MOI
fall onto the tip of the shoulder with arm tucked into side (football)
59
Sx of acromioclavicular injury
bump on shoulder that is worse at bedtime
60
Ligaments in acromioclavicular joint
Coracoclavicular ligament (trapezoid + Conoid), coracoacromial ligament, acromioclavicular ligament
61
PE of AC joint injury
```
swelling/deformity (3rd degree)
AC joint tenderness
Pain aggravated by downward traction (test for instability)
(+) cross over test
Dx confirmed with radiographs
```
62
Dx of AC joint injury
radiographs
63
AC sprain/separation degrees
Grade 1: ac joint intact, capsular distension, ligament stretch (sprain) without separation, point tenderness;
NORMAL RADIOGRAPHS
Grade 2: Separation of superior and inferior AC ligaments, instability with stress testing at AC joint, decreased ROM, CORACOCLAVICULAR LIGAMENTS INTACT with only partial tear or sprain; radiographs: inferior margin of distal clavicle lies above inferior margin of acromion, but below superior margin
Grade 3: separation of superior and inferior AC ligaments AND coracoclavicular ligaments, clinical deformity, instability, decreased ROM, severe pain; Radiographs: inferior margin of clavicle at or above superior margin of acromion
64
Dx of AC sprain
PE and plain radiograph
65
Goals of AC tx
reduce direct pressure and traction at AC joint to allow reattachment of ligaments
66
Tx for AC Injury
shoulder immobilizer for 3-4 weeks
Ice, rest, NSAIDS, and corticosteroid injection if not improving after 2-4 weeks
Surgical: grade III with fixation, ligament reconstruction, distal clavicle resection (not usually needed/supported)
67
Clavicle fracture location
Most: middle 1/3 (displaces superiorly and may be comminuted)
Some: distal 1/3 (may look like AC separation)
Few: proximal 1/3 (internal organ evaluation is essential, R/O sternoclavicular dislocation or physeal fx in peds pts)
68
What must you evaluate for in proximal clavicle fx
Internal organs (lungs)
69
Sx of clavicle fracture
```
visual deformity (evaluate for open fx or tenting)
TTP
Decreased ROM (apprehensive and guarded)
```
70
Imagining for clavicle fracture
single AP radiograph of clavicle
71
Tx for clavicle fracture
Conservative for non-displace or minimally displaced; conservative for nearly all pediatric patients (sling, figure 8 harness, analgesics, muscle relaxers, sleep upright, discuss cosmetic concerns)
Ortho referral: displaced mid clavicle fx and all proximal and distal 1/3 fxs, surfery
72
Muscle relaxers may be good tx for
Clavicle fracture
73
Subacromial bursitis
inflammation or degeneration of the sack-ike structure due to repetitive movement injury; may result from systemic disease (RA, gout, sepsis)
74
Sx of subacromial busitis
```
pain with ROM and at rest
Occasional decreased ROM due to pain
Localized TTP
Not usually isolated finding (rotator cuff tendonitis)
May cause impingement syndrome
```
75
Dx of subacromial bursitis
CLINICAL
Radiographs-limited benefit
U/S for injections
Fluid aspiration - C&S if sepsis suspected
76
Tx for subacromial bursitis
ICE AND NSAIDS
restrict overhead use
aspiration and corticosteroid injection
77
Biceps tendonitis
inflammation of the long head of the biceps tendone as it passes through bicipital groove
78
Cause of biceps tendonitis
repetitive lifting
79
Sx of biceps tendonitis
pain anterior should with abduction and ext. rotation
maximal point of tenderness at biciptal groove
popping sensation
weakness
"popeye" deformity with rupture
80
Tests for biceps tendonitis
Speed's, yergason's
81
Dx of biceps tendonitis
CLINCIAL
U/S beneficial
(radiographs and MRI only rule out underlying pathology or concerns)
82
Goals for biceps tendonitis treatment
reduce tendon inflammation and swelling
strength biceps
prevent rupture
83
Tx for biceps rupture
surgery rarely indicated unless younger patient who are laborers or athletes
84
Tx of biceps tendonitis
NSAIDs, Rest, PT, steroid?, surgery
85
Glenohumeral subluxation/dislocation
shoulder instability can be in one direction or multidirectional (usually ANTERIOR)
86
Sx of shoulder dislocation
arm held in position of protection, sulcus sign, apprehension and relocation test
87
Dx of shoulder dislocation
radiograph and MRI if needed (AP, Y, and axillary); suclus sign, apprehnsion test
88
Tx for shoulder dislocation
Multi-axial instability required PT and education, analgesics, ice and rest needed episodically
Immediate reduction if needed
Shoulder immobilizer: sling and swatch x 2-4 weeks
Analgesics
PT
Surgical intervention with repeat dislocations
89
What requires shoulder immobilizer
Glenohumeral dislocaiton, rotator cuff, AC injury
90
Special considerations for shoulder dislocation
Bankart lesion
Hills Sachs lesion
Axillary nerve
91
Bankart lesion
detachment of anterior inferior labrum from glenoid rim
92
Hill sach's lesion
cortical depression of posterolateral humeral head when humeral head is impacted by anterior rim of glenoid (fracture of humeral head)
93
Axillary nerve test
decreased sensory to lateral should (mid deltoid) and decreased deltoid function
94
Elbow epicondylitis sx
overuse syndrome; localized pain and swelling
95
Two types of elbow epicondylitis
1. Medial: Golfer's elbow: wrist flexors, pronator muscle group
2. Lateral: tennis elbow: wrist extensors, supinator muscle group
96
Most common elbow epicondylitis
Lateral tennis elbow
97
Effects wrist extensors
Lateral epicondylitis
98
Effects wrist flexors
medial epicondylitis
99
Imaging to elbow epicondylitis
x-ray if concerned for loose bodies, fracture, exostosis
100
Tx for elbow epicondylitis
Acute: sling, wrist brace, ice, anti-inflammatory
Preventative: forearm strap, minimize repetitive activity and correct technique
Reccurent: steroid, surgery for debridement
101
Olecranon bursitis cause
trauma, prolonged pressure (occupation), infection (pus), rheumatologic
102
Sx of olecranon bursitis
swelling, +/- pain, +/- restricted ROM
Infection: erythema, warmth
103
Tx for olecranon bursitis
ice, NSAIDs, aspiration (C&S), abx +/- surgery for infection
104
Prevention of olecranon bursitis
elbow pads/sleeve;
| activity changes
105
Cubital tunnel syndrome
compression of the ulnar nerve caused by repetivie motion, constant pressure, fluid or trauma
106
Where does the ulnar nerve run
behind medial epicondyle
107
Sx of cubital tunnel syndrome
ulnar neuropathy (RF/LF tingling or numbness)
decreased grip strength
Chronic: muscle wasting
108
Dx of cubital tunnel
Radiograph, nerve conduction studies
109
Tx of cubital tunnel
NSAIDs, Bracing, PT, Surgery: cubital tunnel release +/- ulnar nerve transposition
110
Carpal tunnel syndrome (CTS)
pain, parasthesia and weakness in median nerve distribution of the hand; pain WORSE AT NIGHT (2-3 hours after falling asleep)
111
Pathogenesis of CTS
repetitive activities result in swelling of synovium or thickening of transverse carpal ligament leading to compression of the nerve
112
Most likely to get CTS
typer/computer use
Congenital smaller tunnel
Females 2:1
113
Most common neuropathy in UE
CTS
114
Other potential causes of CTS
```
direct pressure (osteophytes, anomalous muscle bodies, tumors, hypertrophic synovium, infection)
CT disorders (lupus, gout, scleroderma, polymyalgia rheumatica)
trauma
Pregnancy, long-term renal failure, hypothyroidism
```
115
Chronic progression of CTS
Early: pain intermittent and described as dull ache at risk during and shortly after use
Late: burning pain, numbness, and tingling
116
Pain in UE that often wakes you up at night
CTS
117
PE for CTS
compare color, temp and texture BL
evaluate for thenar muscle atrophy
decreased sensory along median nerve distribution
Decreased gril strength
118
Testing for CTS
Tinels and Phalen's
119
Dx of CTS
wrist x-ray in trauma or rheumatologic disease
grip strength testing
Nerve conduction study (NCS)
Electromyogram
120
NCS
can test both sensory and motor nerves; records time from stimulus to response; delayed in CTS because of demyelination of median nerve fibers
121
Electromyogram (EMG)
needle inserted into muscle to measure electrical activity with muscle relaxed and fully contracted; denervated muscle spontaneously fires during relaxation and produces fibrillation
122
Tx of CTS
Acute (traumatic): require immediate decompression
Chronic: NSAIDS, local steroid injection, brace (working and/or night), PT
Surgery (endoscopic or open)
123
Ganglion cysts
collection of synovial fluid within a joint or tendon sheath; herniation of synovial tissue from capsule or tendon sheath
124
Sx of ganglion cysts
soft mobile mass; fluctuates in size, often with activity; may restrict motion or become painful with repetitive activity
125
Common locations of ganglion cysts:
dorsal radial and volar aspects of wrist
126
Tx for ganglion cysts
NSAIDs - may resolve spontaneously
Aspiration and steroid injection
Surgery for recurrence
127
De Quervain's Tenosynovitis
inflammation of the 1st dorsal compartment of the hand involving the sheath of the abductor pollicis longus and extensor pollicis brevis
128
Cause of De Quervain's
overuse/repetitive gripping
129
Who is at increased risk for De Quervain's?
```
Hormonal changes (postpartum)
W>M, 30-50
```
130
Sx of De Quervain's
pain/swelling along dorsal radial wrist; pain aggravated by thumb and wrist motion (gripping)
131
Test for De Quervain's
Finkelstein
132
Tx for De Quervain's
```
diminish repetitive activity
Thumb spica immbolization
NSAID's
Steroid injection
Surgical referral: decompress 1st dosral compartment
```
133
Boutonniere Deformity
Flexion of PIP
Hyperextension of DIP
Ruptured central slip extensor tendon mechanism
134
Swan neck
Hyperextension of PIP
Flexion of DIP
Volar plate attenuation of PIP joint
135
Dupuytren's Contracture
CT disorder; progressive fibrosis of the palmar fascia
136
Dupuytren risk factors
Males, Northern European descent, >40-50
| Risks: EtOH abuse, smoking, diabetes
137
Sx of Dupuytren's
painless nodules develop into palpable cords along palmar surface (irreversible contractures);
extension loss of fingers (RF and SF most often
138
Dx of Dupuytren's
CLINICAL, no imaging
| severity based on amount of contracture
139
Test for Dupuytren's
Hueston table top test: test ability to flatten hand on table
140
Tx for Dupuytren's
observation
Stretching, splinting, massage do not help progression
Glucocorticoid injection if it becomes painful (tenosynovitis) or for rapid growth of nodules
Surgical referral: progressive presenetation (flexion contraction of >30 degrees at MCP or any PIP flexion is noted; inability to perform Hueston)
Collagenase injections: milder presentation w/ mixed results and high risk of recurrence
141
When to refer for surgery with Dupuytren's
Flexion contracture >30 degrees at PIP
Any DIP involvement
Inability to perform Hueston Table Top Test
142
Stenosing Flexor Tenosynovitis
Trigger thumb/finger
143
Resembles deputyrens
Stenosing flexor tenosynovitis (trigger finger)
144
At risk for trigger finger
W>M, affects both adults and children
145
Trigger finger
idiopathic, benign, and OCCURS SPONTANEOUSLY;
| nodule forms at volar aspect of MCP (mechanical impingement, flexor tendon irritation and inflammation)
146
Sx of trigger finger
digit snaps, catches, or locks with passive/active ROM at IP/PIP- nodule is unable to easily glide through A1 pulley, pt. may need to forcefully unlock digit; progressively becomes painful; concern for contracture if tx not provided
147
Dx of trigger finger
Clinical, no imaging
148
Tx of trigger finger
NSAIDs
Local corticosteroid injection
Surgery to release A1 puller
149
Local glucocorticoid tx used with
CTS, Deputyren's, Stenosing flexor tenosynovitis (trigger finger)
150
Bone tumor/lesion concerning features on radiography
```
Indistinct margin
Abnormal periosteal reaction
Soft tissue mass/invasion
Rapid growth
Pathologic Fx
```
151
Lesions >30
```
Metastasis Myeloma Lymphoma
Metastasis Myeloma HPT
Encondroma Chondrosarcoma
Giant CT
Geode
```
152
Benign lesions
```
Unicameral bone cyst (UBC)
Aneurysmal bone cyst (ABC)
Non-ossifying fibroma (NOF)
Giant Cell Tumor (GCT)
Osteoid Osteoma (OO)
Osteochondroma (exostosis)
```
153
Unicameral bone cyst aka
Simple bone cyst
154
Most common benign tumor
UBC
155
UBC qualities
fluid filled cavity in the bone;
| long bones: upper humerus & femur
156
Imaging for UBC
plain radiograph and MRI or CT if needed
| Bone scan occasionally: evaluate for more cysts
157
Tx for UBC
may resolve spontaneously, observation
Surgery: recurrent pathologic fractures
158
When not to do surgery for UBC
pediatrics: avoid tx if near physis until older, high recurrence rate
159
Aneurysmal Bone Cyst (ABC)
Blood filled cyst in the bone;
Location: spine and extremities
Benign but aggressive
160
Dx for ABC
Radiographs
MRI: fluid-fluid levels
Bx
161
Tx for ABC
refer to ortho for surgery
162
Non-ossifying fibroma (NOF)
benign lesion
MES: metaphyseal, eccentric (on side), sclerotic borders (dense around)
asymptomatic or pain associated with pathologic fx
163
NOF is a MES
Metaphyseal
eccentric (on side of bone)
Sclerotic borders
164
Imaging for NOF
radiograph (usually incidental)
| may have patho fx
165
Tx for NOF
observation with serial radiographs
Ortho referral: lesion >50% diameter of the bone
166
When to refer to ortho for NOF
lesion >50% diameter of bone
167
Giant Cell Tumor (GCT)
benign, aggressive tumor
May develop as growth plate closes: metaphyseal/epiphyseal;
localized pain and possible weakness
168
Aggressive benign tumors
ABC, GCT
169
Painful bone lesions
GCT
Osteoid osteoma (worse at night, NSAIDs relieve)
Osteochondroma (painful with activity, tingling near nerve)
Osteosarcoma/Ewings (sometimes)
Chondrosarcoma (w/ weakness)
170
Imaging for GCT
plain radiograph, MRI, bone scan (hot spot)
171
Osteoid Osteoma
small benign bone tumor: children and adults
| Nidus-center (dot inside) of growing cells surrounded by thickened bone
172
Sx of osteoid osteoma
dull aching pain
Severe night pain*
NSAIDs relieve pain*
173
Imagine for OO
plain radiographs, CT scan
| labs to r/o infection
174
Tx of OO
Refer to ortho or interventional radiology
| CT guided radiofrequency ablation
175
Osteochondroma aka
Exostosis
176
Osteochondroma
abnormal growth of bone and cartilage along surface of the bone
177
Most common benign bone tumor
Osteochondroma (pedunculated or sessile)
178
Sx of Osteochondroma
fixed, non-mobile mass near joints; may be painful with activity;
tingling or numbness if near nerve
179
Tx for osteochondroma
observation; refer if painful
180
Malignant Tumors
Osteosarcoma and Ewing's Sarcoma
| Chondrosarcoma
181
Osteosarcoma & Ewing's sarcom
malignant primary bone tumors;
| osteosarcoma most common bone tumor in children
182
Most common bone tumor in children
Osteosarcoma
183
Sx of osteosarcoma
Asymptomatic vs. pain and swelling
| pathological fracture
184
Tumor most common in kids
Osteosarcoma & Ewing's sarcoma
185
Dx for osteosarcoma/ewing's
radiographs, MRI, CT, bx
186
Tx for osteosarcoma/ewing's
refer to ortho and oncology
187
Chondrosarcoma
bone tumor composed of carilage-producing cells
188
prevalence of chondrosarcoma
>40 yo (most often males 60-80)
189
Location of chrondrosarcoma
hips, shoulder, pelvis
190
Sx of chondrosarcoma
pain, weakness;
| pelvic masses radiate pain to hip/knee
191
Dx of chondrosarcoma
plain radiograph, MRI, BIOPSY (speckling appearance)
192
Tx for chondrosarcoma
refer to ortho;
| +/- radiation, chemo
193
Similar appearance to condrosarcoma
Chondroblastoma/Enchondroma
194
Most common primary bone tumor (malignant)
Multiple myeloma
195
Prevalence of Multiple Myeloma (MM)
>40 yo, M>F, African americans
196
Multiple Myeloma cause
involves entire skeletons; may be associated with radiation or pesticide exposure/HIV
197
Sx of multiple myeloma
Fatigue, fever, nigh sweats, diffuse bone tenderness, pathologic fx
198
Dx of multiple myeloma
Labs, U/A, and imaging (punched out appearance)
199
What does a U/A show in multiple myeloma
Bence-Jones Proteins
200
Punched out appearance on radiograph
multiple myeloma
201
Tx for multiple myeloma
Chemo, Radiation
| Supportive care
202
Metastatic Bone Cancer most common causes
```
(PB KTL)
Prostate (most common in M)
Breast (most common in F)
Kidney
Thyroid
Lung (most common in M)
```
203
Sx of metastatic bone cancer
asymptomatic with pathological fx or painful at presentation
204
Dx of metastatic bone cancer
Labs: anemia
Radiographs: patho fx (osteolytic bone destruction (KTL), osteoblastic formation (P), or mixed (B)
BONE SCAN
205
Causes osteolytic bone destruction
KTL
206
Causes osteoblastic formation
P
207
Mixed osteolytic bone destruction and osteoblastic formation
B
208
Tx for metastatic bone cancer
refer to ortho and oncology
