Upper extremity disorders Flashcards
What is rotator cuff tendonitis associated with
Repetitive overhead activities
-swimmers
-throwers
-tennis
How does rotator cuff tendonitis present
Insidious onset shoulder pain (anterior or lateral)
pain with overhead activities
What will you see on a physical exam with rotator cuff tendonitis
Point of tenderness over the supraspinatus
Decreased ROM and weakness (Abduction especially)
What are the special tests for assessing the supraspinatus (Rotator cuff tendonitis)
Hawkins Kennedy
Neer
Empty can
What is the Hawkins Kennedy test
Shoulder flexed and abducted 90 degrees and then passive IR (Positive = pain)
What is the neer test
Passive forward flexion while arm is pronated (positive = pain)
What is the empty can test
(0 degrees abduction, 30 degrees forward flexion, arms pronated
resist downward force
pain/weakness = positive
What is the diagnostic test of choice for rotator cuff tendonitis
MRI
What is the treatment for rotator cuff tendonitis
NSAIDs
Activity modification & rest
Subacromial corticosteroid injection
PT
What is the sequence of events in a rotator cuff injury
Subacromial impingement / bursitis
Partial RTC tear
Complete RTC tear
RTC arthropathy
What is the #1 cause of shoulder pain
subacromial impingement
What is the MOI for subacromial impingement
Structural narrowing
degeneration of supraspinatus
Inflammation of subacromial bursa
How does impingement present
Similar to RCT with added night time pain
What tests are helpful for determining impingement
Neer test
Hawkins Kennedy test
*Pain will be over the greater tuberosity
What is the first line of imaging done for impingement
Xray to look for structural abnormalities
What is the first line of treatment for impingement
Be conservative
-PT
-NSAIDs
-Subacromial steroid injections
If conservative treatment fails after 4-6 months, what is the next line of treatment for impingement
Surgery - subacromial decompression
Where are the most common rotator cuff tears
Supraspinatus, infraspinatus, or teres minor
how do rotator cuff tears present
Similar to tendonitis and impingement
What are the tests for rotator cuff tears dependent on and what are the possible tests you could do
Depends on tendon involved
-empty can test
-drop arm test
-Infraspinatus test
-lift off test (Subscapularis)
What is the best imaging for a rotator cuff tear
MRI
What is the first line of treatment for a rotator cuff tear
Be conservative
When do you operate on a rotator cuff tear
Complete or significantly symptomatic tears
Which gender more commonly has rotator cuff arthropathy
Females
If a patient comes in with glenohumeral arthritis, RCT insufficiency, Superior migration of humerus and humeral head changes… what is their most likely diagnosis
Rotator cuff arthropathy
What is the imaging of choice for rotator cuff arthropathy
Xray
What is rotator cuff arthropathy treatment
Non-operative vs shoulder arthroplasty
What is bicep tendonitis often associated with
Impingement and rotator cuff pathology
How does bicep tendonitis often present
Anterior shoulder pain
may radiate down bicep
tenderness above bicipital groove
If you do a speeds test or yergasons test on a patient, what are you looking for
biceps tendonitis
What is speeds test
Shoulder flexion, elbow extension, forearm supination and maintain against resistance
What is the yergasons test
Arm at side, elbow flexed 90 degrees, patient supinates against resistance and examiner palpates the bicipital groove
What is the MOI for a bicep tendon rupture
Sudden or prolonged bicep contraction against resistance
If a patient comes in with a characteristic pop-eye deformity, what is their likely diagnosis
Bicep tendon rupture
How does a bicep tendon rupture present
Audible pop
pain
+/- ecchymosis
What are the options of treatment for a bicep tendon rupture
Acute: ice, sling, pain control
Long term: Non-operative vs. surgery
What is another name for adhesive capsulitis
frozen shoulder
Which gender is more likely to get frozen shoulder
Women
If a patient comes in with functional loss of both passive and active ROM in their shoulder that is not attributed to any other cause and worsens at night, what is their likely diagnosis
Adhesive capsulitis
What causes frozen shoulder
Thickening and fibrosis of the capsule
-adheres to itself and the humerus
What is the workup for adhesive capsulitis
Mostly clinical
can confirm for arthrogram
What is the progression of adhesive capsulitis
Freezing/painful (6wks-9months)
Frozen (4-9 months)
Thawing (5-26months)
Who is most likely to get AC joint injuries
Male athletes 10-20 y/o
Which patients have their AC joint injury treated with sling, rest, ice, pain control, and early mobilization?
Grades 1-3
Which AC joint injuries are treated surgically
4-6 or failed non-op treatment
What is the cause of an SC joint dislocation
MVC or sports injury
If a patient has force to the anteromedial shoulder, what type of SC dislocation will they have
Posterior
If a patient has force to the Anterolateral shoulder, what type of SC dislocation will they have
Anterior (most common)
What type of force causes a posterior dislocation of an SC joint
Force to the posterolateral shoulder
A patient present with an unwillingness to use their Right arm, their head is tilted toward the right, and there is a point of tenderness of the SC joint with edema, what is their likely diagnosis
SC joint dislocation
What is important to asses in someone with an SC joint dislocation
Neurovascular status
What are some complications associated with SC joint dislocations
Pneumothorax
SVC injury
esophageal injury
compression of subclavian artery
compression of carotid artery
voice changes
venous congestion
How do you workup an SC joint dislocation
XRAY (especially the serendipity view)
What is the best imaging modality to evaluate the SC joint
CT
Which type of SC dislocation is least amenable to a closed reduction
anterior
Which type of SC dislocation is easily reduced
Posterior
What is the most commonly dislocated major joint
Shoulder
What is the MOI for an anterior shoulder dislocation
Blow to the shoulder while in abduction, extension, and external rotation
anteriorly directed to posterior shoulder
What is the MOI for a posterior shoulder dislocation
Blow to shoulder in adduction, flexion, and internal rotation
blow to anterior shoulder
Who is most likely to have posterior shoulder dislocations
Extreme convulsions, either from seizures or electrocution
What are the tests you can do to assess for shoulder dislocation
Apprehension tests
sulcus sign
What is the apprehension test
Shoulder abducted to 90 degrees, 90degree elbow flexion, slight ER
Examiner applies anterior pressure to posterior shoulder
What is the sulcus sign
Inferior traction to the humerus with thumb on acromion, if a sulcus or depression is seen = joint laxity = positive test
What is the first line workup for a shoulder dislocation
Xray
What is a bankhart lesion
Fx of the anterior inferior glenoid rim, associated with labral injury
What is a hill Sachs lesion
depression of the posterolateral humeral head from impaction of the humeral head into the glenoid
Whois most likely to get a proximal humerus fx and why
women, usually from osteoporosis
What is the most common type of humerus fx
proximal
What is important to check with an proximal humerus fx
axillary nerve function to see if there is sensation over the deltoid
Who would you do an ORIF or arthroplasty on for a proximal humerus fx
Significantly displace +/- comminuted fxs
What is the mechanism of injury for a humeral shaft fx
Direct blow to the arm is most common
FOOSH in elderly females (Spiral / oblique)
If a patient present with a deformity +/- shortening of 1 arm, what is their most likely diagnosis
humeral shaft fx
What are the indications to do surgery on a humeral shaft fx
no adequate reduction
unstable fx
pathologic fx
neurovascular injury
open fx
multi-trauma
body habitus preventing splinting
What is another name for lateral epicondylitis
tennis elbow
What is tennis elbow
Inflammation of the extensor tendon insertion
What is the #1 cause of elbow pain
Lateral epicondylitis
Where does lateral epicondylitis typically occur
The dominant arm
What is the MOI or lateral epicondylitis
Tennis player
Manual labor
heavy lifting
repetitive grasping
What is the presentation for tennis elbow
Pain on lateral aspect of elbow
pain may radiate down extensors
Associated edema
Pain worsens with activities requires wrist pronation
If a patient has tenderness to palpation over the lateral epicondyle, pain with resisted wrist and finger extension, pain with resisted pronation, and pain with deep wrist flexion, what is their most likely diagnosis
lateral epicondylitis or tennis elbow
What is golfers elbow called
medial epicondylitis
What is medial epicondylitis
inflammation of the flexor tendon insertion site
What is the MOI for medial epicondylitis
Golf
Tennis
Weight lifting
Throwers
racket sports
What is the standard of care for medial epicondylitis when you need to r/o other pathologies
MRI
What is nursemaids elbow
Subluxation of radial head
Which elbow is more commonly effected from nursemaids elbow
Left
What is the presentation of nursemaids elbow
Audible snap
Initial pain subsides quickly
child refuses to use arm
Forearm resting in pronation, slightly flexed
What type of elbow dislocation is most common
posterior
What are the three points of articulation in the elbow
ulnotrochlear
radiocapitular
Proximal radioulnar
what is the MOI for an elbow dislocation
FOOSH
What must be done for all elbow dislocations
serial neurovascular checks
If the neurovascularity is intact with an elbow dislocation and is stable through ROM, how do you treat
Splint 90 degrees of flexion and place in a hinged brace
If there is an associate fx with an elbow dislocation or the neurovascularity is not in tact, how do you treat
Surgery
Which gender is most likely to suffer from radial and ulnar shaft fx
men
What is the MOI for a radial and ulnar shaft fx
MVC
Motorcycle accident
sports
altercation (night stick fx)
Fall from height
If a patient has a gross deformity in their forearm, tenderness to palpation, pain with movement, and edema, what is the most likely diagnosis
radial and ulnar shaft fx
What needs to be assessed with a radial and ulnar shaft fx
Neurovascular function
compartment syndrome
How are most radial and ulnar fx treated
ORIF
What is a ganglion cyst
Mucin filled synovial cyst on wrist
What is the most common soft tissue tumor of the hand and wrist
Ganglion cyst
A patient presents with a slightly mobile, palpable mass on their dorsal wrist, that is not tender and transluminates with light, what is the likely diagnosis
Ganglion cyst
What is a home remedy for a ganglion cyst
home rupture (Bible bump)
What causes carpal tunnel syndrome
Compression of median nerve causing neuropathy
What is the most common compressive neuropathy
carpal tunnel syndrome
What is the MOI in carpal tunnel syndrome
Inflammation from repetitive motion and or space occupying lesion
What does the ulnar nerve control
the 5th and half of the 4th metacarpal (anterior and posterior side)
What does the median nerve in the hand control
Half of the 4th - the first metacarpal (anterior side)
What does the radial nerve control
Feeling on the lateral half of the dorsal hand
Patient presents with numbness and tingling in the median nerve distribution, hand clumsiness, and complains the symptoms get worse at night, what is their most likely diagnosis
Carpal tunnel syndrome
What is a chronic finding during a carpal tunnel exam
Atrophy of the thenar muscle
What is the definitive dx for carpal tunnel syndrome
electromyography
What does electromyography test for
nerve motor function and the communication with specific muscle groups
What does nerve conduction velocity test for
How fast the nerves conduct electrical impulses
What is the stepwise algorithm for treating carpal tunnel syndrome
- NSAIDs and wrist brace
- Corticosteroid injection
- surgery
What is the most common fracture of the upper extremity
Distal radius
Which gender is more likely to have a distal radius fx
females
What are the two types of distal radius fx
colles: dorsal displacement (Posterior)
Smith: volar displacement (Anterior)
What is the most commonly fractures carpal bone
Navicular
Where on the scaphoid do most of the fx occur
waist
what is the MOI of a scaphoid fx
FOOSH
When is surgery needed for a scaphoid fx
Displacement, complex, and most proximal pole fx
What are the complications of a scaphoid fx
Wait and proximal pole fx at high risk for non union and AVN
unidirected blood flow
What is DeQuervians tenosynovitis
Inflammation of the extensor tendon sheath at the 1st MCP joint
What is the MOI for DeQuervains tenosynovitis
Overuse
A patient present with insidious onset radial sided wrist pain that is exacerbated by gripping and lifting objects, what is their likely dx
DeQuervains Tenosynovitis
What is the Finkelstein test and what is it used to test for
Grip thumb and place wrist in ulnar deviation…positive= pain
Used to test for DeQuervains tenosynovitis
When is surgery needed with DeQuervains tenosynovitis
If refractory
What is dupuytrens contracture
Benign, progressive, soft tissue disorder that leads to contracture of fascia
What is the most common finger to be affected by Dupuytrens contracture
Ring
What genetic predisposition is dupuytrens contracture
Autosomal dominant
Which gender is generally more effected by dupuytrens contracture
Men (Caucasian)
What are the risk factors for Dupuytrens contracture
DM
ETOH abuse
HIV
anti-seizure meds
What will you find on a physical exam in someone with dupuytrens contracture
Palpable cord in the palmar surface (NOT A TENDON)
What is trigger finger
A stenosing tenosynovitis (Nodules in the tendon sheath)
Which fingers are most commonly affected with trigger finger
4th and 5th digit
Who is at highest risk for developing trigger finger
Diabetics and women
A patient presents with pain at the MCP joint, catching, locking, and clicking with flexion/extension ad a palpable palmar nodule, what is their likely diagnosis
Trigger finger
What is skiers thumb and what is another name for it
Gamekeepers thumb
sprain or tear in the ulnar collateral ligament
What is the MOI for skiers thumb
Forced thumb abduction
A patient present with acute pain, swelling and bruising at the base of their thumb and having difficulty grabbing or throwing objects, what is their likely diagnosis
Skiers thumb
When is surgery needed with skiers thumb
A complete UCL tear
MOI of metacarpal fx for someone in their 20-30s
sports
MOI for metacarpal fx for someone in the 40-50s
Work related
MOI for metacarpal fx for someone in their 60-70s
falls
What type of splint will be placed for metacarpal fractures
ulnar gutter splints
either 4th and 5th or 1st,2nd,3rd
If a patient has a “fight bite” how would you treat
Augmentin or cefuroxime and don’t close the wound
What finger joint is most commonly dislocated
PIP and often misdiagnosed as a sprain
How are phalangeal injuries treated
Buddy taping and activity as tolerated
