UE ortho Flashcards
broad categories for shoulder pain
arthritic picture
impingement
rotator cuff injury
what are we worried about with impingement
i. Subacromial bursitis
ii. Rotator cuff tendonitis
iii. Biceps tendonitis
suction cup that holds the rotator cuff and the capsule attaches to
the labrum
impingement pain would be described as
pain with reach for a seat belt hooking a bra throwing a ball inability to sleep on shoulder pain that radiates from the top of the shoulder to the bicept
upper neck and back pain
loss of strength and motion
with frank weakness in the shoulder
we worry about a tear
with difficulty because of pain
worry about impingement
physical exam
look for TTTP around sub-acromial area looking at passive or active strength testing (out of 5)
” Inspect for any visible deformity
“ Palpate for any point tenderness over biciptal groove, AC joint, posterior subacromial area
“ Passive and active ROM
“ Strength testing
“ Special tests: Jobe (empty can), Neer, Hawkins, Speeds, Cross-body Adduction, Drop Arm
joeb or empty can
abduction against resistance with internal rotation
rotating the humeral head will allow for better understanding of impingement
positive test tells you
rotator cuff
Neer
internal rotation thumb down
examiner supports the scapula while lifting the arm (passive)
looking to see if it ellicits pain
also looking for impingement rotator cuff
Hawkins
internal rotation with flextion 90 degree angle robot wave
examiner hands on bicept and forearm (rotator cuff)
Speeds
for bicepts tendon
Cross-body Adduction
mostly used for AC joint
palpate AC joint and cross arm with 90 degree angle
no joint space at glenohumeral
OA
also visualized with bone spurs
impingement tx
course of anti inflammatories
cortisol injection if no relief with oral NSAIDs in 4-6 weeks
can take 2-3 for cortisone to work
if continued need to rule out a cuff tear with an MRI
what population would you want to avoid cortisone with
DM population-A1C over 9 absolutely, reconsider over 8
high risk for bacterial infection
orthopedic managment of anterior
a. Anterior dislocation: conservative management
b. Short period of immobilization
c. Gradual advance to passive rom, then active rom, then advance to strengthening
d. Can be a long 3-5 month process
e. If continued instability 6 months plus after injury than refer to surgeon
orthopedic management of posterior
a. Not as common, I always review these with surgeon on first visit and defer to their treatment plan
what do you need with a gleno-humeral dislocation
XRAy of shoulder to rule out fracture of glenoid humeral head
post reduction films are needed
a compression fracture of the posterolateral articular surface of the humeral head
Hill Sachs lesion
acromioclavicular MOA
a. Typically caused by direct downward blow to the tip of the shoulder
b. Severity of injury dependent on structures that are compromised
CM of acromioclaviuclar injury
” Focal pain and swelling over AC joint
“ Pain with attempt at overhead motion of arm or cross-body adduction
PE with acromioclaviuclar injury
” Inspect for deformity over AC joint
“ Focalized tenderness over AC joint
“ With mild injuries can access AC joint with cross body abduction (may be too painful for grade II or higher)
dx of acromioclavicualr injury
Diagnostics
- Xrays: AP, lateral and axillary
- AP of both shoulders helpful if displacement or widening of joint not obvious
tx of acromioclavicular injury
” Non operative (grade I-III)
“ Brief period of immobilization, followed by passive range of motion of shoulder and gradually progress to active range of motion with focus on strengthening surrounding structures
what is thoracic outlet syndrome
temperature changes and skin color changes might go down this route
big cause of olecranon bursitis
GOUT
spider bites
banging the elbow
olecranon bursitis what is our red falg
you need to know
NO FEVER NO CHILLS to rule our your seotic arthritis with this
CM of olecranon bursitis
” Patients note limited ROM of elbow due to swelling and discomfort
“ Not always point tender
“ Make sure to ask about fever, chills, nausea, vomiting
PE for olecranon bursitis
” Visible large mass over tip of elbow
“ Redness or erythema to skin not uncommon
Tx for olecranon bursitis
” If mass is small: compression, NSAIDs, ice and limited use of elbow
“ If mass is large: aspiration
“ Cloudy fluid or suspect infection: send aspirate for cell count, cultures, gram stain and crystals
dx tests for olecranon bursitis
joint aspiration if it looks like cottage cheese it’s gout
crystals
gram stain
cell count
tennis elbow aka
a. Lateral Epicondylitis
where does Lateral Epicondylitis and what is it usually due to
Occurs at site of origin of the extensor carpi radialis brevis
sometimes it’s just over the tendon and sometimes it moves down into the actual musculature
Due to tissue degeneration with fibroblast and microvascular hyperplasia
b. Medial Epicondylitis muscles involved
ii. Occurs in common tendinous origin of flexor/pronator muscles just distal to medial epicondyle
iii. Less common than lateral epicondylitis
pain with wrist extension and/or forearm supination
lateral epicondylitis
: pain with wrist flexion and/or forearm pronation is suggestive of
medial epicondylitis
what would you find in a PE of a pt with condylitis
” Point tender over or just distal to origination of affected musculature
“ Pain with resisted wrist and/or forearm action
lateral can see pain with middle finger flexion
Treatment for condylitis
NSAIDs
Ice, massage, topical creams
Activity modification
Bracing: elbow strap and or wrist brace will srtop action at brace and allow for rest
Cortisone injection: locate point of maximal tenderness for target spot to inject
Surgery: debridement and possible release of tendon
Cubital Tunnel Syndrome
Compression of the ULNAR nerve at the cubital tunnel along the medial aspect of the elbow
b. Second most common compression neuropathy in upper extremity
Cubital Tunnel Syndrome
secondary to carpal tunnel
when do you typically see cubital tunnel syndrome
Exacerbated by prolonged flexion of elbow
pts at night
CM of cubital tunnel syndrome
” Parasthesia and numbness of ring and small fingers
“ Nighttime pain
VII. Cubital Tunnel Syndrome PE
” Inspect for atrophy of muscles innervated by ulnar nerve
“ Palpate nerve to see if it is mobile within the tunnel
“ Tinel sign, Elbow flexion test
Cubital Tunnel Syndrome dx
nerve conduction study
VII. Cubital Tunnel Syndrome TX
” Elbow pad to protect nerve
“ Splint for nighttime comfort w elbow in 45 deg flexion
“ NSAIDs
“ Surgical treatment: decompression (release) or ulnar nerve transposition
ulnar nerve respon
pinky and ring
compression of the median nerve
a. Compression of the median nerve within the carpal tunnel
VIII. Carpal Tunnel Syndrome
thumb index middle and half of the ring
what populations do you typically see carpal tunnel in
Commonly affects middle aged or pregnant women
Often idiopathic but is associated with pregnancy, flexor tenosynovitis, overuse, inflammatory conditions, trauma to the wrist, endocrine disorders and tumors
CM of carpal tunnel
” Numbness in thumb, index and middle fingers
“ Pain awakens them at nighttime
“ Aching pain radiates up arm or into thenar area
“ Inability to open jars or clumsiness with holding objects
“ Pain with driving or keyboarding
durken carpal compression
” Inspect for thenar atrophy
“ Phalen maneuver and Tinel sign
“ Durkan carpal compression test
dx study for carpal tunnel
i. Nerve conduction study
carpal tunnel tx
" Bracing (esp nighttime, driving) " NSAIDs " Ergonomic modifictions " Cortisone injection " Surgical release of fibrous surrounding : open or endoscopi
ganglion cysts arise from
a. Arises from the capsule of a joint or a tendon synovial sheath
Cyst contain
b. Cyst contains thick, clear, mucinous fluid
Most common soft tissue tumors of the hand and wrist
cysts
cysts differentiate form cancer
because they are mobile and loose
CM of cysts
” Visible mass or lump that may fluctuate in size
“ May be painful with range of motion at the affected joint or point tender to pressure
PE of cyst
” Soft, mobile mass
“ May be multilobulated
why does cysts come back
because they have their own lining
cysts treatment
” If it is not painful than I tell patients to leave it alone
“ If it is causing pain or discomfort can attempt aspiration of cyst (mindful of volar wrist area)
“ Surgical excision also an option if aspiration unsuccessful
Swelling of sheath that surrounds abductor pollicus longus and extensor pollicis brevis at radial styloid area
X. De Quervain Tenosynovitis
De Quervain Tenosynovitis affects what muscles
abductor pollicus longus and extensor pollicis brevis at radial styloid area
the muscles that deviate the wrist and abduct the arm
baby picking up
where do we see CM of pain
” Pain, swelling and tenderness over radial styloid
“ Pain with thumb flexion, abduction w wrist ulnarly deviated
Physical Exam of pts with suspected De Quervain Tenosynovitis
” Finkelstein test: provocative test to produce symptoms. Flex thumb into palm and ulnar deviate the wrist
Usually positive with De Quervains diagnosis
De Quervain Tenosynovitis
” NSAIDs, immobilization, physical therapy, activity modification
“ Cortisone injection
“ Surgery
Trigger Finger is inflammation of
Inflammation of flexor tendon or first annular pulley
finger when you try to straighten it catches
what SE do you want to warn pts of with cortisone
lightening of the skin
hypopigmentation
CM of trigger finger
” Pain, catching or locking when attempt finger flexion
“ Painful nodule in the distal palm
PE with trigger finger
” Painful palpable nodule at distal palmar crease
“ Palpable hitching along flexor tendon as passively flex finger
tx of trigger finger
” Cortisone injection into flexor sheath
“ Surgical release of A1 pulley if symptoms refractory to injection
Injection technique
“ Idea is to bathe tissue with anti inflammatory liquid
“ Use 1ml syringe with small needle
“ Do not inject fluid directly into tendon
