Upper extremity

Question 1

Red flags

Answer 1

Hot, swollen red, extremely painful (extremely painful with passive motion joint- rule out septic joint
Night pain (especially with constitutional signs eg wgt loss rule out tumor)
Deformity and loss of motionp r/o dislocation or fracture
Rapidly progressing neurologic changes r/o compartment syndrome

Significant, sudden onset of limb swelling pain and bluish skin change r/o DVT
Point bony pain and bleeding r/o open fracture

Question 2

Sprain vs Strain vs tendonitis/tendinosis

Answer 2

Sprain: ligament injury
Strain: muscle injury
Tendonitis/osis: tendon injury

Question 3

Basic strength grading scale

Answer 3

5/5-normal
4/5-weak
3/5 can only move against gravity
2/5 can move but not against gravity
1/5- muscle contractions but no motion
0/5- no contraction

Question 4

Reflex grading scale

Answer 4

4+clonus
3+ hyperactive, no clonus
2+ normal
1+ hypoactive
0-absent

Question 5

Basic vascular grading

Answer 5

Capillary refill under 2 s: normal

Pulse intensity grading scale: 0 absent, 1+ faint but there, 2+ diminished, 3+ normal, 4+ bounding

Question 6

Shoulder exam

Answer 6

Referred pain from neck
Appearance- symmetry and contour, muscle bulk wasting

Palpation: clavivle, AC joint
Range of motion
Strength
Joint stability

Question 7

Range of motion of shoulder

Answer 7

Abduction 160+ (mid deltoid, supraspinatus)
Adduction 45+ (pectoralis major, latissimus dorsi)
Flection 160 (anterior deltoid, coracobrachialis)
Extension 45+ (latissimus dorsi, teres major, posterior deltoid)
External rotation 45 (infraspinatus, teres minor)
Internal rotation 80 (pec major, latissimus dorsi, teres major, subscapularis)
scapular elevation (trapezius, levator scapulae)
scapular retraction (rhomboids)
Scapular Protraction (serratus anterior)
Functional 120 abduction
Painful arc of abduction 80-150 = rotator cuff problems ac pathology
Active= if normal and pain free usually dont need to check passive 
internal rotation and external rotation may be different in dominant and non dominant arms esp in atheletes

Question 8

Strength of shoulders

Answer 8

Rotator cuff: Supraspinatus (full can test pt holds arms at 90 of abduction and 30 anterior to coronal plane with elbows extended and thumbs pointing up and resists examiner pushing downward (hitchhikers); Infraspinatus and teres minor (external rotation); subscapularis litofftest–patient places hand behind back and lifts hand off back with examiner resisiting

Question 9

apprehension test

Answer 9

joint stability of sholder- patient expresses apprehension to loading of joint manner that simulates dislocation forces

Question 10

Neurovascular status of shoulder

Answer 10

sensation
Axillary nerve (lateral shoulder)
Musculocutaneous nerve (lateral forearm

Question 11

Basic elbow exam

Answer 11

Referred pain from neck, shoulder or wrist
Appearance- symmetry and contour (popeye deformities, oldecranon bursa

Palpation: epicondyles, radial head
Range of motion: functional 30-130 extension/flexion and 50 pronation supination, Flexion and extension, forearm pronation and supination

Strength
Joint stability: Valgus stress to test ulnar collateral ligament

Question 12

Basic hand and wrist

Answer 12

Referred pain from neck, shoulder or elbow

Appearance: symmetry and contour, thenar atrophy, finger deformities
Palpatation: snuffbox

ROM
Strength
Joint stability
Neurovastcular status: tinels sign: tapping over the median nerve in the carpal tunnel; phalens : wrists in full flexion

Question 13

Acromioclavicular (AC) sprains

Answer 13

Etiology: most commonly fall directly onto shoulder
Presentation: pain with overhead motions, deformity of superior shoulder
Exam: pain and deformity at AC joint, pain with cross body adduction of afrm (positive cross-chest test), pain arc of abduction over 150

Injury grading: grade1 (AC ligamnet stretch), grade2 AC ligament tear and coronoid-clavicular stretch, grade 3 complete tears of both AC and CC ligaments, grades 4+ tears (clavicular displacement)

Treatments: non operative (grades 1 and 2) for sure operative grade 3

Question 14

Shoulder dislocation

Answer 14

Anterior most common
Etiology: forced extension, abduction and external rotation of the arm (open arm tackle or fall onto abducted arm), or a direct blow to posterior shoulder

Exam: resistance/apprehension to motion, alteration of shoulder contour including (prominent acromion, humeral head anterior to acromion and adjacent to coracoid)
Check distal neurovascular status( axial and musculocutaneous)

Positive apprehension test - feeling ofinstability with stressing of the joint when the joint is reduced, anterior laxity

Treatment: acute, initial dislocation: non operative (immobilixation with sling), surgical for athletes
Recurrent, non tramatic dislocations- early mobilization/physical therapy, radiology

Question 15

Rotator cuff injuries

Answer 15

History: pain with overhead motions
Exam: impingement signs- positive (neers test - pain when arm is elevated thru forward flexion), empty can test (jobes- arms vertically abducted to 90, horizontalu adduct 30, thumbs down to floor, push downward to floor against resistance; hawkins test-pain with resisted external rotation with elbow flexed and across body

rotator cuff weakness: complete tear–profound weakness, painful arc of abduction (80 to120), tender at insertion of supraspinatus tendon on greated tuberosity of humerus.

Treatment: non-operative for small tears and tendonopathies, surgical for large tear or in a younger athlete

Question 16

adhesive capsulitis

Answer 16

frozen shoulder
Hx: painful, stiff shoulder
Etiology: complication of many injuries including dislocation, rotator cuff tendinitis, reflex sympathetic dystrophy and fractures
Exam: limited passive and active ROM- esp noted in external rotation
Treatment: treat underlying cause

Question 17

medial epicondylitis

Answer 17

glofers elbow

Etiology- overuse of the wrist flexors- especially pronator teres and flexor carpi radialis

Symptoms: painful medial elbow with secondary weakness

exam: tenderness over the medial epicondyle and pain with resisted wrist flexion and fore arm pronation

Question 18

lateral epicondylitis

Answer 18

tennis elbow
Etiology: overuse from repetitive extension (esp extensor carpi radialis brevis), incorrect technique and poorly fitted equipment are contributory
Symptoms- pain over lateral elbow radiating into forearm, late weakness
Signs: tenderness over lateral epicondyle, pain with resisted wrist dorsiflexion and middle finger extension

Question 19

scaphoid fracture

Answer 19

etiology- fall on outstretched hand
Exam- tenderness in anatomic snuffbox
Radiology - often need to consider MRI, CT or bone scan

Question 20

Carpal tunnel syndrome

Answer 20

Etiology- irritation of the median nerve in carpal tunner

Symptoms: tingling and pain in median nerve distribution especially at night

Exam:
Tinels sign-percuss the carpal tunnel–reproduces symptoms
Phalens sign: wrists are held in max flexion for 1 minute reproducing symptoms
Sensory loss of radial 3 1/2 fingers
Thena eminence atropy late
Loss of 2 point discriminated: late

Question 21

wrist ganglion

Answer 21

Etiology -overproduction of fluid by a joint of tendon sheath- filled with thick gelatinous material

Symptoms: lump usually firm and mobile (most common location is wrist, followed by hand, foot ankle) Pain if any usually caused by compression of nearby nerve or pinching of the ganglion with motion

treatment: typically clinical observation, aspiration if painful, surgery

Question 22

jersey finger

Answer 22

traumatic avulsion of flexor digitorum profundus from distal phalanx

MOI: forced passive extension of DIP joint during active DIp joint
Loss of active flexion at DIP
Treatment- surgical repair

Question 23

Mallet finger

Answer 23

Traumatic avulsion of terminal extensor tendon from distal phalanx

MOI: forced flexion of the DIP during extension (ball jamming fingertip)

loss of active extension at DIP
Treatment - immobilization, large displacement or joint involvement may require surgery

Question 24

Central extensor slip insertion ruptures/boutonniere deformity

Answer 24

disruption of central extensor slip insertion at the base of middle phalanx

Initially causes loss of full active PIP extension

Chronically adjacent lateral band tendons migrate palmarly resulting in charachteristic boutonniere deformity (PIP flextion and DIP hyperextension)

MOI: forced passive PIP flextion against active extension (dorsal PIP dislocation)– resulting in avulsion of central slip

Exam- tender over central slip on dorsal middle phalax base, with finger bent over table at the pip and the proximal phalanx held down, the pt attempt to extend finger, normally DIP can be passively extended, abnormal test cannot extend finger, and decreased passive DIP

Treatment: closed injury- early pip splinted in I extension with active DIP exercises
Laceration- surgical repair

Question 25

Volar plate disruption / swan neck deformity

Answer 25

Hyperextension of proximal joint with flexion of distal joint
Usually caused by volar plate disruption

Often related to rheumatoid arthritis