Upper extremity Flashcards
Red flags
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
Sprain vs Strain vs tendonitis/tendinosis
Sprain: ligament injury
Strain: muscle injury
Tendonitis/osis: tendon injury
Basic strength grading scale
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
Reflex grading scale
4+clonus 3+ hyperactive, no clonus 2+ normal 1+ hypoactive 0-absent
Basic vascular grading
Capillary refill under 2 s: normal
Pulse intensity grading scale: 0 absent, 1+ faint but there, 2+ diminished, 3+ normal, 4+ bounding
Shoulder exam
Referred pain from neck
Appearance- symmetry and contour, muscle bulk wasting
Palpation: clavivle, AC joint
Range of motion
Strength
Joint stability
Range of motion of shoulder
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
Strength of shoulders
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
apprehension test
joint stability of sholder- patient expresses apprehension to loading of joint manner that simulates dislocation forces
Neurovascular status of shoulder
sensation Axillary nerve (lateral shoulder) Musculocutaneous nerve (lateral forearm
Basic elbow exam
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
Basic hand and wrist
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
Acromioclavicular (AC) sprains
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
Shoulder dislocation
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
Rotator cuff injuries
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
adhesive capsulitis
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
medial epicondylitis
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
lateral epicondylitis
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
scaphoid fracture
etiology- fall on outstretched hand
Exam- tenderness in anatomic snuffbox
Radiology - often need to consider MRI, CT or bone scan
Carpal tunnel syndrome
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
wrist ganglion
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
jersey finger
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
Mallet finger
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
Central extensor slip insertion ruptures/boutonniere deformity
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
