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UE Part 2 Flashcards

1
Q

Bones of the elbow

A
  • humerus
  • Radius
  • ulna
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2
Q

Ligaments of the elbow

A
  • ulnar collateral ligament
  • radial collateral ligament
  • annular ligament
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3
Q

joints of the elbow and their function

A
  • ulnohumeral and radiocapitellar articulation: flexion/extension of the elbow and pronation/supination of the forearm
  • Proximal radioulnar articulation: pronation/supination of the forearm
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4
Q

what does the radius articulate with

A

capitulum

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5
Q

what does the ulna articulate with

A

trochlea

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6
Q

nerves of the elbow

A
  • ulnar
  • median
  • radial
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7
Q

arteries of the elbow

A

brachial branches into
* radial
* ulnar

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8
Q

where does the biceps brachii originate and insert

A

long head intertubercular groove
short head coracoid process
inserts on the radial tuberosity and biceps aponeurosis

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9
Q

where does the triceps brachii originate and insert?

A

long head originates on lateral aspect of scapular
lateral head on posterior humerus
attaches on olecranon via triceps tendon

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10
Q

where are the flexor muscles located?

A

Anterior aspect

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11
Q

where are the extensor muscles located

A

posterior aspect

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12
Q

what cushions the olecranon and should not be palpable in normal patients?

A

olecranon bursa

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13
Q

imaging of elbow

A
  • Standard X-rays: AP and lateral
  • Oblique (radiocapitellar) 45 degree view –> improved radial head visualization
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14
Q

How should the anterior humeral line and the radiocapitellar line align on lateral xray

A
  • Anterior humeral line should bisect the middle third of the capitellum
  • Radiocapitellar line (drawn through enter of radius) should pass through center of capitellum
  • Disruption of these relationships may indicate fracture

anterior humeral line = anterior humerus

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15
Q

What are the most common chief complaints of elbow

A
  • Pain
  • Stiffness
  • Swelling
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16
Q

What does pain on the posterior aspect of the elbow indicate?

A
  • Ulnar nerve compression
  • Olecranon bursitis
  • Fracture of olecranon
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17
Q

What does pain of the medial elbow indicate?

A
  • Arthritis
  • Ulnar collateral ligament tear
  • Medial epicondylitis
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18
Q

What does pain of the anterior elbow indicate

A

Arthritis
Rupture of the distal biceps tendon
Pronator syndrome
Lateral epicondylitis

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19
Q

What does pain of the lateral elbow indicate

A
  • Fracture of the distal humerus
  • Fracture of the radial head
  • Posterior interosseous nerve syndrome
  • Olecranon bursitis
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20
Q

Physical exam of elbow

A

Normal ROM
* 0-150 degree flexion
* 10-15 degree hyperextension
* 80 degree supination/pronation
* Inspect
* Palpate
* ROM
* Muscle strength

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21
Q

What muscles/nerves can be tested in elbow?

A
  • Flexion and supination: bicep, C5-C6, musculocutaneous nerve
  • Extension: tricep, C7-C8
  • Pronation: pronator teres muscles, median nerve, C6-C7
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22
Q

What does valgus stress test of the elbow test?

A
  • Stability of medial ligamentous structures, primarily ulnar collateral ligament
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23
Q

How is valgus stress test of elbow performed?

A
  • Hold elbow in 20 degree flexion with forearm in supination
  • Apply pressure on Lateral side of elbow attempting to open the medial joint line
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24
Q

What does varus stress test determine?

A
  • Stability of the lateral collateral ligament and lateral capsule
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25
Q

How is the varus stress test performed?

A
  • Hold elbow in 20 degree flexion with forearm in supination and apply pressure on the medial side of the elbow, attempting to open the lateral joint line
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26
Q

Disorders of the elbow

A
  • Fractures
  • Subluxation of radial head
  • Epicondylitis
  • Olecranon bursitis
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27
Q

Etiology of distal humeral fractures

A
  • Direct trauma
  • Axial loading transmitted through the elbow
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28
Q

Types of distal humeral fractures

A
  • Supracondylar (MC in children): type A
  • Epicondylar (medial or lateral): type B
  • Intercondular: type C (MC) both epicondyles impacted
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29
Q

Distal humeral fracture complications

A
  • Intra-articular or comminuted fractures
  • Nerve injury to ulnar or radial nerve
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30
Q

How would ulnar nere injury present?

A
  • Sensory changes to medial 2 fingers
  • Flexion/adduction of wrist impacted
  • 4th and 5th DIP joint flexion impacted
  • Finger abduction
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31
Q

How does radial nerve injury present?

A
  • Sensory changes to dorsal thumb, pointer finger and middle of middle finger and wrist
  • Motor: wrist extension
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32
Q

Presentation of distal humeral fractures

A
  • Pain
  • Swelling
  • Tenderness
  • Ecchymosis
  • Crepitus
  • Elbow ROM limited
  • Shortening of arm with displaced shaft fracture
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33
Q

What should be assessed on exam of distal humeral fracture?

A
  • Skin
  • Joints/bones above and below
  • N/V status
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34
Q

What can be impacted with a supracondylar fracture?

A
  • Radial artery
  • Median nerve
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35
Q

What can be impacted in an epidconylar fracture?

A
  • Ulnar nerve (medial)
  • Radial nerve (lateral)
  • depennding on epicondyle impacted
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36
Q

Imaging for distal humeral fracture

A
  • AP and lateral elbow x-ray
  • Look for fat pad “sail sign”
  • MC in kids
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37
Q

What does the fat pad sail sign indicate?

A

Intra-articular bleeding

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38
Q

Management of supracondylar fracture?

A
  • Isolated without displacement or angulation: long arm cast/splint with elbow flexed at 90 degrees
  • Displaced, angulated, or NV compromise: ORIF
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39
Q

Management of epicondylar humeral fracture

A
  • Isolated, minimally displaced: long arm cast/splint with elbow at 90 degrees
  • Medial condyle fracture: forearm in pronation
  • Lateral condyle fracture: forearm in supination
  • Moderate displacement (2-4 mm): percutaneous pinning or ORIF
  • Severe displacement: ORIF
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40
Q

Long arm posterior casting indications

A

Supracondylar distal humerus, olecranon, proximal mid-shaft radius and ulnar fractures

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41
Q

MOI of olecranon fracture

A
  • Fall on a semi-flexed supinated forearm (avulsion) MC
  • 2nd MC: direct trauma
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42
Q

Presentation of olecranon fracture

A
  • Pain, tenderness, swelling, ecchymosis over olecranon process
  • Limited ROM of elbow
  • Deformity if associated elbow dislocation
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43
Q

Exam of olecranon fracture

A
  • Assess distal NV status and overlying skin
  • Ulnar nerve most often affected
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44
Q

Olecranon fracture imaging

A
  • AP and lateral elbow
  • Radiocapitellar view if unclear or complicated presentation
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45
Q

Management of nondisplaced olecranon fracture (<1-2 mm displacement)

A
  • Posterior long arm splint with elbow in any degree of flexion, forearm in neutral position
  • Monitor for vascular compromise
  • Encourage hand/finger ROM/strength
  • Repeat x-ray in 7-10 days to ensure alignment intact
  • Cast/splint removed after 2-3 weeks
  • Start gentle ROM therapy
  • Consider PT referral
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46
Q

Management of displaced olecranon fracture

A
  • Closed: splint and refer for ORIF
  • Open: admit for IV abx and consult ortho
  • If contraindication for surgery, sling and start ROM as pain allows
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47
Q

Complications of olecranon fracture

A
  • Elbow stiffness, loss of ROM
  • Arthritis
  • Non-union
  • Surgical implant failure
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48
Q

MOI of radial head/neck fracture

A

fall on outstretched hand resulting in compression of radial head into the capitellum
Most common fracture of the elbow

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49
Q

Classification of radial head/neck fracture

A
  • Mason classification
  • Type I: <2 mm displacement
  • Type II: displacement > 2 mm
  • Type III: comminuted
  • Type IV: radial head fracture with associated elbow dislocation
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50
Q

Presentation of radial head/neck fracture

A
  • Pain and tenderness along lateral aspect of elbow over radial head
  • Limited ROM related to pain or joint effusion
  • Painful pronation/supination
  • +/- local swelling/ecchymosis
  • Additional exam: assess bones and joints above and below, skin, NV status
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51
Q

Imaging of radial head/neck fracture

A
  • AP and lateral elbow with fracture line, fat pad sign
  • Capitellar view if unable to appreciate fracture on standard views
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52
Q

Management of type I radial head/neck fracture

A
  • Sling with or without a posterior splint –> splint should be removed after 1-2 days
  • AROM after 24-48 hours with full extension, flexion; pronation and supination with elbow flexed at 90 degrees
  • F/U with ortho in 1 week
  • Aspiration if hemarthrosis is present to allow early ROM
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53
Q

Management of type II-III radial head/neck fracture

A
  • Sling and splint with ortho evaluation in 2-3 days to discuss consideration of ORIF
  • Ortho can assess for mechanical block
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54
Q

Management for type IV radial head/neck fracture

A

Immediate consult for reduction and ORIF

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55
Q

What is radial head subluxation?

A
  • AKA nursemaid’s elbow
  • Subluxation of the radial head through annular ligament due to laxity
  • MC in children under 5
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56
Q

MOI of radial head subluxation

A
  • Pulling on a pronated forearm while the elbow is extended
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57
Q

Clinical presentation of radial head subluxation

A
  • Hx of mechanism followed by crying which subsides quickly
  • Arm held semi-flexed, adducted, and pronated
  • ROM is refused: resistance with attempted supination
  • Tender over radial head
  • No swelling or ecchymosis
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58
Q

Imaging of radial head subluxation

A
  • Not necessary for diagnosis
  • X-ray only if suspicion of other injury
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59
Q

Management of radial head subluxation

A
  • Reduction
  • If failed reduction, order radiographs, splint, and refer to ortho
  • If succesful reduction, tylenol/motrin prn +/- sling, parent education
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60
Q

How can radial head subluxation be reduced?

A
  • Premedicate with tylenol or motrin
  • 2 techniques: supination-flexion or hyperpronation
  • Immediate re-assessment of NV status
  • After 15-30 minutes reattempt if no improvement, 3-4 attempts acceptable
  • Reduction less likely to be successful if seen 1-2 days after injury
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61
Q

Supination-flexion reduction technique

A
  1. Hold elbow with thumb over radial head
  2. Quickly supinate fully
  3. Folowed by complete flexion
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62
Q

Hyperpronation reduction technique

A
  • Hold elbow with your thumb overlying radial head
  • Hyperpronate forearm
  • Followed by complete extension then flexion
  • EBM states that this technique is often more effective than the first and may be less painful
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63
Q

What is epicondylitis

A
  • Tendinosis of wrist extensors or wrist flexors at their origination site on their respective epicondyles
  • Lateral: wrist extensors (tennis elbow) MC
  • Medial: wrist flexors (golfers elbow)
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64
Q

MOI of epicondylitis

A
  • Chronic repetitive overuse resulting in micro-trauma at tendon insertion
  • Acute strain due to excessive loading
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65
Q

Epidemiology of epicondylitis

A
  • MC between 30-50 years of age
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66
Q

Presentation of lateral epicondylitis (tennis elbow)

A
  • Pain with wrist extension and gripping- shaking hands, using computer mouse, use of screwdriver, back-handed tennis swing, opening jar
  • Paint tenderness 1 cm distal to epicondyle
  • Pain with wrist extension and supination against resistance (elbow extended)
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67
Q

Presentation of medial epicondylitis

A
  • Pain with arm pronation and wrist flexion, grip pain/weakness-golf swing, overhead throwing, bowling
  • Point tenderness 1 cm distal to epicondyle
  • Pain with wrist flexion and pronation against resistance (elbow extended)
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68
Q

Diagnostics for epicondylitis

A

Normal AP and lateral elbow (not needed for diagnosis)`

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69
Q

Management of epicondylitis

A
  • Activity modification, NSAIDs, ice after use
  • Refer to PT if failure of conservative treatment
  • PT after initial pain subsides: gentle stretching and strengthening
  • Bracing: counterforce brace
  • Steroid injection x 3 max
  • Refer to ortho if symptoms persist for 6 months of conservative therapy
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70
Q

What is olecranon bursitis

A

Inflammation of the olecranon bursa

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71
Q

Mechanism of olecranon bursitis

A
  • Trauma: fall or direct blow to elbow
  • Inflammation: excessive leaning on elbow or secondary to systemic inflammatory conditions (RA, gout, etc)
  • Infection: septic bursitis, MC pathogens staph and strep
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72
Q

Presentation of olecranon bursitis

A
  • Gradual or sudden swelling of the brusa up to 6 cm in daimeter
  • Small lumps of scar tissue remain as swelling subsides
  • +/- pain, tenderness, limited ROM: more so in trauma and infectious etiologies, chronic recurrent swelling is less tender
  • Redness and warmth in acute bursitis
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73
Q

Diagnostics for olecranon bursitis

A
  • Aspiration for large, symptomatic bursa
  • AP and alteral elbow x-ray if hx of trauma
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74
Q

What analysis is performed on bursal fluid

A
  • CBC
  • Gram stain
  • C&S
  • Crystals
75
Q

Management of inflammatory or traumatic olecranon bursitis

A

Mild swelling
* Activity modification and NSAIDS
* Use of elbow pad, compression during acute phase

Significant swelling
* Aspirate, apply compression bandage, and f/u in 2-7 days
* If fluid returns and cultures are negative repeat aspiration and re-culture
* If cultures remain negative but swelling persists, aspiration and injection of 1 mL of corticosteroid into the bursal sac

76
Q

Management of mild, with no immunosuppression, septic bursitis

A
  • Bactrim or keflex
  • Abx tailored to culture and sensitivity once available
77
Q

Management of severe bursitis or immunosuppression

A
  • IV vancomycin
  • Add pseudomonal coverage if associated with trauma ie ciprofloxacin or zosyn
  • Abx tailored to culture and sensitivity once available
78
Q

What are indications of a severe presentation of septic bursitis

A
  • systemic toxicity (fever, hypotension, tachycardia)
  • rapid progression or progression 48 hours after abx
  • unable to tolerate oral therapy
  • close indwelling medical device ex prosthetic joint or vascular graft
79
Q

forearm anatomy

80
Q

forearm series imaging

A

AP and lateral

81
Q

Hand, wrist, and finger series imaging

A

PA
Oblique
Lateral

82
Q

MOI of forearm fractures

A
  • Direct blow
  • Fall on outstretched hand
83
Q

Complicated forearm fractures

A
  • Galeazzi: radial midshaft with instability of distal radioulnar joint
  • Monteggia: proximal third of ulnar shaft with dislocation of radial head due to instability of the proximal radioulnar joint

MUGR

84
Q

Diagnosis of forearm fracture

A
  • Forearm series: should provide you a view of the wrist and elbow
  • Add dedicated elbow or wrist if needed to further evaluate the joint
84
Q

Forearm fracture presentation

A
  • Deformity
  • Swelling
  • Ecchymosis
  • Point tenderness overlying fracture
  • Decreased ROM of joint above and below
  • Assess NV status
  • Assess compartments of forearm
85
Q

Indications for emergent (<1 hour) orthopedic referral for forearm fracture in adult

A
  • Arterial compromise
  • Open fracture
86
Q

Indications for urgent referral to ortho (<24 hours) for forearm fracture ina dult

A
  • Ulnar shaft fracture with <50% apposition or >10 degrees angulation
  • Forearm fracture with any DRUJ or PRUJ instability
  • Forearm fracture with peripheral nerve injury
  • Both bones fracture with displacement
87
Q

Indications for priority orthopedic referral for forearm fracture in adult

A
  • Isolated radial shaft fracture with any displacement
  • Both bones fracture even with minimal or no displacement
  • Isolated proximal third ulna fracture
88
Q

Management of simple, isolated fracture of the ulnar shaft

A
  • <50% displacement, <10% angulation before or after closed reduction and no joint involvement
  • Long-arm posterior splint: elbow at 90 degrees, forearm in neutral position, slight wrist extension
  • After 1-3 weeks remove splint and place in a functional forearm brace for 4-6 weeks to allow protected AROM of the elbow, forearm, and wrist
  • F/u to ensure alignment at 1 week and then q 4 wk until complete healing has occured, usually 8 weeks
89
Q

Management of isolated radial fractures, combined radius-ulna fracture, or galeazzi or monteggia fracture

A
  • Double sugar tong
  • Combined radius-ulna fracture and galeazzi or monteggia, refer to ortho
90
Q

Wrist bone anatomy review

A

scaphoid
lunate
triquetrum
pisiform
trapezium
trapezoid
capitate
hamate

lateral to medial proximal line then distal

some lovers try positions they can’t handle

91
Q

What are the 2 ligaments of the wrist?

A

Ulna collateral and radial collateral

92
Q

What is the ulnar nerve area of sensation?

A
  • Ring finger and pinky finger
93
Q

What is the median nerve area of sensation

A
  • Thumb and first 2 fingers
94
Q

What is radial nerve area of sensation

A

dorsal thumb and first 2 fingers

95
Q

What is the palmar blood flow

A
  • Ulnar and radial artery
  • Deep and superficial palmar arch
  • CCommon palmar digital arteries and proper palmar digital arteries, radial artery index finger
96
Q

What is the dorsal wrist blood flow?

A
  • Radial artery
  • Basal metacarpal arch
  • Dorsal metacarpal arteries
  • Digital arteries
97
Q

MOI of wrist fracture

A

Fall on outstretched hand

98
Q

Common types of wrist fractures

A
  • Colles fracture: distal radius fracture fragment tilted dorsally
  • Smith’s fracture: distal radial fragment tilted volarly
99
Q

What is a dinner fork derormity?

A

Colles fracture

100
Q

What is a garden spad deformity?

A

Smith’s fracture

101
Q

Presentation of wrist fracture

A
  • acute pain
  • tenderness
  • swelling
  • deformity of the wrist
102
Q

diagnostics of wrist fracture

A

wrist x-ray series

103
Q

wrist fracture management for nondisplaced or minimally displaced and non-articular fractures

A
  • sugar tong splint or short arm cast for 2 to 3 weeks
  • Casts should not be placed until 72 hours after injury
  • AP and lateral radiographs should be performed each week for 2 weeks to assure union and reduction
104
Q

management for displaced and open fractures

105
Q

epidemiology of scaphoid fracture

A
  • MC carpal fracture
  • MC in young men
106
Q

MOI of scaphoid fracture

A
  • Hyperextension injury
  • fall on outstretched hand
107
Q

Anatomic considerations of scaphoid fracture

A

Blood supply enters at the distal 1/3 of the bone

108
Q

Complications of scaphoid fracture

A
  • High incidence of delayed diagnosis
  • Non-union
  • Avascular necrosis
109
Q

Presentation of scaphoid fracture

A
  • Wrist pain/swelling along radial aspect
  • Tenderness along anatomical snuff box
  • Grip and ROM may be painful/weak/limited
110
Q

Scaphoid fracture diagnostics

A
  • Wrist series plus
  • Scaphoid (navicular) view: PA view with the wrist in ulnar deviation
  • CT/MRI if x-rays remain negative and suspicion is high
111
Q

Management of nondisplaced or negative x-rays scaphoid fracture

A
  • Thumb spica splint/cast x 6 weeks
  • Refer to ortho
  • Repeat x-rays in 7-14 days if initially negative
  • If x-rays remain negative and tenderness persists –> CT/MRI
  • Monitor for complications and to ensure complete healing with serial x-rays/MRI
112
Q

Management of displaced scaphoid fracture

A
  • ORIF
  • Percutaneous pin placement
  • Monitor for complications and to ensure complete healing with serial x-rays/MRI
113
Q

Indications for thumb spica splint

A
  • Scaphoid
  • Lunate
  • Trapezium
  • 1st metacarpal
  • 1st phalynx bone fractures
  • 1st MCP dislocation
  • Ulnar collateral ligament tear
  • De Quervain’s tenosynovitis
114
Q

What is carpal tunnel syndrome?

A
  • Compression of the median nerve at the carpal tunnel
115
Q

Risk factors for carpal tunnel syndrome

A
  • Repetitive wrist movements
  • Wrist injury
  • Pregnancy
  • Sedentary lifestyle
  • Familial
  • Multiple systemic conditions
116
Q

Presentation of carpal tunnel syndrome

A
  • Burning, tingling pain over median nerve distribution of the hand
  • Exacerbated by activity and at night
  • Aching pain radiating to elbow and shoulder
117
Q

Physical exam of carpal tunnel syndrome

A
  • Tinel’s and Phalen’s signs
  • Carpal compression test
  • Hand elevation test
  • Grip weakness
  • Thenar atrophy (late)
118
Q

Diagnosis of carpal tunnel syndrome

119
Q

Management of carpal tunnel syndrome

A
  • Activity modification
  • Cock-up wrist splint
  • Corticosteroid injection
  • Refer for to ortho for carpal tunnel release
120
Q

Indications for referral to ortho for carpal tunnel release

A
  • Failure of >3 months of conservative therapy
  • Objective neurologic findings of thenar muscle atrophy
121
Q

Anatomy review of hand bones

122
Q

What is the epidemiology of metacarpal factures?

A

Most common in adults

123
Q

What is the most common fracture in the hand?

A

Boxer’s fracture: fracture of 4th or 5th metacarpal that results from a closed fist striking a object

124
Q

What is the epidemiology of phalangeal fractures?

A

MC in children, involving the physis of the 5th phalange
Distal phalynx most commonly injured in adults

125
Q

Presentation of metacarpal/phalangeal fractures

A
  • History of trauma
  • Local tenderness, swelling, deformity, and decreased ROM
  • Boxer’s fracture most likely to be malrotated
  • Assess distal NV status
126
Q

Management of displaced metacarpal neck fracture

A

> 30 degree angulation –> reduction followed by splint/casting
<30 degree angulation –> splint for 2-3 weeks. If 4th or 5th metacarpal, ulnar gutter splint; if 2nd and 3rd metacarpal –> radial gutter splint

127
Q

Management of non-displaced metacarpal/phalangeal fractures

A
  • Non-displaced fractures of the 2-5th metacarpal/phalangeal shaft: splint for 3-4 weeks
  • Gutter splint: metacarpal
  • Phalangeal fracture: buddy tape or aluminum splint
  • Non displaced fracture of 1st metacarpal/phalange: thumb-spica splint, wrist in 30 degrees of extension
  • Non-displaced/non-articular 1st metacarpal base: thumb spica splint/cast x 4 weeks
    *
128
Q

Management of displaced/angulated metacarpal/phalangeal shaft fracture or intra-articular fractures

A
  • Refer/consult ortho for further evaluation
  • Closed vs open reduction and fixation
129
Q

Pathology of Gamekeeper’s thumb aka skier’s thumb

A

Rupture of the ulnar collateral ligament of the 1st MCP joint

130
Q

MOI of Gamekeeper’s Thumb

A

Forced radial abduction

131
Q

Clinical presentation of gamekeeper’s thumb

A
  • Pain, swelling, tenderness along the medial 1st MCP joint
  • Weak pincer formation
  • Stress testing after local anesthesia
132
Q

Diagnostics of Gamekeeper’s thumb

A

1st phalange finger series

133
Q

Management of gamekeeper’s thumb

A

Thumb spica splint
Refer to ortho for surgical repair

134
Q

Pathology of Mallet finger

A
  • Rupture, laceration, or avulsion of the extensor tendon at the distal phalanx
135
Q

MOI of Mallet finger

A

Hyperflexion of DIP

136
Q

Clinical presentation of mallet finger

A
  • DIP is flexed at 40 degrees with the inability to actively extend
  • PROM is intact
  • Mild tenderness over dorsal DIP
  • May be associated with an avulsion fracture of distal phalanx
137
Q

Mallet finger diagnostics

A

Finger series rule out avulsion fracture

138
Q

Management of Mallet finger

A
  • Finger splint DIP in full extension x 4-8 weeks
  • Splint can not be removed
  • If not treated properly will result in swan neck deformity: hyperextension of PIP with flexion of DIP
139
Q

Pathology of Boutonniere deformity

A

Rupture of the central slip of the extensor tendon where it inserts on the middle phalanx

140
Q

MOI of boutonniere deformity

A

Forced flexion of the PIP

141
Q

Presentation of Boutonniere deformity

A
  • Finger is held partially flexed at the PIP and extended or hyperextended at the DIP
  • May not be as noticeable with swelling
  • Swelling, pain along dorsal PIP
  • Point tenderness along dorsal PIP
  • Limited ROM and inability to fully extend the PIP, remains flexed at 30 degrees
142
Q

Diagnostics of Boutonniere deformity

A
  • Finger series to r/o avulsion fracture
143
Q

Management of Boutonniere deformity

A

Finger series to r/o avulsion fracture

144
Q

Management of boutonniere deformity

A
  • Splint PIP in extension leaving DIP free x 4-8 weeks
  • Refer to ortho if indicated
145
Q

When would you refer to ortho for Boutonniere deformity?

A
  • If conservative therapy fails
  • Associated irreducible PIP dislocation
  • Associated open fx
146
Q

What is dequervain tenosynovitis

A
  • Inflammation of the tendon sheath covering the extensor/abductor tendons of the thumb
147
Q

Etiology of de quervain tenosynovitis

A

Overuse syndrome

148
Q

Presentation of de quervain tenosynovitis

A
  • Aching pain and point tenderness along the radial aspect of the wrist with use
  • Pain may radiate up arm
  • Thickened 1st dorsal compartment creating a prominence at the radial styloid
  • Finkelstein test is diagnostic
149
Q

What is a postiive Finkelstein test

A

Ulnar deviation of an adducted thumb reproduces pain

150
Q

Management of De Quervain tenosynovitis

A
  • Thumb spica splint
  • Activity modification
  • NSAID’s
  • Refer to ortho if conservative therapy fails for corticosteroid injections into tendon sheath and surgical release of the first dorsal compartment
151
Q

What is a ganglion cyst

A
  • Fluid-filled swelling overlying a joint or tendon sheath filled with clear, gelatinous, sticky, or mucoid fluid
152
Q

MC location of ganglion cyst

A

Dorsal aspect of the wrist

153
Q

Epidemiology of ganglion cyst

A

MC in females aged 10-40`

154
Q

Pathogenesis of ganglion cyst

A

Unknown, but thought to occur as result of mucoid degeneration of periarticular structures

155
Q

Clinical presentation of ganglion cyst

A
  • Localized intermittent pain/tenderness
  • Cyst is firm, smooth, rounded, rubbery
  • May fluctuate in size over time
  • Transillumination will help differentiate cyst from solid lesion
156
Q

Diagnostics for ganglion cyst

A
  • X-ray to rule out bony pathology
  • US or MRI if atypical presentation
157
Q

Management of ganglion cyst

A
  • Observation: most will spontaneously regress
  • Aspiration, with or without injection of a corticosteroid
  • Surgical removal
158
Q

What is trigger finger

A
  • Idiopathic dysfunction of flexor tendon of finger as it glides through the tendon sheath
  • Often due to a discrepancy in size of the tendon and its sheath
  • 3rd and 4th digits most commonly affected
159
Q

Presentation of trigger finger

A
  • Catching, snapping, or locking of the involved finger
  • Worse upon awakening
  • MOre than one finger may be affected
  • Associated with pain and dysfunction
  • Painful nodule on the palm
160
Q

Management of trigger finger

A
  • NSAIDs, +/- corticosteroid injection into the tendon sheath
  • If symptoms persist, a second injection may be considered in 3 to 4 weeks
  • Patients with RA are at risk for tendon rupture and should only have one injection
  • Failure of conservative therapy –> surgical release considered
161
Q

What is dupuytren contracture?

A

Progressive fibrosis of the palmar fascia

162
Q

Epidemiology of dupuytren contracture

A

Men >50 years old

163
Q

Risk factors for dupuytren contracture

A
  • Epilepsy
  • DM
  • Pulmonary disease
  • Alcoholism
  • Smoking
  • Repetitive vibrational trauma
164
Q

What is the most common phalange affected by dupytren contracture

A

4th phalange

165
Q

Presentation of dupuytren contracture

A
  • One or more painless nodules near the distal palmar crease
  • Nodules gradually thicken leading to a cord that contracts
  • Flexion normal, but extension limited
166
Q

Diagnostics for dupuytren contracture

A

Clinical diagnosis no other testing needed

167
Q

Management of dupuytren contracture

A
  • Night splinting may slow progression
  • Surgery release if 30 degree fixed flexion of MCP, involves excising thickened soft-tissue bands and release of joint contractures
168
Q

BRACHIAL PLEXUS

169
Q

What is brachial plexus syndrome

A

Damage to brachial plexus

170
Q

MOI of brachial plexus syndrome

A
  • Traction force: shoulder depressed and head/neck tilted to opposite side to damage C5, C6, and C7 roots
  • Direct blow to top of shoulder damages C5, C6, and C7
  • Stretching of the plexus when arm abducted forcefully ie grabbing something while falling damages C8 and T1
171
Q

Presentation of brachial plexus syndrome

A
  • Sharp, burning shoulder pain with radiculopathy in the affected nerve root distribution
  • Weakness is common
172
Q

Physical exam of brachial plexus syndrome

A
  • Evaluate sensation, motor function, DTR
  • Injuries to C8-T1 can be associated with Horner’s sundrome d/t preganglionic injury and sympathetic chain disruption
  • Assess lower extremities for spinal cord involvement: spasticity or weakness in ipsilateral leg suggests spinal cord injury
  • Look for associated injuries
173
Q

S/S of Horner’s syndrome

A
  • Ipsilateral ptosis
  • Myosis
  • Anhidrosis
  • Enophthalmos
174
Q

Diagnostics of brachial plexus syndrome

A
  • X-rays: c-spine and shoulder
  • CT c-spine: rule out c-spine fractures if x-ray abnormal
  • MRI: for visualizing spinal cord and nerve roots if x-rays are abnormal or symptoms persist
  • EMG/NCS: may help differentiate location of nerve dysfunction
175
Q

Management of brachial plexus syndrome

A
  • Typically conservation: stretch and strengthen, splint in neutral position of any joints affected by paralyzed muscles
  • Encourage PROM to reduce joint stiffness or tendon constrictures
  • Athletes must have complete resolution of symptoms and normal PE before allowed to return to activity
176
Q

What are the structures of the thoracic outlet?

A
  • First rib
  • Subclavian artery and vein
  • Brachial plexus
  • Clavicle
  • Lung apex
177
Q

What is thoracic outlet syndrome?

A
  • Compression of the brachial plexus and/or subclavian vessels as they exit the narrow space between the superior shoulder girdle and the 1st rib
  • Most commonly affects women 20-50 yo
178
Q

Clinical presentation of thoracic outlet sydnrome

A
  • Compression of the brachial plexus
  • Aching pain/paresthesia
  • Compression of the vascular structures: intermittent swelling and discoloration
  • Fatigue, weakness, and aching pain of extremity
  • Symptoms often exacerbated by lifting arm above the head
179
Q

Physical exam of thoracic outlet syndrome

A
  • Inspect for swelling/discoloration
  • Palpate the supraclavicular fossa to assess for a mass
  • Palpate for distal UE pulses
  • Check sensation and motor function cervical nerve roots
  • Elevated arm stress test
180
Q

What is the elevated arm stress test

A

Both shoulders abducted at least 90 degrees and supported posteriorly the patient opens and closes fists at a moderate speed for 3 minutes.
Positive if reproduced neuro and/or vascular s/s

181
Q

Diagnostics for thoracic outlet syndrome

A
  • AP and lateral c-spine to rule out congenital anomalies
  • PA/lateral CXR to help rule out apical lung tumors
  • MRI to rule out cervical disc rupture or cervical spondylosis
182
Q

Management of throacic outlet syndrome

A
  • Non-surgical (most patients): 3-6 months of home exercise programs emphasizing muscle strengthening and posture
  • Avoid strenuous activities, placing straps over shoulders, and any activity that exacerbates symptoms
  • NSAIDs, muscle relaxers, TENS unit

MSK (11 decks)

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