Upper Extremity Flashcards
Glenohumeral Joint
Anterior Glenohumeral Dislocation - MC
* MOI: Blow to the ABD,ER,extended arm
* XRAY
* Injuries:
■ Bankart Lesion: Avulsion (tear) of the anterior labrum and the anterior band** of the interior GHL from anterior glenoid
■ Hill Sachs Lesion: Chondral impaction fracture of posterior superior humeral head secondary to contact with glenoid rim **
* Treat: Reduce & Sling
Posterior Glenohumeral Dislocation
* MOI: seizures, electric shock,
* Physical Exam: landing on foward flexed,ADD arm, IR
* XRAY - Light Bulb Sign
* Treat: Reduce & Sling
SLAP Tear + Bicep
○ Superior Labrum from Anterior to Posterior
○ Overuse injury in athletes, causes deep pain and biceps tendonitis
■ Biceps tendonitis
● Most likely cause of anterior shoulder pain, pain moving down bicep
○ Presents as pop sensation during overhead motion
○ treatment : nonop,nonop,nonop → steroid injection
○ Physical exam:
■ Speeds test: pain in bicipital groove when pt forward elevate shoulder against resistance
■ Yergason test: pain in bicipital groove when pt tries to supinate against resistance with elbow at 90 degrees
■ Popeye deformity: indicates rupture (pic)
● Conservative treatment: Tendonitis- NSAIDS or steroid injection
● Surgical treatment: Biceps tenodesis or tenotomy
Rotator Cuff Anatomy
- SITS
- Coronal force couple: interior rotator cuff (IS, T M, Subscap) vs. superior moment created by deltoid
- Transverse plane: anterior cuff (subscap) vs posterior cuff (IS, T M)
- Goal: stabile fulcrum for GH motion - force equilibrium in all plane
Rotator Cuff Impingment
- Most common cause of shoulder pain - subacrominal impingement
- Compression of rotator cuff by superior structures (acrominion) leading to inflammation and bursitis
- “First stage of rotator cuff disease”- continuum of disease from: **
■ Impingement and bursitis**
■ Partial or full thickness tear
■ Massive rotator cuff tear
■ Rotator cuff arthropathy**- MOI: Denigration, Impingement, Overload
- Clinical Manifestations: Pain by overhead activities, pain at night
- Physical Exam:
- Hawkins: “Hawk flapping their wings” (IR)
- Neer: FIR, “the one by the ear”
- Empty Can Test: “supraspinatus function”
- Treatment: Conservative
- MRI - evaluate degree of rotator cuff pathology
Rotator Cuff Tears
○ Source of shoulder pain and decreased motion
○ Presentation: night pain, pain, and weakness with a traumatic tear
■ NOTE: RCT has weakness, Impingement doesn’t **
○ Start with Xray, but need MRI to evaluate rotator cuff tears **
Adhesive Capsulitis
- Frozen Shoulder
- Pain and stiffness @ GHJ that has lost distensibility and ROM
- Risk: Diabetes, Thyroid Disorders
- Females (50-60 years)
- Treat: PT!!, GC Injection (intrarticular)
- Three phases: freezing/painful, frozen/stiff, thawing (LONGEST)
Calcific Tenditis of the Shoulder
○ Calcification and degeneration near rotator cuff insertion
■ Supraspinatus most often involved
○ 3 phases
■ Precalcific: pain free, fibrocart metaplasia of the tendon,
Calcific: formative, resting, resorptive,
Postcalcific
○ Treatment:
■ Nonoperative, 60-70% of pts have resolution through PT, NSAIDS
■ Probability of failure
● Large calcifications, deposits in anterior ⅓ of acromion, deposits extending medial to acromion
Degenerative Joint Disease
○ Damage to articular surfaces of humeral head of glenoid
○ Increases with age
○ Primary osteoarthritis
○ Rotator cuff arthropathy
○ Presentation: shoulder pain, loss and motion range, difficulty sleeping
○ Workup: Xrays
■ MRI if suspected rotator cuff tear
○ Total shoulder arthroplasty:
■ Intact rotator cuff
Scapular Fractures
○ Imaging: X-Rays, CT
Proximal Humeral Fractures
○ Displacement of fracture, 4 part classification: Greater tuberosity, lesser tuberosity, humeral head, humeral shaft
○ Check for loss of sensation or diminished pulse
○ Complications in treatment: neurovascular, brachial plexus injuries
Lateral Epicondylitis (Tennis Elbow)
- Overuse injury of the origin of the common extensor tendon leading to tendinitis and inflammation of ECRB precipitated by repetitive wrist extension
- Tennis Players MC
- Physical Exam: Localized tenderness over the lateral epicondyle and pain with extension
- Treatment: Conservative
- Lateral Epicondylitis = Extension
- Cozen Test
- Mills Test: Passive extension of the elbow with forced flexion of the wrist with radial deviation may precipitate pain at the lateral epicondyle
Medial Epicondylitis (Golfer elbow)
- Overuse injury proximal tendons of the promoter tires and FCR due to repetitive forceful forearm pronation and wrist flexion
- Physical Exam: Tendors over Medial Epicondule and pain with resisted wrist flexion
- “Mini Golf Is Fun”
- Valgus Stress Test
Little Leage Elbow
○ Long term repetitive valgus stress to elbow in children who have immature bones
○ Lead to medial epicondylitis, medial epicondyle apophysitis. And traction apophysitis
○ Hypertrophy of medial epicondyle leading to microtearing and fragmentation of th remedial epicondylar apohysis
○ May lead to osteochondritis dissecans of the capitellum
Ulnar contralateral ligament sprain (UCL sprain)
○ Repetitive valgus stress during acceleration phase of throwing
○ Inflammation of the anterior band of the ulnar contralateral ligament
○ Treatment:
■ Rehabilitation for strengthening and stretching
* Injury caused by damage to the UCL of thumb
* Forced abduction and hyperextension of the thumb
* Valgus stess test
* Treatment: Splint
Panner Disease
○ Localized fragmentation of the bone and cartilage of the capitellum **
○ Interference in blood supply to epiphysis **
○ Just think Panner’s = blood supply
○ Imaging: plain films
○ Treatment: Conservative tx (immobilization), avoid surgery
Olecranon bursitis
○ Oral abx ONLY for septic infection due to condition
○ Treatment: NSAIDS
De Quervian Tenosynovitis
○ Trauma to extensor pollicus brevis and abductor pollicis longus
○ 1st compartment of wrist
○ Think: mom carrying baby
* Thick APL, EPB tendons and the tunnel in the first extensor compartment
* “Apples with extra peanut butter are delicious”
* Women, Postpartum
* Clinical: Pain at the radial side of the wrist
● Intersection syndrome
○ Pain on dorsum of forearm a few centimeters proximal to the wrist joint
○ Intersection of APL and EPB (1st dorsal compartment) where they cross over the extensor carpi radialis longus and the extensor carpi radialis brevis tendons (2nd dorsal)
○ Think: drummers (repetative wrist extension)
● CMC joint OA
○ Tenderness and palpation of the 1st CMC joint
○ The grind test
■ Axial compression with circular/translation motion of the 1st metacarpal on the trapezium
● Stenosing Tenosynovitis “Trigger Finger”
○ Repetitive trauma causes inflammation to flexor tendon sheath of digits
○ A1 pulley
● Triangular Fibrocartilage Complex (TFCC)
○ The TFCC interposes between the distal ulna and carpus, serving as both a force - transmitting and stabilizing structure
○ Complex formed by the:
■ Triangular fibrocartilage discus (TFC)
■ Radioulnar ligaments (RUL)
■ Ulnocarpal ligaments (UCL)
○ RUL stabilize the DRUJ (distal radioulnar joint)
○ Injury occurs when fall forward to outstretched hand
○ MRI confirms diagnosis
● Pyogenic Flexor Tenosynovitis
○ Direct compression of TFCC
○ KANAVEL SIGNS
■ Flexed posture of involved digit
■ Tenderness to palpation along flexor tendon sheath
■ Pain with passive extension of digit
■ Fusiform (tapers at both ends) swelling
○ Treatment: Operative I&D with culture-specific antibiotics!
OA vs RA
Osteoarthritis
Prevalence increases with age
Early: Hypercellularity of chondrocytes; cartilage breakdown
Later: hypocellularity of chondrocytes, osteophytes spur formation
Symptoms:
-dull aching pain increased with activity, relieved with rest. Later pain occurs at rest
-joint stiffness for <30 min, becomes worse thru the day
-joint giving away
-articular gelling
Asymmetric narrowing of joint space
Subchondral bony sclerosis - new bone formation with white appearance
Joint involvement: first CMC, DIP, large joints (knee, hip)
Rheumatoid arthritis
Systemic autoimmune inflammatory disorder
Affects multiple organ systems;
Primarily affects the synovial lining of diarthrodial joints
Symptoms:
-morning joint stiffness
-arthritis of 3 or more joints
-arthritis of the hand joints (MCP, PIP, carpal)
-symmetric arthritis
-rheumatoid nodules
-rheumatoid factor (RF) positive
-radiographic changes
Uniform joint space narrowing
Juxta-articular osteopenia - bone washout
Small joint involvement (MCP, PIP, carpal)
Dorsal Compartment of the Hand (2,2,1,2,1,1)
○ 1st compartment:
■ Abductor pollicus longus
■ Extensor pollicis brevis
○ 2nd:
■ Extensor carpi radialis longus
■ Extensor carpi radialis brevis
○ 3rd:
■ Extensor pollicus longus
○ 4th:
■ Extensor digitorum communis
■ Extensor indices proprius
○ 5th
■ Extensor digiti minimi
○ 6th:
■ Extensor carpi ulnaris
Clavicle Fractures
○ Nonoperative criteria:
■ Midshaft fracture
■ <2cm shortening/displacement
■ <100% displacement
■ No neurovascular injury
● AC Joint Injuries:
○ Presents: from direct, traumatic blow to shoulder (Ex. Fall) Abnormal contour compared to contralateral side, tenderness to palpation, cross-body adduction
○ Pain: over AC joint
○ View: X-ray
○ Type I
■ Sprained AC ligament, normal CC ligament
■ No clavicular displacement
○ Type II
■ Disruption of the AC ligaments (complete tear), sprained CC ligaments
■ No clavicular displacement
○ Type III
■ Disruption of the AC and CC ligaments (complete tears)
■ Superior clavicular displacement
■ MOST COMMON TYPE
○ Takeaway: types I and II are not displaced and are not treated with surgery. Types III-VI need orthosurg evaluation. *
○ Radiographs are best way to diagnose (pic=type III)
○ Treatment
■ Types I + II:
● Rest, ice, NSAID; sling for 1-2 weeks, avoid heavy lifting, shoulder-girdle complex stabilization
● Return to play: Type I = 2 weeks, Type II = 4-6 weeks*
■ Type III: Controversial
● Conservative or surg route depends on the patient’s need
■ Types IV, V, VI
● Surgery is recommended
■ Treatment for pain/injuries:
● Corticosteroid injection
● Possible clavicular resection and coracoclavicular ligament reconstruction
○ Complications of AC Joint Injuries
■ Associated clavicular fractures or dislocation
■ Distal clavicle osteolysis
■ AC joint arthritis
