Upper Extremity Flashcards
What muscles will be atrophied in carpal tunnel syndrome?
Thenar muscles
Is ultrasound helpful for diagnosing biceps tendinitis
Yes because it is much more superficial
How do you distinguish between a rotator cuff tendinopathy and a tear?
Lidocaine injection test- they will still have trouble with weakness if its torn
X-ray- elevation of humeral head over 1cm suggests tear
MRI- study of choice when you suspect a full thickness tear
Where would you see a non-ossifying fibroma (NOF)
On outside edge of the bone ** (aka “eccentric”
What is the treatment for shoulder impingement
ice, NSAIDs etc
NO arm sling (they have ROM and strength, we don’t want to limit those)
Physical therapy referral***
What do you need to know about the benign tumor osteoid osteoma?
Severe night pain
NSAIDs relieve the pain
What soft tissue is torn in the shoulder if a patient feels “catching”
Labrum
What causes de Quervain’s tenosynovitis
Overuse/repetitive gripping
Writing
Which muscle groups are affected by lateral epicondylitis/golfers elbow?
Extensors
Supinators
(ESL)
When would you see a “popeye” deformity
When the biceps tendon ruptures and the biceps balls up
How do pts injure the acromioclavicular joint
Fall onto shoulder with arm tucked into side
What is the treatment for dequervains tenosynovitis
Diminish repetitive activity
Thumb spica immobilization 🤚
NSAIDs
Steroids
Surgery to decompress 1st dorsal compartment (very easy)
What direction are 95% of shoulder dislocations?
Anterior **
Only 5% are posterior
Who do you need to call right away if you diagnose adhesive capsulitis/frozen shoulder
PT- you have to get it moving right away
What do pts complain about if they have an acromioclavicular injury/
A “bump” on their shoulder that is worse at bedtime
What are the risk factors of developing dupuytren’s contracture?
EtOH abuse
Smoking
Diabetes (sometimes this is how people find out they’re diabetic when they seek treatment for this)
What is a unicameral bone cyst?
A fluid filled cavity in the bone, usually in the upper humerus and femur.
Benign
What specialized tests can be done for glenohumeral subluxation
Sulcus sign
Apprehension and relocation test
How do you treat ganglion cysts?
NSAIDs
May resolve spontaneously (if they rupture on accident)
Aspiration
Surgery if they recur (and they recur a lot)
What are the goals of treating a rotator cuff tear?
Recover strength
Improve ROM
Treat concurrent tendonitis (inflammation)
Do most patients know if they have a non-ossifying fibroma?
No, they are usually an incidental, benign finding
What is the best imaging modality for a labral tear?
MRA
What is the clinical presentation of someone with a labral tear due to overuse
Clicking/catching
What is the most common malignant bone tumor in children
Osteosarcoma/Ewing’s sarcoma
Can tendinitis/impingement turn into a chronic tear?
Yes
Who is most likely to get chondrosarcoma?
Males 60-80, usually in their hips, shoulder or pelvis
What is the major risk factor for tendonitis/impingement?
Overhead activity
What are the specialized exams you’d do for a labral tear/
Anterior glide test
Speeds test
O’Brien’s test
What order do the rotator cuff muscles tear?
Supraspinatus, infra, teres minor, subscap
So if subscap is torn, you know the first 3 are torn too
What are the 2 ways the rotator cuff can be torn?
Chronic- degeneration, overuse (more common)
Acute- traumatic
What is the treatment for subacromial bursitis
Ice
NSAIDS
Aspirate and steroid injection
What is the treatment for trigger finger?
NSAIDs’
Steroid injection -works great
Surgery to release A1 pulley
How do you confirm a diagnosis of an acromioclavicular injury?
X-rays.
What is the most common primary bone tumor (malignant bone marrow)
Multiple myeloma
Where do 70-80% of clavicle fractures happen?
Middle 1/3 of clavicle
What is a ganglion cyst?
Collection of synovial fluid within a joint or tendon sheath usually on the wrist
How will a pt present if they have a glenohumeral subluxation/dislocation
Arm held in a position of protection**
What will a patient complain about if they have trigger finger?
Digit snaps, catches or locks when they move it.
Nodule is unable to glide through the A1 pulley, and the pt may need to forcefully unlock the digit.
Progressively becomes painful
If you injected lidocaine into the shoulder of someon with adhesive capsulitis, would it change their Neers perfeormace
No, they literally cant move it
What is the specialized test to test for dupuytren’s contracture?
Hurston table top test
Assessing ability to flatten hand on table
What tests can be done for a rotator cuff injury?
Drop arm (complete tear-weakness and ROM)
Empty can (weakness)
Neers (impingement)
Hawkins (impingement)
What is an osteochondroma?
An abnormal growth of bone and cartilage on the surface of a bone.
What is the treatment for a unicameral bone cyst?
May resolve spontaneously
Consider surgery if they’re getting fractures. BUT don’t do surgery on a child if it’s near their physis until they are older
What clinical signs will someone with cubital tunnel syndrome have***
Ulnar neuropathy- tingling in ring finger and pinky
Decreased grip strength
Muscle wasting along ulnar distribution
What are the 2 ways you can tear your labrum?
Acute- FOOSH, or sudden pull
Repetitive overuse- pitchers
What are the muscles of the rotator cuff and which motions does each one do?
Supraspinatus-external rotation and abduction
Infraspinatus-“ “ “
Teres Minor-“ “ “
Subscapularis-internal rotation
What do you look for on the MRI of an aneurysmal bone cyst (ABC)?
Fluid-fluid levels. The blood and cystic fluid don’t mix.
What is a chondrosarcoma?
A malignant bone tumor composed of cartilage producing cells
What is the least common place to fracture the clavicle
Proximal 1/3- internal organ evaluation is essential
Who usually gets chronic rotator cuff tears?
Overhead occupations
What are the 3 special considerations for anterior shoulder dislocation
- Bankart lesion- detachment of the lower part of the labrum from the glenoid rim (3 and 6 o clock)
- Hill Sacks lesion- a type of fracture of the humeral head
- Axillary nerve- make sure you check sensation and deltoid function
What is the number one cause of rotator cuff tendonitis?
Shoulder impingement syndrome
What’d o you need to know about Giant Cell Tumors
Benign but aggressive
Crosses borders-through metaphysis/epiphysis
Requires treatment
What are the main 3 features of non-ossifying fibroma?
They’re a “MES”
Metaphyseal
Eccentric (on outside edge of bone)
Sclerotic borders (dense all around)
What is the clinical presentation of dupuytren’s contracture?
Painless nodules develop into palpable cords along palmar surface, causing irreversible contractures
Which fingers are most often affected by dupuytren’s contracture
Ring finger and pinky (cant extend anymore)
What rotator cuff muscle is the most commonly involved in injury?
Supraspinatus
What is cubital tunnel syndrome?
Compression of the ulnar nerve
What is the difference between tendonosis v tendonitis?
Tendonosis: weakness usually due to aging muscles
Tendonitis: pain causing weakness. Inflammation due to repetitive trauma. Athletes, overhead laborers, etc
What is it:
Shoulder pain that is worse with overhead activity and at night and interferes with sleep
Pain followed by weakness**
Decrease in ability to move the arm
Activities of daily living are restricted to ones that don’t involve lifting arm more than 90 degrees
Chronic tear of rotator cuff
Where does the ulnar nerve run?
Behind the medial epicondyle
How will a patient present if they have rotator cuff tendonitis?
GRADUAL*** pain
Deep ache in lateral shoulder that radiates to deltoid
POINT tenderness*** (pt can point with one finger to pain)
What is an aneurysmal bone cyst?
A blood filled cyst in the bone.
Benign but aggressive
What can cause olecranon bursitis?
Trauma
Prolonged pressure like always resting on armrests
Infection
Rheum conditions
Who is more likely to get trigger finger (stenosis flexor tenosynovitis)?
Women more than men
Can affect adults and children
(This is very different than the 50yo Northern European men who get dupuytren’s)
Who is more likely to get de Quervain’s tenosynovitis?
Women 30-50 yo (hormonal women)
What is the 2nd most common place to break the clavicle
Distal 1/3- may be difficult to discern from AC separation
How many X-ray views do you need for a glenohumeral subluxation/dislocation
Multiple views
AP, Y, and axillary views
Is adhesive capsulitis a mechanical restriction or a pain restriction?
Mechanical
What is a congenital risk for carpal tunnel
Congenitally smaller tunnel***
She said this like 15 times
Would you do imaging for elbow epicondylitis?
Only to r/o some anatomical reason for it
What is shoulder impingement?
A spectrum of findings that generally mean the tendons and bursa are squished and causing pain
What is the difference between trigger finger and dupuytren’s contracture?
Trigger finger comes and goes
Demographics: dupuytren’s is older Northern European men, and trigger finger is people of any age, women more than men
What constitutes a grade 1 AC sprain
No separation, pain only
Xrays look normal
What is dequervains tenosynovitis?
Inflammation of the 1st dorsal compartment involving the sheath of the APL and the EPB
What causes carpal tunnel syndrome?
ANYTHING THAT MAKES THE TUNNEL SMALLER:
-autoimmune
- inflammatin
- connective tissue disorders
- pregnancy (swelling)
- Renal failure (swelling)
Who is most likely to get depuytrens contracture?
Northern European men 40-50yo**
What causes trigger finger?
A nodule forms on the palmar aspect of the MCP that prevents the tendon from moving through the pulley smoothly and it “pops” through like a trigger
When are carpal tunnel symptoms the worst
At night***
Usually 2-3 hours after falling asleep
What does it mean if a patient has “catching” in their joint?
Soft tissue injury
What is the treatment for cubital tunnel syndrome?
NSAIDs
Bracing
Pt
Cubital tunnel release/ulnar nerve transposition
Do ganglion cysts change in size?
Yes***often with activity
How will the ROM decrease with a rotator cuff injury?
Can’t abduct arm above shoulder
If a patient has an acromioclavicular sprain, how will downward traction and the “cross-over test” affect them?
Both will aggravate pain.
What is the treatment for an aneurysmal bone cyst (ABC)?
Refer to ortho for surgery. Even though they’re benign they destroy the bone
What will X-rays of multiple myeloma look like?
“Punched out” appearance
Affects entire skeleton
How does the rotator cuff stabilize the shoulder?
By depressing the numeral head against the glenoid.
So if they muscles give out, the humerus will fall out of the socket
What types of cancers are most likely to become metastatic bone cancer?
Lead Kettle (PB-KTL)
Prostate Breast Kidney Thyroid Lung
What do you have to do if you use the Apley scratch test to evaluate for a frozen shoulder?
Compare both sides**
What do you need to rule out with oelcranon bursitis?
Infection.
Look for redness and warmth, and aspirate if you need to
What is it:
Pain in the anterior shoulder with abduction and external rotation
Popping sensation
Max point of tenderness along bicipital groove
Weakness
Biceps tendonitis
How many X-ray views do we need for a clavicle fracture?
Just ONE
What are the special tests that can be done for tendonitis/impingement?
Neers
Hawkins
Where And when will a pt have pain if they injure their rotator cuff?
Anterior* and lateral aspects of the shoulder
Occurs initially with overhead activity, then just becomes constant
What is the treatment for elbow epicondylitis?
Sling
Wrist** brace (think about which muscles need to be immobilized)
Forearm strap
Modify technique when playing sports
Steroid injections
What is it:
Chronic shoulder pain with gradual global limitation in ROM.
Stiffened glenohumeral joint
+/- adhesions
Adhesive capsulitis/ frozen shoulder
Chondrosarcoma (malignant) and chondroblastoma (benign) look exactly the same on x-ray, so how would you tell the difference?
Biopsy
What two specialized tests can be done to check for carpal tunnel
Tinel’s and Phalen’s
When do we refer to ortho for a clavicle fracture
All proximal and distal 1/3 fractures
Midclavicular fractures when they are displaced
What is the most common benign bone tumor
Unicameral bone cyst (UBC)
Aka “simple bone cyst”
What are the 2 most common types of labral tear?
Bankart lesion- inferior tear due to dislocation
SLAP tear- superior labrum anterior Posterior (extends from 10 to 2 on the clock basically)
MUCH more common
Should you do imaging for a frozen shoulder
Not really
X-ray can really only help you r/o like a giant tumor restricting ROM
MRI might show you thickening of soft tissue and help your dx but its not needed
What constitutes a grade 2 AC sprain?
AC joint torn, but coracoclavicular ligaments are intact
Xrays show some separation of acromion and clavicle. Bottom of clavicle isn’t entirely above top of acromion
What is the treatment for a labral tear?
Nonsurgical
NSAIDS and PT
Which muscle groups are affected by medial epicondylitis/golfers elbow?
Flexors
Pronators
What causes the compression of the median nerve with carpal tunnel syndrome
Inflammation of the synovium
What constitutes a grade 3 AC sprain?
Separation of AC ligaments AND the coracoclavicular ligaments
Xrays show LOTS of separation. Bottom of clavicle is way above acromion
What is the treatment for a rotator cuff tear?
Ice
NSAIDS
Stop reaching overhead
Immobilize shoulder only for a little bit
Stretch- weighted pendulum
Steroid injection- max 3-4/yr
Surgery/joint replacement
What is the main difference between rotator cuff tendonitis and shoulder impingement?
Impingement has full strength***
Full ROM possible with pain relief
What kind of injury will cause an acute rotator cuff tear in someone under 30?
Significant amount of force. Labrum will usually be torn too
Why should you discourage extended use of a shoulder immobilizer for a rotator cuff tear?
Risk of frozen shoulder
Does carpal tunnel start as tingling in the medial nerve distribution?
No, it starts gradually as intermittent pain and then progresses to burning pain, numbness and tingling in median n. distribution
What are the specialized tests for biceps tendonitis
Yergason
Speeds
What is the hallmark physical finding of shoulder impingement?
Pain reproduced by the painful arc of flexion-internal rotation maneuvers.
Neers& Hawkins
What are the diagnostic studies that should be done for carpal tunnel?
Nerve conduction study (non invasive*)- delay in signal due to demyelination?
Electromyelogram-needle! Invasive* but more informative
Grip strength testing-always document lbs of pressure they can do
Wrist xrays if trauma or rheum disease
How do you treat an AC sprain?
Immobilize shoulder for 3-4 weeks to allow the ligaments to reattach
ice, rest, NSAIDS, steroids
Surgery mauybe for grade 3
What is the hallmark sign of a rotator cuff tear?
Muscle weakness.
True weakness that is not just due to pain. Does not improve with analgesics.
How do chronic rotator cuff tears start?
Start as partial tear of supraspinatus that progresses to complete tear of SITS and biceps tendon
Do males or females get carpal tunnel more
Females
What will you find upon urinalysis in a pt with multiple myeloma?
Bence-jones proteins
How do you make a definitive diagnosis of a labral tear?
Arthroscopy
But why would you do this….the only treatment is NSAIDs and PT
