UPPER EXTREMITY Flashcards
function of biceps brachii
supination of forearm
flexion at elbow
function of brachialis muscle
flexion at the elbow
test if concerned for bicep rupture
hook test - hook at elbow with fingers, then pronate/supinate - won’t feel bicep if ruptured
TENNIS ELBOW
lateral epicondylitis
- inflammation of tendon insertion of ECRB (extensor carpi radialis brevis muscle) due to repetitive pronation of forearm and excessive wrist extension
- Lateral elbow pain - especially with gripping, forearm pronation, and wrist extension against resistance
- radiates down forearm, or worsens when lifting objects with forearm prone
TREATMENT = RICE, NSAIDS, PT, brace
- can do intraarticular steroid injection
- surgery if failure of conservative management
GOLF ELBOW
medial epicondylitis
- inflammation of pronator teres-flexor carpi radialis due to repetitive stress and tendon insertion of flexor forearm muscle
MC in golfers, and patients who do household chores
- tenderness over medial epicondyle that is worse with pulling activities - reproduced with wrist FLEXION against resistance
TREATMENT = RICE, NSAIDS, PT, brace
- can do intraarticular steroid injection
- surgery if failure of conservative management
treatment of __________ epicondylitis is more difficult
medial
angiofibromatous metaplasia
epicondylitis
guest speaker says epicondylitis is not actually inflammation, but that the tendinous fibers are being replaced with angiofibromatous tissue
so steroid injections are for pain, not for the inflammation (because not actually inflamed!)
test for tennis elbow
“resistant wrist extension” - arm straight out, resist the pt trying to extend their wrist upwards
test for golfers elbow
resistant wrist flexion
OLECRANON BURSITIS ETIOLOGIES
⦁ gout
⦁ inflammation
⦁ direct trauma (repetitive, microtrauma)
⦁ infection
OLECRANON BURSITIS
- inflammation of bursa over bony prominences
- potential space or sac, but isn’t fluid filled (bursitis = then gets filled with fluid)
- more common in men
- can drain as long as its not infected, but if you try to drain out, now have a connection to outside world - can now get infected. fluid will continue to drain and drain
- so if you want to drain it = have to drain it from above
TREATMENT = NSAIDS & compression; the body will naturally absorb the fluid; don’t have to treat
clinical manifestation of olecranon bursitis
- abrupt “goose egg” swelling - boggy/red elbow
- can be tender or painless
- limited ROM with flexion
- evaluate for skin breaks (to rule out septic bursitis)
treatment = rest, NSAIDS, compression, can do steroid injections. avoid repetitive motions
RADIAL NERVE PALSY
- radial nerve comes off the brachial plexus - starts in back / neck / shoulder –> triceps –> antecubital fossa –> down forearm to thumb region
- can occur when you fall asleep on nerve for too long
- get paralysis (temporary) of the thumb extensor, wrist extensors, and triceps
- the radial nerve innervates the back of the first web space
- the median nerve innervates the thumb, index, middle and 1/2 of the ring finger
PARSONAGE TURNER SYNDROME = radial nerve palsy after a cold (URI)
Most radial nerve palsies get better on their own
most common site for compression of ulnar nerve –> ulnar nerve palsy
cubital tunnel of the elbow
radial nerve palsy after a cold
parsonage turner syndrome
ulnar nerve is what allows finger _________
adduction - putting fingers together - so do froment test
FROMENT’S SIGN
for ulnar nerve palsy
make an OK sign with thumb and index finger
adducting fingers = difficult with ulnar nerve palsy - weakness = have weakness of pinch grip
WARTENBURG SIGN
for ulnar nerve palsy
lay hand down flat - pinky will abduct away
WARTENBURG SIGN
for ulnar nerve palsy
lay hand down flat - pinky will abduct away
ulnar nerve palsy tests
paper test - froment’s sign
wartenburg sign
can do tinnel’s at elbow (tap)
can hold flexion at elbow - pinches off ulnar nerve
- median nerve entrapment / compression
CARPAL TUNNEL
increased incidence of carpal tunnel with
diabetes
CARPAL TUNNEL SYNDROME
- median nerve entrapment / compression at carpal tunnel
- increased incidence with DIABETES
- paresthesias / pain of first 3 digits and 1/2 of ring finger - especially at night - due to normal wrist flexion during sleep
- pain may radiate to neck, shoulder, chest
- Thenar muscle wasting is seen if advanced
CLINICAL MANIFESTATIONS
- paresthesias / pain in thumb/index/middle and 1/2 of ring finger
- worse at night*****
- increased pain with repeated flexion of wrist
- decreased pain when shaking hands
DIAGNOSIS
- Tinel’s sign
- Phalen’s sign
- modified Phalen’s = better = flex at wrist, just like with Phalen’s, but compress median nerve at same time
TREATMENT = volar splint + NSAIDS. Steroid injections. May need surgery in refractory cases
CLINICAL MANIFESTATIONS OF CARPAL TUNNEL SYNDROME
- paresthesias / pain in thumb/index/middle and 1/2 of ring finger
- worse at night*****
- increased pain with repeated flexion of wrist
- decreased pain when shaking hands
feels better when arm held down - increased blood flow; carpal tunnel pressure is inhibiting blood flow to median nerve
- pain may radiate to neck, shoulder, chest
- Thenar muscle wasting is seen if advanced
TESTS FOR CARPAL TUNNEL
- Tinel’s sign (tap on median nerve)
- Phalen’s sign (praying mantis)
- modified Phalen’s = better = flex at wrist, just like with Phalen’s, but compress median nerve at same time
TREATMENT FOR CARPAL TUNNEL
volar splint - make sure STRAIGHT SPLINT - worn at night
- NSAIDS
- steroid injection
- surgery in refractory cases
DUPUYTREN’S CONTRACTURE
- most often confused with trigger finger
- thickening of palmar fascia
- can’t move ring finger (vs trigger finger = cogwheeling of finger)
Most common in men 40-60
RISK FACTORS
- genetic predisposition: Northwestern Europeans
- Alcohol abuse
- diabetes
- Contracture of the palmar fascia due to nodules/cords –> fixed flexion derformity at the MCP - especially seen in the ring finger, and pinky finger
- have nodules over the distal palmar crease or proximal phalanx - nodules are often painful
**Fixed flexion deformity at MCP joint
Treatment = intralesional steroid injections, collagenase injections, PT
- can do surgical correction if contracture is > 30 degrees at MCP joint, or if any PIP contracture
RISK FACTORS FOR DUPUYTRENS
Most common in men 40-60
RISK FACTORS
- genetic predisposition: Northwestern Europeans
- Alcohol abuse
- diabetes
which fingers mostly affected by Dupuytren’s contracture
ring & pinky fingers
dupuytren’s treatment
intralesional steroid injections, collagenase injections, PT
- can easily perform surgery to correct contracture
- Xiaflex = new medication - injection that breaks down collagen in the fascia
GANGLION CYST
- joint fluid leaks into cyst
- don’t drain these! will continuously drain (like bursa) and lead to infection
- need to completely excise it and cauterize it to fully go away to where it won’t fill back up
- can diagnose with transillumination
(can also aspirate fluid to test it, or ultrasound)
Form in the presence of joint or tendon irritation or mechanical changes; occur in patients of all ages. May change in size or disappear completely. May or may not be painful
- not cancerous, and don’t spread
Treatment = don’t drain these! will get infected. Surgery if bothersome. If asymptomatic = don’t need to do anything
Swan Neck & Boutonniere deformity = characteristics of
RA
Swan neck
flexion at DIP
hyperextension at PIP
Boutonniere’s deformity
hyperextension at DIP
flexion at PIP
differentiation for swan neck vs boutonniere’s is important because of
treatment approach
