UE part II - Exam 1 Flashcards
What are the 3 distinct joints in the elbow?
Ulnohumeral and Radiocapitellar Articulation
Proximal Radioulnar Articulation
How are AP views of the elbow shot?
How are lateral views of the elbow shot?
How are oblique views of the elbow shot? What are you trying to visualize?
Oblique (Radiocapitellar) 45° view
shot to improve radial head visualization
How do you interpret a lateral view of elbow imaging?
The anterior humeral line (1-2) should bisect the middle third of the capitellum.
The radiocapitellar line (drawn through the center of the radius, 3-4) should also pass through the center of the capitellum
if not normal, may indicate fracture
What is normal elbow flexion in degrees? Supination/pronation?
Flexion 0-150°
supination/pronation: 80 degrees
What muscle and nerve are responsible for flexion and supination of the elbow?
Bicep, C5-C6, musculocutaneous nerve
What muscle and nerve are responsible for extension of the elbow?
tricep, C7-8
What muscle and nerves are responsible for pronation?
Pronator teres muscles, median nerve, C6-C7
How do you perform the vaLgus stress test? Which ligament are you testing?
Hold the elbow in 20° flexion with the forearm in supination, apply pressure on the lateral side of the elbow to increase the pressure on the medial ligament
testing medial ligamentous structure
How do you perform the varus stress test? What ligament are you testing?
Hold the elbow in 20° flexion with the forearm in supination and apply pressure on the medial side of the elbow, attempting to open the lateral joint line
testing the lateral collateral ligament
In relation to the body, is valgus pulling the hand towards or away from the body?
away
In relation to the body, is varus pulling the hand towards or away from the body?
towards
What are the 3 different fracture patterns of the distal humus? Which one is MC overall? MC in children?
Supracondylar (MC in children) - Type A
Epicondylar (medial or lateral) - Type B
Intercondylar - Type C (MC)
What type of fracture?
type A
supracondylar distal humeral fx
What type of fracture?
type B
Epicondylar (medial or lateral) distal humeral fx
What kind of fracture?
Type C
intercondylar distal humeral fx
If the ulnar nerve motor was damaged in a distal humeral fx, what would the pt NOT be able to do?
Flexion/adduction wrist, 4th and 5th DIP joint flexion, finger abduction
If the radial nerve motor was damaged in a distal humeral fx, what would the pt NOT be able to do?
wrist extension
pain, swelling, tenderness
limited elbow ROM
shortening of arm with displaced shaft
What am I?
distal humeral fx
If the fx is supracondylar, what artery and nerve are likely to be involved?
radial artery and median nerve
If the fx is medial epicondylar humeral, what nerve is likely to be involved?
ulnar nerve
If the fx is lateral epicondylar humeral, what nerve is likely to be involved?
radial nerve
When assesses _____ humeral xray, you see a fat pad “sail sign,” what does that indicate? What can it point to? What is the MC population?
distal
Indicates intra-articular bleeding
May be evidence of an occult fracture
MC seen in kids
fat pad “sail sign” is NOT unique to distal humeral fx, also need in radial head/neck fx
What does this indicate?
distal humeral fx
What is the tx for isolated supracondylar distal humeral fx without displacement or angulation?
Long arm cast/splint with elbow flexed at 90 degrees
What is the tx for isolated supracondylar distal humeral fx WITH displacement, NV compromise or angulation?
ORIF
What is the tx for epicondylar distal humeral fx that is isolated and less than 2 mm displaced? If medial condyle? lateral?
Long arm cast/splint with elbow at 90 °
Medial condyle fx - forearm in pronation
Lateral condyle fx - forearm in supination
What is the tx for epicondylar distal humeral fx that is moderately 2-4 mm displaced? Severe?
Percutaneous pinning¹ or ORIF
ORIF
What is the mechanism of injury for olecranon fracture? What is 2nd MC?
fall on a semi-flexed supinated forearm (avulsion)
direct trauma
What nerve is MC affected with an olecranon fracture? What 3 xray views should you order?
Ulnar nerve is most often affected
AP, lateral and radiocapitellar
What is the management of a less than 1-2 mm displaced (nondisplaced) olecranon fx? When do you need to repeat xrays?
Posterior long arm splint with elbow in any degree of flexion, forearm in neutral position
Encourage hand/finger ROM/strength
Repeat x-ray in 7-10 days to ensure alignment is intact
after cast removal, gentle ROM and consider PT
When can the cast/splint be removed after an olecranon fx?
Cast/splint removed after 2-3 wks
What is the tx for a displaced but closed olecranon fx? open?
displaced closed fx: splint and refer for ORIF
displaced open fx: admit for IV abx and consult ortho
______ is the MC fracture of the elbow! What is the MOI?
Radial Head/Neck Fracture
FOOSH resulting in compression of radial head into the capitellum
What is the classification system for radial head/neck fractures?
Type I - < 2 mm displacement
Type II - displaced > 2 mm
Type III - comminuted
Type IV - radial head fracture with associated elbow dislocation
**A radial head/neck fracture will have what movement especially painful?
**Painful pronation/supination
What is the management for a type I radial head/neck fx?
Sling with or without a posterior splint → splint should be removed after 1-2 days
active ROM after 24-48 hours
Full extension, flexion
Pronation and supination with elbow flexed at 90°
F/u with ortho within 1 week
Aspiration if hemarthrosis is present to allow early ROM
What is the management for radial head/neck type II-III fx?
Type II-III:
Sling and splint with ortho evaluation in 2-3 days to discuss consideration of ORIF
Ortho can assess for mechanical block
type IV:
Immediate consult for reduction and ORIF
What is “nursemaid’s elbow?” Who is the MC pt?
Subluxation (partial dislocation) of the radial head through annular ligament due to laxity
MC in children under age 5 years
What is the MOI for radial head subluxation?
Pulling on a pronated forearm while the elbow is extended
How will the kid present with a radial head subluxation?
hx of swinging mechanism
arm is held semi-flexed, adducted, and pronated
ROM is refused
tender over radial head WITHOUT swelling or ecchymosis
What is the management of radial head subluxation? What are the 2 options? Which one is preferred? What should you do next?
reduce it!!
Supination-flexion
Hyperpronation** this one is preferred
Immediate re-assessment of NV status
What should you do if your first attempt to reduce a radial head subluxation is unsuccessful? What would make a successful reduction less likely?
Reduction is less likely to be success if patient is seen 1-2 days after injury
Is imaging always needed in radial head subluxation?
Not necessary for diagnosis
X-ray only if suspicion of other injury
Describe how to perform the Supination-Flexion Reduction Technique. What is it used for?
radial head subluxation reduction
Describe the hyperpronation reduction technique. When is it used?
radial head subluxation reduction
What is the management if radial head subluxation reduction did not work after 3-4 attempts?
Failed reduction:
Order radiographs
Splint (posterior long-arm) and refer to ortho
What is the management of a successful radial head subluxation reduction?
Tylenol/Motrin prn
+/- sling
Parent education
What is epicondylitis? What is the difference between tennis elbow and golfer’s elbow? Which one is MC?
A tendinosis of the wrist extensors or wrist flexors at their origination site on their respective epicondyles
Lateral: wrist extensors (aka tennis elbow) - MC**
Medial: wrist flexors (aka golfers elbow)
What is the MOI for epicondylitis? What age range?
Chronic repetitive overuse resulting in micro-trauma at tendon insertion
Acute strain due to excessive loading
30-50 years old
Where will tennis elbow be TTP? What is the wrist doing?
Point tenderness 1 cm distal to lateral epicondyle
wrist extension with supination or gripping
Where will golfers elbow be TTP? What is the wrist doing?
Point tenderness 1 cm distal to medial epicondyle
pain with ROM against resistance: elbow flexed. Wrist flexion and pronation
Shaking hands, using computer mouse, use of screwdriver, back-handed tennis swing. These activities would cause pain for someone who has _______
Lateral Epicondylitis (Tennis Elbow)
Golf swing, overhead throwing, bowling. These activities would cause pain for someone who has _______.
Medial Epicondylitis (Golfer’s Elbow)
Do you need xrays for epicondylitits?
Not needed! and they will be normal
What is the management for epicondylitis?
Activity modification, NSAIDs (topical or oral), Ice after use
PT
counterforce brace
steroid injection (max 3)
What am I? When should you refer to ortho for the suspected condition?
counterforce brace used in the epicondylitis
Refer to ortho if symptoms persist for 6 months of conservative therapy
______ can be seen secondary to systemic inflammatory conditions (RA, gout). If infectious, what are the 2 MC pathogens?
Olecranon Bursitis
Septic bursitis - MC pathogens staph and strep
What am I? When is it more likely to be painful, tender and with limited ROM?
olecranon bursitis
in trauma or infectious etiologies
not so much in chronic bursitis
When is aspiration indicated for olecranon bursitis?
large and symptomatic bursa
can do analysis of bursal fluid (CBC, gram stain, C&S, and crystals)
What is the management for olecranon bursitis with only mild swelling and no signs of septic bursitis?
Activity modification and NSAIDs
Use of an elbow pad, compression during acute phase
What is the management for olecranon bursitis with 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
What is the management for mild septic olecranon bursitis?
1st line: bactrim
alt: cephalexin
What is the management for severe septic olecranon bursitis or the pt is immunocompromised? What if associated with trauma?
severe think systemic symptoms (fever, hypotension, tachycardia) or rapid progression after starting oral abx
IV vancomycin
trauma: add ciprofloxacin (Cipro) or piperacillin-tazobactam (Zosyn) for pseudomonal coverage
How are hand, wrist and fingers xrays shot?
PA, oblique, and lateral
How do you shoot an oblique hand view?
PA, about 45 degrees off the table with fingers spread
What is a Galeazzi fx?
Radial midshaft fracture associated with instability of the distal radioulnar joint (DRUJ)
What is a Monteggia fx?
Fracture of the proximal third of the ulnar shaft associated with dislocation of the radial head due to instability of the proximal radioulnar joint (PRUJ)
What are the differences between a Galeazzi and Monteggia fracture?
forearm xray series should automatically provide you with views of ____ and ____
wrist and elbow
need to eval joints above and below fx
What is considered a simple, isolated, fracture of the ulnar shaft? What is the tx?
needs to be middle-distal 1/3
< 50% displacement, <10% angulation before or after closed reduction and no joint involvement
Long-arm posterior splint
What is the proper way to apply a long-arm posterior splint?
Elbow at 90 degrees
Forearm in neutral position
Slight wrist extension
When do you need f/u xray in a simple, isolated, fracture of the ulnar shaft?
F/u x-rays to ensure alignment at 1 wk and then q4wk until complete healing has occurred (usually 8 wks)
What are the indications for a double sugar tong splint?
Isolated radial fractures
Combined radius-ulna fracture
Galeazzi or Monteggia fracture
What am I? When is it used?
double sugar tong splint
complex radial and ulnar fractures
What is the MC MOI for a wrist fracture? What are the 2 common types?
FOOSH
Colles fx
Smith’s fx
What is the difference between Colles and Smith’s fx?
Colles fx (MC) - the distal radius fracture fragment is tilted dorsally
Smith’s fx - the distal radial fragment is tilted volarly
What is the most likely type of wrist fracture?
Colles fx (MC) - the distal radius fracture fragment is tilted dorsally
What is the most likely types of wrist fracture?
Smith’s fx - the distal radial fragment is tilted volarly
What type of deformity? What type of wrist fracture?
“dinner fork” deformity -> Colles
(dorsal)
hand is up compare to wrist
What type of deformity? What type of fracture?
“garden spade” deformity -> Smith’s fx
volar
What is the tx for non-displaced, minimally displaced or non-articular fx? How long do they need to wait? What are the xray requirements?
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
what is the management for displaced or open wrist fractures?
ORIF
What is the MC carpal fx? What pt population? **Why are these especially important to NOT miss?
scaphoid fx
young men
**Blood supply enters at the distal ⅓ of the bone
What are 3 complications of a scaphoid fracture?
High incidence of delayed diagnosis
Non-union
Avascular necrosis
**What is the slam dunk PE finding for scaphoid fracture?
** Tenderness along the anatomical snuff box
What xrays should you order if concerned about scaphoid fracture?
Wrist series PLUS
Scaphoid (navicular) view
How do you shoot a scaphoid (navicular) view?
PA view with the wrist in ulnar deviation
What is the tx for a nondisplaced scaphoid fx? One that has negative xrays? What if the xray remain negative but scaphoid fx suspicion is very high?
Thumb spica splint/cast x 6 wks
Refer to ortho
Thumb spica splint/cast x 6 wks
Refer to ortho
Repeat x-rays in 7-14 days if initially negative
If x-rays remain negative and tenderness persists → CT/MRI
What is the tx for displaced scaphoid fracture?
ORIF or
Percutaneous pin placement
What am I? When am I used?
thumb spica
scaphoid fracture
carpal tunnel is compression of the ______ at the ______
median nerve
carpal tunnel
What are the risk factors for carpal tunnel syndrome?
Repetitive wrist movements
Wrist injury
Pregnancy
Sedentary lifestyle
Familial (idiopathic)
Multiple systemic conditions
burning, tingling pain in the hand
worse with activity and at night
pain may radiate into elbow or shoulder
What am I?
What special PE findings?
carpal tunnel syndrome
Tinel’s and Phalen’s signs
Carpal compression test
The hand elevation test
Grip weakness
Thenar atrophy (late)
How do you dx carpal tunnel? What is the management?
EMG/NCS
Activity modification
Cock-up wrist splint
Corticosteroid injection
Refer for to ortho for carpal tunnel release
What are the indications to refer to ortho for carpal tunnel?
Failure of > 3 months of conservative therapy
Objective neurologic findings or thenar muscle atrophy
What is the MC fracture of the hand? Where?
boxer’s fracture
Fracture of the 4th and/or 5th metacarpal that results from a closed fist striking an object
What am I? What pt population? These are the most likely to be _____
boxers fracture
MC in adults
Boxer’s fracture are most likely to be malrotated
______ hand fx is MC in children. Which one specifically?
Phalangeal Fractures
Involving the physis (growth plate) of the 5th phalange
What is the MC phalangeal fx in adults?
The distal phalanx is the most commonly injured
What is the tx for a metacarpal neck fx with >30° angulation?
reduce!!
then splint/cast
What is the tx for metacarpal neck fracture with < 30° angulation? What if 2nd or 3rd metacarpal? 4th or 5th?
splint for 2-3 weeks!!
2nd and 3rd metacarpal = Radial Gutter Splint
4th or 5th metacarpal = Ulnar Gutter Splint
What am I? When am I used? What should be changed about this picture?
Ulnar gutter splint
4th and 5th metacarpal bone fractures
wrist should be in neutral position NOT extended
What am I? When am I used?
radial gutter splint
fx of the 2nd or 3rd metacarpal bones
What is the tx for non-displaced fractures of the 2-5th phalangeal shaft?
Phalangeal fracture - buddy tape or aluminum splint
What is the management of a non-displaced 1st metacarpal/phalangeal fx?
Thumb-spica splint, wrist in neutral position
What is the tx for a non-displaced/non-articular 1st metacarpal base?
Thumb spica splint/cast x 4 wks
What is the tx for displaced/angulated metacarpal/phalangeal shaft fracture or intra-articular fractures?
Refer/consult ortho for further evaluation
Closed vs open reduction and fixation
aka its orthro’s problem now :)
What is important to remember about buddy taping?
Need to tape above and below the proximal DIP joint
What is gamekeeper’s thumb? (skier’s thumb) What is the MOI?
Rupture of the ulnar collateral ligament of the 1st MCP joint
forced radial abduction
What action will pts with gamekeeper’s thumb NOT be able to do well?
weak pincer function
thumb is very unstable
How do you dx gamekeeper’s thumb? What is the management?
dx: 1st phalange finger series
tx:
Thumb spica splint
Refer to ortho for surgical repair
What is mallet finger? What is the MOI?
A rupture, laceration, or avulsion of the extensor tendon at the distal phalanx
Hyperflexion of DIP
What am I? What is the clinical presentation? ROM?
mallet finger
DIP is flexed at 40° with the INABILITY to actively extend
passive ROM is intact
**What are mallet fingers associated with?
**May be associated with an avulsion fx of the distal phalanx
What is the tx for mallet finger? For how long? What is an important pt education point?
DIP in full extension x 4-8 weeks
Splint can not be removed
If mallet finger is not treated properly, ______ is likely going to be the result. What is it?
swan neck deformity
Hyperextension of PIP with flexion of DIP
What is Boutonniere deformity? What is the MOI?
Rupture of the central slip of the extensor tendon where it inserts on the middle phalanx
Forced flexion of the PIP
What am I? How will the pt present? What will the pt complain of?
Finger is held partially flexed at the PIP and extended or hyperextended at the DIP
Swelling, PAIN, point tenderness along the dorsal PIP with limited ROM
In boutonniere deformity, what can the pt NOT do?
Inability to fully extend the PIP - remains flexed at 30°
What is the tx for Boutonniere deformity? When do you need to refer to ortho?
Splint PIP in extension leaving DIP free x 4-8 wks.
If conservative therapy fails
Associated irreducible PIP dislocation
Associated open fx
What is De Quervain Tenosynovitis? What is the etiology?
Inflammation of the tendon sheath covering the extensor/abductor tendons of the thumb
overuse
How will De Quervain Tenosynovitis present? How do you dx?
Aching pain and point tenderness along the radial aspect of the wrist with use, pain may radiate up the arm
Finkelstein test is diagnostic
How do you perform Finkelstein test?
Ulnar deviation of an adducted thumb reproduces pain
What is the tx for De Quervain Tenosynovitis?
Thumb spica splint
Activity modification
NSAID’s
refer to ortho is conservative tx fails
-injections into tendon sheath
-Surgical release of the first dorsal compartment
What is a ganglion cyst? What is it filled with? Where are the MC location? Who is the MC pt?
A fluid-filled swelling overlying a joint or tendon sheath
Filled with clear, gelatinous, sticky, or mucoid fluid
dorsal aspect of the wrist
MC in females ages 10-40
How will a ganglion cyst present? **What is the highlighted one from lecture? What is a PE test that may help differentiate?
Localized intermittent pain/tenderness
Cyst is firm, SMOOTH, rounded, rubbery
May fluctuate in size over time
Transillumination will help differentiate cyst from solid lesion
What dx do you need to order in a ganglion cyst? Why?
X-ray -> Rule out bony pathology
US or MRI may be used if atypical presentation
What are the 3 management options for a ganglion cyst?
Observation -> Most will spontaneously regress
Aspiration, with or without injection of a corticosteroid
Surgical removal
_____ is an idiopathic dysfunction of the flexor tendon of the finger as is glides through the tendon sheath. What is it due to? What digits are most commonly affected?
trigger finger
Often due to a discrepancy in the size of the tendon and is sheath
3rd and 4th digits are most commonly affected
What is the presentation of trigger finger? When is it worse? _____ is present on the palm
Catching, snapping or locking of the involved finger(s). Pain and dysfunction.
Often worse upon awakening
Painful nodule on the palm
What is the tx for trigger finger?
NSAIDs, +/- corticosteroid injection into the tendon sheath (up to 2)
failed conservative therapy -> sx release
Trigger finger pts who also have _____ are at an increased risk for ______ and should only have 1 injection
RA
tendon rupture
______ is progressive fibrosis of the palmar fascia. Who is the MC pt? **What finger is MC?
Dupuytren Contracture
men > 50 yrs old
**4th phalange is most common
What are the 6 risk factors for Dupuytren Contracture?
Epilepsy
DM
pulmonary disease
alcoholism
smoking
repetitive vibrational trauma
How will Dupuytren Contracture present? What happens as a result?
One or more painless nodules near the distal palmar crease
The nodules gradually thicken leading to a cord that contracts
What am I? Describe the ROM
Dupuytren Contracture
flexion is normal but extension is LIMITED
How do you dx Dupuytren Contracture? What is the tx?
clinical!! no testing needed
night splinting may slow progression but NOT curative
sx release
When is sx release indicted in Dupuytren Contracture? What does it involve?
Indicated if a 30° fixed flexion of the MCP
Involves excising the thickened soft-tissue bands and release of the joint contractures
The brachial plexus is an extension of what nerve roots?
C5-T1
What are the 3 mechanisms of injury that can result in a brachial plexus syndrome?
- Traction force
- Direct blow to the top of the shoulder
- Stretching of the plexus when the arm is abducted forcefully
_____ MOI of brachial plexus syndrome is caused when the shoulder is forcefully depressed & the head / neck are tilted toward the opposite side. What roots?
Traction force
Damages C5, C6, and C7 roots
Direct blow to the top of the shoulder MOI of brachial plexus syndrome causes damage to what nerve roots?
Damages C5, C6, and C7 roots
_____ MOI of brachial plexus syndrome is caused when the pt grabs something while falling. What nerve roots are damaged?
Stretching of the plexus when the arm is abducted forcefully
C8 and T1 roots
What is the presentation of brachial plexus syndrome?
Sharp, burning shoulder pain with radiculopathy in the affected nerve root distribution
weakness is common but not necessary
What 3 things should be included in your PE for brachial plexus syndrome?
Evaluate sensation to light touch, motor function, & DTRs
What are the 4 s/s associated with Horner’s syndrome? What are the associated damaged nerve roots?
ipsilateral ptosis, myosis, anhidrosis and enophthalmos
C8- T1
What nerve root is responsible for the following actions?
Elbow flexion
Shoulder abduction
Elbow flexion
wrist extension
sensory thumb and radial hand
abduction of the fingers
finger flexion
wrist flexion and finder extension
elbow extension
_____ is the best visualization of the spinal cord and nerve roots. When is it indicated?
MRI
Indicated if: x-rays are abnormal or symptoms persists
What is the tx for brachial plexus syndrome?
Strengthening and stretching exercises
Splinting in neutral position of any joints affected by paralyzed muscles
Encourage PROM to reduce joint stiffness or tendon constrictors
Athletes must have a ______ of _____ and normal PE before allowed to return to activity
complete resolution
symptoms
What are the 6 structures involved in thoracic outlet syndrome?
First rib
Subclavian artery
Subclavian vein
Brachial plexus
Clavicle
Lung apex
What is thoracic outlet syndrome? Who is the MC pt?
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 y/o
What is the presentation of thoracic outlet syndrome? **What tends to make s/s worse?
Aching pain/paresthesia due to compression of the brachial plexus
Intermittent swelling and discoloration due to compression of the vascular structure
Fatigue, weakness, and aching pain of extremity
**Symptoms are often exacerbated by lifting the arm above the head
During the PE of thoracic outlet syndrome, you want to assess what 4 things?
Inspect for swelling / discoloration
Palpate the supraclavicular fossa to assess for a mass
Palpate for distal UE pulses
Check sensation & motor function cervical nerve roots
What special PE test is used to check for thoracic outlet syndrome? Describe it. What is a positive result?
Elevated arm stress test
Both shoulders abducted at least 90 degrees and supported posteriorly. The patient opens & closes fists at a moderate speed for 3 minutes.
POSITIVE test if reproduced neuro &/or vascular s/s
What imaging should you order in thoracic outlet syndrome? why?
AP & lateral C-spine: Rule out congenital anomalies (cervical rib or overly long transverse process of C7)
PA/lateral CXR: Help rule out apical lung tumors
MRI: May be warranted to rule out cervical disc rupture or cervical spondylosis
What is the tx for thoracic outlet syndrome?
