Upper extremities + Peds Fx Flashcards
Thoracic Outlet Syndrome
- describe
- etiology—MCC?
- MC in who
- other etiologies
- CMs
- PE
- imaging—how to confirm
- tx
- group of symps
- positional/intermittent compresion of BRACHIAL PLEXUS and/or SUBCLAVIAN ARTERY / VEIN
MCC=hypertrophied scalene muscles that compress vesels/nerves against the clavicle and b/w 1st rib
MC in women 20-25 YO
OTHER ETIOLOGY:
- secondary to neck trauma
- sagging of shoulder girdle—age, obesity, pendulous breasts
- occupation
- faulty posture
- thoracic muscle hypertrophy–>weight lifting, baseball pitching
CM: MAIN symp dep on which structure is compressed (nerve, artery or vein)
*neurologic: shoulder + arm pain, weakness, pain or paresthesia to arm or forearm, ulnar neuropathy (volar aspect of 4th and 5th digits)
- artery: claudication, pallor of fingers on elevation of extremity, sensitivity to cold, ischemic tissue loss and gangrene
- vein: edema, cyanosis of affected arm, esp w/ abduction of arm
***some combo of 4 s/s= pain, numbness, weakness and swelling
PE:
*(+) Adson sign–>loss of the radial pulse with deep breath, head rotated & toward affected side
DIAGNOSIS:
- MRI to confirm
- doppler
- EMG/NCV studies can help
TX:
- conservative management for 95% cases
- PT
- pain relief
- avoid activities that compress neurovasc bundle
- **surgical decompression if the above doesnt work
Olecranon Bursitis
- Etiologies
- CM
- diagnosis
- Tx
ETIOLOGIES:
*direct trauma, repetitive microtruama, gout, inflammation
CM
- goose egg–boggy swelling to the posterior olecranon process area
- if etiology is trauma or chronic: mild tenderness, discomfort with full flexion
- if infectious/inflammatory cause: erythema, warmth, tenderness with painful limited ROM—–>have to examine skin for breaks or cellulitis if considering infection
DIAGNOSIS:
*aspiration of bursa if suspected septic bursitis or gout (WBC >2,000=septic)
MANAGEMENT:
- olecranon bursitis=padding to area, NSAIDS, ACE wrap for compression
- septic bursitis= drainage and ABX—-Dicloxacillin or Clindamycin
Olecranon Fracture
- MOA
- CM
- complications
- tx: displced and nondisplcaed
MOA: direct blow— fall on flexed elbow
CM
pain, swelling, inability to fully extend the elbow*****
Comps
- ulnar neuropathy
- post-traumatic arthritis
- anterior interosseous nerve injury
- loss of extension strength
TX:
- non-displaced: reduction and posterior long arm splint–90 degrees flexion
- *ALLLL are considered intraarticular and need reduction
- –>after splinting–TAKE XR
*displaced: ORIF
Elbow Dislocation
- MOA
- MC way to dislocate?
- often asosc with
- PE
- tx
- complications (5)
- MC sequelae
MOA: FOOSH with hyperextension (high energy) and axial loading
MC dislocation= posterior dislocation–falling forward
–>ASSOC with: radial head or coronoid process fx
PE:
- flexed elbow
- marked olecranon prominence
- inability to extend elbow
TX:
- stable (+pulses)= EMERGENT reduction w/ long (posterior) arm splint at 90 degrees—XR— ortho follow up
- Unstable=ORIF
COMPS
- must r/o brachial artery injury
- r/o. median, ulnar, radial nerve injuries
- lost of terminal extension is MC sequelae
- joint stiffness or contracture if split is left on > 3 weeks
- compartment syndrome
Radial head FX
MOA
PE
DX
MOA: FOOSH
PE: lateral (radial) elbow pain, inability to fully extend elbow
DX: very hard to see on XR–> (+) posterior or displaced anterior fat pad sign (hemarthrosis)
TX
- nondisplaced= immobilization: sling, long arm splint 90 degrees
- displaced: surgical ORIF
Radial head FX MOA PE DX TX--displaced and nondisplaced
MOA: FOOSH
PE: lateral (radial) elbow pain, inability to fully extend elbow
DX: very hard to see on XR–> (+) posterior or displaced anterior fat pad sign (hemarthrosis)
TX
- nondisplaced= immobilization: sling, long arm splint 90 degrees
- displaced: surgical ORIF
whats a normal fat pad
visible
anteriorly
NOT Posteriorly
Ulnar Shaft Fracture
- also called
- MOA
- describe fx
- management
- –>nondisplaced distal 1/3
- –>nondisplaced mid-prox 1/3
- —>displaced
Nightstick fx
MOA: direct blow
Nightstick=fx of the middle portion of the ulnar shaft w/o any associated fxs
Management:
- nondisplaced distal 1/3=short arm cast
- nondisplaced mid-proximal 1/3=long arm cast
- displaced (>50%)= ORIF
Monteggia Fracture
- MOA
- define the fracture
- CM
- TX
MOA: direct blow to forearm
*fx of the proximal 1/3 of the ulnar shaft and radial head dislocation
CM
- elbow pain and swelling
- thumb parasethesias
- sometimes radial nerve injury (17% of cases)—>may develop wrist drop
TX
*unstable fractures require ORIF
difference b/w Monteggia and Galeazzi
MONTEGGIA: proximal 1/3 of ulnar shaft fx + radial head dislocation
GALEAZZI: mid-distal radial shaft fx + dislocation of distal radioulnar joint
Galeazzi Fx
- MOA
- desc fx
- CM
- tx
- complications
MOA: direct blow or fall on outstretched arm
**mid-distal radial shaft fracture with dislocation of the distal radioulnar joint
CM
- fracture and deformity on radial side of wrist
- ulnar head will appear prominent at the wrist (popping out)
TX
- this is unstable fx—needs ORIF
- long arm/sugar tong splint before surgery
complications
- anterior interosseous nerve injury
- loss of pinch b/w thumb and index finger
Lateral Epicondylitis aka? -descrbe/MOA -CM--what motion makes it worse -tx -how long can it take to heal
tennis elbow
*inflamm of tendon insertion of the extensor carpi radialis brevis muscle
MOA: repetitive pronation of the forearm and excessive wrist extension
CM:
- lateral elbow pain–esp with gripping, forearm pronation and wrist extension against resistance
- may rad down the forearm or worsen when lifting objects
MANAGEMENT
- conservative: activity modifications, RICE, NSAIDS, counterbalance braces, interarticular steroid injections for short-term relief
- can take up to 6 MO to heal
- surgery if refractory to conserv management
Medial Epicondylitis aka? -describe -CM -PE -tx
Golfer’s elbow
*inflam of the pronator teres-flexor carpi radialis muscle due to rep overuse and stress at the tendon insetion of the flexor forearm
CM
*tenderness over the medial epicondyle worse with pulling activities
PE
*pain repoducted by perfomring wirst flexion against resistance with the elbow fully extended
MANAGEMENT
- sim to lateral but harder to treat
- conservative=activity modification, RICE, NSAIDS, counterbalance braces, intraarticular steorid injections for short term relief,
- can take up to 6 MO to heal
- srugery if refractory
Cubital Tunnel Syndrome
- describe
- CM–worse with?
- PE
- management
*ulnar nerve compression @ the cubital tunnel along the medial elbow
CM
- Paresthesia and pain along the ulnar nerve distribution
- worse with elbow flexion
PE
- (+) Tinel’s sign at the elbow
- decr sensation to the 5th and the ulnar side of the fourth finger
- (+) Froment sign
MANAGEMENT
- wrist immobilization esp with sleep
- NSAIDS
- chronic=intraarticular steroids
Scaphoid (navicular) fx
- CM
- DX
- TX
CM
*pain along the radial surface of the wrist with anatomical snuffbox tenderness
DX
*radiographs=fx may NOT be evident for up to 2 weeks
**if snuffbox tenderness=tx as a fracture bc of the high tenderness of avascular necrosis or nonunion (since the blood supply to scaphoid is distal to proximal)
TX
- nondisplaced fx or snuffbox tenderness=thumb spica splint
- displaced= >1mm: ORIF or pin placement
what is the MC fractured carpal bone
scaphoid aka navicular
Scapholunate Dissocation
- what is it
- MOA
- CM
- DX
- TX
**widened space b/w scaphoid and lunate bones
MOA: FOOSH
CM
- pain on the dorsal radial side of the wrist with minimal swelling
- pain is incr with dorsiflexion
- might have a click with wrist movement
DX
*widened scapholunate spaces >3mm
TX
- initial: radial gutter splint
- surgical repair of the scapholunate ligament usually req to prevent degenerative arthritis
Colles FX
- MOA
- descr fx
- CM
- PE
- DX
- TX
- complications (6)
- distal radius fx with dorsal angulation
- ulnar styloid fx also seen in 60% of cases
MOA: FOOSH with wrist extended
CM
*wrist pain WORSE with passive motion
PE
*dinenr for deformity
DX:
- lateral view with dorsally displaced or angulated extraarticular fracture of the distal radius
- lateral view needed to distinguish colles vs smith fx
TX:
- stable=closed reduction followedd by sugar tong splint or cast
- ORIF if comminuted or unstable
Complications
- extensor pollicis longus tendon rupture MC
- Malunion or nonunion
- joint stiffness
- median nerve compression
- residual radius shortening
- complex regional pain syndrome
Smith’s Fracture
- describe it
- MOA
- CM— pain worse with?
- PE
- dx
- tx
*distal radius fx with ventral angulation of the distal fragment
MOA: FOOSH with wrist flexed
CM
*wrsit pain worst with passive movement
PE
*garden spade deformity
DX
- lateral view with ventrally displaced or angulated fx of distal radius
- lateral view needed to distinguish this from colles
TX
- Stable + initial management: closed reduction followed by sugar ton splint or cast
- ORIF if comminuted or unstable
Lunate Dislocation MOA -cm -DX -TX -Complications (6)
MOA: high energy injuries while the wrist is extended and ulnarly deviated
*dorsiflexion, ulnar deviation and intercarpal supination
RESULT–>dislocation—lunate does not articulate with both the capitate and radius
CM
- acute wrist swelling + pain
- may develop median nerve symps
DX–XR
- AP view: lunate appears triangular “piece of pie”
- Lateral view: volar displacement and tilt of the lunate “spilled teacup” sign
COMPS
- dev of carpal instability–>early degenerative arthritis
- delayed union
- malunion
- nonunion
- avasc necrosis
- median nerve compression
TX
- ortho emergency!!!!
- emergent closed reduction and split followed by ORIF
Lunate FX
- MOA
- PE
- DX
- TX
- complications
**most serious carpal fx since the lunate occupies 2/3 of the radial articular surface
MOA: FOOSH in hyperextension & ulnar deviation
PE
*tenderness to palpation in shallow indentation on the mid-dorsum of the wrist—>where lunate rises out when wrist is flexed
IMAGING
*XR usually negative
COMPS
*avasc necrosis of lunate bone
WHY? because the luantes blood supply enters thru distal end of bone— risk of proximal avasc necrosis——>leads to lunate collapse—>OA—>chronic pain—>decr grip strength
TX
- immobilization with orthopedic ref/FU
- *NOT ortho emergency like the lunate dislocation is
Mallet Finger
-aka?
Baseball finger
MOA: avulsion of the extensor tendon (what extends DIP) after sudden blow to tip of the finger causing forced flexion of an extended finger
PE
*unable to actively extend the DIP joint
DX
*XR: normal or avulsion fx of distal phalanx at the tendon insertion site
TX
- nonoperative: uninterrupted extension splint of the DIP for 6-8 weeks
- closed reduction & percutaneous pinning if needed
Boutonniere Deformity
MOA
MOA: sharp force against the tip of a partially extended digit–>hyperflexion at the PIP joint with hyperextension at the DIP
disruption of extensor tendon at the base of middle phalanx
MC result of TRAUMA**–>ruptures central slip
TRAUMA=laceration injury to the central slip and dorsal capsule
**can also be sequela of RA
TX
*splint PIP in extension for 4-6 weeks w/ hand surgeon f/u
Sawn Neck Deformity
MOA
- sharp force againt the tip of a partially extended digit–>hyperextension at PIP w/ flexion at the DIP
- disruption of extensor tendon at the base of the middle phalanx
**can also occur in RA: synovitis of PIP renders the volar plate ineffective in preventing PIP hyperextension
TX: surgery
De Quervain Syndrome
*what is it
Stenosing inflammation of tendons (entrapment tendonitis) of the first dorsal compartment
- ->APL (abductor pollicis lungus)
- –>EPB (extensor pollicis brevis)
MOA: excessive thumb use with repetitive action– thumb abduction and extension
CM
- pain along radial aspect of wirst + base of thumb—rad to forearm esp with thumb extension or fripping
- pain and tenderness at the radial styloid
- swelling and thickness over the tendon sheath
DX
*Finklestein test: (+) means–>first dorsal compartment pain with ulnar deviation while the thumb is flexed in the palm or pain with thumb extension
TX
- thumb spica splint initial tx
- NSAID
- PT
- corticosteroid injection if initial tx is unsuccessful
Carpal Tunnel Syndrome
*median nerve entrapment and compression at the carpal tunnel
RFs
- women
- DM
- preg
- occupations w/ repetitive extension and flexion of wrists
CM
- paresthesias or pain of the palmar aspects of the first 3 (&radial half of the fourth) digits esp at night
- thenar muscle wasting in advanced cases
DX
- tinel test=pos if percussion of median nerve produces s/s
- Phalen tests: pos if flexion of both wrists for 30-60 seconds reproduces s/s
TX
- initial/conservative=volar splint, NSAIDS
- corticosteroid injecs
- surgery in refractory cases
Dupuytren Contracture
*progressive fibrosis of palmar fascia–leads to contractures as result of nodules or longitudinal bands (cords) in the palm
RF
- men >40
- ETOH
- DM
- smoking
CM
- visible or palpable nodules over the distal palmar crease of proximal phalanx along the course of the flexor tendons
- fixed flexion deformity at the MCP joint with limited extension of MCP or PIP
TX
- intralesional collagenase and/or corticoid injection
- surgical correction for adv or refrac cases
Boxer’s Fracture
fx thru fifth metacarpal neck
MOA: direct trauma to a closed first against a hard surface
CM
- pain along the dorsum of 5th metacarpal of hand with swelling
- ecchymosis
DX
-XR
TX
- initial=ulnar gutter splint
- ORIF
- check for bite wounds—– if punched in the teeth/face
- ->put them on Augmentin
Radial Head Subluxation
-aka?
Nursemaid’s elbow
*radial head is wedged into stretched annular ligament
MC in kids 2-5YO
*MCC by lifting, swinging, or pulling a child while the forearm is pronated and extended
PE
*arm slightly flexed and child refuses to use the arm
Diagnosis=clinical
XR usually normal
TX
*closed reduction—-pressure on radial head with supination of elbow, followed by flexion of elbow
Clavicular FX
MC fx bone in kids, adolescents and newborns during brith
Males»>females
typically occurs with mid-high energy impact to the area or fall on an outstretched hand
if no h/x of trauma— suspect malignanyc, rickets or abuse (ESP if <2yO)
PE
- pain with ROM
- deformity at site
- holds arm against chest
Comps
- pneumo
- hemo
- coracoclavicular ligament disruption (distal)
- brachial plexus injuries
CLASSIFICATION
- group 1= MC, midshaft, middle
- group 2=lateral (distal) third
- group 3= proximal medial third
TX
- group 1= sling immobilization (with sling or fgure 8 splint)
- if lateral or proximal, get an ortho consult
*surgery is typcally indicated for any open fx, displaced fx, etc
Greenstick fx
- cortex broken one side, bent/bowed on the other
* peds
Anterior Glenohumeral dislocation
- MOA
- PE findings
- subtypes: describe and MOA
MOA=mc after blow to an abducted, externally rotated and extended extremity
others: FOOSH, or posterior humeral force
MC type=anterior
PE: arm will be held in abducted and external rotation (elbow pointing out)
-sqaured off shoulder– humeral head is palpable with loss of deltoid contour
SUBTYPES
`1. Hill Sach Lesion: groove fx of humerus… corticol depression in posterolateral head of humerus
MOA=forceful impaction of humeral head against anterioinferior felnoid rim when shoulder is dislocated anteriorly
- Bankart Lesion: glenoid rim fx–stripping of glenoid labrum and periosteum from anterior-inferior surface of glenoid
* occurs in lower part of labrum
MOA for anterior dislocation vs posterior dislocation
ANTERIOR= abducted, external rotation, FOOSH
POST=adducted, internal rotation, seizures, electric shock
PE findings for anterior vs posterior disloction shoulder
ANT: abduction + external rotation, humeral head palpable–squared off
POST: adducted and internally rotated–shoulder appears flat with prominent humeral head
DX for anterior vs posterior shoulder dislocation
ANT= axillary and Y view *helps disting b/w ant and post POST= light bulb sign
TX for anterior vs posterior shoulder dislocaiton
ANT=reduction and immobilization
MUST CHECK AXILLARY NERVE for injury b4 AND after reductio.
POST=reduction and immobilization
Acromioclavicular joint dislocation/separation
- aka
- MC MOA
- CM
- types and MC
AKA AC separation
- clavicle sep from the scapula
- MCC is falling directly on shoulder—direct blow to adducted shoulder
CM
- pain with lifting arm, unable to lift arm at the shoulder
- can be +/- dtep off at AC joint
TYPES
1, 2 and 3 MC
4 5 6 usually require surgical repair
type 1= AC ligament stretched or partially torn
type 2=AC ligament is totally torn and joint is slightly displaced
type 3=AC ligament AND coracoclavicular ligmanet torn— joint is completely displcaed——-clavicle no longer attached
DX
*xray with weights to help see dispalcement
TX
- types 1-3: conservative (ice, brief sling immobilization and rest). early rehab for ROM preservation
- types 4-6: surgical reattachement of ligaments
Shoulder Impingement syndrome
- when does it occur
- worse when?
- grades
- tx
- when tendons of the rotator cuff and subacrominal bursa are pinched in the narrow space beneath the acromion
- causes tendons and bursa to become inflammed and swollen—“PINCHING”
- worse when arm is adducted
THREE GRADES
I: inflammaiton of bursa and tendons
II: progressive thickening and scarring of bursa
III: rotator cuff degeneration and tears
TX= conserv + PT
Adhesive Capsulitis aka
- define
- MC in who
- CM
- PE
- prognosis
Frozen Shoulder
*stiffness due to inflammation
MC in 40-60s, DM, hypothyroidism
CM
- shoulder pain. stiffness
- decr ROM–esp with external rotation
- pain usually worse at night
PE
*resistance on passive ROM only on affected side
*gradual return to normal ROM– can take up to 18-24 mo
TX
- rehab= mainstay.
- anti-inflamms
- intraarticular steorid inj
- heat
Rotator Cuff Injuries
- MOAs and MCC
- injuries include?
- which muscle in the cuff is MC injured
- CM
*MOA: chronic erosion, trauma
MCC=repetitive overhead movements
OTHER: older age, smoking
INJURIES INCLUDE BOTH:
- tendonitis–inflamma usually assoc with subacromial bursitis
- tear
Supraspinatus is MC injured
CM
- Anterolateral shoulder pain–deltoid pain—with decr ROM
- decr ROM esp with overhead activities, external rotation or abduction—ex reaching for wallet
- passive ROM > active
- continuous pain and weeakness
PE
- Impingement tests= pain= (+) tear
1. Hawkins
2. Drop arm test
3. Neer test
*supraspinatus strength test aka empty can test–>most specific for supraspinatus involvement
describe the tests:
1. Hawkins
HAWKINS= elbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with internal rotation
DROP ARM: pain with inability to lift arm above the shoulder level or hold it or severe pain when slowly lowering the arm after shoulder is abducted 90 degrees
NEER: arm fully pronated (thumbs down) with pain during forward flexion (shoulder is held down to prevent shrugging)
Humeral Head fx
- moa
- PE
- must always r/o what?
MOA=FOOSH, direct blow PE *arm held in adduction *decr ROM *pain *swelling *ecchymosis MUST R/O BRACHIAL PLEXUS INJURY---- test deltoid sensation
TX
Sling immobilization, analgesics & physical therapy
humeral shaft fx
- moa
- pe
- dx
- tx
MOA=FOOSH, direct trauma
PE=pain swelling to arm, ecchymosis, decr ROM
MUST RULE OUT RADIAL NERVE INJURY— (+) injury=wrist drop
TX
Coaptation splint or sling with prompt ortho follow up
Surgical if open fracture, vascular or brachial plexus injuries
